IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


p 


viV 


I 


1.0 


I.I 


■6  3 


1.25 


1.4 


-     6" 


IIM 

1.6 


i.iift 


P 


<9 


/# 


^i 


» 


w 


Photographic 

Sciences 
Corporation 


^ 


%^ 


'^ 


«.- 


^\ 


33  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


<v 


c^ 


#a 


^ 


<> 


'"^^ 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  {Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


l«H^ 


Technical  and  Bibliographic  Notes/Notes  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best 
original  copy  available  for  filming.  Features  of  this 
copy  which  may  be  bibliographically  unique, 
which  may  alter  any  of  the  images  in  the 
reproduction,  or  which  may  significantly  change 
the  usual  methoJ  of  filming,  are  checked  below. 


L'Institut  a  microfilm6  le  meilleur  exemplaire 
qu'il  lui  a  6t6  possible  de  se  procurer.  Les  details 
de  cet  exemplaire  qui  sont  peut-Stre  uniques  du 
point  de  vue  bibliographique,  qui  peuvent  modifier 
une  image  reproduite,  ou  qui  peuvent  exiger  une 
modification  dans  la  m6thode  normale  de  filmage 
sont  indiqu6s  ci-dessous. 


D 
D 
D 
D 
D 
D 
D 
D 


D 


Coloured  covers/ 
Couverture  de  couleur 

Covers  damaged/ 
Couverture  endommagde 

Covers  restored  and/or  laminated/ 
Couverture  restaurde  et/ou  pellicul6e 

Cover  title  missing/ 

Le  titre  de  couverture  manque 

Coloured  maps/ 

Cartes  gdographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couleur  (i.e.  autre  que  b!eue  ou  noire) 

Coloured  plates  and/or  illustrations/ 
Planches  et/ou  illustrations  en  couleur 

Bound  with  other  material/ 
Reli6  avec  d'autres  documents 


Tight  binding  may  cause  shadows  or  distortion 
along  interior  margin/ 

La  reiiure  serr6e  peut  causer  de  I'ombre  ou  de  la 
distortion  le  long  de  la  marge  int6rieure 

Blank  leaves  added  during  restoration  may 
appear  within  the  text.  Whenever  possible,  these 
have  been  omitted  from  filming/ 
II  se  peut  que  certaines  pages  blanches  ajoutdes 
lors  dune  restauration  apparaissent  dans  le  texte, 
mais,  lorsque  cela  dtait  possible,  ces  pages  n'ont 
pas  6t6  filmdes. 


\ 


D 
D 
D 
D 
D 
D 
D 
D 


Coloured  pages/ 
Pages  de  couleur 

Pages  damaged/ 
Pages  er.dommagdes 

Pages  restored  and/or  laminated/ 
Pages  restaurdes  et/ou  pelliculdes 

Pages  discoloured,  stained  or  foxed/ 
Pages  d^colordes,  tachet^es  ou  piqu^es 

Pages  detached/ 
Pages  ddtachdes 

Showthrough/ 
Transparence 

Quality  of  print  varies/ 
Quality  indgale  de  I'impression 

Includes  supplementary  material/ 
Comprend  -u  matdriel  suppl6mentaire 


Only  edition  available/ 
Seule  Edition  disponible 

Pages  wholly  or  partially  obscured  by  errata 
slips,  tissues,  etc.,  have  been  refilmed  to 
ensure  the  best  possible  image/ 
Les  pages  totalement  ou  partiellement 
obscurcies  par  un  feuillet  d'errata,  une  pelure, 
etc.,  ont  6t6  film6es  d  nouveau  de  fa^on  d 
obtenir  la  meilleure  image  possible. 


D 


Additional  comments:/ 
Commentaires  suppl6mentaires: 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  film*  au  taux  de  rdduction  indiqu6  ci-dessous. 


10X 

14X 

18X 

22X 

26X 

30X 

1 

^"^^ 

19X 

16X 

20X 

24X 

28X 

32X 

>r 


The  copy  filmed  here  has  been  reproduced  thanks 
to  the  generosity  of: 

Library  of  Congress 
Photoduplication  Service 

The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  specifications. 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  o.  illustrated  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  — ^  (meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 

Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


L'exemplaire  film6  fut  reproduit  grSce  S  la 
g6n6rosit6  de: 

Library  of  Congress 
Photoduplication  Service 

Les  images  suivantes  ont  6t6  reproduites  avec  le 
plus  grand  soin,  compte  tenu  de  la  condition  et 
de  la  nettetd  de  l'exemplaire  filmd,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 

Les  exemplaires  originaux  dont  la  couverture  en 
papier  est  imprimde  sont  film6s  en  commengant 
par  le  premier  plat  et  en  terminant  soit  par  la 
dernidre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration,  soit  par  le  second 
plat,  selon  le  cas.  Tous  les  autres  exemplaires 
originaux  sont  film6s  en  commengant  par  la 
premidre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  dernidre  page  qui  comporte  une  telle 
empreinte. 

Un  des  symboles  suivants  apparaitra  sur  la 
dernidre  image  de  cheque  microfiche,  selon  le 
cas:  le  symbole  — »-  signifie  'A  SUIVRE  ",  le 
symbole  V  signifie  "FIN". 

Les  cartes,  planches,  tableaux,  etc.,  peuvent  Stre 
fi:m68  d  des  taux  de  r6duction  diff6rents. 
Lorsque  le  document  est  trop  grand  pour  Stre 
reproduit  en  un  seul  clich6,  il  est  film6  ^  partir 
de  Tangle  sup6rieur  s^uche,  de  gauche  d  droite, 
et  de  haut  on  bas,  en  prenant  le  nombre 
d'Images  ndcessaire.  Les  diagrammes  suivants 
illustront  la  mdthode. 


ire. 


] 


1 

2 

3 

1 

2 

3 

4 

5 

6 

'RM 


''  li  I  'I 


.)*; 


RC 

.0% 


M 


Wa^ 


Pf 


THE  PRINCIPLES  AND 
PRACTICE  OF  MEDICINE 


DESIGN!:!)   !'0R    THE   USE   OF  !'RACT!riONERS 
AN!)   STUDENTS   OE  MED!C!NE 


BY 

WILLIAM   OSLHR,   M.  D. 

Fellow  of  the  Roval  Socioly  ;   rdlow  of  the  Royal  Collejje  of   Physicians, 

London  ;   I'ldfcssor  of  Medicine  in  the  Johns  Hopkins  University  and 

riiysician-in-chief  to  the  Johns    Hopkins    Hospital,    Haltiniore  : 

formerly    Professor   of    the    Institutes    of    Meilicine,    Mc(iill 

I'niversity.  Montreal  ;  and  Professor  of  Clinical  Medicine 

in  the  University  of  I'cnnsylvania,  Philadelphia 


THIRD    HDITION 


NEW    YORK 
D.    APPLETON    AND    COMPANY 

1898 


i^aA 


\ 


c  ■ 


L  \^.  1. 


Col-YHKlllT.    IKW,    IWt"),    ISOS, 

Hv    1).   Arri.KTi'N    AMI   COMPANY. 


TWC  COPIES  HECEIVED. 


2nt  <-.-:,.-■.', 
109C. 


iUcmovn  of  mn  <rcacl)cvs: 

WIMJAM    AKTUrK  JOHNSON, 
.•Kii>i'  <ir  Tin:  I'vitisii  iiF  wisniN,  ustauu). 

JAMKS   ISOVEI.L, 

or  Tiir.  ■niiKiNiii  scikmii.  or  mi.hk  isi:,    \M>  m'  riii-; 

1N1VI:K>I  TV    (IF   TlilNllV    tolA.l-Ml.,    TdUuNrd. 

liOlSKllT   PAI.:\IKR  IIOWAKI), 

v.ws  >n-  iiii:  Mi;i)i(  VI.  r\(  i  i.iv  and  i'U(iii:ssok  <ik  mkdh  ini:, 

.MlCll.l,    I  NIVKliSlTV.    MDNTUKAr.. 


itaHK^ 


lMJi:FA(  K   TO   Till-:   TIIIIID    KDITlo.V 


At  ♦^lic  pivscMit  i'ati>  (if  i>ruu;ros>  in  all  <l('|)iirtmoiitf;,  n  tcNt-liook  kIx 
voars  old  needs  a  very  tlidroiiijli  revision.  In  tlii'  socoiid  edition,  issued 
three  years  iiuro,  many  corrections  were  made  and  nnicli  new  matter  was 
a<lded.  The  jiresent  edition  has  iieeii  wholly  recast.  "With  tlii'ir  wonted 
liherality  the  i)ul)lishers  have  I'nnushecl  a  new  font  id'  type  ami  a  some- 
wliat  enlarii'cd  i>aj:;e  so  that  the  additions  have  not  materially  increased 
the  size  (d'  the  volume.     A  ])a])er  of  hetter  (inality  has  also  heen  used. 

The  followiui!;  arti(des  liavc  Itoen  rewritten  or  are  new:  Vaccination, 
15eri-l>eri,  The  Huhoiiic  PIa<ijiie,  Cerebro-spinal  Kever,  Pneumonia,  Alalta 
Fever,  Yellow  Fever,  Dengue,  Leprosy,  Glandular  Fever,  The  (ionor- 
rluea'  Infection,  Cancer  of  the  Stomach,  The  Gastric  JS'euroses,  The 
(Jirrhoses  of  the  Liver,  Jaundice,  The  Diseases  of  the  Lile-passages, 
Diseases  of  the  I'ancreas,  Diseases  of  the  Thynuis  (Jland,  Diseases  of 
the  Spleen,  Lymphatism,  Addison's  Disease,  Knce|)halitis,  Neurasthenia, 
F^rythro-melalgia,  anil  many  shorter  articles,  as  Kther  Pneumonia,  Anses- 
thesia  Paralysis,  Pneunuituria,  Albumosuria,  etc. 

Into  the  sections  on  Typhoid  Fever,  Tuherculosis,  Rheumatic  Fever, 
Diabetes,  (iout,  P.'rasitic  Diseases,  Diseases  of  the  I'lood.,  Heart,  Luiii^-s, 
and  Kidneys,  much  new  matter  has  been  incorporated.  The  section  on 
Diseases  of  the  Xervous  System  lias  l)een  rearrani^ed,  and  an  attempt  has 
been  made  to  n'roup  the  diseases  in  accordance  with  the  modern  conce])- 
tions  of  the  anatomy  and  functions  of  the  part- 

1  have  in  all  sections  tried  to  maintain  the  thoroughly  jiractical  char- 
acter of  the  work,  as  a  guide  in  dia;j,nosis,  symptomatology,  and  treat- 
ment. 

I  have  again  to  thaidv  many  friends  for  much  valuable  help,  without 
■which  the  revision  would  have  been  very  incomjdete.  Dr.  Flexncr  lias 
not  only  given  me  great  assistance  in  connection  with  the  pathology  and 
bacteriology,  but  lias  enabled  me  to  utilize  for  the  jiresent  edition  nuich 
material  from  the  records  of  the  pathological  department  of  my  colleague 


VI 


I'KKFAcK  'i(»  'nn:  ■riiiKit  iiurrioN. 


Dr.  Wclcli.  I)r.  11.  M.  Tlmmas  aiid  Dr.  I.  1".  Unrl^fi-  have  irivcn  imich 
,i,„r  iin.l  invalual.lo  hi'l])  in  tin-  .Tv^sion  ..f  tlii'  m-ku.m  en  Disnixs  <.f  th  • 
iXt'i-v.^urt  SystiM...  To  the  f..niuT  1  nwi'  tiic  i-xci-lliMit  ivaiTan-niii'm  of 
tlie  sul)jiH't.s  in  this  i-cctioii. 

T*.  my  associate  in  the  cliair  <>f  nieilicine.  Dr.  Tliaycr,  and  tu  my  a- 
si>tants,  Drs.  Fuicher  and  McCrae,  1  am  under  many  ol.ii.uations.  Dr. 
Liviu-nnd,  the  assot-iate  in  patholo-y,  hy  wlm-o  untimely  death-  the 
.lohnr  Hopkins  Medieal  ScIk.oI  has  >uirered  a  grievous  loss,  ^v as  most, 
kiml  in  furnisliing  faets  from  the  post-mortem  reeords  of  the  hospital. 

Dr.  Fraid<  K.  Smith  has  very  kindly  seen  the  editi..n  through  tlie 
pre>.s,  and  I  have  again  to  thank  my  seerctary,  Miss  1}.  i  >.  Ihnnpton,  for 
the  preparation  of  the  index. 

And  not  lea>t,  sinee  their  liberal  encouragement  has  made  the  revi- 
si.ni  possible,  1  have  to  thaid<  my  brethren  on  both  sides  of  the  Atlantic 
for  their  kind  reception  of  the  i)revion>  editions. 
,/iih/  .'.■.  is:>s. 


*  lie  was  Olio  of  the  vittinis  in  the  IJuurguguc  disaster. 


ivcMi  niucli 

ilSlS  <lt'  til  ' 
^•("llll'Ilt     ot 

I  til  iiiv  a-- 
ioiis.  \h\ 
Ifiith"  tlu! 
.,  WilS  lunst 
liospital. 
ir(Hit;'li  tlu' 
iiiiptoii,  for 

L-  the-  I'fvi- 
iu!  Atlantic 


CONTEXTS. 


SECTION   I. 
SI'KCIKIC   IN'FKCTIOUS  DISEASES. 


I. 

'rvplioid  iM'vrr 

11. 

'rvpiiiis  i''cvci' .      .      .      . 

III. 

Iti'liilisiiii;  l''cvcr 

IV. 

SiiimII-|i(ix        .        .        .        . 

V,ivi()l:i  Vera 

ll;i'iiiori'li!i;;ic  S.niill-iJ.ix 

Variiildid      .         .         .         . 

V. 

\'ii('i'iriiii  (Cow-pox) — V(iccili;i 

^VI. 

Viiriccllii  (I'liickt'ii-pox)  . 

'   VII. 

Scarlet  FfviT  . 

-  VIII. 

Measles 

.-  IX. 

liubi'llii  (Knilirlli)     . 

'    X. 

I'',pi(|i'ini('  Parotitis  (.Miiiiip--) 

•   XI. 

VVhoopiiijj-coiii,'h 

XII. 

Intliiciiza  .... 

XIII. 

Dcnsuo    .... 

XIV. 

(\'r('l)ro-s]iiiial  .\Ii'iniigilis 

XV. 

Piiciiiiioiii'i 

-    XVI. 

Dilihtlicria       .        .        ,        . 

.  XVII. 

Krysipflas       .        .        .        . 

XVIII. 

Supticirniia  and  I'yaiiiia 

Soptica'iiiia         , 

Scptico-I'ya'iiiia. 

'rcniiinal  Iiifrctions  . 

V    XI.X. 

Iihouinatic  Fcvor    . 

XX. 

Cholera  Ai^iatica 

XXI. 

follow  Fevor   . 

XXII. 

TIk-  Biil'onie  I'lagiic 

XXIll. 

l)ys(  ntory 

XXIV. 

Malarial  l"\>vor 

Intermittent  Fever 

Continued  and  Remittent  ] 

Pernicious  l^Ialarial  Fever 

Malarial  Cachexia 

XXV. 

Malta  Fever    . 

XXVI. 

Heri-bcri  .... 

XXVII 

Anthrax  .... 

XXVIII. 

Hydrophobia  . 

XXIX. 

Ti'tanus    .... 

XXX. 

Glanders  .... 

liar 


iul  I 


P.VliE 
1 

-t!) 

.■.;i 

5(1 
.•i!) 
(Vi 
(>:{ 
(W 
74 
7.") 
ST> 
H!) 
itO 

!)!) 
100 
108 
l:i8 
l.->7 
KiO 
KM 
K!!! 

ur. 

l(J(i 
17r> 
IH2 
IS!I 
193 
202 
20!» 

2i:{ 
21.-) 

210 
210 
220 
224 
227 
2:i0 
233 


«i* 


VIU 


CONTENTS. 


X.X.XI.  Arlinoinycosis.        .        ,        . 
XXXU.  Syiiliilis 

Accjuiivd 

('(jii^'i'iiiiiil 

N'isri'i-iil        .  .... 

XXXIII.  (IdiKM-i'lid'al  Iiifcc      11      ...        . 
,\X.\I\'.  'J'lilx  i(ulii>is    ,        .        .         . 

1.  (Iciii'i'iil  Kti(ilt/,£;y  and  Mnrliid  Aiiaininy 

2.  Acute  Tuborculosis 
o.  'L'uluTculd.sis  of  tlu!  liyinpliiitie  SystiMii 

4.  "  of  till' liUii^s  (I'htlii.sis.  Cdiismi 

5.  "  of  till'  Aliiiit'iitury  Ciinal 
0.            "  of  the  LiviT 

7.  '■  of  tliC  T?r!iin  uiid  Spina!  Cord 

8.  "  of  till!  (ii'iiito-iiriiiary  Sy^^t('lIl 

0.  "  of  the  Maininary  Gland 

10.  "  of  till' (.'ii-<'ulali>i'y  Systi'in 

11.  niagiio>is  of  Tiil)crc'ulosis 

12.  I'l'ogno^^is  in  Tiihcrculosis 
lli.  Prophylaxis  in  Tubi'n'ulcisjs  . 
14.  Troatin.  nl  of  Tuliinx'ulosis 

XX.X'V.  I-i'prosy 

XXXVl.  liifi'ctioiis  Disoasi's  of  Doulitfii!  Nature  . 

1.  I''i'l)riciila  ({'".plii'iuoral  Kcvit) 

2.  Wi'il's  Disease          .... 
;j.  Milk-siekness 

4.  (ilandiilur  Fever     .... 

5.  Moiiiifaiii  Fever      .... 

6.  Miliary  l'\'ver  (Sweat iiii;  Sicklies^;) 

7.  Foot  and  iNhnitli  Disease 


jition 


2:iS 

212 
244 
255 

258 
25S 


•-> 


to 


2S0 
2>S!) 
yi7 
;!2() 

;i2i 


:i27 
:i2s 
:i28 
;i;jo 
;i;!i 
n:',8 

343 

;J43 

344 
344 
845 
34G 
340 
347 


SECTION   II. 
DISFASFS  DrK  TO  ANIMAL  PAIiASI 


I,  IVoi'osperiniasis 

1.  Interiial  I'sorosperminsis 

2.  Cutaneous  l'soros|)ermiasis . 

[J.  I'aiasitie  Infusoria        .... 

III.  Distoiniasis 

IV.  Diseases  iMUsed  by  Nellialodes     . 

1.  Ascariasis 

2.  Trieliiniasis 

3.  Anehylostoniiasis 

4.  Filariasis 

5.  Dracontiasis  .... 

0,  Other  Nematoc'^s 

,\eantlioei  ,.iiala 
V.  Diseases  <-aused  by  Ceslodes 

1,  Intestinal  Cestodes;  Tape-worms 

2,  Visceral  Cestodes 

Cysticereiis  Cellnlosa' 
Fchinococcus  Disease 
Mullil.eular  Eeliinocoecus 


IKS. 


349 
349 
350 
351 
351 
353 
352 
354 
359 
300 
303 
364 
305 
305 
305 
;108 
308 
370 
374 


CONTENTS. 


IX 


VI.  Parasitic  Aracliiiidf 
VII.  Parasitic  Insects  . 
VIII.  Myiasis 


I'.Tti 


i 


II. 
III. 
IV. 

V. 


VI. 


SECTION   III. 
TIIH   TXTOXICATIOXS   AND  SUX- STROKE. 


Alcoliolisin 

1.  Acutu  Alcdlinlism    . 

2.  Chronic  Alcoliolisin 
.!.  i)i'liriuni  'rrcnuiis    . 

^lorpliiii  ilaliil  .... 

Lead  Poisoniiii;        .... 
Arsenical  Poisoning' 
Food  PdisoniniC        .... 

1.  ^Icat  Poisdiiin;; 

2.  Poisoninj;  liy  Milk  Products    . 
8.  Poisoninj,'  liy  Sliell-lisli  and  Fis 
4.  (irain  Puisonini; 

Sun-stroke 


SECTION   IV. 

coxsTrruTioxAL  diseases. 


I.  Artlirilis  Ocfnrnians    . 
II.  Chronic  Hheuiniilisin   . 

III.  Muscular  Uluiunatisin 

IV.  Cout      .        .         .        . 
V.  Diabetes  Mellitus 

W.  Diabetes  lnsi|)i(lns 
VI  i.  Rickets. 
VIII.  Obesity. 


SECTION  V. 


DISEASKS   OF   '1 

I.  Diseases  of  the  Mnutli . 
Stonuitilis 
A|ihtlious  Stoiuiitltis 
Ulcerative  Stonuitilis 
Parasitic  Stonuititis  (Thrush) 
Oauiirenous  Stonuititis 
Mercurial  Stomatitis 
Iv'zeuui  of  the  Toni,Mic 
Leukop!:-':;:'.  Iinccaiis 
II.  Diseases  of  the  Salivary  (ilands 
Snpersecretion  . 
Xerostomia         ... 
Ii  ''aninuition  of  tlu^  Salivary  ( 
III.  Diseases  of  the  Pharynx 

Circulatory  Dislurbuiices 
Acute  Pharynjiitis     . 
Chronic  Pharvn^'itis 


IIH    DIGESTIVE   SYS 


te:\i. 


SfiO 

\\m 
;is2 

;5S4 

;i!(0 

8!)1 

■i'x\ 
;!!t;j 
:!ii4 
;;u5 


40.") 
4(Jt} 
407 
418 
4:J2 
4.'i4 
43i< 


441 
441 
441 
442 
44:5 
444 
444 
445 
44(3 
44() 
446 
447 
447 
448 
44H 
448 
449 


di^ 


X 


CONTENTS. 


I'lcpnition  of  tlu!  I'liiivyiix 

Aciuu  InlVctiniis  rhli'tjiiinii  of  llic  I'lian  iix 

l!et  ro-pliiiryii!;('iil  Abscess 

Aiiiiiim  liUd  ivici 

IV.  Kiscascs  of  tli(>  Tonsils          .... 
Follicuhir  or  LfUMinar  ToiisiUiiis 
!Suii()m'ative  Tonsillitis     .        ■         .        ■ 
Clirouic  Tonsillitis 

V.  Discuses  of  Ur' (I-'.soiiliagiis  . 

Acute  (I'".soiiliM,i,'itis 

Spasm  of  llio  (Kso|ilia,!;iis 
Slrii^ttivc  of  the  (Ksopliagiis 
Cancer  of  tlie  (lOsophagiis 
Hiiliture  of  llie  (I'lsopliajjiis 
Dilatations  and  Diverticula      . 

VI.  Diseases  of  the  Stomach       .        .        .        • 

Acute  (iaslrit is 

P!ilc;;monous  (iastiilis  .... 

Toxic  (Sastritis 

Diphtheritic  (iastritis    .        .         .        ■ 

^Mycotic  Gastritis 

Chronic  Gastritis  (Chronic  Dyspepsia)  . 
Dilatation  of  Stomach  .  .  .  • 
I'eptic  I'lccr  (Gastric  anil  Duodenal) 

Cancer  of  Stomacli 

IIypertroi)hic  Stenosis  of  the  rylorus 
IlaMHorrhage  from  the  Stomacli 
Neuroses  of  the  Stomach  .... 

VII.  Diseases  of  the  Intestines     .... 

1.  Diseases  of  the  Intestines  associated  willi 

Catarrhal  Enteritis    .... 

Diarrluru 

Enteritis  in        ildren 

Diphtheritic  ■     <'roiipous  Enleiilis  , 

l'jilci,'moiious  I'lnteritis 

Ulcerative  Enteritis  .... 

2.  A|.pendicilis  (Typhlitis  and  IVrityphlitis 
:}.  Intestinal  Obstruction. 

4.  Constii)atioii  (Costiveness)    . 

5.  Ent<n-optosis  (Glenard's  Disi^ase) 
(i.  Jliseellaiu'ous  .MTections 

Mucous  Colitis 

Dilatation  of  the  Colon     . 
Intestinal  Sand  .... 

Affections  of  the  :^Icsentery      . 

VIII.  Diseases  of  the  Liver 

.laundice  (Icterus)  .... 

Icterus  Neonatoriiin      .... 
Acute  Yellow  Atrophy     '     . 
.MTections  of  the  ISlood-vessels  of  the  i.i 
Di.seases  of  the  I5ile-passages  and  tiall-b 

Cholelitliinsis 

Cirrhoses  of  the  Diver  .... 
Abscess  of  the  Liver     .... 


1. 


4. 
0. 


r.M.r. 

44!t 

4.-i(l 

4.')(l 

4r)t) 

4.-.1 

4.")1 

4.10 

4.14 

4.')8 

4.-.8 

4.")!) 

4(>0 

4(il 

4m 

Wi 

403 

4(>:i 

4(54 

405 

405 

4(i() 

400 

J  74 

4TS 

4S0 

4!)4 

4!)5 

497 

rm 

Diarrluea 

no.-) 
r)()5 

50S 

->Vi 

.     513 

.  r,vi 

.     51!) 
.  .5:51 
.  5:i8 
.  .541 
.  544 
.  544 
.  545 
.  540 
.  540 
.  548 
.  .548 
.  551 
.  551 

vcr 

.  55:5 

ladder  . 

.  555 
.  501 
.  50!) 
.  577 

I'OXTKXTS. 


XI 


I'.M.r. 
41!t 
4.->(l 
450 
4.-)() 
4.".1 
4:>l 
4.VJ 
4r)4 
4. "is 

4r,s 

4.")!) 
4()0 
4()1 
4(i'i 
Wi 
46;i 

4(i;i 

404 

4c,r, 

405 

400 

400 

474 

478 

4S0 

4!)4 

4!)5 

407 

505 

505 

505 

505 

50S 

513 

513 

513 

51il 

5:U 

5;)8 

541 

544 

544 

545 

54(! 

540 

548 

548 

551 

551 

55:5 

555 

501 

509 

577 


!>.  \r\v  Ordwlli'^  ill  1)11'  I.ivi'v  . 

1(1.  Fiiily  Liver  .... 

1 1.  Aiiiylciiil  liivcr 

I','.  Aiiiiiiiiilii's  in  l-"iiriii  iiinl  I'n-i 
IN.   I)isi'a<cs  (if  till'  l'iMii-'rc;i>- 

1.  Ilii'iiionli!iL;c 

3.  Vi'Mli'  I'iiiicn'iililis 

;).  Ciiroiiic  I'liiuMvatilis    . 

4.  I'lUuiL'iitii'  (.'ysis  . 

5.  'I'mimrs  (if  ilic  raiu'n'i(,'^ 

0.  I'aluTcatic  Calculi 

X.  Discuses  III' llii'  I'ei'itoiia'iiiii 

1.  Aeiile  (Iriieral  I'eritoiiilis 
'■^.  i'ei-ildiiilis  in  Infants   . 

;i.  Liicali/.ed  I'eriliinilis    . 

4.  ( 'lininie  I'erildnitis 

5.  New  (irciwtlis  in  the  Perilmia 
G.  Ascites  (ilyili'ii-iierituna'iini) 


<l  I 


l.i 


VI. 


DISKASES   OF 


SECTION 

TIIK    liKSI'lKAToUY   SV 


1.   Diseases  of  the  Xose        .... 

Acute  C'oryzii 

I'hronic  Xasal  Catarrh        .        .  '      . 
Autumnal  Catarrh  (Hay  l''cvcr). 

I'-liistaxis 

II.  Diseases  (if  the  Laryi'.x   .... 

1.  Acute  Catarrhal  Larynj^itis    . 

2.  Chronic  Laryiifiit is. 

3.  (KdL'inatdUS  Larynjjilis  . 

4.  Spasniodic  Larynjfitis  (Laryuni^unis  st 

5.  Tuberculdus  Laryn.LMlis  . 

6.  Syphililic  Laryngitis 

HI.    Diseases  (it  the  UroiU'hi   .... 
1.  Acute  linmchitis     .... 

3.  Chronic  Bronchilis . 

;i.   Mnmchiectasis  .... 

4.  iJriiuchial  Asthnni  .... 

5.  Kiliriudus  lirciuchitis 

1\'.   Diseases  df  the  Lungs     .... 
1.  Circulatciry  Disturbances  in  the  Lun 

3.  Mronchci-iineiniidnia  (Caiiillary  Brunch 
;{.  Chrdiiic  Interstitial  I'ueuiiidin'a  ;Cirrh( 

4.  I'neuindiiiikduidsis  .... 

5.  Kniiihysenui 

Conipcnsatiiry  I'jn]ihysenia 
llyiiertrci|iliic  lMn)ihysenia  , 
Atrophic  Kinphyseiua 
Acute  \'(>sicular  Kniphyscuia 
Interstitial  iMuphysema 
0.  (iangrene  of  the  Lung    , 

7.  .Miscess  of  the  Lung 

8.  Xcw  Growths  in  the  Lungs     . 


idul 


tis) 


Lui 


STKM 


r.\ar. 
5s3 
5s5 
5S0 
5s7 
5ss 
5SS 
5S!) 
5!  13 
5!  13 
511  ( 
5tl5 
5!)() 
5!  10 
lilKI 
000 
003 
004 
005 


010 
oil) 

oil 

013 
014 
015 

015 

i;io 

017 
017 
01!) 
030 
031 
031 
03:i 
030 
038 
(;;!3 
0:i4 
0:i4 
041 
040 
053 
054 
055 
055 
05!) 
0<iO 
000 
000 
003 

oo;i 


m^ 


XI 1 


CONTENTS. 


V.  Disrasps  of  tlic  I^K'nr.-i     .... 

1.  Acute  I'lcmisy        .... 

Filii-iiiiiiis  (If  riii>iii'  rii'iii-i.-y     . 
Soni-tilii-iiKiiis  rii'iirisy 
runilc'iil  riciirisy  (Kiiipycinii)    . 
TulH-Tfiiloiij;  I'li'urisy  . 
OlliiT  Varit'tics  1)1'  I'lciiri-y 

2.  Cliniiiic  rii'urisy     .... 

;i.  Ilydi-otliiinix 

4.  I'nciimollKHMX  (llyilro-piii'Uiiiolli.n-ux  iiinl  ryo-iinruiiiniliniiiN) 

AlTt'ctioiib  ul'  llic  .Mcdiuslimiiii 


liO.) 
(Km 
tid") 
(iiil) 
OTl 
G7;J 
07:i 
(iTS 

GSl 
(i!^4 


DISEASES  OF  THE  ('[KcrL.n'oPiV  SVST 

I.  Disonsps  of  till'  1*1  ricanliuiu    .... 

1.  I'criciirilitis 

',*.  OlluT  AlToctioiis  of  till!  IVriciinliiuii 

II.  Disoasicsof  tlic  Heart 

1.  Emlocanlilis 

Acuti!  Eiiilociinlitis      .... 

Clironic  E.i(l(ii'iir<litis   .... 
;,'.  C'lu'oiiii.^  Viilvuliir  Discusf 

(ioiioral  Introduction   .... 

Aortic  Inconipotoncy    .... 

Aortic  Stenosis 

antral  Incompetency    .        .        .        • 

Mitral  Stenosis 

Tricuspid  Valve  Disease 

Piihnonary  Valve  Disease    . 

CoMibined  Valvular  Lesions 

3.  llvpertropliy  and  Dilatation    . 

IIy[)ertropliy  of  the  Heart    . 
Dilatation  of  the  Heart 

4.  AlTeclions  of  the  MyoeardiiiMi 

Aneurism  of  the  Heart 
U\ipture  of  the  Heart    .... 
Nesv  (irowths  and  Parasites 
Wounds  and  Foreign  Hodies 

5.  Neuroses  of  the  Heart       .... 

Palpitation 

Arrhythmia 

liapid  Heart  (Tachycardia)  . 
Slow  Heart  (Hradycardia)    . 

Ansiina  Pectoris 

G.  ('onj;enital  AlTections  of  the  Heart 

III.  Disea^'s  of  the  .Vrleries 

1.   l)e,Lr('nl'ration^• 

:,'.  Arterio-sclerosis  (.\rlerio-caiiillary  Filu■osi^ 

3.  Aneurism 

Aneurism  of  the  Thoracic  Aorta 

AiuM.i'isni  of  the  Aliilominal  Aorta      . 

Aneurism  of  the  Brunches  of  the  Abdominal  Aorta 


M. 


()«8 
(JSS 
(IDT 
OiiS 

{;!i8 

ti!l8 
70.1 
707 
707 
70!) 
715 
717 

72r, 

728 

7:15 
741 
740 

:■,;] 

754 

754 
755 
T55 
750 
758 
75!) 
701 
705 
770 
770 
770 
770 
Ti  I 
780 
787 


roXTFNTS. 


xiu 


I'AdK 

(Km 
(i(l-) 
(i(i() 
071 
(J7:i 

(ITS 

'■,so 
tj'^l 


(iss 
(iss 

(IDT 
«!I8 
{ii)8 

(;!i8 

TO.-, 
T(IT 
TOT 
TOO 

Tir, 

TIT 
T-,M 
T2.-, 
T27 
T28 
T:15 
T:)5 
T41 
T-JG 
75:5 
7.-);5 
754 
754 
755 
755 
75« 
758 
75!) 
701 
705 
770 
,  770 
,  770 
,  770 
7 1 1 
.  780 
.  787 


II, 

ill. 

IV. 

V. 

V[. 

VII. 

VIII. 

IX. 

X. 


XI. 


Aricrio-vonons  Aiioiin'stii 
<'imi,'-ciiiiiil  Aneurism    . 


SI'XTION    VIII. 
DISKASK.S   OK   Till-:    I!I,(M>|)   ANI)  KTCTLIXs   (iL.WD.'^. 

An.rinia 

Sci'diidiiry  Aii.'i'iiii.i   . 
I'riiiiiiry  or  Kssciiiiiil  Anii'iiiia 

lyl'lliwl'llliil  .  .  .  ,  , 

llll(lL:l<i|l'.S  nist'iisc 

I'lii'jiuni, 

Il.i'iiKijiJiiliii 

Si'iii'vy  ...... 

Sliiliis  Lyin|]|ialieiis 
IMsrjiscs  (if  tlic  Siiiirarciial  liodii's 
Oiscast'.s  of  tho  SjilL't'ii  . 
Discasfs  of  tlic  Thyroid  Olaiid 

(ioiire 

'I'lmiors  of  the 'riiyroid      . 

K\o[)liilialiiiic.'  (ioitrc 

My.Kd'dciiia 

Disi'asfs  of  the  Tlivimis  Cilaiul     . 


IMOK 

Tss 

7NH 


SECTION 


DISEASES  (IF 

I.  M.dfortnal  ions      .... 
11,  MovaMc  Kidnoy   . 
III.  Circulatory  Dislurljai,.    -      . 
I\'.  Anomalies  of  (he  I'riiiary  Secretion 

1.  Anuria  .... 

2.  Ila'Uiaturia  .... 

3.  IIa'moj;loljinuria 
Allmminuria 

Pyuria  (I'us  in  the  I'rine)  . 
Cliyluria  (Xon-parasitic)  . 
Eilliuria       .... 

8.  Oxaluria      .        .        .        ". 

9.  Cystinuria   .... 
10    I'liospliaturia 

11.  Indieanuria 

1'i.   Melanuria    .... 

l;i.  I'lieumatnria 

14.  ether  SuUstances 

V.  rni'inia 

VI.  Acute  Bright's  Disease 
VII.  Chronic  Hrighfs  Disease 

Ciironic  Parenchymatous  Ne|iliritis 
Chronic  Interstitial  Xephritis  . 
VIII.  Amyloid  Disease  . 
IX.  Pyelitis  ....". 

X.  Hydronephrosis    .... 


IX. 
IvIDXEV.S. 


780 
780 
702 
803 
SO!) 
SI4 
SIO 
821 
82(> 
8','8 
8;i3 
8;J5 
8;!5 

8;i« 
8;;(i 

840 

84;j 


840 

840 

840 

850 

8.50 

851 

85-3 

854 

858 

850 

850 

S(il 

NOl 

802 

803 

80:{ 

804 

804 

805 

800 

874 

8T5 

877 

884 

8N0 

880 


[;•■ 


XIV 


roXTI'A'TS. 


XI.  NVplirnlillii!i-i<  (IJiMiiil  ('iilcnliis 
\!!.  'riunnrs  nl'  (lie  KuUu'V 
XIII.  Cystic  Disease  i;!'  tlie  Ki'iiev 
Xl\'.  lVi'iiiepliri(t  Alisc'ss      . 


SKCTIOX   X. 

Dl-^KASr.S   OKTIIK   NKIiVnrs   SY'^TF.M. 

1.  (ieneriil  iiilroiluel  imi 

li.  System  Discuses 

1.  liitrodiictiDii 

•i.  Diseii-'     'if  the  AlVeiTiil  nr  Seiisoi-y  Syst.Mii 

Ldeoiiiotdi'  Ataxia 

:',.  Diseases  of  the  KITerciit  111' Mi'lor 'I' raet      . 

or  the  Wiii.lc  Ti-aet 

Pr(ii,'ressive  (Ceiilral)  Museulav  Al'Mphy      . 
I'.iilliai'  rai'alysis 

Progressive  Neural  Miisciiiar  Atropliy 

The  Muscular  Dyslrtipliies   .... 
System  Diseases  of  the  Upper  .Motor  Se-uieiit 

Spastic  I'aralvMs  of  Ailults  .        .        .         ■ 

Si)aslic  T'aralysis  of  Infaiils. 

llenMlitiivy  Spastic  l'ai-aplc,i,'ia      . 

Erl/.s  Syphilitic  Sjiiiial  Paralysis  . 

Secondary  Spastic  Paralysis. 

Hysterical  Sjiastic  Parajileiiia 
System  Diseases  of  the  Lower  Motnr  Se'.'innil 

'chronic  Anterior  Polio-myclilis   . 

()()hthalmoplesia 

Acute  Anterior  Polio-myclilis      . 
Acute  and  Sulsieute  Polio-inyclitis  in  Adults 
Acute  Ascendiuir  (Landry's)  Paralysis 
Asthenic  (P.ulliar)  Paralysis. 

4.  Combined  System  Diseases 

Ataxic  Paraplegia 

i'rimary  Combined  Sclerosis  (Putnam)    . 

Ileredilarv  Ataxia  (Friedreich's  Ataxia) 


;v 


I'rogressivo  Interstiti.-d  Hypertrophic  N< 

Toxic  Combined  Sclerosi.; 
111.   DilTuse  Diseases  ot  the  Nervous  System 
1.  AtTect ions  of  the  Meninges  . 

Discasi's  of  the  Dura  .Mater  (Pachynicnii 

lla'Miorrhagi<-  Pachynu'ningitis 

Diseases  of  lla'  Pia  Mater 

I'osterior  Meningitis  of  InlauH 
',>.  Scleroses  of  the  IJrain  .         .         .         • 

Insular  Sclerosis        .        .        .        • 
:i.  Ciironic  DitTuse  Meningo-encephalilis 
IV.  DilTuse  and  Fncal  Diseases  of  the  Spinal  Cord 

1.  To[>ical  Diagnosis         ,        .        .        • 

2.  Affections  of  the  niood-vess'ls     . 

Congest  ior.         .        .         ■        •         • 

.Vna'Uiia 

Kmbolism  and  'I'hrombosis 


ilisof  Infi 


■itis) 


e\iiK 
S'.ll 
Hi  Mi 
s!)S 
!)i)l) 


'.'ill 
!)!'.» 
'.Il!» 
!)•,'() 

'J','S 

i)'.'S 

!):iJ 
!);!:! 
«,);!:! 
!i:ic. 
!i;!7 
!):!S 
!)1() 
'J40 

on 

i»41 
941 
'.Ml 
!)1'2 
!)t2 
<J-4(> 
!)4t» 
947 
947 
,  948 
.  949 
.  949 
.  'Jol 
.  9.-)  I 
.  !)r)l 
.  951 
.  9.-)l 
.  OoS 
.  il."»4 
.  !)o7 
.  9:)  7 
.  959 
.  9(i0 
.  9t)4 
.  9(')4 
.  9()(> 
.  960 
.  900 
.  9t)0 


CONTENTS. 


XV 


".'ill 


Endartpritis 

ll;i'iii(irrlm:;t'  into  llin  Spinal  Monibi.iiio* 

IIa'iniiri'lm,L;(>  into  the  S|iin:il  Conl 

' 'aisson  l)is('a.-:i> 

S.  f'iini[ircssif)n  of  till' S|iiniil  (.'(inl 

Li'sions  of  the  Cauda  Ecpiina  and  Conns  Mi-dnll 

4.  Tumors  of  the  Spinal  I'onI  and  its  Mcinliratips . 

T).  Svrintroniyciin 

•1.  .Vcnic  Myelitis 

V.  DilTuse  and  Focal  Diseases  of  the  Hraiii   . 

1.  'I'opical  Diaifnosis 

2.  Aphasia       ! 

;i.  .Ml'eetionsof  the  Blood-vexels  . 

llypelienia 

Ana'inia 

(Edenni  of  the  lirain 

('el'el)i'al  Ila'inorrhajie 

Eniholisni  and  Tlironihosis    .... 
Aneurism  of  the  Cercliral  Ai'teries 

Endarteritis 

'i'hromliosis  of  the  C'rebral  Sinn-^es  and  Veins 
Ileniii)lef,'ia  in  Children 

4.  Tumors,  Infectious  Grannloiiiata,  and  Cysts  of  the 

5.  Indanimalion  of  the  1!:-ain         .... 

Acute  Eneepluiliiis 

Aliscess  of  the  lirain 

C.  Hydrocephalus 

VI.  Diseases  of  the  l'eri|ilieral  Nerves     .... 

1.  Neuritis  (Inllaniniation  of  the  Bundles  of  Nerve  V 

2.  Neuromata 

3.  I>iseasp?  of  the  Cerebral  Nerves 

Olfactory  Nerves  and  'J'racts  .... 
Optie  Nerve  and  Tract 

Ijesions  of  tlu>  Retina 

Lesions  of  the  Optic  Nei-vi' 

Alfeciions  of  the  Chiastna  and  Tract . 

A IVuct ions  of  the 'I'rael  and  Centres  . 
IMotor  Nerves  of  the  Evehall  . 
Fifth  Nerve     .."....' 
I'acial  Ne've    ...... 

Auditory  Nerve 

'J"ho  Cochlear  Nerve 

The  Vestibular  Nerve 

Olossn-pharyntfeal  Nerve 

]'neuinoi:astric  .Verve 

Spinal  Accessory 

Ilypojjlossal  Nerve 

4.  Diseases  of  the  Spinal  Nerves    .... 

Cervical  Plexus       .... 
!5rachial  Plexus       ...."."." 
Lumbar  and  Sacral  Plexuses. 

Sciati<'a 

VIL  Genera!  and  Functional  Diseases       .... 
I.  Acute  Delirium  {Bell".-  .Alaniu) 
i: 


ran 


br 


es). 


rAiiE 
!»(t7 
!»(IT 
!)t!8 
!Mi!) 
!»T(I 

!»:;{ 
!»:.■) 
!i7<; 
'.<:'.) 

!t7it 
!)HS 
!l!l-t 
!)'.lt 

uur, 

!MIT 
'J!  IT 

KMIS 

11)11 

llllo 
11)17 

1024 
1024 
1025 
I02S 
lO.'Jl 

lOo'l 

10;i7 

i();w 
lo:is 
10:i!» 
10:i!) 
1040 
1041 
1043 
1040 
1050 
1051 
10,56 
105(> 
1058 
105!) 
tOtiO 
lOfili 
lOOtJ 
1007 
10()7 
lOfiO 
1072 
1073 
1075 
1075 


i«H* 


XVI 


vni 


CONTKNTS. 


2.  Panilysis  Agitnii's 

(Mlicr  Kiinns  of  Tremor        .         .        .        • 

3.  Acute  ('lior.ii(Sy<lciilmM>"sCli(in'a:  St.  Vitus 

4.  other  AlTpctioiisili'scribcd  as  (  lunca 

Ti.   Iiiratitilt' Conviilsioiis  (Kfliiiiii'-ia)    . 

(i.   I'liiilfpsy 


(Iccuiialiiili  Ncm  isc: 


7.  Mi>,'raiiu'  . 
H.  N('iiral;.'ia  . 
•I,   l'r(il'(v->ioiial  Spasms 

10.  'rttaiiy 

11.  Hysteria 

\'i.  Ncurastlit'iiia 

i:i.  Tlu-'rraiiiiiaiii'  Ni'Hiosi's. 

11.  OlhiT  Forms  of  Fuiutioiial  Paralysis      . 
t'crioilifal  Paralysis       .         .         •         • 

.\stasia:  Abasia 

Vaso-motor  and  Tropliic  Disor.lfi's   . 

1.  Uayiuimrs  Disease 

2.  Krylliromelal,L;ia 

I!.  AiiKio-neurolie  (Ivliiiia    .        •        •        ■ 

4.  Facial  Uemialropiiy         •        ■        ■        • 

5.  Aerome;;aly       ..•••• 

Osteitis  DetoriJians         .         .         ■         • 
llypL-rtrophie  I'liliiioiiary  ArthropaUiy 

Leoliliasis  Ossea 

Microiiu'Kaly 

6.  Scleroderma 

Aiuliuiii 


SECTION   XI. 

DISEASES   OF  THE   .MUSCLES 


T.  ]\Iy(jsiiis 

H.  Myotonia  (Tlioiiiseii's  Disca^e) 
III.  Parumyoeluiius  Mulliiilox     . 


:i 


CllAIiTS   ..M)    ILLISTKATIONS. 


1148 
114!) 


I.  Tyiilidiil  l-'i'Vi'i- Willi  I!cIm|.m' 1,-, 

II.  llliiNiriiiiMu' till'  !>Iimm1  ('liiuij:i-i  ill 'rv|i|iiiii||'"cvrr o{) 

III.  Tyiiliiiid  {■'(■viT — Ilii'iiiiiri'liiii;!' I'riiiii  the  li<i\vi'ls* o.j 

IV.  Illiisiraliiii;  liilluiMuiMif  M.iilis  ill 'rv|ili(ii(l  Kcvii- 45 

y.   I!i'lu|isiii^'  l'"rvcr  (lifter  Miircliismi) t-^- 

\[.   Slll;ll|-|Mix  (lifter  Strillll|icll) i;i) 

\'\\.  Sciii'let  Fever  (iif'.er  Sti'iini|ii'll) ^^sj 

VIII.  .Meiisli's  (lifter  Sii-iiiii|iell) s,^ 

l\.  Telii|iel'iitun'.  I'lilse.  mill  Kespil'iiliiiii  CliiiM   ill  I'll,. mil,, ni.i    ....        IKJ 
X.  Slmwin;,'  (.'(liiieiijeiit    l»riip  in   tlie   Fever  mid   in  tie'   l.iiUMieytes  in  I'lu'ii- 

iimiiiii    .•••.........  i'>| 

XI.  .Miiliiriii — Terliaii  .\i,nie .jlO   .j|j 

XII.  Ciii'imie 'riilii'i'culiisis. 'r\v(i-li,iiiily  Cliart  f,ii- 'i'liM'e  Diivs      ....       ;!(),j 
Xlli.   C'ilS'  (,r  Siiii-stiMl(e  treated   with   lee-lialli.      Iiee,,\ery.     (Iti^elal  'rein|i,Ta- 

turesi jjjiy 

XI\'.  She, Willi;  Trie  Acid  and  l'liii-|ilii,ii,'  Acid  Output  in  a  Case  i<(  Ariite  Cent  .       41'3 
XV,   Illiistratini,'  Iiilliienee  of  Diet  mi  Siiirar  iiimI  AiiK.iint  (,f  I'rine  in  hialietes.      4:i() 
X\'l.   Diaufaiiis  alliT  Martins,  sliowini:  selieinatii'iillv  tlie   I'dwer  of  tiie  Heiirl 

Musele ■ 

W'll.   r.Kmil  Cliarl,  iiliislratiiiL,' Anieiniii    .1  l'iir|iura  ll,eiiiiirrlia,i;iia 

XN'III.   IJIimmI  Cliart.  illiisiratini;  Clikirosis 

Xl.\.   lilcMiil  Cliiirt,  illiistratiiii;  I'eriiieidiis  Anieinia 

XX.  liiiiiiil  ( 'liart.  illiistriit  inir  lA'iika'niiii 

XXI.   Iil(i,id  ('hurt,  illiistratin.u'  Rapid  I'mdnetinn  nf  Anieiiiia  in  I'nrpiira  liaMU 
iirrhaiiieii 


:o,s 
v.n 

T!)S 
so  7 


Kl' 


Fi(a-,u- 

1.  I'iasniin  (if  Miitiir  Tilth  (Van  (iehiieliten)       .... 

2.  Hianram  of  ^lutur  Path  fnun  li'i^lit.   IJraiii  (Van  (ie)iuehten) 
.'i.  I)iaj;riiin  of  Cerelu'iil  I.neiilizatidii 

4.  I)iiii,'rain  of  Jlotor  and  Sensory  Represent  at  ion  in  the  Internal  ( 

5.  Dia^'rani  of  Motor  and  Sensory  Paths  in  ("riirii 

6.  Diatrniin  of  C'ross-seelion  of  Spiiiiil  Cord        .... 

7.  H,  Head's  Diagniiiis  of  Skin   Areas  corresponding  to  the   Dilfere 

Segments 

0.  Diagram  of  Visual  Paths  (Vialet) 

10.  Liehtheim's  Sehemii 

11.  Diagram  of  .Motor  Path  from  liight  lirain     , 


ipsiile 


904 
!)()7 
!)(W 
ilO!) 
.  iJO!) 
lit    S[iiiial 

.       (MO.  Oil 

.    104:f 

!IS!) 


*  The  red  shows  the  two-hourly,  the  blaek  the  morning  and  evening  toinjioraturo. 

xvii 


rink 


••  Iv-.poriflicL"  i-^  fiilhici'iiis  iiiul  juiVu'inriit  ilillicull." 
llil'iMK  i.ATi>:  Aiili'irisiii.'^,  I. 

'•And  1  >w\  '.f  inrdiciiif,  thai  lliis  is  mii  iirl  wlii.-li 
,.,,nsi.li-rs  tho  (MMisiiiuliou  or  ih,'  patinil.  iiml  luis 
Vriiiciiilfs  (if  iiclinii  mill  i-('u>niis  ill  .■m.-1i  cum'."' 

I'i.atd:  (iiinjKi-'^. 


A   l^E.Vr-BOOK   ON 
THE   ITvACTICE   OF  MEDICINE. 


SECTION    I. 

specifk;  infectious  diseases. 


I.    TYPHOID    FEVER. 

Definition. — A  f,'ciici'iv!  iniVction  ciUustMl  l)y  tlic  Lacillus  typliosus, 
(■liiinictoiizi'd  iiiiiitoinicully  by  Ivy'KTpliifiiii  and  ulccnitioii  of  the  lynipli- 
folliclcs  of  the  iritivstiiu's,  swi'lliii^^  uT  tlu;  nu'scntoric  jrliiiKLs  and  yplcoii, 
and  paroncliymatous  cliangos  in  tho  other  origans.  Wliih'  tliose  lesions  are 
almost  constant,  there  are  cases  in  which  the  local  s^hanges  are  slight  or 
absent,  and  there  are  otliers  with  intense  localizatuirf  of  tlio  poison  in  the 
Inngs,  spleen,  kidneys,  or  cerebro-spinal  system.  C'liniv;i]|y  the  disease  is 
marked  by  fever,  a  rose-colored  eruption,  diarrhwa,  abdominu)  tenderness, 
tympani*^es,  and  '.'nlargement  of  the  spleen ;  but  these  symptonts  are  ex- 
tremely inconstant,  and  even  the  fever  varies  in  its  character. 

Historical  Note.— The  dates  1813  and  1850  include  the  modern  dis- 
cussion of  the  subject.  Prior  to  the  former  year  many  observers  had  noted 
clinical  dift'ercnces  in  tlie  continued  fevers,  lluxham  in  particular,  in 
his  remarkable  Essay  on  Fevers,  had  "taken  notice  of  the  very  great  dif- 
ference there  is  between  the  pufritl  malignan!  aiul  the  xhno  nervous  fenr.'" 
In  1813  Pierre  BretoTineau,  of  Tours,  distinguished  "dothienenterite  "  as 
a  separate  disease  ;  and  Petit  and  Serres  described  entero-mesenteric  fever. 
Trousseau  and  Velpeau,  students  of  Bretonneau,  wei-e,  in  lSt>(),  instru- 
mental in  making  his  views  known  to  Andral  and  otliers  in  Paris.  In  l8:i!» 
Louis' great  work  ajjpeared,  in  which  the  name  "typhoid"  was  given  to 
the  icver.  At  this  period  typhoid  fever  alone  prevailed  in  Paris,  and  it 
was  universally  believed  to  be  identical  M-ith  the  continued  fever  of  (Jreat 
Britain,  where  in  reality  typlioid  and  typhus  coexisted ;  and  the  in  "stiiial 
lesion  was  regarded  as  an  accidental  occurrence  in  tlie  course  of  ordinary 
typhus.  Louis'  students  returning  to  their  homes  in  dilTerent  countries 
had  opportunities  for  studying  the  prevalent  fevers  in  the  thorough  and 
systematic  manner  of  their  master.  Among  these  were  certain  young 
American  physicians,  to  one  of  whom,  Gerhard,  of  Pliiladeli)hia,  is  due  tiie 
great  honor  of  having  first  clearly  laid  down  tlie  dilfi'rences  between  tlic 
two  diseases.  His  papers  in  the  American  Journal  of  the  Medical  !Sci- 
1  1 


m^ 


2  SPKCIKIC   IN'FI'XTIOI'S   UISKASES. 

oiioos,  ISP,:,  iir(>  undonl.tr.lly  tli.'  first  in  niiy  Innjrunfro  wliicli  jiivc  a  full 
aixl  siitisfiK'ti.ry  u.'coimt  ..f  tin'  .•liiiicai  iiii.l  aiK.t..mi.'al  distmctions  wv  ix.w 
ivco^xnizt'.  No  stutli'iit  sli.mld  fiiil  to  ivud  these  urtides.  iimonj,'  tho  most 
chiHsiciil  in  Anicricaii  rncdicnl  literatuie. 

I.(.iiis'  iiitluoncc  wiis  early  felt  in  Hoston,  whither,  in  is:',:?,  .lames  .lack- 
son,  Jr.,  had  returned  fn.m'  Paris.  In  this  year  he  demonstrated,  in  his 
father's  wards  at  the  Massachusetts  (leneral  IFospital,  the  identity  of  the 
typhus  of  this  count rv  with  the  typhoid  of  Louis,  lie  had  already,  in 
is:i(),  noti.'ed  the  intestinal  lesions  in  the  c.,nimon  fever  of  New  Kn^land. 
Tliouj^'li  cut  olT  at  the  very  outset  of  his  career,  wo  nniy  reasonahly  attrihute 
tohis'^inspiration  the  two  elaborate  memoirs  on  typhoid  fever  wliich,  in 
ls:Wanil  is;i!l,  were  issued  fr.mi  the  Ma.ssachu^etts  (leneral  Hospital,  hy 
James  .lackson,  Sr.,  and  Enoch  Hale.  Tliese,  with  (ierhard's  articles,  con- 
tributed to  make  typhoid  fever,  as  distinf,niished  from  typhus,  widely  known 
in  the  profession  here  hm.ii  before  the  di  tinctions  were  recoj,MUzed  gener- 
ally in  Knrope.  Thus,  they  were  described  with  admirable  clearness  under 
different  headings  in  the  HrsL  edition  of  Hartlett's  work  on   Fevers,  pub- 

lishe<l  in  1S4-^. 

The  recognition  in  Paris  of  a  fev.>r  distin('t  Irom  typhoul,  without  intes- 
tinal lesions,''was  due  largely  to  tlu'  inilu-n<-e  of  the  able  papers  of  (Jeorge 
C  Shattuck,of  Boston,  and  Alfred  Stille,of  Phihuh'lphia,  which  were  nad 
l)efore  the  Societc  medicale  (PObservation  in  ls:)S.  At  Louis'  re.iuest. 
Shattuck  went  to  the  Lomlon  Fever  Hospital  to  study  the  disease  m  Kng- 
land,  where  he  saw  the  two  distinct  atTcctions,  and  brought  back  a  report 
which  was  very  convincing  to  the  m.'inbers  of  the  society  (Medical  Kx- 
aminer,  Philadelphia,  1S4()). 

Stille  had  the  a<l vantage  of  going  to  Paris  knowing  thorouglily  the 
clinical  features  of  typhus  fever,  for  he  had  been  (lerhanl's  house-i)hysician 
at  the  Philadelphia  Hospital  during  the  epidemic  of  is:5(;.  At  La  I'lti.', 
with  Louis,  he  saw  quite  a  ditrcrent  affection,  while  in  London,  l)iil)lin, 
and  Naples  he  recognized  tvphus  as  he  had  seen  it  in  Philadelphia.  The 
results  of  his  observations  were  given  in  an  exhaustive  paper  which  pre- 
sented in  ta1)uhir  form  the  contrasts  an.l  distinctions,  .■linieal  and  anatom- 
ical, which  we  now  recognize. 

In  (ireat  Hritain  the  noii-identitv  of  typhus  and  typhoid  was  eU>arly 
established  at  (ilasgow,  where  from  \s:W  to  1S:J8  A.  P.  Stewart  studied  the 
continued  fevers,  and  in  1840  published  the  results  of  his  observations.  In 
the  decade  which  followed,  many  important  works  were  issued  and  more 
correct  views  gradually  prevaile.l ;  but  it  was  not  until  tlie  publnuition  ot 
Jenner's  observations  between  1840  aTid  1851  that  tho  question  was  fiiuuly 

settled  in  England. 

Etiology.— Tvphoid  fever  prevails  especially  in  temperate  climates, 
in  which  it  constitutes  the  most  commcm  continued  fever.  Widely  dis- 
tributed throughout  all  parts  of  the  world,  it  probably  presents  everywhere 
the  same  essential  characteristics,  and  is  everywhere  an  index  of  the  sani- 
tary intelligeiK'e  of  a  communitv.  Defective  drainage  and  contaminated 
water  supply  are  the  two  special  conditions  favoring  the  distribution  and 


TYIMIOID   KHVKll. 


3 


ell  fjivc  a  full 
ictioiis  \v<'  now 
;U)tl^  the  most 

',],  .lamt's  .lack- 
istratftl,  in  liis 
identity  of  tlif 
111(1  already,  in 
New  Kn<:'.and. 
inably  attrilmte 
fever  wliieh,  in 
al  Hospital,  l)y 
I's  artiek's,  con- 
^,  widi'ly  known 
eof^nized  geiiiT- 
elearness  under 
)ii    Fevers,  pul)- 

1,  without  intes- 
apcrs  of  (ieorge 
vliieh  were  read 

Louis'  recpiest. 

disease  in  Kng- 
it  back  a  report- 
ty  (Medical  Kx- 

tliorouglily  the 
lionse-physieian 
;.  At  La  Pitie, 
London,  Dnhlin, 
ladelphia.  The 
ia))er  which  pre- 
ical  and  anatom- 

hoid  was  clearly 
wart  studied  the 
)bsorvations.  In 
issued  and  more 
10  publication  of 
>stion  was  finally 

iporato  climates, 
vcr.  Widely  dis- 
sents everywhere 
ndex  of  the  sani- 
nd  contaminated 
distribution  and 


^'rowth  of  the  bacilli;  (iltli,  oven-rowdin;.     .nd  bad  ventilation  are  acces- 
sories in  lowering'  the  resistani'c  of  the  individuals  exposed. 

While  improved  sanitation  has  done  much  to  reduce  the  mortalitv  from 
typiioid  fever,  particularly  in  the  lar;,'e  cit's,  a  reduction  amounting  to 
l.").l  percent  in  vM  out  of  '>'4  iMigiisii  towns  ( Drcschfeld)  (ligurcs  illustrat- 
ing which  will  he  referred  to  umler  I'rophylaxis),  the  disease  is  still  far  too 
[trevalent,  and  in  suburban  and  rural  districts  in  this  country  there  is 
evidence  to  show  that  it  is  on  the  increase.  In  iS'.tl)  the  death-rate  from 
typhoid  fever  per  1()(),()()(»  of  population  was,  in  the  riiiled  States,  I'l.yT  ; 
in  Kngland  and  Wales,  IT.!);  in  Italy,  (i.'i.S ;  in  .\ustria,  fl.O ;  and  in  I'rus- 
sia,  ^'0.4. 

Si'i/sim. — I*^  prevails  most  in  the  auiumn  months.  Of  l,ss!i  eases  ad- 
mitted to  the  Montreal  (Jeneral  Hospital  in  twenty  ycais,  more  than  fifty 
per  cent  were  in  the  months  of  August,  September,  and  Ociolicr.  Of  1,;!n1 
cases  treated  during  twelve  years  at  the  'J'oroiito  (Jcncral  Ilosjiital,  T<il 
occurred  in  these  months  ((iraliam).  It  lias  been  well  called  the  autumnal 
fever.  It  has  been  obsei'Ved  to  be  esjiccially  prevalent  in  hot  and  dry 
seasons.  According  to  I'ettenkofer,  epidemics  are  most  common  when  the 
ground-water  is  low,  under  which  circumstMnccs  the  spi'iugs  a.id  water- 
sources  drain  more  thoroughly  contaminated  foci  and  air  more  likely  to  lie 
highly  charged  with  jioison.  It  may  be  also,  as  iJaumgarten  suggests,  that 
in  dry  seasons  the  poison  is  more  disseminated  in  the  dust. 

N'.c. — Males  anil  females  are  about  c(|ually  liable  to  the  (liscas<',  but 
males  Avitli  tyjihoid  are  nuich  more  freciiiciitly  admitted  luio  hospitals. 

.1///'.— Typhoid  fever  is  a  disease  of  youth  and  early  adult  life.  'J'lu^ 
greatest  susceptibility  is  between  the  ages  of  fifteen  and  twenty-live.  Of 
(iSf)  cases  treated  to  January  1,  1M!)S,  in  my  wards  at  the  .Johns  Hopkins 
Hosjiital  there  were  under  iifteen  yeai's  of  age,  Ta ;  between  liflecn  and 
twenty,  1:58;  between  twenty  and  thirty,  I!!?;  between  thirty  and  forty, 
98;  between  forty  and  fifty,  ;5:i;  belM-ccn  iifty  and  sixty,  (1;  atiove  sixty, 
0;  age  doubtful  in  ]'■>*.  Cases  are  rare  over  sixty,  although  Manges  be- 
lieves that  they  are  more  common  than  the  records  show.  As  tlie  cour.se 
is  often  atypical  tl-.e  diagnosis  may  be  uncertain.  In  two  of  my  cases  the 
disease  was  not  recognized  until  iJie  autopsy.  It  is  not  very  infrer|uent  in 
childhood,  but  infants  are  rarely  attacked.  Murchison  saw  a  cast'  at  the 
sixth  month.  The  disease  may  be  congenital  in  cases  in  which  the  mother 
has  contracted  it  late  in  pregnancy. 

Ltimiini/i/.—As  in  other  fever.s,  not  all  exposed  to  tlie  infection  take 
the  disease,  and  there  are  grades  of  su^cei)tibility.  Some  families  seem 
more  disposed  to  infection  than  others.  One  attack  usually  protects.  "  Of 
2,000  cases  of  enteric  fever  at  the  Hamburg  Ceneral  Hospital,  only  14  per- 
sons were  affected  twice  and  only  1  person  three  times"  (Ureschteld). 

The  Bacillus  typhosus.— The  researches  of  Ebeitli,  Koch,  (uitfky,  ami 
others  have  shoAvn  that  there  is  a  special  micro-organism  coHstauthi  asso- 


m 


♦Vols.  iv.  V.  and  vii  of  the  Jolins  Hopkins  Ilospitiil  Reports  contain  the  Studies 
on  Typhoid  Fever  referred  to  in  this  urlicle  us  .Studies  I,  II,  uiid  111, 


rin* 


4  SPECIFIC  INFECTIOUS  DISEASES. 

ciixtod  witli  typhoid  fevor.     {a)  (IrnrruJ  CJiarart,rs.—U  is  a  rather  short, 
thick,  fl.!g('Hiiti'(l,  motile  hacillus,  with  rounded  ends,  in  one  of  which, 
sometimes  in  botli  (particuhirly  in  cultures),  there  can  be  seen  a  glistening 
round  body,  at  one  time  belicyed  to  Tie  a  spore ;  but  these  polar  structures 
are  probab'ly  only  areas  of  degenerat(>d  protoplasm.     It  grows  readily  on 
various  nutritive  media,  and  can  now  be  ditferentiatetl  from  the  harkrium 
roll  ivm.innw,  ,vitli  which,  and  with  certain  other  bacilli,  it  is  apt  to  be 
confounded.     This  organism  fulfils  two  of  the  reciuirements  of  Ko'  ii's  law 
—it  is  constantly  present,  and  it  grows  outside  the  body  in  a  specific  man- 
ner.    The  third" requirement,  the  production  of  the  disease  experimentally 
1)V  the  cultures,  has  not  yet  been  met.     Probably  the  animals  used  for  ex- 
perimentat  on  are  not  susceptible  to  typhoid  fever.     The  bacilli  or  their 
toxins  inoculated  in  large  quantities  into  the  blood  of  rabbits  are  patho- 
genic, and  in  some  instances  ulcerative  and  necrotic  lesions  in  the  intes- 
tine may  be  produced.     But  similar  intestinal  lesions  may  be  caused  by 
other  bacteria,  including  the  hackrium  roll  commune. 

Cultures  are  killed  withiii  ten  minutes  when  exposed  to  a  temperature 
of  00°  C,  wiiile  they  resist  for  days  temperatures  as  low  as  —  10°  C,  oven 
when  frozen  and  thawed  successively.  Althougli  the  typhoid  bacillus  does 
not  produce  spores,  it  resis.^s  ordinary  drying  for  months.  The  direct  rays 
of  the  sun  (piickly  injure  the  bacilli  in  cultures,  and  completely  destroy 
them  in  from  four  to  ten  hours'  exposure.  Honillon  cultures  are  destroyed 
by  carbolic  acid,  1  to  200,  ami  by  corrosive  sublimate,  1  to  2,r!00. 

{f>)  Distrihulioii  in  fhe  riody.—hx  recent  typhoid  infections  the  bacilli 
are  found  in  the  lymphoid  tissues  of  tlie  intestines,  in  the  inesentenc 
glands,  in  the  spleen,  in  the  bone  marrow,  in  the  liver,  and  in  the  bile. 
They  occur  also  in  irregular  clumps  in  the  contents  of  the  intestines  and 
in  the  stools ;  and  since  the  introduction  of  improved  methods  of  cultiva- 
tion (Eisner,  Capaldi)  they  have  been  demonstrated  in  the  latter  in  about 
50  per  cent  of  the  eases  examined.  They  may,  however,  be  incapable  of 
demonstration  even  in  fatal  cases.  The  bacilli  have  been  found  m  the 
blood  and  in  the  rose-colored  spots.  In  the  urine  they  may  be  present  m 
numbers,  where  th"v  -.ay  persist  for  months  after  recovery  (Mark  Richard- 
son), and  they  have^been  found  in  the  sweat  and  sputa.  From  the  endo- 
cardial vegetations,  from  meningeal  and  pleural  exudates,  and  from  foci  of 
suppuration  in  various  parts,  the  bacilli  have  also  been  isolated. 

(r)  The  Jianlli  Ovtsitle  the  //o<7//.— Outside  the  body,  in  water,  ine 
bacilli  retain  their  vitality  for  weeks ;  but  whether  an  increase  can  occur 
is  not  yet  finally  settled.  Bolton  denies  it,  but  the  general  opin  n  seems 
to  be  that  it  may  take  place  to  some  extent  at  first.  They  disappear  from 
ordinary  water  in  competition  with  saprophytes  in  a  few  days.  In  milk 
they  undergo  rapid  development  without  changing  Hs  appearance.  They 
may  increase  in  the  soil  and  retain  their  vitality  for  months.  They  are  not ' 
killed  by  freezing,  but,  as  Prudden  has  shown,  may  live  in  ice  for  months. 
In  many  epidemics  the  liacilli  have  been  isolated  from  the  infected  water. 
The  detection,  however,  of  the  typhoid  bacillus  in  drinking-water  is  by  no 
means  easy,  and  the  question  in  individual  cases  must  be  settled  by  experts 


TYPHOID  FEVER.  5 

wlio  have  had  special  oxporionce  with  this  genu.  Botli  I  niudon  and  Ernst 
liavo  found  it  in  wator-fdtors.  Through  tlie  use  of  Eisner's  culture-niedium 
Koiulingor  and  Sclmeider  chiitu  to  liave  obtained  tlie  I)aeillus  in  small 
numbers  from  tlio  stools  of  healthy  persons. 

The  direct  infection  by  dust  of  exposed  food-stuffs,  such  as  milk,  is 
very  probable.  The  bacilli  retain  their  vitality  for  many  weeks;  in  gar- 
den earth  twenty-one  days,  in  tilter-sand  eighty-two  days,  in  dust  of  the 
street  thirty  days,  on  linen  sixty  to  seventy  days,  on  M'ood  thirty-two  days 
(Uffelmann). 

Modes  of  Conveyance.— (^/)  r'oiifin/iou.— The  possibility  of  the  direct 
transmission  through  the  air  from  one  person  to  another  must  be  acknowl- 
edged, although,  as  shown  by  (ierniano,  when  cnmpMchj  dried  in  air-cur- 
rents, the  speciiic  bacillus  (piiekly  dies.  There  are  house  epidemics  in  whicii 
contamination  of  water  or  food  could  be  almost  positively  excluded.  The 
nurses  and  attendants  who  have  to  do  with  the  stools  and  body-linen  of 
the  patients  are  alone  liable  to  direct  infection.  During  six  years  one 
nurse,  one  orderly,  and  one  patient  contracted  the  disease  in  my  wards. 
The  contagion  may  be  spread  by  means  of  clothing  and  wash-linen— a 
mode  of  infection  whicli  is  especially  to  be  feared  in  military  garrisons, 
where  the  same  clothing  is  sometimes  used  by  different  i)ersons. 

{b)  Iiifi'cfioH  of  n-dfcr  is  untiuestionably  the  most  common  mode  of 
conveyance.  Many  epidemics  have  been  sliown  to  originate  in  the  con- 
tamination of  a  well  or  a  spring.  A  very  striking  one  occurred  at  Plym- 
outh, Pa.,  in  LSSo,  wliich  was  investigated  by  Siuikesi)eare.  The  town, 
with  a  population  of  8,000,  was  in  part  su])i)lied  with  drinking-water  from 
a  reservoir  fi'd  by  a  mountain  stream.  During  January,  February,  and 
March,  in  a  cottage  by  the  .side  of  and  at  a  distance  of  from  (iO  to  80 
feel  from  this  stream,  a  man  was  ill  with  typhoid  fever.  T]u>,  attendants 
were  in  the  habit  at  night  of  throwing  out  the  evacuations  on  the  ground 
toward  the  stream.  During  these  months  tlie  ground  was  fi-ozen  and  cov- 
ered with  snow.  In  the  latter  part  of  March  and  early  in  Ajiril  there  was 
considerable  rainfall  and  a  thaw,  in  which  a  large  part  of  the  three  months' 
accumulation  of  discharges  was  w-.shed  into  the  brook,  ijt  GO  feet  dis- 
tant. At  the  very  time  of  this  tliaw  Jie  patient  had  nunieruuo  and  copious 
discharges.  About  the  10th  of  April  cases  of  typhoitl  fever  bi'..>ke  out  in 
the  town,  appearing  for  a  time  at  the  rate  of  fifty  a  da).  In  all  about 
1,^00  people  were  attacked.  An  immense  majority  of  all  tiie  cases  were  in 
the  part  of  the  town  which  received  water  from  the  infected  reservoir. 

The  recent  experience  at  Maidstone  illustrates  the  widespread  and  seri- 
ous character  of  an  epidemic  when  the  water-supply  becomes  badly  con- 
taminated. 'I'he  outb-eak  began  idjout  the  niidiUe  of  Hcptember,  and 
within  the  first  two  weeks  509  cases  were  reported.  By  October  27th  there 
were  1,748  cases,  and  by  Xovember  17th  1,818  eases.  In  all,  in  a  popula- 
tion cf  35,000,  about  1,900  persons  were  attacked.  Xo  epidemic  of  the 
same  magnitude  has  ever  occurred  in  England,  and  it  shows  the  terrible 
danger  of  a  badly  constructed  water-supply  easily  contaminated  by  surface 
drainage. 


.  t! 


i* 


^^ 


n 


SPECIFIC  INFECTIOUS  DISEASES. 


{()  /iifrrfion  (if  Fooil.—Milk  may  be  tli(>  souivo  of  iiifoction.  One  of 
the  most  tlioroiiirlily  stiidit'd  cijidcmics  ilnc  to  tliis  cause  was  tliat  investi- 
gated by  Ballard  in  Islinj^ton.  'I'lie  milk  may  be  eontaniinated  l)y  infected 
water  used  in  cleansing  th(>  cans.  In  fresh  milk  it  has  been  shown  that 
the  germs  grow  rapidly.  I'fulil  has  repc^-ted  an  epidemic  in  ■  military 
garrison  cause(l  by  milk.  The  dairyman  was  nursing  a  son  sick  of  typhoid 
an<I  afterward  l)ecamc  himself  ill.  Only  those  who  drank  the  milk  un- 
boiled suffered.  The  milk  epidemics  have  been  collected  by  Ernest  Hart 
and  by  K()l)er,  of  Washington. 

Iji  addition,  the  germs  may  be  conveyed  in  ice,  salads  of  various  sorts, 
celery,  etc. ;  and  the  food  may  be  readily  contaminated  by  the  soiled  fin- 
gers of  the  attendants  or  of  the  ])atient  liimself.  A  ily  which  has  alighted 
on  the  soiled  linen  of  a  typhoid  patient  in  a  ward  may  subse(iuently  con- 
taminate the  milk  or  other  food. 

()i/!<t('r.<i  may  become  inf(>cted  during  the  process  of  fattening  or  fresh- 
ening. In  the  Middletowii  epidemic,  reported  by  II.  \V.  Conn,  the  chain 
of  circumstantial  evidence  seems  complete ;  Lavis  reports  an  epidemic  oc- 
curring in  N.'ii)les  caused  by  infected  oysters  ;  and  most  suggestive  sporadic 
eases  have  been  recordcMl  by  Sir  William  Rroadbent  and  others. 

C.  J.  Foote  has  made  an  interesting  l)acteri(>logical  study  of  the  suliject. 
Oysters  tak<'n  from  the  feeding-grounds  in  rivers  contain  a  very  much 
larger  number  of  micro-organisms  of  all  soi-ts  than  those  from  the  sea.  He 
has  shown,  too,  that  KixTth's  bacillus  will  live  in  the  brackish  water  in 
which  oysters  are  fattened  even  'vhen  frozen  ;  and  that  it  will  also  live  in 
th(^  oyster  itself,  and  for  a  longer  time  than  in  the  water  in  which  the 
oyster  grows.  Whether  nniltipl'cation  takes  place  iti  the  oyster  is  doubt- 
ful. Chantemesse  also  found  ty])hoid  germs  in  oysters  which  hatl  lain  in 
infected  sea-water  even  after  they  had  been  transferreil  to  and  ke2)t  in 
fresli  water  for  a  time. 

{(I)  ('ntitdiiiiuafidii  (if  f/ir  ,sV;/7.— Pettenkofer  holds  that  the  poison  is 
not  eliminated  in  a  condition  capable  of  communicating  the  disease  di- 
rectly, but  that  it  must  lirst  undergo  changes  in  the  soil,  which  changes 
are  favored  by  the  ground-water. 

Filth,  1)ad  sewers,  or  cesspools  can  not  in  themselves  cause  typhoid 
fever,  but  they  furnish  the  conditions  suitable  for  the  preservation  of  the 
bacillus,  and  possibly  for  its  propagation. 

The  history  of  typhoid  fever  in  Munich,  as  told  anew  by  Childs  (Lan- 
cet, 1898,  ii),  indicates  that  the  soil  pollution  has  much  to  do  with  the  oc- 
currence of  sporadic  cases  and  of  recurrent  outbreaks.  Robertson's  stud- 
ies show  that  the  typhoid  bacillus  is  capable  of  growing  rapidly  in  certain 
soils,  and  that  it  can  ujider  certain  conditions  sui-vive  from  one  summer 
to  another. 

Modes  of  Infection.— The  work  of  the  past  few  years  has  widened  con- 
siderably our  concH'ption  of  the  intimate  processes  of  infection  in  typhoid 
fever.  Sidney  Phillips,  J.  W,  Moore,  Jind  others  had  reported  cases  of 
typhoid  fever  without  enteric  lesions.  The  wide  existence  of  the  typhoid 
bacilli  has  been  repeatedly  shown  in  cases  which  had  the  clinical  features 


ion.  One  of 
thiit  iiivcsti- 
il  by  iufoctcd 
L  shown  that 
in  ',  militiiry 
'k  of  typhoid 
the  milk  un- 
Ernest  Hart 

various  sorts, 

:ie  soik>d  fin- 

liiis  iilifihted 

.'(juently  con- 

linji:  or  fresli- 

111,  the  f'liiiin 

e}ii(U'nue  oc- 

^tive  sporadic 

s. 

f  tlio  sulijeet. 

a  very  nuieli 

the  >sea.  lie 
cisii  water  in 
1  also  live  in 
in  wliieh  the 
*ter  is  doulit- 
li  hail  lain  in 

and  ke2)t  in 

the  poison  is 
lie  disease  di- 
ll ieli  ehanges 

'ause  typhoid 
I'vation  of  the 

Cliilds  (Lan- 
0  with  the  oo- 

ertson's  stud- 

dly  in  certain 

one  swnimer 

widened  con- 
on  in  typhoid 
)rted  cases  of 
if  the  typhoid 
inical  features 


TYriI(»lI>   FKVHR.  7 

(if  the  disease,  hut  without  lesions  in  the  small  intestine.     Tlie  question 
has  been  very  fully  considered  i>y  Cliiari  ami  Knius,*  irodenpyUt  Nii'liolls 
and   Keenan,  J  and  I>y  Flexner  (Studies  HI).     Tyiihoid  fever  is  no  more 
primarily  intestinal  than  is  sni'dli»ox  primarily  a  cutaneous  disease,     ^\'e 
may   rec'it,niize   the    foUowinij;   <,m'ou])s  :    1.    On/i/utr!/   Iiiphnid  frrcr  ii'illi 
iiKirked  ciitcrif  li'sliuis.     An  immi'nse  majority  of  all  the  cases  are  of  this 
charact'i'.      The  infec*'  -n  has  taken   place  through   the  intestines,  and 
while  the  s]»leen  and  mesenteric  ghuuls  are  involved  the  lymphatic  ajipa- 
ratus  of  the  intestinal  walls  bears  the  brunt  of  the  attack,     'i.   Tiiplmid 
svptiat'inid,  a  (p'Hcnd  i/tfrf/ioii  irilli  llie  Itarilli  icitliiiiil  spfciid  UicaJ  iiKini- 
fesfdlltjii.s.     Anatomically,  as  Chiari   points  out,  these  cases  may  not  be 
recognizahle,  and  the  diagnosis  may  ri'st  iipon  the  existence  of  tlie  Widal 
reaction  and  the  demonstration  of  the  bacilli.     They  present  the  symptoms 
of  a  severe  intoxication  wit  ii  high  fever  and  delirium.     :).   Tiiphoid  fcirr 
with  hiraUzati(iui<  (dlivr  tl.tin  e)ilcrir.     In  the  ordinary  form  it  is  common 
enough  to  tind  in  conjunction  with  the  enteric  lesions  special  localizations 
in  diirerent  parts  of  the  body;  but  we  have  of  late  learned  to  recognize 
that  these  particular  localizations  may  exist  either  with  very  slight  or  with- 
out any  intestinal  lesions.     The  organs  attacked   may  be  the  lungs,  the 
spleen,  tiie  kidneys,  or  the  ceivbro-spinal   meninges.     Clinically  wc  have 
long  recognized  this  variabh"  character  of  the  infection,  ami  liave  spoken 
of  cases  of  pneiimo-typhoid,  neiihro-typhoid,  cerebro-spiiial   ty])hoi(l,  and 
spleno-typhoid.     The  case   recently  rcjiorted   by  Flexner  ilbistrates   very 
well  the  importance  of  recognizing  these  forms.     A  man  aged  sixty  was 
admitted  to  my  ward,  October  'v'S,  with  shortness  -Jl  breath  and  signs  of 
pneumonia  in  the   lower  lobe  of  tlie   right  lung.     Ik   died   twenty-four 
liours  after  admission,  after  an  illness  of  about  two  months'  duration.     The 
case  was  naturally  regardi'd  as  one  of  senile  pneumonia.     The  autopsy 
showed  an  extensive  involvement  of  the  lower  lobe  in  fresh  luieunionia, 
passing  on  to  gangrene  witiiout  any  lesion  of  the  intestine.     Pure  cultures 
of  the  typhoid  bacillus  were  isolated  from  the  lung.s,  liver,  kidney's,  and 
sjileen.      \o  other  organisms  were  present.      4.  Mixed   iiifrrfiiuis.     It  is 
well  to  distinguish,  as  Dreschfeld  jtoints  out,  between  double  infections,  as 
with  tho  bacillus  tubercidosis,  the  diphtheria  bacillus,  and  the  ])lasniodia 
of  Laveran,  in  which  two  dilfcrent  diseases  are  present  and  can  be  readily 
distinguished,  ami  the  true  mixed  or  secondary  infections,  in  which  the 
conditions  induced  by  one  organism  favor  tlie  growth  of  other  pathogenic 
forms;  thus  in  the  ordinary  typhoid  fever  cases  secondary  infection  with 
the  colon  bacillus,  the  streptococcus,  staphylococcus,  or  the  pneumococcus, 
is  (|uite  common.     The  part  played  by  the  paracolon  bacillus  of  Widal  in 
typhoid  infection  is  yet  to  be  defiiu'd.     Owyn  *  isolated  from  the  blood  of  a 
typical  case  of  typhoiil  f'ver,  occurring  in  my  wards,  this  organism,  which 
agglutinated  with  tlie  patient's  serum,  while  no  action  was  exerted  upon 
the  typhoid  bacillus. 


•  Zditsflirift  f.  IIi'ilkiii)(li>.  189T 
t  IJnl.  Med.  Jour.,  Ib07,  ii. 


X  Montroiil  Mfd.  .lour.,  18!IS. 

"  Jdiiiis  Hopkins  llosjiiiul  Huiiclin,  18i)8, 


r*  ii  1, 


8  SrariFIC   INF^'^TIOUS   DISr<:ASKS. 

Protfiirfs  of  f/ir  (•'roirf/i  of  fhr  IhirllU.—  Wwgov  and  Fracnkol  luivo 
soparatod  from  ])ouilloii  cultures  a  poison  belonging  to  the  group  of  tox- 
albumins,  to  Avliich  the  name  tyjdiotoxin  lias  been  applied.  The  ehief 
poison,  aecording  to  PfeitTer,  ])rodiU'ed  by  the  typhoid  germ,  is  intimately 
bound  up  with  the  protei<l  of  the  bacterial  cell,  and  goes  over  in  small 
quantities  into  the  tluids  in  which  the  bacilli  are  cultivated.  Sterilized 
cultures,  therefore,  are  still  toxic.  Cultures  sterilized  by  heat  or  by  fdtra- 
ti<m  give  rise,  when  injected  into  susceptible  animals,  to  an  intoxication 
similar  to  that  caused  hy  the  living  germs.  Changes  in  the  lymphatic 
apparatus  of  the  intestine  are  produced  by  this  poison  as  well  as  by  that 
yielded  by  the  bacillus  coli  communis. 

Morbid  Anatomy.— The  statistical  details  under  this  heading  arc 
based  upon  eighty  auto])sies,  a  majority  of  which  were  performed  at  the 
Montreal  General  Hospital,  and  upon  the  records  of  two  thousand  post- 
mortems at  the  Munich  Pathological  Institute.* 

Intestines.— A  catarrhal  condition  exists  throughout  the  small  and 
large  bowel,  and  to  this  is  due,  m  all  probability,  the  diarrhea  with  the 
thin  pea-soup-like  stools.  Associated  with  this  catarrh  there  is  some  epi- 
thelial desquamation. 

Specific  changes  occur  in  the  lymphoid  elements  of  the  bowel,  chiefly 
at  the  lower  end  of  the  ileum.  The  alterations  which  occur  are  most  con- 
veniently described  in  four  stages : 

1.  lit/prrpla.v'd,  which  involves  the  glands  of  Peyer  in  the  jejunum  aiul 
ileum,  aiiil  to  a  variable  extent  those  in  the  large  intestine.  The  follicles 
are  swolh'U,  grayish-white  in  color,  and  the  patches  may  project  to  a  dis- 
tance of  from  three  to  five  mm.  In  exceptional  cases  they  may  bo  still 
more  prominent.  The  solitary  glands,  Avhich  range  in  size  from  a  pin's 
head  to  a  large  pea,  are  usually  deeitly  imbedded  in  the  submucosa,  but 
project  to  a  variable  extent.  Occasionally  they  are  very  prominent,  and 
may  be  almost  pedunculated.  Microscopical  examination  shows  at  the 
outset  a  condition  of  liypera?mia  of  the  follicles.  Later  there  is  a  great 
increase  and  accumulation  of  cells  of  the  lymph-tissue  Avhich  may  even 
infiltrate  the  adjacent  mucosa  and  the  muscularis  ;  and  the  blood-vessels 
are  more  or  less  compressed,  which  gives  the  whitish,  aiKvmic  appearance 
to  the  follicles.  The  cells  have  all  the  characters  of  ordiiuiry  lymph-cor- 
puscles. Some  of  them,  however,  are  larger,  epithelioid,  and  contain  several 
nuclei.  Occasionally  cells  containing  red  blood-corpuscles  are  seen.  This 
so-called  medullary  infiltration,  which  is  always  more  intense  toward  the 
lower  end  of  the  ileum,  reaches  its  height  from  the  eighth  to  the  tenth 
day  and  then  undergoes  one  of  two  changes,  rcsoJiifioii  or  iierro.v's.  Death 
very  rarely  takes  place  at  this  stage.  Resolution  is  accomplished  by  a  fatty 
and  granular  change  in  the  cells,  which  are  destroyed  and  absorbed.  A 
curious  condition  of  the  patches  is  produced  at  this  stage,  in  which  they 
have  a  reticulated  ajipearance,  the  phiqvr.<i  a  siirf(frr  niiruh'e.  The  swoll- 
en follicles  in  the  patch  undergo  resolution  and  shrink  more  rapidly  than 


*  MUnchciicr  mcdicinischc  Wochcnschritt,  Xos.  3  and  4,  1891. 


raonkol  luivo 
Troup  of  tox- 
l.  Tho  chief 
is  intimatt'ly 
3Vor  in  small 
d.  Sterilized 
it  or  by  fdtra- 
1  intoxication 
he  lymphatic 
ell  as  by  that 

:5  heading  are 
orincd  at  the 
liousand  post- 
he  small  and 
ha\a  with  tho 
e  is  some  epi- 

bowel,  chiefly 
are  most  cou- 

?  jejunum  and 
The  follicles 
roject  to  a  dis- 
f  may  bo  still 
>  from  a  pin's 
ubmucosa,  but 
»rominent,  and 
shows  at  the 
liere  is  a  great 
lich  may  even 
e  blood-vessels 
lie  appearance 
ary  lymph-cor- 
contain  several 
ire  seen.  This 
ISO  toward  the 
1  to  the  tenth 
•rrosisi.  Death 
shed  by  a  fatty 
I  absorbed.  A 
in  which  they 
'(k.  The  swoli- 
•e  rapidly  than 

.891. 


TYPnoID  FEVER. 


9 


the  nirrounding  framework,  or  what  is  more  probable  the  follicles  al()H(>, 
owing  to  the  intense  hyperplasia,  become  necrotic  and  disiiitegrutc,  leaviiij^ 
the  little  pits.  In  this  process  sujicrficial  ha'iiiorrliages  may  result,  and 
small  ulcers  may  originate  by  tlie  fusion  of  these  superficial  losses  of  sub- 
stance. 

'I'licre  is  nothing  distinctive  in  the  liyperplasia  of  the  lymph-follicles 
in  typhoid  fever;  but  apart  from  this  disease  we  rarely  see  in  adults  a 
marked  aifection  of  these  glands  with  fever.  In  children,  however,  it  is 
not  uncommon  wlien  death  has  occurred  from  intestinal  alfections,  aiul  it 
is  also  met  with  in  measles,  diphtheria,  and  scarlet  fever. 

2.  ycrrosi's  and  SlotKjhituj. — When  the  hyperi)lasia  of  the  lympli-fol- 
liclos  reaches  a  certain  grade,  resolution  is  no  longer  possible.  The  l)lood- 
vessels  become  choked,  there  is  a  coiulition  of  amvmic  necrosis,  and 
sloughs  form  which  must  be  separated  and  thrown  off.  The  necrosis  is 
probably  due  in  great  part  to  the  direct  action  of  tho  l)acilli.  The  process 
may  bo  superficial,  affecting  only  the  upper  part  of  the  mucous  coat,  or  it 
may  extend  to  and  involve  the  submucosa.  The  "  slough  "  nuiy  sometimes 
lie  upon  the  Peyer's  patch,  scarcely  involving  tho  epithelium  (Marchand). 
It  is  always  more  intense  toward  the  ileo-ca^cal  valve,  and  in  very  severe 
cases  the  greater  part  of  the  mucosa  of  the  last  foot  of  the  ileum  may  be 
converted  into  a  l)rownish-black  eschar.  The  necrotic  area  in  the  solitary 
glands  forms  a  yellowish  cap  which  often  involves  only  tho  most  promi- 
nent point  of  a  follicle.  The  extent  of  the  necrosis  is  very  varial)le.  It 
may  pass  deep  into  the  muscular  coat,  reaching  to  or  even  perforating  the 
peritonfcum. 

rs.  FlnTd/id)). — Tho  separation  of  the  necrotic  tissue — the  sloughing — 
is  gradually  ellected  from  the  edges  inward,  and  results  in  the  formation 
of  an  ulcer,  the  size  and  extent  of  which  are  directly  proportionate  to  tho 
amount  of  necrosis.  If  this  be  superficial,  the  entire  thickness  of  the 
mucosa  may  not  be  involved  and  the  loss  of  substance  may  be  small  and 
shallow.  ]More  commonly  the  slough  in  separating  exposes  the  submucosa 
and  mnseularis,  particularly  the  latter,  whicii  forms  the  floor  of  a  majority 
of  all  typhoid  ulcers.  It  is  not  common  for  an  entire  Peyer's  pati'h  to 
slough  away,  and  a  perfectly  ovoid  ulcer  opposite  to  the  mesentery  is 
rarely  soon.  Irregularly  oval  ami  rounded  forms  are  most  common.  A 
large  patch  may  present  three  or  four  ulcers  divided  by  septa  of  mucous 
membrane.  Tho  terminal  i)  or  S  inches  of  the  mucous  meml)rane  of  tho 
ileum  may  form  a  large  ulcer,  in  which  are  here  and  there  islands  of 
mucosa.  The  e<lges  of  the  ulcer  are  usually  swollen,  soft,  sometimes  con- 
gested, and  often  undermincil.  At  a  late  period  the  ulcers  near  tho  valve 
may  have  very  irregular  sinuous  borders.  The  base  of  a  typhoid  ulcer 
is  smooth  and  clean,  being  usually  formed  of  the  submucosa  or  of  the 
mnseularis. 

There  may  be  largo  idcors  near  the  valve  and  swollen  liypera}mic 
patches  of  Peyer  in  the  upper  part  of  the  ileum. 

4.  Henlinrj. — This  begins  with  the  development  of  a  thin  granulation 
tissue  which  covers  tho  base  and  gives  to  it  a  soft,  shining  appearance. 


di^ 


10 


SI'KriFIC   INFECTlors   DISKASKS. 


The  ninrosa  praduully  extends  from  tlie  edfre,  and  a  now  fxrowtli  of  ejii- 
thelinin  is  formed.  The  f^dandidar  elements  are  reformeil  ;  tlie  healed 
ulcer  is  somewliat  deju'essed  and  is  usually  pifrmented.  Oecasiunallv  an 
appearance  is  seen  as  if  an  ulcer  liad  healed  in  (mc  i)laco  aiul  was  extend- 
ing in  another.  In  death  durint,'  relapse  JKalin},'  ulcers  may  he  seen  in 
some  ])atehes  with  fresh  ulcers  in  others. 

We  nuiy  say,  indeed,  that  liealin<(  hejiins  with  the  separation  of  the 
slou,!,'hs,  as,  when  resolution  i.-;  impossible,  the  removal  of  the  ncrosed 
j.art  is  the  tirst  step  in  the  process  of  re|tair.  I'lujtically,  in  fatal  cases, 
we  seldom  meet  with  evidences  of  cicatrization,  as  the  majority  of  deaths 
occur  before  this  sta^e  is  reached. 

Large  Intestine. — The  ca>cum  ami  colon  are  alTected  in  ai)out  one  third 
of  the  cases.  Sometimes  the  solitary  f^lands  are  greatly  enlarged.  'J'iie 
ulcers  are  usually  larger  in  the  ctecuni  than  in  the  colon. 

Perforation  of  the  Bowel. — Iiicidoirc  nt  Anfapsi/. — In  114  cases  of  the 
*^,0()()  Munich  autoj)sies  (.'),T  per  cent)  and  in  'i'i  instances  in  my  series,  the 
intestine  was  perforated  and  death  caused  by  peritonitis.  According  to 
Choniel,  "the  accident  is  sonu'times  the  result  of  ulceration,  sometimes  of 
a  true  eschar,  ami  sometimes  it  is  produced  by  the  distention  of  the  intes- 
tine causing  tlu!  rupture  of  tissues  weakened  by  disease."  In  only  a  few 
cases  is  the  perforation  at  the  bottom  of  a  clean  thin-walled  ulecr.  In 
one  instance  it  had  occurred  two  weeks  after  the  temi>eratui-e  had  become 
normal.  The  sloughs  arc,  as  a  rule,  adherent  about  the  site  of  perforation, 
which  in  a  majority  of  the  cases  occur  in  small  deep  ulcers.  There  may  be 
two  or  three  i)erforati.ins ;  in  a  few  instances  they  have  been  very  numer- 
ous. The  orilice  is  u.^i'  illy  within  the  last  foot  of  the  ileum.  In  only  one 
of  my  cases  was  it  distant  18  inches.  In  4  cases  of  my  series  the  appendix 
was  perforated  and  in  "i  the  large  bowel.  Peritonitis  was  present  in  every 
instance.  In  1(17  cases  collected  by  Kitz  the  ileum  was  perforated  in  136, 
the  large  intestine  in  'iO,  the  appendix  in  .5,  Meckel's  diverticulum  in  4, 
and  the  j'junum  in  'i.  In  the  large  intestine,  according  to  Hawkins,  the 
sigmoid  flexure  is  the  most  fre(|uent  seat  of  perforation. 

Dt'dfh  from  Jnrniorrliaijc  occurred  in  9!)  of  the  Munich  cases,  ami  in  11 
of  50  deaths  in  my  (!85  cases.  The  bleeding  seems  to  result  directly 
from  the  separation  of  the  sloughs.  I  was  not  able  in  any  instance  to  find 
the  bleeding  vessel.  In  one  case  only  a  single  patch  had  sloughed,  and  a 
firm  clot  was  adherent  to  it.  The  bleeding  may  also  come  from  the  soft 
swollen  edges  of  the  patch. 

The  mcKcntiric  (jlanih  at  first  show  intense  hypera;mia  aiul  subsequently 
become  greatly  swollen.  Spots  of  necrosis  are  common.  In  several  of  my 
cases  suppuration  had  occurred,  and  in  one  a  large  abscess  of  the  mesentery 
was  i)resent.  Fatal  luvmorrhage  into  the  peritonanim  may  come  from  ru^v 
ture  of  a  swollen  gland.  The  bunch  of  glands  in  the  mesentery,  at  the 
lower  end  of  the  ileum,  is  especially  involved.  The  retroperitoneal  glands 
are  also  swollen. 

The  sjAccH  is  invariably  enlarged  in  the  early  stages  of  the  disease.  In 
only  one  of  my  cases  di'l  it  exceed  20  ounces  (000  grammes)  in  weight. 


TOWtll  of  cjii- 
;  tlio  lu'iilfd 
coasionully  an 
(I  was  oxtcud- 
iiy  be  socii  in 

iration  of  the 

tlio  no'Tosc'd 

in  fatal  t'ascs, 

rit2  of  deaths 

)out  one  third 
uhirged.     'J'lie 

4  cases  of  tlio 

luy  series,  the 

According  to 

,  sometimes  of 

L  of  the  intes- 

In  only  a  few 

led  ulcer.     In 

re  hud  become 

of  perforation, 

There  may  be 

'u  very  numcr- 

.     In  only  one 

j  the  appendix 

resent  in  every 

f orated  in  136, 

rticulum  in  4, 

Hawkins,  the 

ases,  and  in  11 
result  directly 
istance  to  find 
loughed,  and  a 
from  tlie  soft 

d  subsequently 
1  several  of  my 
the  mesentery 
•ome  from  ruj> 
sentery,  at  the 
ritoneal  glands 

be  disease.  In 
les)  in  weight. 


TVl')l(HI)   FKVEll. 


11 


The  tissue  is  soft,  even  diftluent.  Infarction  is  not  infref|uent.  Kupture 
may  occur  spontaiu'ously  or  as  a  result  of  injury.  In  tlie  Mniiicli  iiutojjsies 
there  were  5  instances  of  rujiture  of  tiie  spleen,  one  of  which  resulted 
from  a  gangrenous  abscess. 

The  Urcr  shows  signs  of  parcncliymatous  degeneration.  Karly  in  the 
disease  it  is  byperu'mic,  and  in  a  majority  of  instances  it  is  swollen,  some- 
what pale,  on  section  turbid,  and  microscopically  the  cells  are  very  granu- 
lar and  loaded  with  fat.  Nodular  areas  (microscopic)  oci-ur  in  many  eases, 
a<  dcscril)cd  by  Ilundford,  Reed,  in  Welch's  lal)oratory,  could  not  deter- 
mine any  relation  between  the  groups  of  bacilli  and  these  areas  (Stuilies 
II).  Some  of  tiu'  nodules  are  lymjihoid,  others  are  lU'crotic  (Amyot).  In 
VI  of  the  .Munich  autopsies  liver  abscess  was  found,  aiul  in  :5,  acute  yellow 
atrophy.  Pylephlebitis  may  follow  abscess  of  the  mcsc  utery  or  i)erforation 
(if  the  apjiendix.  Affections  of  the  gall-bladder  are  not  uncommon,  and 
are  fully  (lescribed  under  the  clinical  features. 

Kidneys.— Cloudy  swelling,  with  granular  degeneration  of  the  cells  of 
the  convoluted  tubules,  less  commonly  an  acute  lu'phritis,  may  be  present. 
Haver,  Wagner,  and  others  described  tlie  occurrence  of  tuunerous  small  areas 
iiitiltrated  with  round  cells,  which  nuiy  have  the  a))pcarance  of  lymphomata, 
or  may  pass  on  to  softening  and  suppuration,  producing  the  so-iallc<l  iiiiliani 
ahsir/<svH.  It  is  usually  a  late  change.  The  typhoid  bacilli  aloiu'  have  l)e(  ii 
fouiul  by  sonu>  observers  in  these  areas.  They  may  al>o  be  found  in  the 
urine.  In  10  cases  of  jiyuria  in  typhoid  fever  in  my  wards,  Hluuur  found 
the  bacilli  in  -i.  Diphtheritic  inflammation  of  the  pelvis  of  the  kidney 
nuiy  occur.  It  was  jjresent  in  .'3  of  my  cases,  in  one  of  which  the  tips  oV 
the  papilhe  were  also  aifected.  Catarrh  of  the  bladder  is  not  unconuiuui. 
Diphtheritic  inflammation  of  this  viscus  may  also  occur.  Orchitis  is  oc(  a- 
sionally  met  with. 

Respiratory  Organs  — riceration  of  the  larynx  occurs  in  a  certain  num- 
ber of  cases  ;  in  the  Munich  series  it  was  uoIcmI  10~  times.  It  may  come 
on  at  the  same  time  as  the  ulceration  in  the  ileum,  I)ut  the  bacilli  have 
not  yet,  I  believe,  been  found  in  the  ulcers.  They  occur  in  the  posterior 
Avail,  at  the  insertion  of  the  cords,  at  the  liasc  of  the  epiglottis,  and  on  the 
ary-epiglottidean  folds.  The  cartilages  are  very  apt  to  become  involved. 
In  the  later  periods  catarrhal  and  diphtheritic  ulcers  may  be  present. 

(Edema  of  the  glottis  was  present  in  -H)  ol  the  Munich  cases,  in  8  of 
which  tracheotomy  was  performed.  Dii)litheritis  of  the  i)harynx  and  larynx 
is  not  very  uncommon.  It  occurred  in  a  most  extensive  form  in  'i  of 'my 
cases.  Lobar  pneumonia  may  be  found  early  in  the  disease  (see  Pxkimo- 
TVPiir-s),  or  it  may  be  a  late  event.  Hypostatic  congestion  and  the  con- 
dition of  the  lung  spoken  of  as  splenization  are  very  common,  (iangrene 
of  the  lung  occurred  in  40  cases  in  the  Munich  series;  abscess  of  the  lung 
in  14;  luemorrhagic  infarction  in  I'i'.).  Pleurisy  is  not  a  very  common 
event.  Fibrinous  pleuri-sy  occurred  in  about  0  per  cent  of  the  Munii  h 
cases,  and  emjiyema  in  nearly  2  per  cent. 

Changes  in  the  Circulatory  System.~/A'«/-/  Lesli,)is.--Enilornnmis  is 
rare.     I  have  met  with  •->  cases.     The  typhoid  bacilli  have  been  found  in 


12 


SPECinC   INFRCTIOrS   DISEASES. 


I 


^1 


tlip  vofjctations.  Prn'rardifis  m-m  present  in  14  eases  of  the  Munich  au- 
topsies. MjiornnHlis  is  not  very  iiifreiiuent.  Dowevro,  in  ii  series  of  4S 
ruses,  found  in  KJ  f,n-iinuhir  or  fatty  degeneration,  and  in  Ii  a  proliferating 
endarteritis  In  tlie  small  vessels.  It  is  remarkable  that  evei'  in  cases  of 
death  from  heart-failure,  with  intense  fever,  the  eell-tll)res  may  present 
little  or  no  observable  change. 

Lesions  of  f lie  Bfood-vcssrls — Typhoid  Gamjrenp. — Inilammation  of  the 
arteries  with  thrombus  formation  has  been  freipiently  described  i!i  typhoid 
fever.  Bacilli  have  been  found  in  the  thrombi.  The  artery  may  be 
blocked  by  a  thrombus  of  cardiac  origin — an  embolus — but  i:i  the  great 
majority  of  instances  they  arc  autochthouous  and  due  to  arteritis,  oblit- 
erating or  partial.  Thrombosis  in  the  veins  is  very  much  more  frequent 
than  in  the  arteries,  but  is  not  such  a  serious  event.  It  is  most  frequent 
in  the  femoral,  and  in  the  left  more  often  than  the  right.  The  conse- 
quences are  fully  considered  luider  the  si/nijifoms. 

Nervous  System. — There  are  very  few  coarse  changes  met  with.  !Men- 
ingitis  is  extremely  rare.  I  have  never  seen  a  case  at  autojjsy.  It  occurred 
in  oidy  11  of  the  2,000  ^lunich  cases.  The  exudation  may  be  either  serous, 
sero-fibrinous,  or  purulent,  and  typhoid  bacilli  liave  been  frequently  iso- 
lated. Two  interesting  cases  have  recently  been  reported  by  Ohlmacher 
from  the  Cleveland  City  Hospital.  In  both  bacilli  were  found  in  the 
meninges.  In  some  of  the  cases,  as  Kamen's,  the  enteric  lesions  have 
been  slight.  Optic  neuritis,  which  occurs  sometimes  in  typhoid  fever,  has 
not,  so  far  as  I  know,  been  described  in  connection  with  the  meningitis. 
The  anatomical  lesion  of  the  aphasia — seen  not  infrequently  in  children — 
is  not  known,  possibly  it  is  an  encephalitis.  Parenchymatous  clianges 
have  been  met  with  in  the  peripheral  nerves,  and  appear  to  be  not  very 
uncommon,  even  when  there  have  been  no  symptoms  of  neuritis. 

The  rolmifari/  niKsrJes  show,  in  certain  instances,  the  changes  described 
by  Zenker,  which  occur,  however,  in  all  long-standing  febrile  affections, 
and  are  not  peculiar  to  typhoid  fever.  The  muscle  substance  within  the 
sarcolemma  undergoes  either  a  granular  degeneration  or  a  hyaline  trans- 
formation. The  abdominal  muscles,  the  adductors  of  the  thighs,  and  the 
pectorals  are  most  commonly  involved,  llupture  of  a  rectus  abdominis 
has  been  found  post  mortem.  Hamiorrhago  may  occur.  Abscesses  may 
develop  in  the  muscles  during  convalescence. 

Symptoms. — In  a  disease  so  complex  as  typhoid  fever  it  will  be  well 
first  to  give  a  general  description,  and  then  to  study  more  fully  the  symji- 
toms,  complications,  and  seqneliu  according  to  the  individual  organs. 

General  Description. — The  period  of  incubation  lasts  from  "  eight  to 
fourteen  days,  sometimes  twenty-three  "  (Clinical  Society),  during  which 
there  are  feel'ugs  of  lassitude  and  inaptitude  for  work.  The  onset  is  rarely 
al)rupt.  There  may  be  prodromal  symptoms,  either  a  rigor,  Avhich  is  rare, 
or  chilly  feelings,  headache,  nausea,  loss  of  appetite,  pains  in  the  back  and 
legs,  and  nose-bleeding.  These  symptoms  increase  in  severity,  and  the 
patient  at  last  takes  to  his  bed.  From  this  event,  in  a  majority  of  cases, 
the  definite  onset  of  the  disease  may  be  dated.     During  tho  Jirst  week  there 


i 


s^M 


MBia 


TYPHOID  FKVER. 


13 


lie  Miinicli  iiu- 
ii  sci'Il's  of  48 
11  prolitVniting 
ven  in  ciisos  of 
s  may  present 

iniiition  of  tlic 
bed  in  typlioid 
artery  may  be 
t  in  tlic  great 
arteritis,  oblit- 
moro  frequent 
most  frequent 
t.     The  eonse- 

et  with.  ^len- 
y.  It  oceurred 
u  either  serous, 
frequently  iso- 
by  Ohlmaeher 
found  in  the 
ic  lesions  have 
ihoid  fever,  lias 
the  meningitis, 
y  in  children — 
atous  changes 
to  be  not  very 
ritis. 

inges  described 
rile  affections, 
,nce  within  the 
I  hyaline  trans- 
thighs,  and  the 
.'tus  abdominis 
Abscesses  may 

'  it  will  be  well 
fully  the  symj)- 
il  organs, 
rom  "  eight  to 
,  during  which 
L>  onset  is  rarely 
',  which  is  rare, 
n  the  back  and 
'erity,  and  the 
ijority  of  cases, 
Hrst  week  there 


is,  in  soino  cases  (but  ])y  no  means  in  all,  as  has  long  been  taught),  a 
.steady  rise  in  the  fever,  tiie  evening  reeord  rising  a  degree  or  a  degree  and 
It  lialf  higher  each  day,  reaeiiing  lO.T  or  1(»1'.  The  jmlse  is  rapid,  from 
100  to  110,  full  in  volume,  but  of  low  tension  and  often  dicrotic;  tlie 
tongue  is  coated  and  white;  the  abdomen  is  slightly  distended  and  tender. 
I'nless  the  fever  is  high  there  is  no  delirium,  but  tbe  patient  complains  of 
lieaduche,  and  there  may  be  mental  confusion  and  wandc>riiig  at  iii'dit. 
The  bowels  may  be  constipated,  or  there  may  be  two  or  tlirce  l,>osc  move- 
ments daily.  Toward  the  end  of  the  week  the  spleen  becomes  enlari'ed 
and  tbe  rash  api»ears  in  the  form  of  rose-colored  spots,  seen  lirst  on  the 
-kin  of  tbe  abdomen.  Cough  and  bronchitic  symptoms  are  not  unconiiuon 
at  the  outset. 

IvL  the  scnnul  irrc/c,  in  cases  of  moderate  severity,  tlu"  symptoms  lie- 
come  aggravated  ;  the  fever  remains  high  and  the  morning  remission  is 
slight.  The  pulse  is  rapid  and  loses  its  dicrotic  character.  There  is  no 
longer  headache,  but  there  are  mental  torpor  and  dullness.  ';i'he  face  looks 
heavy;  the  lips  are  dry;  the  tongue,  in  severe  cases,  becomes  dry  also. 
The  abdominal  ,-ym])toms,  if  present— diarrhu'a,  tympanites,  and  tender- 
ness— become  aggr.ivated.  Death  may  occur  during  this  wcH'k,  with  pro- 
nounced nervous  sympioms,  or,  toward  the  end  of  it,  from  haniorrhage  or 
licrforation.  In  mild  cases  the  temi)erature  declines,  and  l)y  the  four- 
teenth day  may  be  normal. 

In  the  f/u'rd  irrck,  in  cases  of  moderate  severity,  the  ])ulse  ranges  from 
110  to  1150;  the  temperature  now  shows  marked  morning  nuiiissions,  and 
there  is  a  gradual  decline  in  the  fever.  The  loss  of  liesh  is  now  more 
noticeable,  and  the  weakness  is  pronounceil.  Diarrhcea  and  meteorism 
may  now  occur  for  the  first  time.  I^nfavorable  symi)toms  at  this  stage  are 
the  pulmonary  complications,  increasing  feebleness  of  the  heart,  and  pro- 
nounced delirium  with  muscular  tremor.  Special  dangers  are  perforation 
and  hiumorrhage. 

With  i\\G  fourth  vcrk,  in  a  majority  of  instances,  convalescence  begins. 
The  temperature  gradually  reaches  the  normal  point,  the  diarrlnwi  stops, 
the  tongue  cleans,  and  the  desire  for  food  returns.  In  severe  cases  the 
fourth  and  even  the  fifth  week  may  present  an  aggravated  picture  of  the 
third ;  the  patient  grows  weaker,  the  pulse  is  more  rapid  and  feeble,  the 
tongue  dry,  and  the  abdomen  distended.  He  lies  in  a  condition  of  pro- 
found stupor,  with  low  muttering  delirium  and  subsultus  tendinum,  and 
passes  the  faices  and  urine  involuntarily.  Ilciirt-failure  and  secondary 
complications  are  the  chief  dangers  of  this  period. 

In  the  Jif.'h  (ind  si.tih  weeks  protracted  cases  may  still  show  irregular 
fever,  and  convalescence  may  not  set  in  until  after  the  fortieth  day.  In  this 
period  we  meet  with  relapses  in  the  milder  forms  (n-  slight  recrudescence 
of  tlie  fever.  At  this  time,  too,  occur  many  of  the  complications  and  sequehv. 
Special  Features  and  Symptoms.— J/orA?  of  OitseL— As  a  rule,  the 
symptoms  develop  insidiously,  and  the  patient  is  unable  to  fix  definitely 
the  time  at  which  he  began  to  feel  ill.  The  following  are  the  most  impor- 
tant deviations  from  this  common  course  : 


u 


SI'KCIKIC    INFKCTlOl'S    DISKASHS. 


!iii 


(n)  fhisri  irillt  /'riiiii)i(iirctl,soini'tiiiirn  Siii/i/rii,  Xfrrnus  }f(inift'stnfioiiK. 
— IIciKliiclic,  (if  ii  si'vcrc  and  iiitractul)!*'  nature,  i.-i  liy  no  means  an  iiifrc- 
(|ii('nt  initial  syiiiptoni.  Ajrain,  a  severe  facial  neiiral;,Ma  may  for  u  few 
(lays  put  tlie  practitioner  olT  his  fjuanl.  In  eases  in  wliieli  tlie  patients 
liave  kept  aliout  ami,  as  they  say,  fou,i,'ht  the  disease,  the  very  tirst  mani- 
festation may  he  pronouneed  delirium.  Such  jjatients  iiuiy  even  leave 
homo  and  wamhT  ahout  for  (hiys.  In  rare  cases  th.e  disease  sets  in  with 
the  most  intense  eerehro-spimil  symptoms,  siiniUatin;,'  meiiin^rit is- -severe 
hea(hiche,  j)hot(t])h()l)ia,  rotraetion  of  the  head,  twilchinj,'  of  the  muscles, 
ami  even  eonviilsions.  Occasionally  drowsiness,  stu])or,  and  si^ns  of  hasi- 
lar  mejiingitis  may  exist  for  ten  days  or  more  hefore  the  chuructoristic 
sym])toms  (h'velop;  oeeasionaliy  the  onset  is  with  mania. 

(/i)  With,  ridiioitiu'cil  I'uhiiiiiHirji  Sjiinptdiiis. — The  initial  hronchial 
catarrh  may  he  of  <rreat  severity  ami  ohscnro  the  other  features  of  the 
disease.  More  striking,'  still  are  those  cases  in  which  the  disease  sets  in 
with  a  sin;,de  chill,  with  pain  in  the  side  and  all  the  characteristic  features 
of  lohar  pneumonia,  or  (»f  acute  pleurisy. 

{(•)    With  Jnft'iise  (}n>itri>-i)iti'sfinal  Sipiipfowa. — The  vomitin<;f  may  \y 
incessant  and  uncontrolla1)Ie.     Occasionally  there  are  eases  with  such  in- 
tense vomiting  and  diarrhcea  that  a  suspicion  of  poisoninj^  may  he  aroused. 

(r/)  With  s;/iiipl<iiiis  iif  (III  Ill-life  iii'jihritis,  smoky  or  hloody  urine,  with 
much  alhumin  and  ttdie-casts. 

(r)  Aiiihiiliitdrii  Funii. — T)e;ervinjj  of  especial  mention  are  lIioso  cases 
of  tyi)hoid  fever  in  which  the  patient  keeps  ahout  and  attempts  to  do 
work,  or  perha})s  takes  a  long  journey  to  his  home.  lie  may  come  nnder 
ohservation  for  the  first  time  with  a  tem])crature  of  10-1°  or  105°,  and  with 
the  rash  well  out.  Many  of  these  cases  run  a  severe  course,  and  in  general 
hospitals  they  contrihutc  largely  to  the  total  mortality.  Finally,  there 
are  rare  instances  in  which  tyjdioid  is  unsuspected  until  perforation,  or  a 
profuse  ha-morrhage  from  the  howels  occurs. 

Facial  Aspect. — Early  in  the  disease  the  cheeks  are  flushed  and  the 
eyes  hright.  Toward  the  end  of  the  first  week  the  expression  becomes 
more  listless,  and  when  the  disease  is  Avell  established  the  patient  has  a 
dull  and  heavy  look.  There  is  never  the  rapid  anannia  of  nndarial  fever,  and 
tlie  color  of  the  lips  ami  cheeks  may  he  retained  even  to  the  third  week. 

Fever. — {«)  Ui'jiuhir  Coxrsn.  (Chart  I.) — In  the  stage  of  invasion  the 
fever  rises  steadily  during  the  first  five  or  six  days.  The  evening 
tomiiorature  is  ahout  a  degree  or  a  degree  and  a  half  higher  than  the 
morning  remission,  so  that  a  temperature  of  104°  or  10")'  is  7iot  uncom- 
mon by  the  end  of  the  first  week.  Having  reached  tlie  fastigium  or 
height,  the  fever  then  persists  with  very  slight  daily  remissions.  The 
fever  may  he  singularly  persistent  and  but  little  infiuenced  by  bathing 
or  other  measures.  At  the  end  of  the  second  and  tliroughout  the  third 
week  the  temperature  becomes  more  distinctly  remittent.  The  difference 
between  the  morning  and  evening  record  may  be  3°  or  -1°,  and  the  morning 
temperature  may  even  be  normal.  It  falls  by  lysis,  and  the  temperature 
is  not  considered  normal  until  the  evening  record  is  at  dS.2°. 


f(inifi'slnii(i)is. 
ciins  iiii  iiifrc- 
iiiiy  for  ii  few 
1  tlic  piitii'iits 
rry  lirst  iiiiiiii- 
iiy  even  leave 
<e  sets  ill  with 
in;ritis-  -severe 
I"  the  imiscU's, 
siLjns  of  busi- 
iliaructeristic 

tiiil  hroncliiiil 
I'litiires  of  tile 
<iiseiise  sets  in 
.■ristic  features 

litinjif  may  Iv 
with  such  in- 
lay 1)0  aroused. 
i(ly  urine,  willi 

.re  lIioso  cases 
ttempts  to  do 
ay  come  under 
105°,  iind  with 
and  in  general 
Finally,  there 
^rf oration,  or  a 

ished  and  the 
■ssion  becomes 
>  patient  has  a 
trial  fever,  and 
third  week. 
)f  invasion  the 
The  evening 
gher  than  the 
is  )iot  uncom- 
!  fastigium  or 
nissious.  The 
ed  by  bathing 
lout  the  third 
The  difference 
d  the  morning 
e  temperature 


«■* 


10 


SPKflFIC  INFFXTIOrs  DISEASKS. 


(//)  Viiriiitions  fn.in  tlic  typical  ti'tiipcniturc'  oiirvo  uro  eomnion.  We 
do  iidt  iilwuys  M'i'  tlir  ;,'rii(luiil  stc|ilikc-  ufcciit  in  tlii'  curly  .st:ij,'c  ;  tlic  cases 
(1(1  not  often  conic  under  oltscrviition  at  this  time.  When  the  disease  sots 
in  with  a  chill,  or  in  children  with  a  convidsion,  the  temperature  nuiy  rise 
at  oiu'c  to  lO.T  or  HU'\  In  many  cases  defervescence  occurs  at  the  end  of 
the  second  week  and  the  temperature  may  fall  rapidly,  reachinj:  the  nor- 
mal within  twelve  or  twenty  hours.  An  inverse  type  of  ti'inperature,  hi^h 
in  the  moridiif:  and  low  iii  the  eveiiin;.',  is  occasionally  seen  hut  has  no 
especial  si^'iiilicance. 

Sudden  falls  in  the  temjierature  may  occur  ;  thus,  a.s  sliown  in  Chart 
III,  a  drop  of  10' may  follow  an  intestinal  luvmorrha^'c,  and  tiie  fall  may 
be  very  api)iirent  even  hefore  the  hlood  has  appeared  in  the  stools.     Some- 
times durin;i  the  ana'iiua  which   follows  a  .severe  ha'morrhaj,'e  from  the 
bowels  there  arc  remarkal)le  oscillations  in  the  temperature.     Hyperpy- 
rexia, temperature  above  1()<)°,  is  not  very  common  in  typlu»id  fever  excejit 
just  before  death,  when  I  have  known  tiie  thermometer  to  rcfiister  10!J.5'. 
(r)  J'u.sl-T!/ji/i:ti<l   J-:kr(iliinis—Fvirr    nf   Coiinilcstrure.—lhmng   con- 
valescence, after  the  temi)erature  has  been  nornud,  perhaps  for  live  or  bix 
days,  the  fever  may  rise  suddenly  to  lO'^'  or  \M\  and,  after  iiersistinj,'  for 
from'  one  to  three  days  or  even  loufjer,  fall  to  normal.     With  this  there  is 
no  constitutional  disturbance,  no  furring  of  the  tongue,  no  distention  of 
the  abdomen.     'iMuse  so-called  recrudescences  are  by  no  means  uncom- 
mon, and  are  of  esj.ccial  importi-ncc,  as  they  cause  great  anxiety  to  tlic 
i.ractitioner.     They  arc  attributed  most  fre(|uently  to  errors  in  diet,  con- 
stipation, emotions,  and  excitement  of  any  sort,  such  as  seeijig  friends. 
A  long  series  of  these  cases  is  recorded  in  our  reports  (Studies  11  and  III). 
There  are  cases  in  whicdi  the  temperature  declines  almost  to  the  iior- 
nvil  at  the  end  of  the  third  week,  the  tongue  cleans,  and  the  patient  enters 
apVarently  upon  a  satisfactory  convalescence.     The  evening  temperature, 
however,  does  not  reach  !W.5^  but  constantly  keeps  about  1)0.5°  or  100 ', 
and  occasionally  rises  to  100.5^     This,  in  the  late  stages  of  convalescence, 
I  liave  seen  due  to  the  post-typhoid  anaemia.     Complications  should  be 
carefullv  Icoked  for,  particularly  insidious  pleurisy  or  bone  lesions 

III  certain  of  these  cases  the  persistence  of  the  fever  seems  to  be  really 
a  nervous  phenomenon,  and  there  is  nothing  in  the  condition  of  the  pa- 
tient to  cause  uneasiness  except  the  evening  elevation  of  tempeiaturc.  If 
the  ton-nie  is  clean,  the  appetite  good,  and  there  are  no  intestinal  symi)- 
toms,  it  mav  be  disregarded.  I  have  freciuently  found  this  condition  best 
met  by  allowing  the  patient  to  get  up  and  by  stopping  the  use  of  the  ther- 
mometer This  prolonged  slight  elevation  of  the  temperature  after  the 
disappearance  of  all  the  symptoms  is  most  common  in  children  and  m  pa- 
tients of  marked  nervous  temperament. 

(,/)  The  Fevvr  of  the  Ihhipxc.—Thh  is  a  repetition  in  many  instances 
of  the  original  fever,  a  gradual  ascent  and  maintenance  for  a  few  days  at 
a  certain  heiiriit  and  then  a  gradual  decline.  It  is  shorter  than  the 
original  pyrexia,  and  rarely  continues  more  than  two  or  three  weeks. 
(Chart  I.) 


TYI'IIOIM    KKVKU. 


17 


niuiion.  \V»' 
,'c' ;  t  lu'  cast'H 

•  (lisi'iisc  rsfts 
lire  inuy  rise 
at  till'  i'ikI  of 
liiij^  tlic  n»ii'- 
iTiiUiri',  liij;li 
1  Itiit  has  iiu 

iwii  in  Cliarl 
tilt'  I'all  iiKiy 
tools.     SoiiK'- 
i^'c  from  the 
T.     llyperpy- 
1  k'wr  oxcrj)t 
■fiistiT  10!).5^ 
-During    Con- 
or live  or  six 
persisting  for 
I  tiiis  there  is 
distention  of 
noans  iineoin- 
nxiety  to  the 
'.  in  diet,  eon- 
eeing  friends. 
■s  II  and  III). 
st  to  the  nor- 
patient  enters 
;  temperature, 
•J0.5°  or  100°, 
convalescence, 
uns  should  be 
esions. 

ins  to  be  really 
ion  of  the  pa- 
Tiperaturc.  If 
testinal  symp- 
coiiditiou  best 
ise  of  the  ther- 
ture  after  the 
reu  and  in  pa- 

Tiany  instances 
r  a  few  days  at 
)rter  than  the 

•  three  -weeks. 


(r)  Afrhrih'  Tjipliiiiil. — There  are  eases  ileserilieil  in  whicli  the  chief 
features  of  the  disease  have  been  present  without  the  existence  of  fever. 
They  are  extremely  rare  in  this  eountry.  No  instance  of  the  kind  has 
come  umler  my  observation.     Fisk,  of  Denver,  has  nu't  with  it. 

( /■)  Chills  occur  (d)  sometimes  with  the  fever  of  onset;  (A)  occasion- 
■illy  at  inter\als  throug!u)Ut  the  course  of  the  disi'ase,  a!id  followed  by 
sweats  (so-called  sudoral  form);  (r)  with  the  advent  of  complications, 
pleurisy,  pneumonia,  otiti.-i  nu'dia,  i)eriostitis,  eti'. ;  {il)  with  active  anti- 
pyretic treatment  by  the  coal-tar  remedies;  (c)  (tccasionally  <luring  the 
period  of  defervescence  without  relation  to  any  compination  or  seipiel, 
probably  due  to  a  septic  infection;  (_/')  according  lo  llerringham,  cliills 
may  result  from  consti|)ation.  There  are  cases  in  which  throughout  the 
latter  half  of  the  disease  chills  recur  with  great  severity.  (Sei'  Chills  in 
Typhoid  Fever,  Studies  II.) 

Skin. — The  rash  of  typhoid  fever  s  very  characteristic.  It  consists  of 
a  variable  numl)er  of  rnse-colorcd  spots,  which  ajipear  from  the  seventh  to 
the  tenth  day,  usually  tirst  upttn  the  abdomen.  The  s|>ots  are  llattened 
jnipules,  slightly  raised,  of  a  rose-ri'd  color,  disapp'aring  on  pi'cssure,  and 
ranging  in  diameter  from  'i  to  4  millimetres.  They  can  be  felt  as  ilis- 
tinct  elevations  on  the  skin.  Sometimes  each  sjjot  is  capped  by  a  small 
vesi(de.  The  sjjots  may  lie  dark  in  color  and  occasiomilly  become  pete- 
chial. After  jicrsistiiig  for  two  or  three  days  they  gradually  disappear, 
leaving  a  brownish  stain.  They  come  out  in  successive  crojis,  lint  rarely 
appear  after  the  middle  of  the  third  week.  They  are  present  in  the  typ- 
ical relapse.  The  rash  is  most  abundant  upon  the  abdomen  and  lower 
thoracic  zone,  often  aljounds  upon  the  back,  and  may  spread  to  th(( 
extremities  or  even  to  the  face.  1  can  not  say  that  in  my  ex[ierience  these 
cases  with  the  more  abundant  eruption  have  been  of  especially  si'vi-re  type. 
The  rash  is  not  always  present.  Murchison  states  that  it  is  frcijuently 
absent  in  children.  In  several  instances  within  the  i)ast  few  years  the 
rash  has  persisted  after  the  tem])erature  has  sul)side(l. 

A  branny  des([uamation  is  not  rare  in  children;  it  Is  associated  usually 
with  abundant  sudamiiui.     Occasionally  the  skin  may  jx-el  in  large  Hakes. 

The  following  accidental  rashes  are  met  with  in  typhoid  fever: 

1.  Erythema.— It  is  not  very  uncommon  in  the  first  week  of  typhoid 
fever  to  find  the  skin  of  the  abdomen  and  chest  of  a  vivid  red  color;  tlus 
rash  may  also  spread  to  the  extremities.  It  may  possibly  in  some  instances, 
but  certainly  not  always,  be  due  to  quinine.  I  have  seen  it  much  more  fn 
quently  in  the  past  live  years  (during  which  time  I  have  rarely  ordered  a 
dose  of  quinine  in  this  disease)  than  I  did  in  Montreal,  where  we  used  this 
drug  largely  as  an  antipyretic. 

2.  The  laches  lleudtrcs — Pdiomata. — Tliese  arc  pale-blue  or  steel-gray 
spots,  subcuticular,  from  4  to  10  mm.  in  diameter,  of  irregular  outline  and 
most  abundant  about  the  chest,  abdomen,  and  thighs.  They  sonu'times 
give  a  very  striking  appearance  to  the  skin.  It  can  be  readily  seen  that 
the  injection  is  in  the  deeper  tissues  and  not  suiierficial.  This  rash  is 
quite  without  significance.     Since  my  attention  was  called  to  its  associa- 


•»« 


''  i 


«■* 


18 


SPECIFIC   INFECTIOUS   DISEASES. 


<m 


tinn  with  body  lire,  I  have  mot  with  no  instaiu'o  in  whicli  tlioso  worn  not 
[jvcsont.  SoviTiil  Frcncli  ol)st'rvers  niiiintain  that  tiicy  aro  duo  to  the  irri- 
tating efforts  of  the  ihiid  secreted  by  pediculi  {vide  Ilowetson,  J.  11.  11. 
UuHotin,  vol.  v).     They  aie  not  poiMiliar  to  typlioid  fovor  (Duckworth). 

;{.  Sudaminal  and  miliary  eruptions  are  coniniou  in  all  cases  in  which 
there  is  profuse  sweating. 

4.  Urticaria  is  occasionally  met  with  ;  and  lastly  herpes,  very  uncom- 
mon in  typhoid  fever,  in  comparison  with  its  fre{(uency  in  malaria  and 
pnounionia. 

The  tann  (■erchralc,  a  rod  line  with  white  borders,  I'an  be  })•  oduced  by 
drawing  the  nail  over  the  skin.  It  is  a  vaso-motor  pluiu)nienon  Avhich,  as 
in  other  fevers,  can  be  readily  elicited,  particularly  in  nervous  subjects. 
Exposure  of  the  abdomen  may  be  sutticient  to  cause  a  j[)inkish  injection, 
which  may  in  places  change  to  an  ivory  white,  giving  a  curious  mottled 
appearav.c  0  to  the  skin.  A  similar  appearance  may  be  seen  on  the  arms. 
Tlie  general  tint  mi.y  be  white,  with  irregular  patches  or  streaks  of  pink 
or  dark  rod.  The  skin  of  the  palms  of  the  hands  nniy  become  very  dry 
and  yellow. 

i^wcats. — At  the  heiglit  of  the  fever  the  skin  is  usually  dry.  Profuse 
sweating  is  rare,  but  it  is  not  very  uncommon  to  see  the  abdomen  or  chest 
moist  with  perspiration,  particularly  in  the  reaction  which  follows  the 
bath.  Sweats  in  some  instances  constitute  a  striking  feature  of  the  dis- 
ease. They  may  occasionally  be  associated  with  chilly  sensations  or  actual 
chills.  Jaccoud  and  others  in  France  have  especially  described  this  i<i(donil 
form  of  typhoid  fever.  There  may  be  rei'urring  paroxysms  of  chill,  fovor, 
and  sweats  (even  several  in  twenty-four  hours),  and  the  case  may  be  mis- 
taken for  one  of  intoiniittent  fever.  The  fever  toward  the  end  of  the 
second  woi-k  and  during  the  third  week  may  bo  intermittent.  Tiio  char- 
acteristic rash  is  usually  present,  and,  if  absent,  the  negative  condition  of 
the  blood  is  sulHcient  to  exclude  malaria.  I  have  seen  cases  of  this  foi'Ui  in 
Montreal,  where  there  could  have  been  no  suspicion  of  malarial  infection. 

(Edema  of  the  skin  occurs  : 

1.  As  the  result  of  vascular  obstruction,  most  commonly  of  a  vein,  as  in 
thrombosis  of  the  femoral  vein. 

2.  In  connection  with  nephritis. 

;}.  In  association  with  the  antvmia  and  cachexia. 

The  hair  is  very  apt  to  fall  out  after  an  attack  of  typhoid  fever.  In- 
stances of  permanent  baldness  are  of  extreme  rarity.  As  in  other  diseases 
associated  with  fever  the  nutrition  of  the  nails  suffers,  and  during  anti 
after  convalescence  transverse  ridges  are  seen. 

It  is  stated  that  a  peculiar  odor  is  exhaled  from  the  skin  in  typhoid 
fever.  "Whether  due  to  a  cutaneous  exhalation  or  not,  there  certainly  is  :i 
very  distinctive  smell  connected  with  many  patients.  I  have  repeatedly 
had  my  attention  directed  to  it  by  nurses.  Nathan  Smith  describes  it  as 
of  a  "  semi-cadaverous,  mu.sty  character." 

As  a  sequel,  lines  of  atrophy  of  the  skin  may  develop  on  the  abdomen 
and  lateral  aspects  of  the  thighs,  similar  in  all  respects  to  those  seen  after 


■gpr 


TYIMIOII)    [^EVEH. 


19 


lircgiiiiiicy.  Those  linm  atruphinv  nrc  possihly  iltic  to  neuritis,  iiiid  Duck- 
wortli  has  irportcd  a  caso  in  which  the  skin  iidjacciit  to  thcin  was  iiypcr- 
a'stlictic. 

Itctl-siiri'fi  arc  not  unconiinoii  in  protracted  cases,  with  <,n'('at  emacia- 
tion. As  a  ride,  tiiey  result  from  jircssure  and  are  seen  iii)on  the  sacrum, 
more  rarely  tiie  ilia,  tlu'  sliouidi'rs,  and  the  heels.  These  are  less  com- 
mon, 1  think,  since  the  introduction  of  hydrotherapy.  Scrupulous  care 
ami  watchfulness  do  much  for  their  prevention,  hut  it  i-s  to  i)e  remem- 
hcred  that  in  cases  with  profound  involvenuiit  of  the  nerve  centres 
acute  hed-sores  of  the  hack  and  heels  may  occur  with  very  siij,dit  tires- 
sure. 

/)'o/,'.v  constitute  ii  common  and  trouhlesome  sequel  of  the  disease. 
They  appear  to  he  nuire  frecjuent  after  liydrotherapy. 

Circulatory  System.— The  hJnoil  presents  important  chanpos.  The  fol- 
lowing statements  are  hased  on  studies  which  W.  S.  Thayer  has  made  in 
my  wards  (Studios  I  and  III) :  During  the  lirst  two  weeks  there  may  ho 
little  or  no  change  in  the  hlood.  Profuse  sweats  or  copious  diarrho'a  may, 
as  llayom  has  shown,  cause  the  corpuscles— as  in  the  collapse  stage  of 
cholera— to  rise  ahovo  normal.  In  the  third  week  a  fall  usually  takes 
place  in  corpuscles  and  ha'inoglohin,  and  the  nund)er  may  sink  rapi:'ly 
even  to  1,:500,0()()  per  c.  mm.,  gradually  rising  to  normal  during  con  va- 
les',. nee.  When  the  patient  first  gets  up,  there  may  he  a  slight  fall  in  the 
numl)er  of  corpuscles.  They  diminish  slightly  throughout  the  course,  and 
reach  the  lowest  point  toward  the  end  of  dofervesceneo. 

The  amount  of  lui'inoglohin  is  always  reduced,  and  usually  in  a  greater 
relative  ^portion  than  the  nundxT  of  red  corpuscles,  and  during  recov- 
ery the  normal  color  .stamlard  is  reached  at  a  later  period.  The  luunher 
or  colorless  corpuscles  varies  little  from  the  normal  standard  (0,(){)()  ±  per 
c.  mm.).  They  diminish  slightly  throughout  the  course  and  reach  the 
lowest  point  when  convalescence  is  well  hegun.  'I'he  al)sence  of  leucocyto- 
rtis  may  he  at  times  of  real  -liagnostic  value  in  distinguishing  ty])hoid  fever 
from  various  septic  fevers  and  acute  inflammatory  processes.  The  relative 
proportion  of  the  leucocytes  shows  fairly  constant  variations,  the  large 
mon(muclear  and  transitional  forms  are  increased,  while  the  ]tolynuclear 
neutrophiles  are  diminished  often  heloAv  (10  or  even  HO  per  cent.  This  is 
in  nuirked  contrast  to  the  condition  in  other  acute  diseases  in  whicli  the 
polynuelear  neutroiihiles  are  increased.  When  an  acute  inflammatory  pro- 
cess occurs  in  typhoid  fever  tlie  leucocytes  show  an  increase  in  the  poly- 
nuclear  forms,  and  this  may  he  of  great  diagnostic  moment,  as  in 
perforation. 

'Phe  accompanying  hlood-chart  shows  these  changes  well.  (Chart  II.) 
The  post-typhoid  aniemia  may  reach  an  extreme  grade.  In  one  of  my 
cases  the  hlood-corpuscles  sank  to  I,:}0(),00n  ])er  (>.  mm.  and  the  Inemo- 
glohin  to  ahout  '.'O  per  cent.  These  severe  grades  of  aiKomia  are  not  com- 
mon in  my  experience,  in  the  .Munich  statistics  there  were  o4  cases  with 
general  and  extrenu'  arnvmia. 

Of  changes  in  the  blood  plasma  very  little  is  known. 


I- 


% 


'?; 


I     : 


20 


SIMiClFU"   INFHCTlors    IHSEASKS. 


The  pul.sc  ill  t.y])lioi(!  fVvcr  presents  no  sjieeial  eliuriietors.  It  is  in 
croiised  in  nipidity,  l)ut  not  always  in  jmiportion  to  the  iieif^'lil  of  tlie 
fever.  As  a  rule,  in  tlie  iirst  week  it  is  above  100,  i'lili  in  vohiine  and  often 
dicrotic.  Tliere  is  no  acute  disease  with  which,  in  the  early  stage,  a 
dicrotic  pulse  is  so  frequently  asso<-iated.  Even  with  liijrh  fever  the  pulse 
may  not  he  <freatly  accelerated.  As  the  disease  prop'esses  the  ])ulse  he- 
comes  more  rajiid,  feebler,  ami  small.     In  the  extreme  prostration  of  severe 


ore  ,  ' 

JANUAHV,    1P11 

fEDHUARV                       I                   MARTH                    1 

."),000,000   , 

'.?. 

?2    7t 

29. 

31 

?.. 

.1. 

9 

\i 

IS 

16 

2,.; 

2Tiao 

3 

- 

Mi:; 
........ 

i 

1 

i 

20   2  3 

1 

.>6i  1 

t 
i 

.      7ll0!u 

1 

- 

— 

- 

- 

t 
1 

i 

1 

4-  - 
i 

- 

(10,-? 

- 

\ 

fiO^ 

^, 000,000 

- 

i 

M 

- 

1 

i 

70,t 

- 

1 

- 

- 

- 

dOf 

8,000,000 

i 

/ 

\ 

i 

/ 

1 

GO;J 

i 

- 

1 

/ 

1 

- 

,« 

\ 

._ 

- 

r 

-. 

/ 

40;? 

2,000,000 

\ 

! 

\ 

7:< 

i 

i 

1 

1 

- 

— « 

''' 

... 

30;J 

^ 

y 

1 
1 

1 

1 

4< 

'V 

* 

1 

1 

20;f 

1,000,000 

.--' 

- 

- 

1 

j- 

1 

1 

1 

-A.. 
\ 

^' 

' 

lO,'? 

500,000 

i 

1 
1 

I 
1 

* 

-■.If ;» H: 

-;i  - 

— v 

L 

-fL 

•!• 

^ 

■A 

-■■ 

j; 

* 

\ 

1 

i 

1 

•*r 

1 

i' 

! 

1 

i 

io.ooo_ 

H,000^ 

- 

~ 

- 

- 

1 

1 

i 

1 

i 

! 

■■-*■■•■ 

*K 

^ 

1 

i 

- 

i 

/n 

('.,000 

/■ 

-> 

^ 

^ 

-4\ 

/ 

1 ,000 

•r- 

\i 

' 

2,000 

K 

I 

^ 

^■■ 

i 

1 

1 

1 

1 

i 

1 

1 

BLACK,   RED  CORPUSCLES. 


BED,  HAEMAGLOBIN. 

rtlAKT    TI. 


MEAN  NORM, 

NUMBER    OF 

WHITE 

CORPUSCLES 


BLUE,    COLORLESS  CORPUSCLES, 


cases  it  may  reach  150  or  more,  and  is  a  mere  undulation — the  .so-called 
runninc;  pulse.  The  lowered  arterial  pressure  is  manifest  in  the  dusky 
lividity  of  tlie  skin  and  coldness  of  the  hands  and  feet. 

Durinir  convalescence  the  pulse  gradually  returns  to  normal,  and  occa- 
eionally  becomes  very  slow.     After  no  other  acute  fever  do  we  so  fre- 


rs.  It  is  ill 
ii'iglil  of  tlic 
nil'  and  often 
iirly  stage,  ii 
vcr  tlio  pulse 
the  ]tiilse  lie- 
tion  of  severe 


i^ 


N 


MEAN  NORM. 
NUMBER   or 

WHITE 
CORPUSCLES 


LESS  CORPUSCLES. 

-the  so-called 
in  the  dnsky 

rial,  and  oeea- 
lo  wo  so  fre- 


TVI'IIOID   FKVKH. 


21 


fiuontly  meet  with  l)radyrardia.     I  have  counted  the  pulso  as  low  as  ;{(), 
and  instances  arc  on  ri'cord  of  still  fewer  beats  to  the  niimitc. 

The  hnirl-,s,nnnls  are  at  first  clear  and  loud,  and  free  from  murmur 
hut  m  severe  cases,  as  the  prostration  develops,  the  first  sound  becoih"s' 
feeble  and  there  is  often  to  be  heard,  at  tlic  ajiex  and  along  the  left  sternal 
margin,  a  soft  systolic  murmur.  The  first  sound  may  be  gradual',  nni- 
hilated,  as  i)ointed  out  by  Stokes.  In  the  extreme  feebleness  of  the  graver 
forms,  the  first  and  second  sound  become  very  similar,  and  the  long  pause 
IS  much  shortoiied  (embryocardia).  I  am  much  impressed  with  the  rarity 
of  grave  heart  symptoms  in  tyjihoid  fever. 

Of  cardiac  complicaticms,  ^w;vVv//v//V/.v  is  rare  and  Juis  been  met  with 
chiefly  in  children  and  in  association  with  pneumonia.     It  was  not  pres- 
ent in  any  of  my  ^ases  and  occurred  in  only  14  of  the  ;-,0()()  Munich  post- 
mortems.    Eiuhrardilis  is  also  uncommon.     I  have  seen  only  -i  cases  •  and 
vhere  were  only  II  cases  noted  in  the  Munich  recor.ls.    Myocarditis  is  more 
common.     'I'he  following  statement  may  be  made  witl/ reference  to  the 
condition  of  the  lieart-muscle  in  this  disease :  In  protracted  cases  the  mus- 
cle-filjre  is  usually  soft,  flabby,  and  of  a  pale  yellowish-brown  color      The 
softening  may  be  extreme,  though  rarely  of  the  grade  described  by  Stokes 
in  which,  when  held  apex  up  by  the  vessels,  the  organ  collap.scd  over  tht' 
hand,  forming  a  mushroom-like  cap.     Microscopically,  the  fibres  may  show 
little  or  no  change,  even  when  the  impulse  of  the  heart  ha.s  been  extremely 
feeble.     A  granular  parenchymatous  ilegeiieration  is  common.     Fatty  de- 
generation may  be  present,  particularly  in  long-standing  cases  with  ana-mia. 
1  he  hyaline  change  is  n..t  common.    The  segmenting  myocarditis,  in  which 
the  cement  substance  is  s(.ftcned   so   that  the  muscle-cells  separate,  has 
also  been  found,  but  probably  us  a  iiost-inortem  change. 

VouipUrations  in  the  Jr/cnVi-v.-Obliteration  of  large  or  small  arterial 
trunks  IS  one  of  the  rare  complications  of  tyi)hoid  fever.     A  considera])le 
number  of  cases  are  scattered  through  the  literature.     The  obliteration 
may  be  due  either  to  embolism  or  to  thrombosis.     In  a  majority  of  ca.ses 
the  femoral  artery  is  involved  ami  gangrene  of  the  foot  and  leg  occurs 
In  several  cases  there  has  been  obliteration  of  both  femorals  with  extension 
of  the  clot  into  the  aortu  with  gangrene  of  both  legs.     In  a  case  which 
1  saw  with  Roddick,  of    Montreal,  the   obliteration  of  the   left  femoral 
occurred  on  the  sixteenth  day.     On  the  twentieth  dav  the  patient  had 
pain  in  the  right  leg  and  there  was  no  pulsation  in  the  femoral  artery. 
Gangrene  gradually  developed  in  both  feet,  and  death  took  .dace  in  tlie 
Jixth  m'ck.     In  these  cases  the  condition  is  probably  due  to  thrombosis, 
not  embolism,  and  is  associated  with  u  blood  state  which  favors  clotting, 
or  possibly  with  a  local  arteritis.     In  his  recent  ruonograph  Keen  refers  to 
40  cases  ot  arterial  gangrene,  of  which  S  were  bilateral,  1!)  on  the  ri-ht 
side,  and  l!j  on  the  left. 

Thrombi  in  the  r.t«.,.-This  is  a  much  more  frcfjueat  complication, 
and,  according  to  Murclnson,  is  met  with  in  about  1  per  cent  of  the 
cases  It  occurs  niost  frequently  in  a  crural  vein,  and  more  commonlv  in 
the  left  than  in  the  right;  due  possibly,  us  suggested  by  Liebermeister, 


IM* 


99, 


SPECIFIC  infp:ctious  dtseases. 


•'  J 

I 


I 


to  the  fact  that  in  the  loft  common  iliac  vein,  heing  crossed  hy  the  right 
iliac  artery,  the  floAV  of  blood  is  not  so  free  as  in  the  right  vein.  Throm- 
l>osis  is  indicated  by  enlargement  and  cedema  of  the  limb.  It  is  not  a  very 
unfavorable  comp  ication.  In  one  case  of  my  series  the  thrombus  suppu- 
rated and  there  was  pyicmia.  Occasionally  the  thrombosis  may  extend  into 
the  pelvic  veins  and  into  the  vena  cava.  In  one  inslanee  the  thrombus 
was  in  the  right  circundlex  iliac  vein  alone,  and  the  superficial  veins  on 
the  right  side  of  the  abdomen  were  in  conseciuence  greatly  enlarged. 
Sudden  death  has  been  caused  by  dislodgnu>nt  of  a  throml)us  and  plugging 
of  the  pulnu)niiry  artery.  Typhoid  bacilli  have  been  found  in  Jie  wall  of 
the  vein  and  in  the  clot.  Keen  has  collected  128  cases  of  venous  coagula 
following  typlnis  and  typhoid.  "Only  4  involved  the  upper  extremity 
alone,  2  of  which  were  followed  by  gangrene  ;  2  involved  both  arm  and  leg, 
but  all  the  other  Vi\  cases  Averc  limited  to  the  lower  extremities."  I  do 
not  think  that  gangrene  ever  results  from  obstruction  of  the  vein  alone. 

Infarcts  in  the  kidneys,  spleen,  and  lungs  are  by  no  means  uncommon 
in  typhoid  fevf-r.  They  are  associated  usually  with  thrombosis  in  tlie  arte- 
ries, rarely  with  embolism. 

Ti/pJioid  r;rt«r/?THP.— Following  blocking  of  the  femoral  or  popliteal 
arteries  the  leg  becomes  numb  and  cohl.  There  may  be  complete  amvs- 
thesia  with  motor  paralysis,  and  occasionally  a  good  deal  of  pain.  There 
is  rarely  much  swelling;  gradually  the  skin  beconrts  discolored  and  the 
process  of  dry  gangrene  begins.  When  both  artery  and  vein  are  involved 
the  gangrene  is  usually  moist,  and  spreads  more  rapidly.  In  a  nund)er  oi 
cases  the  gaTigrene  is  not  specially  localized  to  vascular  areas ;  thus  the  dis- 
tribution in  the  cases  collected  by  Keen  is  as  follows :  Ears,  0  caek-s ;  nose, 
10  cases;  face,  neck,  and  trunk,  47  cases ;  anus  5  cases;  genitals,  20  cases; 

legs,  12(5  cases. 

Digestive  System.— Loss  of  appetite  is  early,  and,  as  a  rule,  the  relish 
for  food   is  not  re^'aiued    until    convalescence.      Thirst  is  constant,  and 
should  be  fully  and  freely  gratified.     Even  when  the  mind  becomes  be- 
numbed and  the  patient  no  longer  asks  for  water,  it  should  be  freely  given. 
The  to)if/vc  presents  the  changes  inevitable  in  a  prolonged  fever,  but  there 
are  no  distinctive  chara<'ters.    Early  in  the  disease  it  is  moist,  swollen,  and 
.•oated  with  a  thin  white   fur,  which,  as   the   fever  progresses,  becomes 
denser.     It  may  remain  moist  throughout.     In  severe  cases,  particularly 
those  with  delirium,  the  tongue  becomes  veiy  dry,  partly  owing  to  the  fact 
that  sucli  patients  breathe  with  the  mouth  open.     It  may  be  covered  with 
a  brown  or  brownish-black  fur,  or  with  crusts  between  which  are  cracks 
iind  fissures.      Acute  glossitis  occurred  in  one  case  at  the  onset  of  the 
relapse.     In  these  cases  the  teeth  and  lips  maybe  covered  with  a  dark 
])rowni  '    matter  called  sorties— a  mixture  of  food,  epithelial  debris,  and 
micro-. rganisms.     By  keeping  the  mouth  and  tongue  clean  from  the  out- 
set the  fissures,  which  are  extremely  painful,  may  be  prevented.     During 
convalescence  the  tongue  gradually  becomes  clean,  and  the  fur  is  thrown 
off,  almost  imperceptibly  or  occasionally  in  flakes. 

The  secretion  of  saliva  is  often  diminished  ;  salivation  is  rare. 


by  tho  right 
'in.     Throm- 

is  not  a  very 
)nibns  snppn- 
y  extend  into 
ho  thrombus 
K'ial  veins  on 
tly  enl\rge(h 
iinil  phigging 
n  ^he  wall  of 
?nous  coaguhi 
tcr  extremity 

arm  and  leg, 
lities."     I  do 
vein  alone. 
us  uncommon 
;is  in  tlie  arte- 

I  or  popliteal 
omplete  anivs- 

piiin.  There 
lored  and  the 
n  are  iiivolved 

II  a  number  of 
;  thus  the  dis- 
C,  cases ;  nose, 
itals,  "^0  cases ; 

•nlc,  the  relish 
constant,  and 
d  becomes  be- 
•e  freely  given, 
ever,  but  there 
t,  swollen,  and 
esses,  becomes 
!s,  particularly 
ing  to  the  fact 

0  covered  with 
ich  are  cracks 
B  onset  of  the 
h\  with  a  dark 
ial  debris,  and 

1  from  the  out- 
■nted.  During 
3  fur  is  thrown 

rare. 


TYPHOID    KKVKR. 


2;} 


/'arofi/is,  not  so  frequent  as  in  tyi)Iius  fc'ver,  was  jiresent  in  A:,  of 
tlie  :3,()()()  Munich  eases.  It  occurred  in  only  V  of  my  series  of  fatal  cases. 
Of  -i-iX  instances  colh'cted  by  Keen  occurrii'ig  aftcr'tvp.'ius  and  typhoid, 
only  rr.  followed  the  latter.  Tsnally  unilateral,  and  in"  a  majoritv  of  cases 
going  on  to  suppuration,  it  is  regarded  as  a  very  fatal  .•omplicati(.n,  but 
recovery  has  followe<I  in  4  or  5  of  my  cases.  It  undouhtedly  may  arise 
from  extension  of  intlammation  along  SteiH)'s  (hict.  This  is  ])rol)ab!v  not 
so  .serious  a  form  as  when  it  arises  from  metastatic  inflammation.  The 
submaxillary  gland  may  be  involved  aloiu'.  Parotitis  may  occur  after  the 
fever  has  suhsiiknl.  A  reniarkal)le  localized  sweating  ,  the  parotid  region 
is  an  occasional  seipiel  of  the  iibscess  (see  Studies  III). 

Tlie  plHiripix  may  l)e  the  seiit  of  slight  catarrli.  Sometimes  th(>  fauces 
are  deei)Iy  congested.  MembraiH)ns  pharyngitis,  a  serious  and  fatal  com- 
plication, may  come  on  in  the  third  week.  Difhculty  in  swallowin<r  may 
result  from  ulcers  of  the  (esophagus,  and  in  one  of  our  cases  strict u^'e  fol- 
lowed.*    F.  A.  Packard  has  also  rei)orted  a  case. 

Tho  (jasfrir.  ,si/mpfo,ii,^  are  extremely  variable.  Nausea  and  vomitini,^ 
are  not  common.  There  are  instances,  Jiowever,  in  which  vomiting,  re- 
sisting all  measures,  is  a  marked  feature  from  the  outset,  ami '"mav 
directly  cause  death  from  exhaustion.  Vomiting  does  not  often  o<-c'ur 
in  tho  second  ami  third  week,  unless  associated  with  some  serious  com- 
plication. In  ;',  few' of  tlieso  cases  ulcers  liave  been  found  in  tlie  stom- 
ach. 

IntcxtitKtl  SuDiphms.—iyuiYYlwii  is  a  very  variable  svmptom,  occuri'in<r 
in  only  -Z^  or  ;{()  per  cent  of  tho  cases,  and  in  ordv  about'  10  per  cent  of  my 
cases   have  tlie   movements  boon   frerpient.     Of  !»!(  cases  under  mv  care 
during  1S!»7  diarrha;a  occurred  in  only  Vi.     Its  absence  must  not  iKaakeii 
as  an  indication  that  tlie  intestinal   h'sions  are  of  slight  extent,     i  have 
seen,  on  several  occasions,  the  most  extensive  infiltration  and  ulceration'  of 
tlie  Peyer's  glands  of  the  small  intestine,  with  the  colon  filled  with  s.did 
fa'(;es.     The  (liarrlui'a  is  caused  less  liy  the  ulcers  than  l)v  the  associate.) 
catarrh,  and, as  in  tuberculosis,  it  is  probable  that  wlieii  this  is  in  the  lar-e 
intestine  tho  dis.diarges  are  more  frerpient.     It  is  most  eommon  toward  the 
end  of  the  first  and  throughout  the  second  week,  but  it  may  not  o.'cnr 
until  the  third  or  even  tlio  fourth  week.    The  number  of  <lischar<res  ran-^es 
from  :i  to  8  or  10  in  the  twenty-four  hours.     Tliey  are  usually  al,uiula7it, 
thm,  grayish-yellow,  granular,  of  the  consistency  and  appearance  of  pea- 
sou]),  ami  resemble  very  much,  as  Addison  remarked,  the  normal  contents 
of  the  small  bowel.     The  reaction  is  alkaline  an.i  tho  odor  offensive      On 
standing,  tho  discharges  separate  into  a  thin  serous  layer,  co.itainin<r  all.ii- 
niin  and  salts,  and  a  lower  stratum,  consisting  of  epitlielial  ilehnS,  remnants 
of  food,  and  numerous  crystals  of  triple  pliosphates.    Blood  may  be  in  small 
amount,  and  only  recognized  by  the  microscope.     Sloughs  of'  the   Peyer's 
glands  occur  either  as  grayish-yellow  fragments  or  occasionally  as  ovoid 
masses,  an  inch  or  more  in  length,  in  which  portions  of  the  bowel  tissue 


*  Mitciiell,  (Esophageal  CompIinUioiis  in  Typlu.id  I'Vvor  (Slu.lifs  III,. 


i 


24 


SPECIFIC   INFECTIOUS   DISEASES. 


may  bo  found.     The  Inicilli  iiro  not  foun.l  in  the  stools  until  tin-  on<l  of 
the  lir.st  or  the  middle  of  the  second  week. 

Hwmorrhitqe  from  the  bowels  is  ii  serious  compliention,  oceurrin<;  m 
from  :5  to  5  per  eent  of  all  cases.  It  had  oeeurred  in  !•!)  of  tl.e  ^,000 
f-ital  Munich  cases.  In  (i85  cases  treated  in  my  wards,  hasmorrhagc  oc- 
curred in  :i:5,  and  [M-oved  fatal  in   l.<i  p<'r  cent  of  the  total  series.     Of  (50 


«   s 


s   s 


g    s   1 


SSSSSSSSSSi 


a 

5 


'H"hrhiti::liiii-^..;.. 


■■■:■«:■■•>■ 


..:^^,., 


u-p:pX\-kW^ 


s 

a. 
S 


cases  reported  by  K.  (;.  Curtin,-3S  .lied.  It  was  present  m  -;'  y<'^^  ";«; 
Murchison's  l,5(;4  cases.  Tl>ere  nn.y  be  only  a  sh,,ht  trace  ot  bloou  n  the 
stools,  but  too  often  it  is  a  profuse,  free  luemorrhase  whu.h  ^apu  l.Y  ov  |>; 
fatal.     It  occurs  most  commonly  between  the  end  ..t  the  second  an.l  tlu 


tlu'  cnil  of 


till"  2,000 
rrluigo  oc- 
L'h;.     Of  W 


a} 


;r{ 

ri 

a. 

S3 

— 

W 

— 

tn 

a 

— 

is 

o 



J 

« 

J3 

■' 

-«-> 

S 

o 

»t-t 

Oi 

bc 

sa 

rr) 

J3 

3 


7  ])('r  cent  of 

hloou  in  the 

iipidly  proves 

jond  and  the 


TVPIIOID  FEVER.  „, 

beginning  of  the  fourth  week,  the  time  of  tlio  separation  of  the  sh.n-rh. 
Oeeasionally  it  resultn  simply  from  the  intense  hypera-mia.  It  usuallv 
comes  on  witliout  warning.  A  sensation  „f  sinking  or  eolhipse  is  expoii 
eneecl  l.y  the  patient,  the  temperature  falls,  and  may,  as  in  the  annexed 
ehar drop  8  or  10_  in  a  few  hours.  Fatal  collapse  nuiy  supervene  before 
the  h  ood  appears  in  the  stool.  TlaMuorrhage  usually  occurs  in  cases  of 
eonsideral.le  severity,  (u-aves  and  Trousseau  held  that  it  was  not  a  very 
.langerous  symptom,  but  statistics  show  that  death  follows  in  from  ;iO  to 
^0  per  cent  of  the  cases. 

It  must  not  be  forgotten  that  m..hena  may  also  be  part  of  a  general 
Inemorrhagic  tendency  (to  be  referred  to  latc'r)',  in  which  case  it  is  associ- 
ated with  petecliiic  and  Inwmaturia.  There  mav  l)e  a  special  family  pre- 
disposition to  intestinal  luemorrhages  in  typhoid  fever.  Thus  Pate  *  re- 
ports 34  cases  in  four  generations  in  one^  family  oecurring  between  the 
years  1884  and  1891.  ^      m 

Mvfi'orism,  a  frequent  symjitom,  is  not  seri<.us  if  of  moderate  grade- 
bu  when  excessive  is  usually  of  ill  omen.  Owing  to  defectiy,.  tone  in  the 
walls,  in  severe  cases  to  their  infiltration  with  seru.u,  gas  accumulates  in 
tlie  small  an.l  large  bowels,  particularly  in  the  latter.  It  is  rightly  held  to 
be  to  some  extent  a  measure  of  the  inti-nsif,  of  tlu-  local  lesions  When 
extreme  It  pushes  up  the  diaphragm  and  interferes  very  mu.di  with  the 
action  of  the  heart  and  lungs.     It  undoubtedly  also  favors  perforation. 

_  AlHlomnud  fcm/cnirss  on  i)ressure  and  /y»/Y/////,/  iu  the  right  iliac  fossa 
exist  ma  large  proportiou  of  all  the  eases.  The  teiHlerness  may  be  more 
orless  diffuse  over  the  abdomen,  but  it  is  commonly  limited  to  the  ri-dit 
side.  It  IS  rarely  excessive,  and  may  be  elicited  only  on  de..p  pressure, 
(nirglmg  in.licates  simidy  the  presence  of  gas  and  fluid  fanes  in  th(>  colon 
and  ca.cum.  In  a  few  instances  the  pain  is  very  severe  at  the  onset,  h>val- 
ized  m  the  riglit  ihac  fossa,  and  may  suggest  appendicitis. 

Occasionally  severe  pain  may  be  assoeiated  with  the  degeneration  of 
the  abdonnnal  muscles,  or  with  rupture  of  the  recti  abdomiuales.  It  is 
stated  tha  the  t  nckenod  ileum  may  be  felt  in  typhoid  fever,  and  also  that 
tlie  mescmtenc  glamls  may  be  palpable.  This  is  a  point  of  some  moment. 
The  resistance  and  apparent  tumor  have  led  to  the  diagnosis  of  appendicitis 
and  operation.  ^  '■ 

Pjrfvmt;on.~Oi  my  G85  cases  there  were  ;54  (:>.48  per  cent)  with  per- 
foration. In  4,.J80  cases  tabulated  by  Fitz  the  mortality  from  this  accident 
was  O.o8  per  cent.  It  is  more  frequent  in  men  than  in  w^nnen.  It  is  usually 
indicated  by  the  onset  of  sudden  acute  pain  iu  the  abdomen,  and  symrf- 
onis  of  collapse.^  It  is  most  comm(,n  at  the  en.l  of  tlie  second  or  in  the 
third  week  butm  one  of  my  cases  it  occurred  as  early  as  the  eighth  day 
and  m  another  ,n  the  sixth  week,  two  weeks  after  the  Evening  temperature 
had  become  normal.  In  Fitz's  series  4.!.5  per  cent  occurred  iu  the  third 
or  four  h  week,  4  cases  occurred  in  the  first  week,  and  1  case  as  late  as  the 
sixteenth  week.     It  is  not  infrequently  associ.ied  with  luemorrhage. 


*  Xortli  Carolina  Jlcdical  Journal,  So;,cenil)or,  1894. 


^  \ 


f! 


h 


\  I 

ill 


M 
it  '^ 

I    J! 


*i* 


r 


2fi 


SPPX'II'MC   INFECTIOUS   DISKASKS. 


Wo  do  not  know  iill  the  fircunistiinros  wliich  li'iul  to  porforation. 
Thoro  is  ccrtiiinly  no  n>liitionslii|i  Itotwccn  this  accidc'it  and  tlio  severity 
of  the  disease.  It  occurs  not  infrci|ncMtly  in  very  mild  cases.  Anionjf 
causes  assiifiiecl  are  the  takiiij:^  too  early  of  iiidij,'estil)le  food,  severe  vomit- 
ing, excessive  inetcorisni,  and  ascaridcs.  The  tulihinj;  has  hecn  accused  of 
increasing  the  ])erccntage,  hut  Hare's  Hrishane  statistics  do  not  show  it, 
nor  do  ours.  Perforation  of  the  appendix  is  not  very  uncommon,  and  may 
cause  pain  in  the  right  iliac  fossa,  (icneral  peritonitis  or  a  localizet'  ah- 
seess  may  result.  Recovery  from  jterforatioii  is  undouhtedly  j)ossil)le, 
though  rare.  Peritonitis  without  perforation  nuiy  also  occur  by  extension 
from  the  ulcer  or  occasiomiUy  l)y  rupture  of  a  softened  mesenteric  gland. 
It  was  present  in  2.2  per  cent  of  the  Munich  auto])sies. 

Si/i)ij)f)i>iis  of  I'crfnrttlioH,. — The  cases  may  lie  grouped  into  {(t)  those 
with  abrupt  and  well-defined  onset.  In  about  three  fourths  of  the  cases 
there  is  a  sudden  acute  i)ain  in  the  abdomen,  followed  by  marked  tender- 
ness, rigidity  of  the  abdominal  walls,  vomiting,  a  collapsed,  pinched  ex- 
pression, and  a  small  rapid  pulse.  In  eases  in  which  there  has  been 
marked  tympanites  and  teiuleriiess  the  symptoms  may  l)e  more  obscure, 
and  I  have  once,  at  least,  been  deceived  l)y  the  good  (juality  of  the  pulse 
and  general  condition  in  the  presence  of  pretty  well  marked  local  signs. 
{h)  Cases  in  which  the  onset  is  gradual  and  the  symptoms  ill-defined. 
When  the  ]Kitient  has  been  very  ill  and  delirious  or  comatose,  the  increas- 
ing distention  of  the  abdonu'u  and  sitrns  of  tenderness  on  deep  pressure 
may  be  the  only  suggestive  features.  It  is  to  be  borne  in  mind  that  tym- 
panitic distention  is  by  no  means  a  necessary  accompaniment  of  i)crfora- 
tion.  The  abdomen  may  be  flat,  with  boardlike  hardness,  {r)  In  a  small 
group  of  cases  there  are  no  symptoms  whatever  suggestive  of  perforation, 
ami  it  is  found  accidentally  i)ost  mortem.  These  are  usually  cases  which 
have  been  desperately  ill,  and  the  local  features  are  completely  masked  by 
the  severity  of  the  toxa-mia.  Of  additional  features  the  fall  in  tempera- 
ture is  sometimes  well  marked  and  suggestive.  Obliteration  of  the  liver 
dullness  in  froTit  may  bo  almost  complete,  and  would  be  a  very  valuable 
sigi\  wore  it  not  for  the  fact  that  one  sometimes  in  extreme  meteorism 
finds  the  same  condition.  In  the  absence  of  local  abscess  or  otitis  media 
the  prosen->e  of  a  lcuco(>ytosis  is  a  much  more  imjiortant  symptom,  the 
value  of  whi-'h  in  the  diagnosis  of  perforaion  has  been  demonstrated  by 
Thayer  in  several  cases  in  my  wards. 

The  xplcen  is  invariably  enlarged  in  typhoid  fever,  and  in  a  majority  of 
cases  the  edge  can  bo  felt  below  the  costal  margin.  By  the  end  of  the  first 
week  the  eidargement  is  evident,  unless  there  is  great  distention  of  the 
colon,  when  thw  spleen  may  be  pushed  far  back  aiul  difficult  to  feel.  Even 
the  normal  area  of  dullness  may  not  be  obtainable.  I  ha\j  seen  a  very 
large  spleen  post  mortem,  when  during  life  the  increase  in  size  was  not 
observable.  Toward  the  fourth  week  it  diminishes  in  size.  In  four  of 
my  autopsies  it  weighed  less  than  normal.  Infarcts  and  abscesses  are 
occasionally  found.  Rup*^  e  of  the  spleen  in  typhoid  fever,  due  to  a  slight 
blow,  has  been  seen  by  Bartholow.     Spontaneous  rupture  may  also  occur. 


TVIMIOM)    FKVFH. 


27 


perforation, 
tho  severity 
cs.  Anionj,' 
I'vero  voiiiit- 
1  iieeused  of 
lot  sliow  it, 
on,  jind  may 
oealizec'  al)- 
lly  })os«il)le, 
)y  ^wtension 
iteric  gland. 

to  {(i)  those 

of  the  oases 

rlsed  tender- 

jiinehed  ex- 

ro  lias  been 

ore  obscure, 

[)f  the  pulse 

loeal  signs. 

s  ill-defined. 

the  inereas- 

eep  pressure 

id  that  tyni- 

t  of  iierforii- 

■)  In  a  small 

perforation, 

cases  which 

y  masked  by 

in  tempera- 

of  the  liver 

ery  valuable 

e  meteorism 

otitis  media 

ymptom,  the 

onstrated  by 

1  majority  of 
d  of  the  first 
ntion  of  the 
)  feel.    Even 

seen  a  very 

size  was  not 

In  four  of 

ibsccsses  are 

ue  to  a  slight 

also  occur. 


Liver.— Symjitoms  on  the  part  of  this  organ  are  rare. 
(a)  J,nnuli,r  is  o.'casionaliy  seen,  ami  mav  be  due  to  catarrh  of  tlie 
ducts,  to  toxtemui,  to  abscess,  and  occasionallv  to  gall-stones. 

{h)  J/>.vr<'.v,v.-Solitary  abscess  is  exceedingly  rare.  I  have  never  seen 
an  instance.  It  may  follow  the  intistinal  icsi.m  or  more  commonly  one  of 
the  complications,  as  j.arotitis  or  necrosis  of  bone.  Suppurativ  pvh.i.hle- 
bitis,  which  IS  more  frc.,uent  thini  abscess,  may  follow  pcrforat ion' ot'  the 
ai-jiendix.     Sii])purative  cholangitis  has  been  described 

(c)  Cholniislills  ami  nuUu,,,i,is.-.\\,^,,,,i  observations  have  shown 
that  tlie  gall-bladder  in  fatal  cases  often  contains  tvphoid  bacilli  •  J<t  „f  -^o 
cases  in  Cliiari's  scries,  7  in  14  of  Flcxncr's.  Tlu/may  be  present  without 
.ausing  any  mischief,  or  they  may  excite  an  acute  inflammation  with  sup- 
puration, i.erforation,  an<l  jieritonitis.  The  symptoms  may  oci'ur  during 
tiie  course  of  the  disease  or  months  after  convalescence  has  been  estalt 
lished.  iliree  .^ases  have  been  operated  upon  at  tlie  Johns  Hopkins  Hos- 
pital. Keen  has  coilec'tc.l  ;K)  cases  of  perforation.  Mason's  paiier  in  the 
Iransactiousof  the  Association  of  American  Physicians,  vd.  xii,  ami  those 
by  Camac  and  myself*  show  how  im])ortant  is  this  complication. 

{d)  r.V//-.s'^;/r.v.— BiTtiheim  called  attention  to  the  fre<,uency  of  chole- 
lithiasis after  typhoid  fever.  It  is  probably  associated  with  the  presence 
of  typhoid  bacilli  in  the  gall-bladder  (see  under  Oall-Stones) 

Respiratory  System.-A>/,v/r^,/.v,  an  early  symi.tom,  prcedes  tvi.hoid 
fever  more  commonly  than  any  other  febrile  atfection.  It  is  occasionally 
l)rofuse  and  serious. 

LariiuiiUh  is  not  very  common.  Tho  ulcers  and  the  perichondritis 
have  alrca.ly  been  described.  (E,h.,ua,  apart  from  ulceration,  is  rare  In 
this  country  the  laryngeal  complications  of  tvphoi.l  fever  seem  much  less 
frerpient  than  on  the  Continent.  I  have  twice  only  seen  perichondritis; 
ooth  of  the  cases  recovered,  one  after  the  expectoration  of  large  iiortions 
of  the  thyroid  cartilage. 

Keen  and  Liining  have  collected  221  cases  of  serious  uirgical  conipli.^a- 
tions  of  the  larynx.  General  emphysema  may  follow  the  perforation  of  an 
ulcer,     bteiiosis  is  a  very  serious  sequence. 

From  some  recent  studies  it  would  ai)pear  that  paralysis  of  the  laryn- 
gejd  muscles  is  mucli  more  common  than  we  have  supposed.  Przedborski 
(Xolkmann's  Sammlung,  Xo  182)  has  systematically  examined  the  larynx 
in  100  consecutive  cases  and  found  25  with  paralysis.  The  conditio^  is 
nearly  always  due  to  neuritis,  sometimes  in  connection  with  alfcetions  of 
other  nerves. 

Bronrhitis  is  one  of  the  most  frequent  initial  symptoms.     It  is  indi- 
cated by  the  presence  of  sibilant  rAles.     The  smaller  tubes  mav  lie  involved 
producing  urgent  cough  and  even  slight  cyanosis.     Collapse  and  lobular 
pneumonia  may  also  occur. 

Lobar  pueumoma  is  met  with  under  two  conditions  : 
^^l^^Itnmy  be  the  initial  symptom  of  the  disease.     After  an  indisposition 

*  Studies  in  Typhoid  Fever,  Series  III,  Johns  Hopkins  Hospital  Reports,  vol.  vii. 


. 


I  ) 


^^ 


28 


Sl'IX'Il-'lC   INl'HCTTors   DISHASRS, 


iil; 


of  11  (lay  or  so,  llio  pat  icnt  is  seized  witli  a  eliill,  lias  lii,i,'li  fevor,  ])aiii  in  the 
side,  iiud  witiiiii  t'orty-ei{,'lit  iioiirs  there?  are  si^Mis  of  coiisoliihitioii  and  the 
cvidoiipos  of  an  ordinary  lobar  pnennionia.  Tlio  intestinal  symptoms  may 
not  develop  until  toward  the  onil  of  the  first  week  or  later;  the  imlmonary 
Kymi)toms  persist,  crisis  does  not  occur  ;  th(>  as{)ect  of  the  patient  chanjre-i, 
and  hy  the  end  of  the  second  week  the  clinical  [)icture  is  tliat  of  typhoid 
fever.  Spots  may  then  he  present  and  douhts  as  to  the  nature  of  the  case 
are  solved.  In  other  instances,  in  the  ahseiu'o  of  a  characteristic  eruption, 
the  case  remains  douhtful,  and  it  is  im})ossiblo  to  say  whether  the  disease 
has  been  pneumonia,  in  which  tiie  so-callod  typhoid  symptom.s  iiave  devel- 
oped, or  whether  it  was  ty]thoid  fever  with  early  inii>lication  of  the  lungs. 
This  condition  may  depend  uj)on  an  early  localization  of  the  typhoiil  bacil- 
lus in  the  lung.  1  have  twi(  e  performed  autojjsies  in  cases  of  thk  j> // en dio- 
fi/phus,  as  it  is  called  by  the  French  and  (lernnins,  'ind  can  speak  positively 
of  its  onset  with  all  tlie  symptoms  of  a  frank  jnieunionia. 

2.  Lobar  pneumonia  forms  a  serious  and  by  no  means  infrc(|uent  com- 
lilieiitioii  of  the  second  or  third  week.  It  was  present  in  over  S  p(>r 
cent  of  the  Municdi  eases.  The  symi)toins  avo  usually  not  marked.  There 
may  be  no  rusty  sputa,  aTid,  unless  sought  for,  the  condition  is  fretpiently 
overlooked.  Infarction,  abscess,  and  gangrene  are  occasional  pulnu)iuiry 
complications. 

llillKisttilir  ((i/ii/i'.s/imi  of  the  lungs  and  (cdema,  duo  to  enfeebled  circu- 
lation in  the  later  periods  of  the  disease,  are  very  comnu)n.  The  })hysical 
signs  are  defective  resonance  at  the  bases,  feeble  l)reath-sounds,  and,  on 
deep  inspiration,  moist  rales.  I'leurisy  is  ])y  no  means  an  uncommon  com- 
l)licatiou.  It  was  ])resent  in  about  .S  per  cent  of  the  Munich  autopsies. 
It  may  develoj)  at  the  outset — pleuro-typhoid — or  slowly  during  convales- 
cence, in  which  case  it  is  almost  always  purulent.  I'lU'uniothorax  occa- 
sionally develops.  Hale  White  has  rei)orted  two  cases,  in  botli  of  which 
pleurisy  existed.  The  condition  may  be  duo  to  straining,  or  to  the  rup- 
ture of  a  small  pytvmic  abscess.  Anotlicr  occasional  jjulmoiuiry  complica- 
tion is  //(I'ltio/ifi/Kis,  which  I  once  saw  at  the  height  of  the  disease.  It  may 
•  occur  also  during  convalescence.  After  death,  no  lesions  of  the  lungs  or 
bronchi  were  discovered.  C'reagh  reports  a  case  in  which  the  haemoptysis 
caused  death. 

Nervous  System. — Ccrvhro-spi^al  Fornt. —  Vs  already  noted,  the  disease 
may  set  in  with  intense  and  persisting  lu^adache,  or  an  aggravated  form 
of  neuralgia.  There  are  cases  in  which  the  effect  of  the  poison  is 
numifested  on  the  nervous  system  early  ami  Avitli  the  greatest  intensity. 
There  are  headache,  photophobia,  retraction  of  the  neck,  marked  twitcli- 
ings  of  the  muscles,  rigidity,  and  even  convulsions.  In  such  cases  the  diag- 
nosis of  meningitis  is  invariably  made.  I  have  examined  jiost  mortem  three 
such  cases,  in  two  of  which  the  diagiuisis  of  cerebro-spinal  fever  had  been 
made.  In  not  one  of  them  was  there  any  trace  of  meningeal  inflammation, 
only  the  most  intense  congestion  of  the  cerebral  and  spinal  pia.  Menin- 
gitis, however,  nuiy  occur,  but  is  extremely  rare,  as  shown  by  the  ^Munich 
record,  in  which  there  were  only  11  among  the  ^,000  cases.     Convulsions, 


m 


TVPIIorD   I''FVKR. 


20 


)iiiii  in  till' 
)ii  iiiul  tlic 
[ttoins  may 
puliiioiiiiry 
it  cliiuijrcH, 
of  typhoid 
>r  tilt!  ciiso 
!•  eruption, 
he  disi'iiso 
iivv'u  dovol- 
thc  lungrt. 
ihoid  l)iicil- 
lis  ]))iniiti(i- 
c  positively 

(uont  coni- 
ivcr  S  per 
Ml.  ThcTo 
frociuently 
puliiioiuiry 

blod  eircu- 
:iu  pliysie.il 
ds,  and,  on 
iiinon  ooni- 
uutopsics. 
g  couvales- 
lorux  occa- 
I  of  whicli 
to  the  rup- 
j  coinplica- 
le.  It  may 
10  lungs  or 
ia3moptysis 

;ho  disease 
'ated  form 
poison  is 
t  intensity, 
cod  twitcli- 
;s  the  diag- 
•rtem  three 
■  had  been 
lammation, 
a.  Menin- 
he  Munich 
ouvulsions, 


marked  opisthotono.s  s(ral)isinus,  and  signs  of  involvement  of  the  eraiiial 
nerves  arc*  necessary  in  typlioid  fever,  as  in  pneumonia,  for  the  positive 
diagnosis  of  nuMiingitis.  .V  numiier  of  genuine  easrs  have  l)een  reported 
ef  late  years,  and  the  literature  is  (piit'  fully  given  hy  Ohlmaeiier*  to 
May,  l.S!»r.  U'oltr  has  collected  IT-i  eas's  in  wliicii  a  Imeterioiogieal  exam- 
ination was  made;  in  only  ;.'.sr  per  cent  were  the  typhoid  Imciili  found. 
Marl<ed  convulsive  movements,  local  or  u'eiieral,  witii"  coma  and  delirium, 
are  seen  also  in  tliromhosis  of  the  cerebral  veins  and  sinuses. 

Ucliriinii,  usually  present  in  very  severe  cases,  is  certainly  less  fre(|uent 
under  a  rigid   plan  of  liyilrothcrapy.     It   may  exist  from  tiie  outset,  hut 
usually  does   not  develop  until   the  second  and   sometimes  not   until  the 
third  week.     It   may  be  slight  and  only  nocturnal.     It  is,  as  a  rule,  a  quiet 
ilelirium,  tlu)ugh   there  are  cases  in  which   tlie  patient   is  very  noisv  and 
constantly  tries  to  get  out  of  bed,  and,  unless  carefully  watched,  may  es- 
<ape.     The  patient  does  not  often  become  nnmiaeal.     In  heavy  drinkers 
the  delirium  may  have  the  character  of  delirium  tremens.     Kvcn  in  cases 
wliieh  have  no  positive  delirium,  the  mental  processes  are  usually  dulled 
and  the  aspect  is  listless  and  apathetic.     In  severe  eases  the  patient  passes 
into  a  condition  of  unconsciousness.     The  eyes  may  l)e  o])cn,  hut  he  is  ob- 
livions to  all  surrouiuling  circumstances  and  neither  knows  nor  can  indi- 
cate In's  wants.     The  urine  and  fa'ces  are  i)as.sed  involuntarily.     In  this 
pseudo-wakeful  state,  or  coma  vigil,  as  it  is  called,  the  eyes  are  open  and 
tile  patient  is  constantly  muttering.     The  lips  and  tongue  are  tremulous  ; 
there  are  twitchings  of  tlie  fingers  and  wrists— snbsultus  teiidimim  and 
carphologia.     He  picks  at  the  liedelothes  or  grasps  at  invisible  objects. 
These  are  among  the  most  serious  symptoms  of  the  disease  and  always 
indicate  danger. 

Convulsions  hi  t\])hon\  fever  are  rare.  Inehildn-i  they  may  occur  at 
the  onset.  In  September,  ISDC,  a  child  of  ten  years  was  admitted  in  coma 
following  a  sudden  convulsion  after  a  full  meal.  This  was  the  starting- 
point  of  a  severe  atta(>k  of  typhoid.  Their  rarity  may  be  gatheri'd  from  the 
tact  that  in  2,0(i0  cases  .Murchison  only  met  with  convulsions  in  0.  They 
may  be  associated  with  an  acute  enci'phalitis  or  with  tliromlii  in  the  arte- 
ries or  in  the  veins.  In  the  case  of  my  late  assistant.  Dr.  ()i)i.enlieimer,  the 
convulsions  developed  on  the  eighth  day  of  the  fever,  and  proved  fatal  in 
twelve  hours.  Thrombosis  of  the  branches  of  the  left  mi<ldle  cerel)ral 
artery  was  found.  In  other  instances,  as  in  one  reported  by  J.  \V.  Moore, 
no  brain  lesions  are  found.  In  very  nervous  women  I  have  seen  hysterical 
convulsions. 

Ac/iriiis,  which  is  not  uncommon,  may  be  local,  or  a  widespread  affee- 
tion  of  the  nerves  of  the  legs  or  of  hotli  arms  and  legs. 

I.ocal  Xi'ii rif is.— Thh  may  occur  during  the  height  of  the  fever  or  after 
convalescence  is  established.  It  may  set  in  with  agonizing  pain,  and  with 
sensitiveness  of  the  alfected  nerve  trunks.  In  two  instances  I  liave  seen 
great  tenderness  of  the  muscles,  and  some  of  these  may  be  cases  of  myo- 


*  Journal  of  Americaii  ."^IcJiciil  Assooiution,  1897,  ii. 


^^ 


I'J 


no 


SPKCIFIC  INFKCTIOrs  DISEASKS. 


Kitis.  Tlicrc  niiiy  !)•'  oxtniiic  Hciisitivt'iu'Hs  of  tlic  muscles  witliout  any 
Ki^'iisuf  iifiiritis.  The  ('(mditioii  iiiiiy  sii1>si(li'  witlnmt  Itavin;;  any  atrophy. 
Tlif  local  neuritis  followiiij,'  tyi)li(ii(l  fever  may  alTect  the  iiervts  of  an  arm 
or  of  ii  le;,',  and  involve  cliietly  tiie  oxteiisor»,  80  that  there  is  wrist-droj)  or 
foot-droj)  of  the  alTectctl  limh.  Some  of  the  cases  are  very  diillcnlt  to 
wi)arate  from  those  with  jtoliomyelitis. 

A  curious  condition,  i)rohai)iy  a  local  neuritis,  is  that  which  was  llrst 
deserilicd  hy  liandfonl  as  ivmbr  fm-.s,  and  which  appi'ars  to  he  much  more 
common  after  the  cold-hath  treatment.  The  tips  and  pads  of  the  toes, 
rarely  the  pads  al  tlieir  hases,  heconu'  ex(|uisitcly  sensitive,  so  that  the 
l)atii'iit  can  not  hear  the  weifrht  of  the  hedelothes.  There  is  no  discolora- 
tion and  no  swellinir,  and  it  disapiicars  usually  within  a  week  or  ten  days, 

Mii/h'ji!c  nnirillK  in  typhoid  fever  develo|ts  usually  duriiif^  convalcs- 
epiu'e.  The  le<is  may  he  utVect.'d,  or  the  four  extremities.  'J'he  eases  arc 
often  dillicult  to  dillerentiate  from  those  with  suhacute  i)oliomyelitis.  Ke- 
coverv  is  the  rule.  Of  4  cases  with  involvement  of  arms  and  legs,  ;{  recov- 
ered comiiletely  and  1  improved  (Studies  11). 

Poliomyelitis  may  develop  with  the  symptoms  of  acute  ascoiuling  paral- 
ysis and  prove  fatal  in  a  few  tlays.  More  freijuently  it  is  less  a<'ute,  and 
causes  eithi^r  a  imrajtlejiia  or  a  limited  atrophic  paralysis  of  one  arm  or  lej,'. 
IIi'rn)t/rf/i(t  is  a  rare  complication.  Francis  Hawkins  has  eolleeted  17 
eases  from  the  liti'rature  ;  ai)hasia  was  present  in  lt».  The  lesion  is  usually 
thromliosis  of  the  arteries,  less  often  a  inenintro-enci'phalitis.  The  aphasia 
in  children  often  disappears  (Studies  111). 

True  fcfdii!/  oeeurs  sometimes,  ami  a  numher  of  cases  have  develoiicd 
in  certain  eiudemics.  It  may  set  in  during;  the  full  height  of  the  disease. 
This  comi)lication  is  extremely  rare  in  this  country,  and  .laiu'way,  so  far  as 
I  know,  has  alone  reported  instiiuccs. 

I'ost-fehrile  insaiiihi  is  perhaps  more  frequent  after  typhoid  than  after 
any  other  disease.  Wood  regartis  it  as  eonfusional  insanity,  the  result  of 
impaired  nutrition  and  exhaustion  of  the  nervous  centres.  Y'xyq  cases 
have  come  under  my  observation,  in  four  of  which  recovery  took  place 
(Studies  I). 

Special  Senses— /v"//'.— Conjunctivitis,  simple  or  phlyctenular,  sometimes 
with  keratitis  and  iriti.s,  nuiy  develop.  Panophthalmitis  has  been  reported 
in  one  case  in  association  with  ha'uiorrhage  (Finlay).  Loss  of  accommoda- 
tion may  occur,  usually  in  the  asthenia  of  convalescence.  Oculo-motor 
paralysis  has  been  seen,  due  probably  to  neuritis.  Retinal  hivmorrhages 
may  occur  alone  or  in  association  with  other  luvmorrhagic  features.  Double 
optic  neuritis  has  lieen  described  in  the  course  of  the  fever.  It  may  be 
independent  of  meningitis.  Atrophy  may  follow,  but  these  eomplications 
are  excessively  rare.  Cataract  may  follow  intiamnuition  of  the  uveal  tract. 
Other  rare  complications  are  thrombosis  of  the  orbital  veins  and  orbital 
liivmorrhage.  (See  De  Schweinitz  in  Keen's  moTiograph  for  full  considera- 
tion of  the  subject.) 

Ear.— Oixixf,  media  is  not  infre(iuent,  2.5  per  cent  in  Ileng-st's  collected 
cases.     We  have  never  found  the  typhoid  bacillus  in  the  discharge.     Seri- 


TVIMIOin   FKVKR. 


k'itliout  any 
my  atropliy. 
s  (it°  an  arm 
•riHt-droj)  or 
(litllriilt   to 

ill  was  firnt 
niiicli  more 

of    till'   t()<'S, 

so  tliat  tilt' 
lo  ilist'olora- 
ir  ten  days. 
\fi  convak'S- 
'hc  cases  arc 
yclitis.  Kc- 
I'gs,  ;{  ICCOV- 

luling  paral- 
s  ai'iitc,  and 
'  arm  or  li'<,'. 
collected  IT 
on  is  usually 
Tlic  aphasia 

ve  dcvcloptd 

the  disease. 

viiy,  so  far  as 

d  than  after 

the  result  of 

Five  cases 

y  took  place 

ir,  sometimes 
een  reported 
accommoda- 
Oculo-motor 
hitmorrhages 
ires.  Double 
.  It  may  be 
:omplications 
e  uveal  tract. 
i  and  orbital 
nil  considera- 

st's  collected 
liarge.     Seri- 


mis  results  are  rare;  only  oiu'  case  of  mastoid  disease  occurred.     The  otitis 
may  set  in  with  a  chill  and  an  iig;rravatioii  of  the  fever. 

Renal  System.  — Hetent Ion  of  urine  is  an  early  syniplum  in  many  cases, 
and  is  more  fre(|Uent  in  some  epidemics  than  in  others.  The  condition 
may  recur  fur  several  weeks.  'I'lic  urine  is  usually  diminished  at  lirst,  has 
the  ordinary  febrile  characters,  and  the  pigments  arc  increased,  j.atcr  in 
the  disease  it  is  more  abundant  and  lighter  in  color. 

Khrlich  has  described  a  reaction,  which  lie  l)elieves  is  rarely  met  Avith 
excejit  in  typhoid  fever.  This  so-called  ili<r.ii-rr<irlliii)  is  produced  as  fol- 
lows:  Two  solutions  are  emi)loyed,  kept  in  separate  bottles  :  one  containiii"' 
a  saturated  solution  of  sulphanilic  acid  in  a  solution  of  liydrocliloric  acid 
('>()(■('.  to  1,0(10  ('('.);  the  other  a  half  percent  solution  of  sodium  nitrite. 
'I'o  make  tiie  test,  a  few  cubic  centimetres  of  urine  are  placed  in  a  small 
test-tube  with  an  equal  (juuntity  of  a  mixture  of  the  solution  of  the  sul- 
phanilic acid  (K)  cc.)  and  the  sodium  nitrite  (1  cc),  the  whole  being 
thoroughly  shaken.  One  cubic  centimetre  of  annnonia  is  then  allowed 
to  flow  carefully  down  the  side  of  the  tub(>,  forming  a  colorless  zone  above 
the  yellow  urine,  and  at  the  junction  of  the  two  a  deep  lirownisb-red 
ring  will  be  seen  if  the  reaction  is  present.  With  normal  urine  a 
lighter  brownish  ring  is  produced,  without  a  shade  of  red.  The  color  of 
the  foam  of  the  mixed  urine  and  reagent,  and  the  tint  they  produce 
when  largely  diluted  with  water,  are  characteristic,  l)eing  in  i)oth  cases 
of  u  delicate  rose-red  if  the  diazo-reaction  be  present ;  but  if  not,  brown- 
ish-yellow. 

It  was  present  in  130  of  mO  cases  examined  at  my  clinic  (Ifewctson, 
.Studies  I).  It  may  be  present  previous  to  the  occurrence  of  the  rash,  and 
as  late  as  tlie  twenty-second  day.  Tlie  value  of  the  test  is  lessened  by  its 
occurrence  in  cases  of  miliary  tuberculosis,  aiul  occasionally  in  the  acute 
diseases  associated  with  high  fever.  The  toxicity  of  the  'urine  is  much 
increased  in  typhoid  fever,  and  the  toxic  products  are  eliminated  in  greater 
(luantities  in  cases  treated  with  the  cold  bath. 

The  I'cnal  complications  in  typhoid  fever  may  be  thus  grouped  : 
{(i)  Febrile  albuminuria,  which  is  very  common  and  of  no  special  sig- 
nificance; thus,  in  the  first  ^I'O  cases  adinitted  to  the  Johns  Hopkins  llos- 
pita'  "Ibuminuria  was  noted  in  104,  with  tube-casts  in  lo:}. 

ute  nephritis  occurring  at  the  onset  or  during  the  height  of  the 

-tiie  iiephro-tjiphnx  of  the  (';ermans,  the  Jienr  tiipliindc  ()  forme 

.  of  the  French— may  set  in,  with  all  the  syinptom.s  of  the  most  in- 

ii.^'c  Bright's  disease,  masking  in  many  instances  the  true  nature  of  the 

malady.     After  an  indisposition  of  a  few  days  there  may  be  fever,  pain  in 

the  back,  and  the  passage  of  a  small  amount'of  Itloody  uHnc.    In  -IX  of  the 

229  cases  evidence  was  present  of  a  definite  nephritis— much  albumin  and 

many  tube-casts.     In  10  there  were  also  red  blood-corpuscles.     In  2  there 

was  a  genuine  lia?morrhagic  nephritis.     Seven  of  these  21  cases  dieil— 5 

from  perforation,  not  one  from  the  renal  complication. 

(r)  The  nephritis  of  convalescence.     Tliis  is  more  common  but  less 
serious.     It  develops  after  the  fall  of  the  fever,  ami  is  usually  associated 


{I, 


^^ 


32 


SPECIFIC   IN'FHCTKH'S   DISKASES. 


with  n>(loiiia.     It  does  not  iiro>:ciit  chiinictors  ditTeiviit  from  the  ordimiry 
])Of;t-feliril('  nephritis. 

{i/)  'Phe  rcniiirkiihlc  lyniphomatons  nephritis,  lU'scrihinl  by  K.  Wag'niT 
iinil  others,  and  ah'eady  referred  to  in  the  section  on  morbid  anatomy,  pro- 
dnees,  as  a  rule,  no  symptoms. 

(r)  /'i/tin'ii  is  a  not  nneomnion  romi)lication.  Bhinier  (Studies  II)  has 
reported  10  cases  in  my  wards.  In  7  the  colon  haciiUis  was  present,  in  '2 
the  typhoid  bacillus,  and  in  1  the  stapliylococcus  albus. 

(/')  Posl-tjiplioiil  I'l/clifix. — In  this  the  p"lves  of  the  kidney  and  the 
calices  are  at  lirst  covered  with  a  membranous  exudation,  Init  erositm  and 
ulceration  may  sultsequently  occur.  There  may  be  blood  and  pus  in  the 
uri  t  Tliis  condition  occurred  in  .']  of  my  cases,  in  one  of  which  it  was 
associated  with  extensive  membranous  inilammation  of  the  bladder. 

Simple  catarrh  of  tlic  bladder  is  rai'e. 

Ori'liHlx  is  occasionally  met  with  during  convalescence.     Sadrain  col- 
lected 1<!  cases  in  the  literature.     It  is  usually  associated   with  a  catarrhal 
urethritis.     Induration  or  atrophy  may  occur,  ami  n.ore  rarely  suppura- 
tion.    In  one  case  dmible  hydrocele  developed  suddenly  on  the  uineteem 
day  (Dunla]t). 

Osseous  System. — Among  the  most  cor.nnon  and  troubl-.'somo  of  the 
sequelai  of  th<!  disease  are  the  hoitc  hsions.  Of  237  cases  collefied  by 
Keen  there  was  pei'io;-,titis  in  110,  necrosis  in  85,  and  caries  in  13.  They 
are,  I  am  sure,  much  nu)re  freciuent  than  the  figures  indicate.  Six  cases 
camo  under  my  notice  in  the  course  of  a  year,  and  formed  the  basis  of 
Parson's  paper  (Studies  II).  The  legs  arc  chiefly  involved.  In  Keen's 
series  the  tibia  was  alfected  in  01  cases,  the  ribs  in  40.  A  majority  of 
the  cases  occur  after  convalescence  is  established.  Of  51  cases  in  M'hich 
bacteriological  examinations  were  made,  in  13  pyogenic  bacteria  were  found ; 
in  38  there  were  typhoid  bacilli  (Keen).  The  typhoid  bone  lesion  is  apt 
to  form  what  the  old  writers  called  a  cold  abscess.  Only  a  few  of  the 
cases  are  acute.  Chronicity,  indolence,  and  a  remarkable  tendency  to 
recurrence  are  perhaps  the  three  most  striking  features  of  the  typhoid 
■  bone  lesions.  If  not  thoroughly  treated  sinuses  may  remain,  and  typhoid 
bacilli  have  been  found  in  these  old  lesions  for  as  long  as  seven  oi  more 
years. 

ArthritiK  is  fully  considered  in  Keen's  monograiih.  Rheumatic  and 
septic  forms  are  described,  as  Avell  as  a  typhoid  arthritis  proper.  The 
complication  is  exceedingly  rare,  and  yet  Keen  has  collected  from  the 
literature  81  cases.  One  of  the  most  important  points  relating  to  it  is 
the  frecpiency  with  which  spontaneous  dislocations  occur,  particularly  of 
the  hip. 

Ti/jfioi.-f  Spinr. — There  is  a  remarkable  disorder  of  convalescence  to 
Avliii^'^  (iibiiey  has  given  this  nii.ne.  The  patient  has  usually  been  up  and 
alsout,  and  may  have  had  a  slight  jar  or  shock,  after  which  he  compkins 
of  great  pain  in  the  back,  and  of  pain  on  moving  the  legs.  The  condition 
may  persist  foi  weeks  without  fever  or  any  signs  of  Pott's  disease,  spondy- 
litis, or  nenriuis;  but  there   are   usually  marked  nervous  or  hysterical 


symptoms, 
dition  dcpc 
(Studies  I), 

The  III// 
but  it  raret 
tile  muscle^ 
in  or  botwe 

Post-tj 
protracted 
\  esccnce  tb 
100°  or  101 
to  indicate 
great  severi 

Typhoid 
which  are  1: 
instances  tl 
ated  about 
Internal  ab 
instances  ol 
tensive  peri 
tancous  abs 

Associi 
tion,  most  i 
Basel  it  oc 
per  cent. 

Measles 
pox  and  n( 
flan- '  lations 
tyjilioid  fin 
typho-malai 
It  is  intcres 
single  insta 
of  the  disc 
regions. 

Typhoid 
In  4  of  my  i 
fever.  Mili 
sonal  exper 
there  is  a  j 
other  fevers 
with  in  the 

In  epilc] 
during  an  a 
be  alisent  d 

Varietj 


TVPIIOII)   FEVER. 


33 


symptoms.  The  outlook  i.s  good.  It  is  not  known  npon  wliat  tliis  con- 
dition depends.  It  seems  to  lie  ii  neurosis  ratlier  tlian  a  ])erispondyIitis 
(Stu<iies  I). 

The  im/.'^rh's  may  be  the  seat  of  tlie  dejjeneration  already  referred  to, 
lint  it  rarely  causes  any  symptoms.  IlaMnorrlmfie  oeeasioiiidly  occurs  into 
the  muscles,  and  late  in  j)rotraeted  cases  abscesses  may  develop,  sonu'tiiiics 
in  or  between  the  abdomiiuil  muscles. 

Post-typhoid  Septioaemia  and  Pyaemia. — Following,'  sivere  and 
jirotracted  cases  there  may  be  signs  of  septic  infection.  .Vfti'r  the  defer- 
vescence the  ])atient  may  in  d  week  or  so  present  a  sliglit  fever,  rising  to 
100°  or  101",  with  sweats  and  weakness,  but  with  no  signs  other  than  fever 
to  indicate  a  relapse.  There  may  be  Avith  this  recurring  chills,  often  of 
great  severity.* 

Typhoid  pyaemia  has  its  chief  manifestation  in  inultii)le  al).scesses, 
which  are  by  no  nu>a us  uncommon  in  protracti..  cases.  In  a  majority  of 
instances  these  are  subcutaneous,  or  they  nniy  take  the  form  of  lioils,  situ- 
ated about  the  buttocks,  the  calves,  the  tiiighs,  the  axilhe,  or  shoulders. 
Internal  abscesses  are  less  common.  Wo  have  had  in  the  hospital  several 
instances  of  extensive  ])erirectal  abscess,  and  I  saw  with  Dr.  Salzer  an  ex- 
tensive perinephric  abscess.  In  no  case  from  the  boils  or  from  the  subcu- 
taneous abscesses  has  the  typhoid  bacillus  been  isolated  in  my  wards. 

Association  of  other  Diseases. — Erysipelas  is  a  rare  conijilica- 
tion,  most  commonly  met  with  during  convalescence.  In  1,4'.'0  cases  at 
Hasel  it  occurred  10  times.  Gricsingcr  states  that  it  is  met  with  in  :i 
per  cent. 

Measles  may  develop  during  the  fever  or  in  convalescence.  Chicken- 
pox  and  noma  have  been  reported  in  children.  Pseu<lo-membranous  in- 
flan-  nations  may  occur  in  the  pharynx,  larynx,  or  genitals.  Malarial  and 
tyidiuid  fevers  may  bo  associated,  ")ut  a  majority  of  the  cases  of  so-called 
typho-malarial  fever  are  either  remittent  nudarial  fever  or  true  typhoid. 
It  is  interesting  to  note  that  among  the  (iSS  cases  of  tj'phoid  fi  ver  in.  not  a 
single  instance  were  the  plasmodia  found  in  the  blood  during  the  course 
of  the  disease.  Many  of  our  typhoid  fever  cases  came  from  malarious 
regions. 

Typhoid  fever  may  attack  an  individual  the  subject  of  tuberculosis. 
In  4  of  my  80  autopsies  tuberculous  lesions  coexisted  with  those  of  typhoid 
fever.  Miliary  tuberculosis  occasionally  developed  after  it,  but  my  per- 
sonal experience  does  Tiot  warrant  the  belieJ!  held  by  some  writers,  that 
there  is  a  greater  susceptibility  to  tuberculosis  after  typhoid  than  after 
other  fevers.  Acute  miliary  tuberculosis  and  typhoid  fever  have  been  met 
with  in  the  same  subject. 

In  epilepsy  ami  in  chronic  chorea  the  fits  and  movements  usually  cease 
during  an  attack,  and  in  typhoid  f'>ver  in  a  diabetic  subject  the  sugar  may 
be  absent  during  tliC  height  of  the  disease. 

Varieties  of  Typdoid. — Typhoid  fever  presents  an  extremely  com- 


See  paper  on  Chills  in  Typhoid  Fever  (Studies  II), 


3i 


SPECIFIC   INFECTIOUS   DISEASES. 


plcx  symptomatolofjy.  Many  {onus  liuvn  hoon  doscribcd,  some  of  wliicli 
prc'SiMit  cxajigoralioii  of  ooniiiioii  syinptoins,  otiiers  modilication  in  the 
oourso,  others  again  greater  intonfity  of  action  of  tlie  })oison  on  certain 
organs.  As  we  have  seen,  wlien  the  nervous  system  is  specially  involved, 
it  has  been  called  the  cereln-o-spinal  form  ;  when  the  kidneys  are  early  and 
severely  affected,  nephro-typhoid  ;  when  the  disease  begins  with  pulmo- 
nary symptoms,  pneumo-typlioid  ;  with  pleurisy,  pleuro-typhoid  ;  when  the 
dise.ise  is  characterized  throughout  by  profuse  sweats,  the  sudoral  form 
of  the  disease.  It  is  a  mistake,  I  think,  to  recognize  or  speak  of  these  as 
varieties.  It  is  enough  to  remember  that  typhoid  has  no  fixed  and  con- 
stant course,  that  it  nuiy  ;"^t  in  occasionally  with  syjnptoms  localized  in 
certain  organs,  and  that  nniny  of  its  symptoms  are  extremely  variable — in 
one  epidemic  uniform  ami  text-book-like,  in  another  slight  or  not  met  with. 
This  diversified  symptomatology  Inis  led  to  many  clinical  errors,  and  in  the 
absence  of  the  salutary  lessons  of  morbid  aiuitomy  it  is  not  surprising  that 
practitioners  have  so  often  l>een  led  astray.  We  may  recognize  with  Mur- 
chison  the  following  varieties ; 

1.  The  mild  and  abort ivn  forms.  It  is  very  important  for  the  practi- 
tioner to  recognize  the  mild  tyi)e  of  typhoid  fever,  often  spoken  of  as 
gastric  fever  or  even  regarded  as  simple  febricula.  In  this  form,  the 
typhus  JorisKiiiiiis  of  (iriesinger,  the  symptoms  are  similar  in  kind  but 
altogether  less  intense  than  in  the  graver  attacks,  although  the  onset  may 
l)e  sudden  and  severe.  The  temperature  rarely  reaches  103°,  and  the 
fever  of  onset  mr.y  not  show  the  gradual  ascending  evening  record.  The 
spleen  is  enlarged,  the  rose-s])ots  may  be  jnarked  ;  often  they  are  very 
few  in  number.  The  diarrluea  is  variable  often  it  is  not  present.  In  such 
cases  the  symptoms  may  persist  for  from  ten  to  fourteen  days. 

In  the  abortive  form  the  symjttoms  of  onset  nuiy  be  marked  with  shiv- 
erin"-  and  fever  of  1015°  or  even  higher.  The  date  of  onset  is  often  defi- 
nite, a  point  upon  which  Jiirgenseu  lays  great  stress.  Kose-spots  may 
occur  from  the  second  to  the  fifth  day.  Early  in  the  second  week  or  at 
the  end  of  the  first  week  the  fever  falls,  often  with  profuse  sweating,  and 
convalescence  is  establislied.  In  this  abortive  forin  relapse  may  occur  and 
may  occasionally  prove  severe.  When  typhoid  fever  prevails  extensively 
these  cases  are  not  uncoTumon.  I  agree  with  J.  C.  '  nson,  who  states  that 
they  are  not  nearly  so  common  in  this  country  as  in  Europe. 

2.  The  (J rare  form  is  usually  characterized  by  high  fever  and  pro- 
nounced nervous  symptoms.  In  this  CMtegory,  too,  come  the  very  severe 
cases,  setting  in  with  pneumonia  and  Bright's  disease,  and  with  the  very 
intense  gastro-int-  stinal  or  ccrebro-spinal  symptoms. 

;].  Th'.' !(i/()if  or  (niilji(li(jn\i/  iorm  of  tj-phoid  fever,  which  is  particu- 
larly common  in  hospital  practice.  The  symptoms  are  often  very  slight, 
and  the  patient  scarcely  feels  ill  enough  to  go  to  bed.  lie  has  languor, 
perhaps  slight  diarrluea,  but  keeps  about  and  nuiy  even  attend  to  liis  work 
throughout  the  entire  attack.  In  other  instances  delirium  sets  in.  The 
wo"st  cases  of  tliis  form  are  seen  in  sailors,  who  keep  up  and  about,  though 
feeling  ill  and  feverish.     When  brought  to  the  hospital  they  often  develop 


TYPIIOin   FEVER. 


35 


of  wliicli 
on  in  till' 
on  certain 
,'  involvt'd, 
!  early  and 
th  pulnio- 

wlien  tile 
loral  form 
»f  these  as 
d  and  oon- 
)ealizod  in 
iriable — in 
t  met  with, 
and  in  tlie 
rising  that 

mth  Mur- 

the  practi- 

jken  of  as 

form,  the 

kind  but 

onset  nuiy 

°,   and  the 

eord.     The 

y  are  very 

t.     Ill  such 

I  with  shiv- 
often  deti- 
-spots  may 
week  or  at 
eating,  and 
I  occur  and 
extensively 
states  that 

r  and  pro- 
very  severe 
th  the  very 

is  particu- 
very  slight, 
las  languor, 
to  his  work 
ts  in.  The 
3ut,  though 
ten  develop 


,-ytnptoms  of  a  n-ost  sevor(>  type  of  the  disease.  iriPinorrhage  or  perfora- 
tion maybe  the  first  marked  symptom  of  this  ambulatory  type.  Sir  \V. 
■  lenner  has  called  attention  to  the  dangers  of  this  form,  and  i)artienlarly 
to  the  grave  prognosis  in  the  ease  of  persons  who  have  traveh-d  far  with 
the  disease  it)  progress. 

Hipworrhnyic  Tiiphoid  Fevcr.~Y\\\^  is  excessively  rare.  Among  Ous- 
kow's  0,51;}  eases  there  were  only  4  deaths  with  general  ha^morrhagic 
diathesis.  Only  one  instance  was  present  in  our  085  eases.*  IIa>morrlKi"e3 
tiiay  be  marked  from  the  outset,  but  mor*^  commonly  they  develoj)  durru" 
the  course  of  the  disease.  The  condition  is  not  liecessarily  fatal.  Our 
case  recovered,  as  did  several  of  tliose  reported  l)y  Nieiiolls  from  the  Royal 
\'ictoria  Hospital,  Montreal. 

Ati  afebrile  typhoid  fever  is  recognizcil  i-'  authors.  Liebermeister  says 
tliat  the  cases  were  not  uncommon  at  Htisel.  The  patients  presented  las- 
situde, depression,  heada<>he,  furred  tongue,  loss  of  tippetite,  slow  pulse, 
atid  even  the  spots  and  enlarged  spleen.  I  have  no  personal  knowledge  of 
such  cases. 

Typhoid  Fever  in  Children.— Cases  are  not  uncommon  under  the  age 
of  ten,  but  the  disease  is  rai-e  in  infants  under  two  years  of  age.  Ca.sos 
have  been  reported,  however,  in  sucklings  (nine  months.  Fuller  ;  four  and 
a  half  months.  Ogle),  and  perforation  has  been  met  with  in  ati  infant  five 
days  ohl.  Epistaxis  rarely  occurs  ;  the  rise  in  temperature  is  less  gradual  ; 
the  initial  bronchial  catarrh  is  often  ol)served.  The  nervous  symptoms  iire 
often  prominent;  there  are  wakefulness  and  delirium;  diarrluiea  is  ofien 
absent.  The  rash  may  be  very  sliglit,  l)ut  the  most  copious  eruption  I 
have  ever  seen  was  in  a  child  of  eight.  The  al)dominal  svmploms  are 
often  mild.  Fatid  ha?morrbage  and  perforation  are  rare.  '  Among  tlie 
sequela',  aphasia,  noma,  and  bone  lesions  maybe  mentioned  as  mofe''com- 
mon  in  children  tlian  in  adults.  The  mortality  of  tvphoid  fever  in  chil- 
dren is  low.  In  cases  fatal  early  in  the  disease  otify  a  careful  bacterio- 
logical examination  can  decide  whether  the  swollen  Peyer's  patches  and 
mesenteric  glands— not  un<>ommon  in  children  with  fever- depend  upoti 
infection  with  typhoid  bacilli. 

Typhoid  Fever  in  the  Aged.- After  the  fortieth  vear  the  disease  runs  a 
less  favorable  course,  and  the  mortality  is  verv  l:igh.  Of  U  fatal  cases, 
7  were  over  forty  years  of  age  ;  1  was  aged  sixty-three,  another  seventy! 
The  fever  is  not  so  high,  but  comiilications  are  more  common,  particu- 
larly pneumonia  and  heart-failure. 

Typhoid  Fever  in  Pregnancy.— Tiie  disease  is  rare  iti  pregmmt  women. 
Only  1  case  occurred  in  our  085  cases.  The  imijority  of  the  patients  are  af- 
fected during  the  first  half  of  pregnancy.  Abortion  or  premature  delivery 
follows,  usually  in  the  second  week  of  the  disease— in  1!)!)  of  .'510  Ciises  col- 
lected by  Sacquiti.  The  mortality  in  pregnant  women  with  typhoid  fever 
is  high— 10  in  91  cases  (Hrieger),  17  per  cent  in  18:}  oases  collected  l)y 
\  may.     The  experience  of  Ikand  and  of  the  physicians  of  the  Lyons 


i 


*  Hamburger,  Ha>iiiorrhagic  Form  of  Typhoid  (Studies  III). 


M^ 


36 


SPECIFIC   INFECTIOUS  PISKASKS. 


Hchool  would  show  thiit  the  rold-lmtli  tivatmcnt   is  not   only  not  contni- 
indiciitcd,  but  most  crticiicious. 

Typhoid  Fever  in  the  Foetus.— W.  Fordyoe,  who  has  recently  studied 
the  .iuestic.n  most  thorou^'hly,  eoneludes  as  follows  :  (1)  That  typhoid 
fever  could  be  communicated  to  tlic  fo'tus  hi  iiln-n  :  {'i)  tluit  as  a  result  ol 
this  infecticm  the  fo'tus  un;rl-.t  die,  and  l)e  expelled  prematurely  ;  (:i)  that 
the  f.r'tus  miKht  be  born  alive  but  weakly,  and  evidently  sulfcring  from 
the  infect  ion"  (-1)  that  the  fa>tus  might  he  born  alive  and  healthy,  havin- 
passod  through  th(>  infection  in  vfrro.  Finally,  the  infection  of  the  child 
did  not  necessarily  follow.  This  last  was  the  ease  in  a  foetus  aged  five 
months,  whoso  mother  died  of  tvphoid  fever  in  my  wards.  Flexner  found 
the  blood  and  tissues  sterile.  .1.  V.  V.  (iritlith  found  the  Widal  reaction 
in  a  child  seven  weeks  old,  born  when  the  mother  had  typhoid  fever. 

Relapse —Kehipses  varv  in  fretiuency  in  dilterent  epidemics,  and,  it 
would  appear,  in  different^  places.  The  percentages  of  different  authors 
ran<'efrom  U  per  cent  (Murchison),  11  per  cent  (Hiiumler),  to  1.)  or  is 
per" cent  (Immermanu).  In  Wagner's  clinic,  from  1882  to  LSSO,  there 
were  49  relapses  in  501  cases.     In  085  cases  there  were  54  relapses. 

We  may  recognize  the  genuine,  the  intercurrent,  and  the  spurious  re- 
lapse. ^    .  ,   ,  .1 

The  fruc  rdapxo  sets  in  after  complete  defervescence.  Irving  noted  the 
avera<n^  duration  of  the  interval  in  his  cases  as  a  little  over  five  days. 

In  one  case  there  was  complete  apyrexia  for  twenty-three  days,  followed 
by  a  relapse  of  fortv-one  days'  duration ;  then  apyrexia  for  forty-two  days, 
followed  by  a  second  relapse  of  two  weeks'  duration.  As  a  rule,  two  of  the 
three  important  svmptoms— steplike  temperature  at  onset,  roseola,  and  en- 
larged spleen-should  be  present  to  justify  the  diagnosis  of  a  relapse.  The 
intestinal  symptoms  are  variable.  The  onset  may  be  abrupt  witli  a  cull, 
or  the  temperature  may  have  a  typical  steplike  ascent,  as  shown  in  Chart 
I  The  number  of  relapses  range  from  3  to  5.  Da  Costa  has  twice  seen 
5  relapses.  The  attack  is  usually  less  severe  and  of  shorter  duration.  Of 
Murchison's  53  cases,  the  mean  duration  of  the  first  attack  was  about 
•    twenty-six  days ;  of  the  relapse,  fifteen  days.     The  mortality  of  the  relapse 

is  not  high.  .        •        *  -n  i 

The  ininrurnnt  relapse  is  quite  common.  A  series  of  cases  will  be 
found  in  our  Studies  in  Typhoid  Fever.  .Miiny  protracted  cases  are  of  this 
nature  The  temperature  drops  and  the  patient  Improves;  but  after  re- 
maining between  100°  and  10'^°  for  a  few  days,  the  fever  again  rises  and 
the  patient  enters  upon  another  attack,  which  may  be  even  more  severe 

than  the  original  one.  ,       ■,     ,  »        i 

Spuriom  relapses  arc  very  common.  They  have  already  been  referred 
to  on  page  1  launder  post-typhoid  elevations  of  temperature.  They  are 
recrudescences  of  the  fever  due  to  a  number  of  causes.  It  is  not  always 
easy  to  determine  whether  a  relapse  is  present,  particularly  in  cases  in 
which  the  fever  persists  for  only  five  or  seven  days  without  rose-spots  and 
without  enlargement  of  the  spleen. 

The  relapse  shows  a  reinfection  from  within,  but  of  the  conditions  ta- 


lot  contra- 

:ly  studicil 
at  typlioid 
ii  result  of 
: ;  (:!)  that 
I'l'inj;  from 
lliy,  liaviuLf 
if  tho  fliiM 
s  ai^ed  fivr 
xiier  fouiul 
al  reaction 
revor. 

ics,  and,  it 
.'lit  authors 

0  15  or  IS 
18«t;,  tliere 

.SOS. 

spurious  rc- 

g  noted  the 
days. 

lys,  followed 
ty-two  days, 
.\  two  of  tlu' 
H)la,  and  en- 
elapse.  The 
with  a  chill, 
wn  in  Chart 
,s  twice  seen 
iinition.  Of 
V  was  about 
f  the  relapse 

cases  will  be 
?s  are  of  this 
but  after  re- 
liii  rises  and 
more  severe 

jeen  referred 
c.  They  are 
is  not  always 

1  in  cases  in 
ose-spots  and 

conditions  fa- 


■5? 


TYIMIOII)   Fi:VKR. 


37 


vorinp:  its  occurrence  wo  as  yet  know  little.  Krrors  in  diet  arc  sonieti.nes 
held  responsible  and  occasionally  the  rise  in  temperature  follows  abruptly 
upon  some  i:;discretion.  Immunity  in  typhoid  is  ac.piired  slowly,  and  we 
know  that  even  for  a  long  period  after  the  fever  has  disapi)cared  the  ty- 
phoid bacilli  may  be  found  in  the  stools,  in  the  spleen,  and  in  the  meseii- 
icric  <rlaiids.  Cliiari  su<rjre.sts  that  the  ri'lnfcction  may  be  associated  with 
the  persistence  of  bacilli  in  tho  bile-passayes ;  an  indiscretion  in  diet  may 
cause  their  discharf,a>  into  the  intestine. 

Diagnosis.— There  are  several  points  which  the  physician  shouhl  re- 
member. In  the  first  place,  typhoid  fever  is  the  most  c(")ninH)n  of  all  con- 
tinued fevers.  Secondly,  it  is  extraordinarily  variable  in  its  manifesta- 
tions. Thirdly,  there  is  no  such  hybrid  malady  as  typho-nudarial  fever. 
And  lastly,  errors  in  dia<,'nosis  are  inevitai)le,  even  under  the  most  favor- 
able conditions.  In  at  least  4  or  5  cases  in  our  series  the  diagnosis  of 
tyjihoid  fever  was  not  made  until  autopsy. 

Data  for  Diagnosis.— (^/)  (Unci-il.—^o  single  symptom  or  feature  is 
characteristic.  The  onset  is  often  suggestive,  particularly  the  occurreiu-e 
of  epistaxis,  and  (if  seen  from  the  start)  the  ascending  fever.  The  steadi- 
ness of  the  fever  for  a  week  or  longer  after  reaching  the  fastigium  is  an 
important  point.  The  irregular  remittent  character  in  the  tliird  week 
iind  the  intermittent  features  with  chills  are  common  sources  of  error. 
While  there  is  nothing  characteristic  in  the  pulse,  dicrotism  is  s.i 
nmch  more  common  early  in  typhoid  fever  tluit  its  presence  is  alwavs 
suggestive.  The  rash  is  the  most  valmd)le  single  sign,  and  with  the  fever 
usually  clin(dies  the  diagnosis.  The  enlarged  spleen  is  of  less  import- 
ance, since  it  occurs  in  all  ft-brile  conditions,  but  with  the  fever  and  the 
rash  it  cotistitutes  the  diagnostic;  triad  of  the  disease.  The  ab.sence  of 
leucocytosis  and  the  presence  of  Ehrlich's  reaction  are  valuable  accessory 
signs. 

(//)  Sinrific—Tlw  Svntm  /Jiaf/nosis.— The  diagnosis  of  tvplioid  fever  by 
the  isolation  of  the  bacilli  during  life  is  diflieult.  Taiijiiiig  of  the  spleen 
for  the  puri.()se  is  not  a  justifiable  procedure.  Cultures  from  the  blood  give 
positive  results  in  only  a  small  number  of  instances,  thou<rh  during  the  past 
year  they  have  been  obtained  in  0  cases  in  my  wards  (.\.  H.  (Jwyii)  Cul- 
tures from  the  typhoid  stools  made  by  the  methods  of  Klsner,' Hiss  and 
others  are  really  not  suitable  for  general  clinical  puri)oses.  It  was  accord- 
ingly with  great  satisfaction  that  the  announcement  of  a  comparatively 
simple  method  of  serum  diagnosis  was  received.  In  1894  Pfeilfer  showed 
that  cholera  spirilla  when  introduc'cd  into  the  peritona>um  of  an  immu- 
nized animal,  or  vhen  mixed  with  the  serum  of  immunized  animals  lose 
their  motion  and  break  up.  Tliis  "  Pfeiffer's  phenomenon  "  of  agglutina- 
tion and  immobilization  was  thoroughly  and  systematically  studied  by 
Durham,  in  ({ruber's  laboratory.  It  is  well,  as  ^\•elch  has  pointed  out  to 
hear  in  mind  the  importance  of  this  work,  since  by  it  was  determined 
the  value  of  the  test  for  the  differentiation  of  bacterial  species  and  for  the 
determination  of  a  previous  attack  of  cholera  or  of  tvphoid  fever ;  and  also 
that  the  immobilization   and    agglutination  was  a  siiecific    effect  of  in- 


!l! 


'Ii: 


«i* 


38 


SPKCIFIf   INKECTIOUS   DISKASKS. 


m 


> 


foption  or  intoxication.     Wiiliil  took  tlio  motliod  luul  made  It  iivailublo  in 

clinicul  work. 

Method  of  Application.— Tlio  tcst^,  as  -jivcn  Uy  Widul,  aro  as  foUow.s  -.  (<o 
.]ftirr(>srnj)ir(iL—T\w  blood  or  serum  to  be  tosted  is  added  either  "to  a  youn-; 
l)onillon  culture  of  tiie  typboid  bacillus  or  to  sterile  Iwuillon,  whicb  is  tluii 
at  once  inoculated  with  the  bacillus.     In  the  former  case  the  reaction  witli 
typhoid  serum  appears  usually  within  two  or  three  hours,  and  consists  in 
clarification  of  the  previously  turbid  fluid  aiul  the  formation  of  a  clumpy 
sedinuMit  composed  of  accumulated  bacilli.     In  the  latter  case  the  tube  is 
placed  in  the  incubator,  and  within  lifteen  hours  the  reaction  is  nnmifested 
by  growth  of  the  bacilli  in  the  form  of  a  sediment  at  tlie  bottom  of  the 
tube,  the  fluid  remaininj,'  nearly  or  (piitc  dear."     (/>)  Mirrosmpic  Test.— 
The  blood  or  .serum  is  mixed  witii'M  young  bouillon  culture  or  with  a 
suspension  in  bouillon  or  .salt  solution  of  a  fresh  growth  of  the  typhoid 
bacillus,  and  a  drop  or  two  of  the  mixture  is  examined  at  once  under  the 
microscope.     With  a  dilution  of  1  to  10  this  micro.scopie  typhoid  reaction 
appears,  as  a  rule,  immediately  or  within  a  few  minutes,  and  is  evidenced 
by  loss  of  motility  and  by  dumping  of  the  bacilli  into  masses  of  various 
sizes  and  shapes."     Since  then  various  modifications  have  been  introduced 
and  the  dilution  has  been  increased,  as  a  rule  to  1  to  50  or  even  higher. 
Wyatt  Johnston  introduced  the  use  of  the  dried  blood,  which  is  of  great 
eonvenieiu-e,  and  has  developed  the  method  of  work  in  municipal  labora- 
tories.    For  fuller  details  the  student  is  referred  to  the  text-liooks  of  bac- 

teriologv. 

Results  —The  largest  collection  of  cases  has  been  given  l)y  Kneass  ai\d 
Stengd  ((iould's  Yearbook,  18!»S).     Of   2,'.>S:J  typhoid  cases  the  reaction 
was  present  in  !>5.5  per  cent.     In  l,:u;5  non-typhoid  cases  there  was  no  re- 
action in  98.4  per  cent.     The  experience  in  my  wards  of  Hlock  aiul  Gwyn 
up  to  March,  1898,  shows  that  in  151  cases  the  reaction  was  present  in  144. 
In  4  of  the  negative  cases  the  clinical  course  was  not  certain.     A  very  im- 
portant point  is  the  time  of  api)earahce  of  the  reaction.     In  only  4(J  of  the 
last  108  cases  was  the  reaction  obtained  on  the  day  of  admission.     In  only 
•  "f,  cases  of  the  series  was  the  reaction  present  before  the  seventh  day  ol 
the  disease.     It  may  be  long  delayed.     In  4  cases  it  devdoped  on  the 
twenty-second,  twenth-sixth,  thirty-lifth,  and  forty-second  days  respectivdy. 
W'hile  on  the  whole  the  serum  reaction  is  of  very  great  value,  there  ar(> 
certain  difficulties  and  objections  which  must  bo  considered.     A  perfectly 
characteristic  case  with  ha>morrh'iges,  rose-spots,  etc.,  may  give  no  reaction 
throuc^hout.    A  case  of  this  sort  has  been  reported  from  my  wards  by  (.wyn, 
in  wldch  a  so-called  paracolon  bacillus  was  repeatedly  isolated  from  the 
blood.     The  Widal  reaction  was  not  present  at  any  time  during  the  course 
of  the  disease  or  after  convalescence.     Brill  has  reported  a  series  of  IT 
cases  with  the  clinical  features  of  typhoid  fever,  but  without  the  Uidal 

reaction.  ,      ,. 

Common  Sources  of  Error  in  Diagnosis.-An  early  and  intense  localiza- 
tion of  the  infection  in  certain  organs  may  give  rise  to  doubt  at  first. 

Cases  coming  on  with  severe  headache,  photophobia,  delirium,  twitching 


^. 


TVPIIOID  FKVFIl. 


railalilo  ill 

)llows :  {(i) 
to  a  yonnt; 
icli  is  tluii 
etion  witli 
[•onsists  ill 
f  ;i  olniiipv 
the  tube  is 
manifested 
torn  of  till' 
l>ic  Test.— 
or  with  :i 
lie  typlioiil 
!  under  tlu- 
id  reaction 
i  evidenced 
5  of  various 
introduced 
yen  higher, 
is  of  great 
ipal  hibora- 
)oks  of  bae- 

Kneass  and 
lie  reaction 
3  was  no  rc- 
;  and  Gwyn 
sent  in  144. 
A  very  ini- 
ly  4(J  of  the 
n.  In  only 
enth  day  of 
ped  on  tlie 
•espectively. 
le,  there  ar(> 
A  perfectly 
no  reaction 
dsby  Gwyn, 
>d  from  the 
^  the  course 
scries  of  IT 
t  the  Widal 

use  localiza- 

,t  first. 

11,  twitching 


89 


of  the  muscles  and  retraction  ..f  tl.e  head  are  almost  invariably  rc^inle.l  as 
r,n'hro-si,uH,l  n,nm,;,Uis.  Tuder  such  .wn-umstances  it  n>ay  f^.r  a  few 
dMys  be  impossible  to  mak-,>  a  .satisfactory  diagnosis.  I  have  tlu-i,.e  per- 
omied  autopsies  on  cases  of  this  kiml  in  whici.  no  suspicion  of  typhoid 
hver  liad  been  present  the  intense  cerebro-spiual  .nanifestations  liaving 
donunated  the  scene.  I  ntil  the  appearance  of  ab.lo„,i„al  .yn.pt<.ms,  <»• 
ilierash,  It  may  -  rpute  impossible  to  determine  the  nature  of  the  case 
<  .■rebnKspn.al  nuningitis  i.s,  hoNvever,  a  rare  disoa-.e;  typhoid  fever  a  very 
;  o.nmon  om-  and  the  onset  with  severe  nervous  symptJms  is  by  no  means 
.nfre.p.ent.  l-ully  one  half  of  the  cases  of  so-caile.l  brai-i-fevef  belong  t^o 
tins  category.  ° 

I  have  already  spoken  of  the  misleading  pulmonary  symptoms,  which 
e  ■.•asionally  .hnclop  at  the  very  outset  of  the  disease.  The  bronchitis 
rarely  o^'usos  error   though  it  may  be  intense  and  attrac't  the  chief  atten- 


t  ion.     .More  diilicult  are  the  cases  setting  in  with  chill  and 


foil 


OWl'( 


rapidly 


\^y  P»e,uno>aa.     I  have  brought  such  a  case  before  the  class  one  welk  as 
typu.al  pnenmo.ua   and  a  fortnight  later  shown  the  same  case  as  undoubt- 
ed y  one  of  typboid  fever.     In  another  case,  i,i  which  the  onset  was  will, 
definite  pncun.o.ua,  no  spots  developed,  and,  though  there  were  diarrluea 
.netconsm  and  the  most  pronounced  nervous  symptoms,  the  doubt  sti  i 
.•ema.ns  whether    .t    was  a  case  of  typhoi.l   fever  or  on;  of  pneun,;.! 
n.  winch  severe  secondary  symptoms  developed.     There  is  less  da,,  r 
nustak.ng  the  pncumoM.a  which  develops  at  the  height  of  the  diseas^  an 
^'■t  this  ,s  possible,  as  m  a  case  admitted  a  few  years  ago  to  my  wa  d  - 
-  .nan  aged  seventy,  insensible,  with  a  ,lry  tongue,  tremor,  ecch/moses 
..poll  the  wnsts  and  ankles,  no  rose-spots,  enlargement  of  th    spl  cm,  am 
eonsolidation  of  Ins  right  lower  lobe.     It  was  very  natural,  p^frtic^,^  v 
s.ace  there  was  no  history,  to  regard  such  a  case  as  senile  pn  u mo  li     dth 
profound  constitutional  disturbance,  but  the  autopsy  showed  tircuu 
j..^  oristic  lesions  of  typlioid  fever.     Karly  involvemenVof  the  ^eu  lo     he 
kidneys  may  for  a  time  obs(.urc  the  diagnosis 

Of  diseases    with  which  typhoid  fever  may  be  confounded,   malaria, 

::;t  i^^-iS:"  ^'^'"'  ^^^-^^^^-^^^  tuberculous  pentomti; 

From  n,ahn-lal  fern-  typhoid  is,  as  a  rule,  readily  recognized.     There 

"la  adj.  ljpb.0  d  fever  ami  malarial  fever  in  rare  instances  may  coexist 
...  the  same  patient.  Of  .185  cases  of  typhoid  fever,  almost  all  .Sh  b  o 
examinations,  aiul  a  majority  of  them  coming  from  malarial  regions  in  no 
a  single  ms^nce  were  the  malarial  parasites  found  in  the  blood  d  ring 
the  fever.  There  is  now  no  excuse  whatever  for  the  continued  u  e  b^ 
IH-actit.oners  of  the  term  typho-malarial  fever,  and  still  less  for  i  flifi^ 
-  K,n  of  VI  al  statistics  by  death  certificates  signed  with  tin    dia^^ 

of    e      it?  '  1  '"'  ''''  '''''''''  ''  ^^■^^^^'  ^"^^^^  't  gives  a  falsf  sen  e 

•t  security,  and  may  prevent  proper  measures  of  prophylaxis.  The  au- 
umnal  type  of  malarial  fever  may  present  a  striking  .simikrityn  it   ea    v 

'lays  to  typhoid  fever.     Differentiation  may  be  made  only  by  Jho  bboc 


t 


i§m^ 


40 


KPKCiriC    INFKCTlorS    DISEASKS. 


cxiimiiuition.  Tlicrc  may  hv  no  cliills,  tlio  remissions  may  bo  oxtremH\ 
sliglit,  tluTc  is  a  liistory  pcrliaps  of  iiuihiisr,  woaknoss,  diarrlKva,  und  soni. 
times'vomitiiif:.  The  ton.^ur  is  furred  an<l  white,  tlie  elieeks  Ihislied, 
the  spleeii  slijrhtly  eiihirjied,  and  tlie  temperature  eontinuous,  or  witli  very 
sliglit  remissions.  Tlie  a'stivo-autiimnal  variety  of  tlie  mahirial  parasit- 
miiy  not  be  present  in  the  eireulatiiif,'  bb)od  for  several  days.  Kvery  ye;n 
we  have  one  or  two  cases  in  whieh  the  diagnosis  is  in  doubt  for  a  f(  \\ 

days. 

/'V^pwm.— The  long-continued  fever  of  obscure,  deep-seated   snppnni 
tion,  without  chills  or  sweats,  may  .simulate  typhoid.     The  nior- chroni. 
cases  of  ulcerative  endocarditis  are  usually  diagnosed  enteric  fever.     Th.' 
presence  or  absence  of  leucocytosis  is  an  important  aid.     The  W  idal  reac- 
tion now  offers  additional  and  valuable  lu'lp. 

Anife  milim'ii  tubermhms  is  not  infreciuently  mistaken  for  typhoid 
fever.  The  points  in  diiferential  diagnosis  will  be  discussed  uiub'r  tlmt 
disease.  Tii/icrnihits  prrifoiiifis  in  certain  of  its  forms  may  closely  simu- 
late typhoid  fever,  and  will  be  referred  to  in  aiu)tlier  section. 

Puncture  of  the  spleen  for  the  purpose  of  obtaining  cultures  is  justifi- 
able only  in  exceptional  circumstances. 

Prognosis.— (^0  /^Y^///-;v^/f'.— The  mortality  is  very  variable,  ranging 
in  private  practice  from  5  to  12  and  in  hospital  practice  from  7  to  SO  per 
cent.  In  some  large  epidemics  the  death-rate  has  been  very  low.  In  the 
recent  outbreak  at  Maidstone,  England,  it  was  between  7  and  8  per  cent. 
In  recent  years  the  deaths  from  typhoid  fever  have  certainly  diminished, 
and,  under  the  influence  of  Brand,  the  reintrotluetion  of  hydrotherapy 
has'reiluced  the  mortality  in  institutiims  in  a  remarkable  manner,  even 
as  low  as  5  or  0  per  cent.  "  Of  the  (185  cases  treated  to  January  1,  1898,  in 
my  wards,  8  per  cent  died.  The  death-rate  since  the  introduction  of  hy- 
drotherapy has  been  7.1  per  cent.  The  Metropolitan  Fever  Hospitals  still 
show  a  high  rate  of  mortality— about  17  per  cent— and  Uresehf eld  gives 
17.18  per  cent  as  the  death-rate  in  the  ]\Ionsall  Fever  Hospital  for  the  ten 
years  ending  1804.  The  last  Report  of  the  British  Army  Medical  Depart- 
ment (180(1)  show:;  an  increase  in  both  incidence  and  mortality.  In  the 
United  States  arny  for  ten  years,  to  1800,  there  was  an  average  annual 
prevalence  of  138.5'cases,  with  mortality  of  10.2  per  cent. 

{/))  Special  F'fitiires  in  /'/•or/^o.s/.v.— Unfavorable  symptoms  are  high 
fever,  toxic  symptoms  with  delirium,  meteorism,  and  htemorrhage.  Fat 
subjeks  stand  typhoid  fever  badly.  The  mortality  in  women  is  greater 
than  in  men.  The  com[)lieations  and  dangers  are  more  serious  in  the  am- 
bulatory form  in  which  the  patient  has  kept  about  for  a  week  or  ten  days. 
Karly  involvement  of  the  nervous  system  is  a  bad  indication ;  and  the  low. 
muttering  delirium  with  tremor  means  a  close  fight  for  life.  Prognostic 
signs  from  the  fever  alone  are  deceptive.  A  temperature  above  104°  may 
btt  well  borne  for  many  days  if  the  nervous  system  is  not  involved. 

(c)  Sudden  Dcaf/i.— It  \s  difficult  in  many  cases  to  explain  this  most 
lamentable  of  accidents  in  the  disease.  Tliere  are  cases  in  which  neither 
cerebral,  renal,  nor  cardiac  changes  have  been  found ;  there  are  instances 


nacs 


TYIMKHI)    Fi:VKU. 


41 


p  extremely 
I,  iuid  sonic- 
L'ks  Hushed, 
or  with  Yen 
'iiil  parasiti 
Kvery  Vt'iir 
l)t  for  ii  f(\\ 

eil  siij)piini 
iioro  chronic 
fever.     TIi- 
•  Widiil  rear- 

for  typludil 
1  uiidt'r  tliat 
closely  siiiiii- 

res  is  jiistili- 

ible,  raugiii;,' 
n  7  to  liO  jier 
low.  In  the 
il  8  per  eent. 
I  diminished, 
liydrotlierapy 
manner,  even 
ry  1,  1898,  in 
uction  of  hy- 
lospitals  still 
'schfeld  give< 
al  for  the  ten 
dieal  Depart - 
ility.  In  the 
erage  annual 

3ms  are  high 
jrrhago.  Fat 
en  is  greater 
)us  in  the  ani- 
k  or  ten  days. 
,  and  the  low. 
.  Prognostic 
jove  104°  may 
)lved. 

ain  this  most 
which  neither 
I  are  instances 


..0  in  whn.h  It  docs  n.;t  seen,  likely  that  tiuTe  could  have  heen  a  special 
localization  of  tiie  toxins  in  the  piu.nniogu.stric  centres.     Mcl'hcdran   in 
reporting  u  ca.se  of  the  kin.I,  in  uhid,   the  post  niurtcm  sh„wcd  „<,  ade- 
quate cause  of  death,  s,ig;r,,sfs  that  the  experiments  of   .M.'W  iUiam  on  su.l- 
d  11  cardiac  laih.rc  prol.ahly  explain   the  occurrence  of  .iealh  in  .•ertain  of 
tlie  cases  in  wliK'h  iieitiu-r  einholism  nor  uru'iuia  is  present,     ruder  condi 
nous  of  ahuorinal  nutrition  there  is  sometimes  iudu.-e.l  a  state  of  ,Miri„n, 
'W^v,  which   may  develop  .spontaneously,  or,  in  the  ,.ase  of  animal.s,  <„. 
.hght  irritation  of  the  heart,  with  .he  result  <.f  extrein..  irregularity  and 
l.nally  failure  of  action.     Sudden  .leatli  .xn-urs  more  frcpuMitlv  in  ni..,, 
than  in  woinc,,  according  to  Dewevre's  .statistics,  in  a  |.roport^uM.f  1 14  to 
;'.,.    It  may  occur  at  the  lu'lght  of  the  fever,  and,  as  pointed  out  i,v  Crave, 
may  also  liappen  during  convalescence. 

Prophylaxis, -In  cities  the  ].revalence  of  tvphoid  fever  is  directlv 
in-oport.onate  to  the  ii.elli..icncy  of  the  drainage'  and  the  water-sumilv 
1  here  IS  no  truer  u.dicati.m  of  tlie  sanitary  comlition  of  a  t<.wn  than  .he 
returns  o  the  num her  ,.f  cases  of  this  di.sea.se.  With  the  improvem,.nt  in 
drainage  the  mortality  in  many  citi.'s  has  heen  reduced  one  halforevn 
"'ore  One  of  the  most  striking  instances  is  atfordcl  l,v  the  eitv  of  .Munich 
Unlds  has  rcrntly  reviewed  the  sanitary  history  of'this  town  as  far  as 
typhoid  fcv,.r  IS  concerned,  and  the  iignres  are  truly  astonisliing.  The 
annual  mean  death-rate  ,,er   .()(),00()  inhahitants  was  from   18.^1   to  18.;() 

S;f'.cT      "iln'/':"'  "'•"'  '''^""  '"''   ^"  ^««'^'  '^''•' '  ^'■•^'»  ^«^'  to 
1^00,  10;  from  18!)1  to  18%,  5.(1. 

Ry  most  rigid  metho.ls  of  disii,fe..tion  much  may  bo  <lone  to  prevent 
tiie  spread  of  the  infection.  ' 

The  following  procedures,  suggested  by  (iilman  Thompson,  should  be 
earned  out  in  hospital  practice,  and,  with  modili.-atioi.s,  in  private  hous   , : 

1  lhebe,-ad..siutectantsof  typhoid  urine  ami  stools  for  pra<.ti(.d  use 
aie  (1)  a  1  ,n  500  acidulated  solution  of  corrosive  sublimate;  (ii)  a  1  in  iO 
crude  carbohc-acid  solution  ;  (iii)  chlorinated  limo. 

2.  Owing  to  the  possibility  of  injury  to  plumbing,  the  carbolic-acid  so- 
lution ,s  preferable  wherever  plumbing  is  concerned.  The  lime  is  best  for 
country  use  in  privies  and  trenches. 

;{.  The  disinfectant  should  be  thoroughly  mixed  with  the  stool  and  left 
jn  contact  with  it  for  fully  two  hours.  I-nough  of  the  disinfectant  must 
be  added  to  completely  cover  the  stool  with  the  solution 

4.  The  bed-pan  should  be  kept  ready  tilled  at  all  times  with  at  least  a 
pint  of  the  disinfectant,  into  which  the  stool  is  at  once  discharge.l,  and 
should  be  cleaned  with  scalding  water  and  one  of  the  disinfecting  so- 
lutions.  * 

5.  Rectal  thermometers,  syringes,  tubes,  and  all  utensils  coming  in  con- 
tac  with  any  of  the  fecal  matter  must  be  .lisinfected  with  the  corrosive 
sublimate  or  carbolic-acid  solution. 

(!.  After  each  stool  the  patient's  perinanim  and  adjacent  parts  should 
be  washed  and  sponged  with  a  1  in  2,000  corrosive  sublimate  solution. 
7.  Curses  and  attendants  should  be  cautioned  to  wash  their  own  hands 


4-2 


SI'KCIFIC   INFECTIOUS    DISKASES. 


tliorouu'lilv  imd  inimcrso  tlicin  in  u  1  in  1,000  rorrosivo  Buliliiniito  solution 
iiftiT  liaiullin;;  the  hcd-piin,  tiiorinoinetor,  syringe,  or  piilioiit,  or  givini: 
sponge-  or  tn])-l)uths. 

8.  All  linen  iin;l  bed-elotliing  used  by  the  ]):itieiit  sliould  be  soaked  in  n 
1  in  :20  eiirholie-acid  solution,  and  sul>se(|Ui-r,tly  boiled  (or  fully  two  hours. 

0.   Disinfeetion  of  the  stools  should  be  begun  as  soon  as  the  diagnosi 
of  enteric  fever  is  established,  and  should  be  eontinued  for  ten  days  afti  r 
the  teni|>erature  lias  remained  at  the  normal. 

10.  In  localities  where  a  proper  drainage  sj'stem  is  ladung,  the  stool« 
should  either  be  mixed  with  sawdust  and  eremated  or  buried  in  :i  troneli  1 
feet  deep  after  being  covered  with  chloride  of  linu'. 

Wlien  epidemics  are  prevalent  the  drinking-water  and  the  milk  used  in 
families  should  be  boiled.  These  precautions  should  be  taken  also  by 
recent  residents  in  any  locality,  and  it  is  much  safer  for  travellers  to  drink 
light  wines  or  mineral  water  rather  than  ordinary  water  or  milk.  Care 
should  be  taken  to  thoroughly  cook  oysters  wiiich  have  been  fattened  or 
freshened  in  streams  contaminated  with  sewage. 

The  physician  should  ever  keep  in  mind  the  fact  that  each  iiiiUriihtnl 
rtisp  of  hipliiiidfvi'cr  is  a  fonts  for  tlic  spread  of  i/w  (/isciisr.  To  mrry  out 
cffirt'ii'c  mrdsurcs  of  2)rophijlaxis  is  quite  (is  much  a  ptirf  of  his  duty  as  thr 
rare  of  the  patient. 

Aiititiiphoid  Varri)ie. — A.  E.  Wright  has  prepared  a  vaccine,  and  at  the 
Army  .Medical  School,  Xetley,  and  at  .Maidstone,  he  luis,  in  conjunction 
with' I).  Senip!(>,  inoculated  a  number  of  persons.  The  paiients'  bloo  i 
subsefpiently  gave  the  Widal  reaction,  and  they  believe  them  to  have  been 
rendered  inmiune  against  tyjthoid  fever. 

Treatment.— ('0  General  Management.— The  profession  was  long  in 
learning  that  typhoid  fever  is  not  a  disease  to  be  treated  mainly  with 
drugs.  Careful  nursing  and  a  regulated  diet  are  the  essentials  in  a  nni- 
jority  of  the  eases.  The  patient  should  be  in  a  well-ventilated  room  (or  in 
summer  out  of  doors  during  the  day),  strictly  conlined  to  bed  from  the  out- 
set, aJid  there  remain  until  convalescence  is  well  established.  The  bed 
should  be  single,  not  too  high,  and  the  mattress  should  not  bo  too  hard. 
The  woven  wire  bed,  with  soft  hair  nuittress,  upon  which  are  two  folds 
of  blanket,  combines  the  two  great  qualities  of  a  sick-bed,  smoothness 
and  elasticity.  A  ru])ber  cloth  should  be  placed  under  the  sheet.  An  intel- 
ligent nurse  should  be  in  charge.  When  this  is  impossible,  the  attending 
physician  should  write  out  specific  instructions  regarding  diet,  treatment 
of  the  discharges,  and  the  bed-linen. 

{h)  Diet.— Those  forms  of  food  should  be  given  which  are  digested  with 
the  greatest  ease,  and  which  leave  behind  the  smallest  amount  of  residue 
to  form  fiTces.  Some  regard  should  be  paid  to  the  fancies  of  the  patient. 
Milk  is  the  most  suitable  food.  If  used  alone,  three  pints  at  least  may  be 
given  to  an  adult  in  twenty-four  hours,  always  diluted  witi:  water,  lime- 
water,  or  aerated  waters.  Partially  peptonized  milk,  when  not  distasteful 
to  the  patient,  is  occasionally  serviceable.  The  stools  of  a  patient  on  a 
strict  milk  diet  should  be  examined  with  great  care,  to  see  if  the  milk  is 


TVi'iioiM  i'i;\i:i{. 


4;i 


niito  solution 
it,  or  i^'iviiiL' 

0  soiikcd  in  a 
y  two  liours. 
ho  dia;,Miosi-: 
■II  (liiys  at'trr 

ijr,  tlie  stool-' 
in  :i  troncli  1 

milk  used  in 

iikon  also  liy 

Hers  to  drink 

milk.     Care 

1  fattened  or 

■It  iiitliridHiil 

'/'()  rarnj  oiif 

is  (lutij  as  the 

10,  and  at  tlic 
I  conjunction 
iLients'  bloo  1 
to  have  l)cen 

I  was  long  in 
maiidy  with 
itials  in  a  ma- 
d  room  (or  in 
from  the  out- 
cd.  The  bod 
be  too  hard, 
are  two  folds 
1,  smoothness 
3ct.  An  intcl- 
the  attending 
iet,  treatment 

digested  with 
lilt  of  residue 
)f  the  patient. 
;  least  may  bo 
,i:  water,  limo- 
lot  distasteful 
patient  on  a 
if  the  milk  is 


(  ntiroly  digested.  Fever  iiutietits  often  receive  more  than  they  can  utilize, 
ill  ^vilich  ca.st'  musses  of  curds  are  scon  in  the  stools,  or  micros<(ipirai!v  fat- 
(■(iri.usdes  in  extraordinary  abundance.  I'ndcr  tlicso  circumstances"  it  is 
host  to  substitute,  for  part  of  the  milk,  mutton  or  cliickcn  broths,  or  l)ccf- 
jiiice,  or  a  clear  n,iist,iiniii\  all  of  which  may  be  made  very  jialatahle  by  the 
addition  of  fresh  vegetable  juices.  If,  liowever,  diarriuea  exist.s,  animal 
liroths  are  apt  to  aggnivate  it.  Some  patients  will  take  whey,  butter- 
milk, kiimyss,  or  matzoon  wlicn  the  ordinary  milk  is  distasteful.  Thin 
liarley-griiel,  well  strained,  is  an  e.xccllcnt  food  for  typhoid-fever  ])aticnts. 
Kggs  may  be  given,  either  beaten  up  in  milk  or,  better  still,  in  the  form  of 
alltumen-watcr.  This  is  jirepared  by  straining  the  whites  of  eggs  through 
a  cloth  and  mixing  them  with  an  ecpial  <|uantity  of  water.  It  may  bo  flav- 
ored with  lemon,  and,  if  the  jjalient  is  taking  spirits,  whisky  or  brandy  is 
very  conveiviontly  given  with  it.  Patients  who  are  unable  to  take  milk  can 
subsist  for  a  time  on  this  alone.  The  whole  egg  beaten  up  in  milk  or  water 
may  be  used. 

The  patient  should  bo  given  water  freely,  which  may  be  pleasantly  cold. 
Iced  tea,  barh'v-water,  or  lemonade  may  also  be  used,  and  there  is  no' objec- 
tion to  eotfeo  or  cocoa  in  moderate  (luantities:  Fruits  are  not,  as. a  ride, 
allowable,  though  the  juice  of  lemon  or  orange  may  lie  given.  Typhoid 
patients  should  be  fed  at  stated  intervals  through  the  day.  At  night  it 
depends  ujion  the  general  condition  of  the  jiaticnt  whether  he  should  bo 
aroused  from  sleep  or  not.  In  mild  ca.ses  it  is  not  well  to  disturb  the 
patient.  When  there  is  stupor,  however,  the  jiatient  should  be  roused  for 
food  at  the  regular  intervals  night  and  d..y. 

Alcohol  is  not  necessary  in  all  cases,  but  may  be  given  when  the  weak- 
ness is  marked,  the  fever  high,  and  the  luilso  failing.  In  young  healthy 
adults,  without  nervous  symptoms  and  without  very  liigh  fever,  it  is  not 
required ;  but  when  the  heart-beat  is  feeble  and  tlie  first  sound  becomes 
obscure,  if  there  are  a  muttering  delirium,  subsultus  tendinum,  and  a  dry 
tongue,  brandy  or  whisky  should  be  freely  given.  In  such  a  case  from 
eight  to  twelve  ounces  of  good  whisky  in  the  twenty-four  hours  is  a  moder- 
ate amount. 

It  would  be  too  much  like  hoisting  the  teetotaler  with  his  own  petard 
to  attribute  the  high  rate  of  mortality  from  typhoid  fever  at  the  London 
Temperance  Hospital— 1.5  to  IG  per  cent  during  the  i)ast  twenty  year.s— to 
failure  to  employ  alcohol. 

{(■)  Hydrotherapy.— The  use  of  Wiiter,  inside  and  outside,  was  no  new 
treatment  in  fevers  at  the  end  of  the  last  century,  when  .lames  Ciirrie  (a 
friend  of  Burns  and  the  editor  of  his  poems),  wrote  liis  Medical  Keports  on 
the  Effects  of  Water,  Cold  and  Warm,  as  a  Remedy  in  Fevers  and  other  Dis- 
eases. In  this  country  it  was  used  witli  great  effect  and  recommended 
strongly  by  Nathan  Smith,  of  Yale.  Since  1801  the  value  of  bathing  in 
fevers  lias  been  specially  emphasized  by  the  late  Dr.  Brand,  of  Stettin. 

Hydrotherapy  may  be  carried  out  in  several  different  ways,  of  which, 
in  typhoid  fever,  the  most  satisfaciory  are  by  sponging,  the  wet  pack,  and 
the  full  bath. 


in 

li 


'■il 


1. 


n 
k 

i! 


p- 


m^ 


44 


SPKCIKIC    IN'FKCTIOUS   DISKaSKS. 


(d)  Ciihl  Spniif/uii/.—Thi'  water  may  1h'  ti'pic],  .'ol.l,  or  i.'c-colil,  actovdinL,' 
t(»  the  hci^lit  of  tlio  fever.  A  thoroii;;!!  spoiij^e-liatli  slioiilil  take  from 
lifteen  to  twenty  minutes.  Tlio  ieo-eold  sponj^in^'  is  <iuite  as  fornii(lal)l<' 
m  the  full  cold  batli,  for  wliieh,  wlien  there  is  an  insuperable  ohjeetiun 
in  ])rivate  practice,  it  is  an  excellent  alteriuitive.  Mut  rre(|uently  it  i- 
(lillicult  to  j,'et  the  friends  to  api»reeiate  tlu^  advantaf,'es  of  tho  sp(m<,Mn:,'. 
When  such  is  the  case,  and  in  children  and  delieuto  persons,  it  can  he 
made  a  little  less  formiilalde  l)y  spouf^iuf;  liinh  hy  limh  and  then  the  hack 
and  abdomen. 

{!))  Tho  rtilil  park  is  not  so  j^'ejierally  useful  in  typhoid  fever,  but  in 
eases  with  very  ])ronounced  nervous  symi)toms,  if  tlie  tnl)  is  not  availal)lc, 
the  patient  may  be  wrapped  in  a  sheet  wruuf,'  out  of  water  at  00'  or  O-'i  , 
and  then  cold  water  sprinkled  over  him  with  an  ordinary  watering-pot. 

{<•)   The  JhitJi.— The  tub  should  be  ionj,'  enough  so  that  the  patient  can 
l)e  completely  covered  exct-pt  his  head,     in  institutions  ii  rigid  system  of 
hydrotherapy   should  be   practiced,   following    l^rand's   instructions,  with 
nioditications  to  suit  the  in<lividual  eases.     In  my  elinie,  since  the  practice 
was  introduced  by  Dr.  Lallcur  the  following  plan  has  been  carried  out : 
Every  third  hour,  if  the  temperature  is  above  lO'^. .")'',  tiie  patient  is  placeil 
in  a  hath  (at  70°  Fahr.),  which  is  wheeled  to  tho  bedside.     Tii  this  he 
remains  from  iifteen  to  twenty  minutes,  anil  is  then  taken  out,  wrapped 
in  a  dry  sheet,  and  covered  with  a  light  blanket.     Enough  water  is  used  to 
cover  the  patient's  body  to  the  neck.     The  head  is  sponged  during  the 
bath,  and,  if  there  is  much  torpor,  t-old  water  is  poured  over  it  from  a 
height  of  a  foot  or  two.     The  lind)s  and  trunk  are  rubbed  thoroughly, 
eitlua-  with  the  hand  or  with  a  suitable  "  rubber."     The  rectal  temperature 
is  taken  immediately  after  the  bath,  and  again  three  quarters  of  an  hour 
later.     The  patient  often  complains  ])itterly  when  in  the  bath,  and  sliiver- 
ing  and  blueness  are  almost  a  constant  sequence.     Food  is  usually  given 
with  a  stimulant  after  the  1)ath.     The  only  eontra-indieations  are  perito- 
nitis and  h«morrhage.     Neither  bron(>hitis  nor  pneumonia  are  so  regardeil. 
The  accompanying  chart  (Chart  IV)  shows  the  number  of  baths  and  the 
influence  on  the  fever  during  two  days  of  treatment.     The  good  effects 
of  the  baths  are:   (1)  The  reduction  of  the  fever;   (2)  tho  intellect  be 
comes  clearer,  the   stupor  lessens,  and  the   muscular  twitchings   disap- 
pear; (3)  a  general  tonic  action  on  the  lun-vous  system  and  particularly  on 
the  heart;  (4)  insomnia  is  lessened,  the  patient  usually  falling  asleep  for 
two  or  three  hours  after  each  bath ;  aTul  (5),  most  important  of  all,  tlu' 
mortality  is,  undcn-  this  plan  of  treatnumt,  reduced  to  a  minimum.     This 
liraiirl  metliod,  as  it  is  called,  has  steadily  advanced  in  favor  both  in  hospi- 
tal and  private  practice,  in  spite  of  the  difficulties  and  tho  unpleasant 
features  necessarily  connected  with  it. 

The  spongings  fre(|uently  have  to  be  substituted  for  the  tubs  in  cases 
of  extreme  weakness,  or  when  there  is  much  meteorism,  or  when  there  is 
marked  collapse  after  tho  baths.  While  a  temperature  at  70°  is  usually 
Avell  borne,  in  the  case  of  children  and  delicate  persons  the  luke-warm  bath 
gradually  cooled  may  be  employed. 


TVIMKHIi    ri;VKI{. 


45 


1,  iii'fovdin,' 
I  take  t'niin 
f()nnitlal)lc 
Ic  oltjivtiiiii 
iic'Utly  it  is 

0  spongiiif,'. 
s,  it  can  ln' 
en  tilt'  l)iiik 

fovor,  but  ill 
ot  iivailii1)l«', 
t  (iO '  or  <i")  , 
ring-pot. 
!  patient  can 
id  sj'.><terii  ol' 
ctions,  witli 
the  pruc'tiri' 
carried  out : 
;nt  is  placcil 
Tn  this  lit' 
)ut,  wnippt'il 
x>r  is  used  to 

1  during  the 
iw  it  from  a 

thoroughly, 
tenipcratuii! 
•s  of  an  hour 
1,  and  shiver- 
Lisually  given 
IS  are  perito- 
}  so  regarded. 
)aths  and  the 
good  effects 
intellect  be 
;hinga  disap- 
irticularly  on 
ng  asleep  for 
nt  of  all,  the 
imum.  This 
joth  in  hospi- 
0  unpleasant 

tubs  in  cases 
when  there  is 
ro°  is  usually 
ke-warm  bath 


Tht'  results  of  iiyilrothcrapy  are  very  gratifying.  I?y  it  in  general  Ims- 
jtit.als  from  (I  to  S  patients  in  every  limnireil  cases  are  saveil.  in  itistitn- 
(ion.s  in  which  the  expectant  or  other  plans  ot'  treatnieiit  are  eniplt.y-d, 
there  is  a  nitn-tality  of  frDiii  \->  tt.  I.-,  per  cent.  In  many  it  is  as  high  as  ir 
per  cent.  There  is  a  remarkalilc  iinilorniity  in  the  ileath-rate  in  hospitals 
which   carry  t.ut    liyilrothera'iy.     Since  .lii'lv,    ISDO,  when   we   intnnlitceil 


Jll 

»c  1 

/* 

Tvm]) 

M 

, 

■ 

*     . 

m 

• 

•■    .     i.    .  ■ 

» 

•       ^      #;..:.«       .   ;1. ,       i. 

m 

■ 

5               '• 

I        ■        i        .    ' 

'■>         i"      /    ■  •■     ■> 

:■■ 

IOC 

■     ■ 

..       .        .,     . 

.      -. 

.   ^.  ..      .       .  I..  ,      . 

vx, 

" 

•                           T 

im 

^^ 

•     a*.       .....       J,,^;^     . 

103 

v..      ^/^ 

.,  .  ,.    j,. 

t  ■ 

">> — r-'T'T''^.  ^"~>^- 

>t 

102 

vr  .  \ 

f:  '■•; 

•   r  • 
r   I'  * 

i  . 

101 

..... 

::.\::U- 

tr-i 

(•rr,       .             . 

100 

r. .' 

■  \  '-■  • ' . 

Hii--\ 

]:;..,..  ... 

go 

\;7    .      . 

•  '  •^' 

-.-:■:■:  .  -^. -.,  :• 

w 

'.      tf 

■    • 

•  ■]■■:■:  .■  ^  ••    -  ;  .    -i     ... 

•               *       '■       m       ' 

VI 

■••■4 

i    ;    t    '    ,   ... ',  -    ..--    - ,.  .    ■ 

'     •       ■       •■■■•- 

M 

Temp. 

m.'g.h! 

Pulse 

"U.i, 

,..     .      i»      ,. 

•'      '*«..'     'i'  i     *         ','  1  .   Ut     '     :     ;:.|;  ' 

:.','■        'u*- 

Rifp. 

".V  i,. 

■    '"    '   i, 

•      j,  J* 

....  f'fl  '   ».»..>       ■'  i  '"    '       "l. ..  ' 

21 

Stools 

:» 

1 

1 

! 

1 

1 

1 

>i    1  1  1  1  i  i  i  js 

1 :  i  i  "I--- 

TniTT" 

rrhio 

1 

1 

1 

1 

1 

1 

1 

1  '  1 

!         ' I 1 

1 — 1  ■  !   .   '  ,  ■ 

1'       .-i L_- 

iiiy  of 

[ffU.Sf. 

' ^,.  —i 

la 

r.i 

• 

( 

H.Uil'    l\'. 

hydrotherapy,  there  have  been  treated  in  my  wards,  tt)  .lamiary  1,  1S!»S, 
O.W  cases.  The  total  mortality  has  been  r.l  per  cent.  This  imlutles  all 
cases,  those  ailmitteil  and  tlying  within  twenty-four  tir  forty-eight  hours, 
andtho.se  in  which  the  tliagnt)sis  was  only  niatle  at  autopsy.*  Still  mtirc 
striking  by  contrast  are  tiie  figures  publisheil  by  F.  K.  Hare  from  the  Hri.-<- 
bane  Hospital  (Practitioner,  September,  ISilT).  Of  1,S-.>,S  cases  treatetl  on 
the  general  or  exiiectant  plan,  the  mortality  was  l-l.S  per  cent.  Of  !,!»()•.> 
cases  treated  since  the  introduction  of  hydrotherapy,  the  mortalitv  was 
tmly  7..')  per  cent.  Ktpially  gooil  results  have  been  obtainetl  bv  .1.  c'  Wil- 
son  and  Tyson  in  I'hilatlelphia,  by  (Jilman  Thompson  in  .New  Yt)rk,  ami  at 
numerous  hosp-'tals  in  (iermany  and  France.  The  imiiortant  (|m'stion 
comes  up  whether  the  serious  cDmplications  of  the  disease  are  increased  by 
hydrotherapy.     My  own  statistics  bear  out  Hare's  that  the  rcmarkiible  life- 


*  From  May.  188!>.  when  (lie  hospii.al  was  opiMied,  to, Inly,  1890,  tlio  onlinary  expcetaiiL 
plan  was  followed.     Tht-  mortality,  inchusivu  of  this  pt'rioil,  is  8  jier  cent. 


46 


Sri'X'IFIC    INFECTIOUS   P'SKASKS. 


siiviiif,'  ill  liydnitlu'rupy  does  not  dquMui  upon  ii  (liiiiiiuitioii  in  tiio  iiuinhcr 
of  fatal  cai^cs  from  perforation  or  from  iia!iiiorriia,ir('.     The  i»orccnta.-:('  of 
perforation  cases  in  my  series  was  '3.4S,  wliieii  is  a  little  under  the  avera-e. 
At  Brisbane  it  was  -.'.It  per  rent,  both  before  ami  after  tlio  introdiietion  of 
balii'.i.u'.     ila'inorrlia.u'e  occurs  in  from  :>  to  5  per  cent  of  '"'e  cases.     In  my 
series  it  occurred  in  1.5:5  per  cent  of  all  cases  since  Jie  lairo.liiction  of  hy- 
drotherapy.    The  Brisbane  statistics  ^ive  before  the  introduction  of  hydro- 
therapy l.S  per  cent  of  fatal  cases,  and  after  the  introduction  1.-.'  per  cent. 
A  care'riil  study  of  the  recent  statistics  shows  tiiat  neither  peri'or'ition  nor 
ha'morrha,<,^e  is  more  frecpunt  with  hydrotheraiiy.     As  to  relapse,  i*  is  moic 
ditlicult  to  speak,  the  percentage  varies  so  widely— from  :$  to  Ki.     It  must 
be  remem!)ered  that  more  cases  are  saved  to  have  rela])se.     My  percenta.iie 
i)f  T.SS  is  somewhat  above  the  averaj^e,  but  the  increase  in  the  relapses  is 
not  so  fireat  as  to  seriously  impuirn  the  treatment.     Hydrotherapy  does 
not  i)roi)abIy  shorten  the  duration  of  the  st'iy  in  liospital,  which  was  forty- 
two  days  ill  my  series.     We  do  not,  however,  send  out  our  tynhoid  cases 
until  they  are  (piite  stroni,'  and  well. 

{(I)  Medicinal  Treatment— In  hospital  practice  medicines  are  not  (ifteii 
needed.  A  <,n-i'at  majority  of  my  cases  do  not  receive  a  dose.  In  private; 
practice  it  mav  l)e  safer,  for  tlu^ young  practitioner  especially,  to  order  a 
I'nild.  fever  mixture.  The  question  of  medicinal  antipyretics  is  important : 
they  are  used  far  too  often  and  ^oo  rashly  in  typhoid  fever.  An  occasional 
dose  of  antifebrin  or  antipyrin  may  do  no  harm,  but  the  daily  use  of  these 
dru'^s  is  most  injurious.  Quinine  in  moderate  doses  is  still  much  em- 
ployed. The  local  use  of  guiaeol  on  the  skin,  3  ss  painted  on  the  Hank, 
e;\uses  a  ]irompt  fall  in  the  temperature. 

iH/isrp/ir  Mi;lir(tti()u.—\(n-y  laudable  endeavors  have  been  made  m 
many  r|uarters  to  introduce  methods  of  treatment  directed  toward  the 
destruction  of  the  tvphoid  bacrilli,  or  the  toxic  agent  which  they  produce, 
but  so  far  without  suc.'css.  <M.od  results  have  been  claimed  from  the  car- 
bolic a,nd  and  iodine  treatment.  Of.iers  advocate  corrosive  sublimate  or 
.•alomel,  ^-naphthol,  the  salic'n  preparations  and  guuu'ol.  I  can  testity 
•  to  the  inetlici.'iicv  of  the  carbolic  acid  and  iodine  and  ot  the  /3-naphthol. 
With  the  mercurial  preparations  I  liavi'  no  experience.  Fortunatdy  for 
the  patients,  a  majority  of  these  medicines  meet  one  of  the  two  objects 
.hich  Hippocrates' says  tlu'  physician  should  always  have  in  vu-w-they  do 
no  harm.  Irrigation  "of  the  clou  has  been  recommended,  with  a  view  to 
wa-'hiiur  out  the  toxic  matters  (Mosler,  Seibert). 

(.)  Eliminative  and  Antiseptic  Treatment— Basi'd  on  tie  erroneous 
view  that  the  bacterial  growth  is  chieily  in  the  intestine  itselt,  J  lustle  and 
others  ha  advocated 'what  h  known  as  th.  eliminative  and  antisep  ic 
treatment.  The  elimina/K.n  is  atti'Uii.ted  by  th..roiigh  evacuation  of  the 
l)owels  daily,  and  the  other  factor  in  the  treatment  is  the  use  ot  intes- 
tinal antiseptics,  of  which  salol  is  re..ommended.  If,  as  in  cholera  tiie 
bacilli  developed  and  produced  the  poison  in  the  intestinal  ^'ontents,  t  lere 
M.i-ht  be  some  reasona])leness  in  this  method,  but  the  bacilli  multiply  m 
tiK'  intestinal  walls,  in  the  mesenteric  glaiuls,  and  in  the  spleen.      I  hey 


are  sometime; 

An  importan 

large  series  oi 

"  the  patients 

through  the ( 

mel  purge,  so 

(/)  Antiti 

ic.il  trials  tlit 

l)een  2)laeed  o 

improvement. 

(//)  Treatn 

tympanites  an 

latter,  if  well 

great  stress  o 

directed  it  to 

the  jiatient,  ai 

water,  with  a 

the  abdomen  :i 

The  fiietvo) 

the  gas  is  in  tl 

given.     For  i\ 

r.sed  by  the  ol 

try  by  the  late 

in  the  severer 

beef-juice  and 

le.>isens.     Char( 

For  th'3  di 

four  stools  da: 

mouth,  a  comb 

the  acid  diarrl 

(TTl  15-20),  and 

iiied  to  see  thai 

('nnstfpnfioi 

do  harm,  yet  it 

If  a  laxative  if 

janos  or  Fricdri 

IfwmorrJiiiffi 

of  lead  and  opii 

h'd  taken  in  tin 

tient  to  pass  tin 

the  iynount  of 

is  u  tendency  j 

hypodermic  inj 

styptic  mixture 

warmly  recomm 

Pci'ifoin'/is.- 

plication,  tnoug! 


TYPHOID  PKv;<m. 


47 


nro  Romotimos  not  fou.i.l  in  tho  stools  until  the  cud  of  the  soc-oiid  w.vk 
An  unportaut  objection  to  the  use  of  pnr^'iitivos  is  tiio  fact  that  in  any 
lar^ro  series  of  cases  those  with  diurrho'a  do  budlv.  (iravcs  remarked  that 
"the  patients  who  liuve  escaped  tietive  purfration' before  admission  will  <r,.t 
through  the  disease  with  little  or  no  tympanites."  The  preliminary  ea!,)- 
mel  purge,  so  much  used,  is  unnecessary. 

(./■)  Antitoxine  Treatment.— I n  spite  of  many  oxp(>rinients  and  elm- 
icil  trials  the  results  are  still  unsatisfactory.  An  antityphoid  serum  has 
l)een  placed  on  the  market,  and  u  few  cases  liave  been  reported  with  rapid 
improyement. 

(//)  Treatment  of  the  Special  Symptoms.— The  abdominal  i)ain  and 
tympanites  are  best  treated  with  fomentations  or  turpentine  stup;'s  The 
latter,  if  well  applied,  give  great  relief.  Sir  William  Jenner  used  "to  lay 
great  stress  on  the  advantages  of  a  well-applied  turpentine  stupe.  II(> 
<hrected  it  to  ])e  applied  as  follows  :  A  liannel  roller  was  placed  beneath 
the  patient,  and  then  a  ('ouble  layer  of  thia  flannel,  wrung  out  of  very  hot 
water,  with  a  drachm  or  turpentine  mixed  Avitli  the  water,  was  applied  to 
the  abdomen  aiul  covered  with  tlie  ends  of  the  roller. 

The  metfvrisni  is  a  diihcuilt  and  distressing  symptom  to  treat.  AVhen 
the  gas  IS  111  the  '.arge  bow.-l,  a  tube  may  be  passed  or  a  turpentine  enema 
given,  hox  tympanites,  with  a  dry  tongue,  t:  rpentine  was  extensively 
r.sed  by  the  older  Dublin  physicians,  and  it  was  introduced  into  this  coun- 
try by  the  late  George  H.  Wood.  Unfortunately,  it  is  of  very  little  service 
m  tlie  severer  cases,  -whicli  too  often  resist  ail  treatment.  Sonietinuw  if 
beef-juico  and  all)umen-water  are  substituted  for  milk,  the  distention 
lessens.     Charcoal,  bismuth,  and  ;8-iiaplithol  may  be  tried. 

For  tli'3  dinrrlum,  if  severe— that  is,  if  there  arc  more  than  thre-  or 
four  stools  daily— a  starch  and  opium  enema  may  be  given-  or  l)y  the 
luouth,  a  combination  of  bismuth,  in  large  doses,  with  Dov  .r's  powder-  or 
the  acid  diarrha^a  mixture,  acetate  of  lead  (grs.  :>),  dilute  acetic  acid 
(TTl  15-20),  and  acetate  of  morphia  (gr.  i-J).  The  stools  should  be  exam- 
ined to  see  that  the  dia'  -iKca  is  not  aggravated  by  the  presence  of  curds 

ioHHtipntwn  IS  i^resent  in  many  cases,  and  tliougli  ]  have  nevvr  seen  it 
do  harm,  yet  it  is  well  every  third  or  fourth  day  to  give  an  ordinary  enema 
It  a  laxative  is  needed  during  the  course  of  the  disease,   the    ilunyadi- 
jaiios  or  Fiiidriclishall  water  may  be  given. 

Ifwrnorrluuii'  from  the  bowels  is  best  treated  with  full  doses  of  acetate 
of  lead  and  opium.  As  absolute  rest  is  essential,  tlie  greatest  care  should 
ba  taVen  m  the  usf,.  of  the  bed-pan.  It  is  perhaps  lietter  to  allow  the  pa- 
tient to  i.ass  tlie  motions  into  the  draw-sheet.  Ice  may  be  freelv  given  and 
the  iunount  of  food  sliould  be  restricted  for  eight  or  ten  hours.  If  there 
IS  a  tendeiHT  to  collapse,  stimulants  sliould  be  given,  and,  if  necessary 
liypodermic  injections  of  ether.  The  patient  may  be  spared  the  usu^d' 
styptic  mixtures  witli  which  he  is  so  often  dreiu-he<l.  Turpentine  is 
warmly  recommended  by  certain  authors. 

^    PeritoHilis.-\n  a  majority  of  the  cases  this  is  an  in.'vitably  fatal  com- 
plication, tiiougli  recovery  is  possible.     If  the  peritonitis  be  due  to  iierforo- 


i     i    !! 


48 


SrKCIFIC   INFECTIOUS  DISEASES. 


tion,  tho  question  of  laparotomy  slioul.l  be  immediately  tliseussed.  Ordciv 
slumld  1)0  issued  to  the  nurse,  and  in  hospitals  to  the  house  physicians,  to 
watch  carefully  for  the  iirst  symptoms  of  peritonitis.  The  recent  rc- 
Hults  arc  most  gratifying.  Finney  (Studies  ill)  and  Keen  have  recently 
reviewed  the  wliole  question.  The  latter  has  collected  «:{  ca^.'swith  Ki 
recoveries.  The  danger  of  delay  is  illustrated  by  the  following  figures : 
Of  15  cases  operated  on  within  twelve  hours,  4  recovered;  of  20  eases 
operated  on  between  the  twelfth  and  twenty-fourth  hour,  G  recovered ;  of 
13  eases  operated  on  in  tho  second  twenty-four  hours  only  1  recovered.  No 
case  \a  so  desperate,  unless  actually  moribund,  as  to  be  without  sor.ie  hop. 
in  the  bunds  of  a  good  surgeon. 

/ioiw  Lcsi(,)is.— The  tvphoid  periostitis  in  the  ribs  or  in  the  tibia  does 
not  always  go  on  to  suppuration,  though,  as  a  rule,  it  requires  operation. 
Unless  the  practitioner  is  accustomed  to  do  very  thorough  surgical  work, 
he  should  hand  over  the  patient  to  a  competent  surgeon,  who  will  clear 
out  tlie  iliseased  parts  with  the  greatest  thorouglmess.  lleeurrence  is  in- 
evitable unless  the  operation  is  complete.  _ 

For  the  progressive  hrirt-ii'v(d-m'f<^  alcohol,  strychnine  hypodermically 
in  full  doses,  digitalis,  ami  hypodermic  injections  of  ether  may  be  tried. 

The  mrvou^siimptomH  of  typhoid  fever  are  best  treated  by  hydrother- 
apv  One  special  advantage  of  this  plan  is  that  the  restlessness  is  allayed, 
the  delirium  (,uieted,  and  sedatives  are  rarely  needed.  In  the  cases  which 
set  in  early  with  severe  headache,  meningeal  symptoms,  and  high  fever,  the 
cold  bath,  or  in  private  practice  the  cold  pack,  should  be  employed.  An 
ice-cap  may  be  placed  mx  the  head,  and  if  necessary  morphia  administered 
hvpodermically.  Tho  practice,  in  such  eases,  of  applying  blisters  to  the 
narie  of  the  neck  and  to  the  extremities  is,  to  paraphrase  Iluxham's  words, 
,m  una^hoUsome  m-cr(7^,  which  should  long  ago  have  been  discarded  by 
the  profession.  For  the  nocturnal  restlessness,  so  distressing  in  some  cases, 
Dover's  powder  should  bo  given.  As  a  rule,  if  a  hypnotic  is  indicated,  it 
is  best  to  give  opium  ir.  some  form.  Pulmonary  complications  should,  U 
severe,  receive  appropriate  treatment.  . 

In  protracted  cases  very  special  care  should  be  taken  to  guard  against 
bed-sorv.^.  Absolute  cleanliness  and  careful  drying  of  the  parts  after  an 
evacuation  should  be  enjoined.  Tho  patient  should  be  turned  from  side 
to  side  and  propped  with  pillows,  and  the  back  ean  then  be  sponged 
with  spirits.     On  the  first  appearance  of  a  sore,  the  water-  or  air-bed  should 

"^  "Jm  The  Management  of  Convalesceuce.-Convalescents  from  typhoid 
fever  frequently  cause  greater  anxiery  than  patients  in  the  attack,  llic 
question  of  food  has  to  bo  met  at  once,  as  the  patient  develops  a  ravenous 
appetite  and  clamors  for  a  fuller  diet.  My  custom  has  been  not  to  allow 
solid  food  until  the  temperature  has  been  normal  for  ten  days.  Ihis  is,  1 
think,  a  safe  rule,  leaning  perhaps  to  the  side  of  extreme  caution-  but, 
after  all,  with  eggs,  milk  toast,  milk  puddings,  and  .lellies,  the  patient  can 
take  a  fairlv  varied  diet.  Many  leading  practitioners  allow  solid  food  to  a 
patient  so  soon  as  he  desires  it.     Peabody  gives  it  on  the  disappearance  of 


TYPIIOin   FEVER. 


49 


d.  Onh'iv 
^'sicians,  to 
recent  vc- 
ve  recent ly 
.!S  with  Hi 
ig  figures : 
)f  'ZO  eases 
iovered ;  of 
ivereil.  No 
soriie  liop  • 

e  tibia  does 
I  operation, 
•gieal  v--orl\, 

0  will  clear 
rence  is  iii- 

odcrmieally 
be  tried. 
[  liydrother- 
,s  is  allayed, 
cases  whieli 
rh  fever,  the 
r)loyed.  An 
dniinistered 
sters  to  the 
lam's  words, 
lisearded  by 

1  some  cases, 
indicated,  it 
ns  should,  if 

aard  against 
:irts  after  an 
ed  from  side 
he  sponged 
ir-bed  should 

rom  typhoid 
attack.  Tlie 
)s  a  ravenous 
not  to  allow 
s.  This  is,  1 
caution;  but, 
e  patient  can 
olid  food  to  a 
ippearance  of 


the  fever;  the  late  Austin   Flint  was  also  in  favor  of  giving  solid  fo,.d 
early.     I  had  an  early  lesson  in  this  matter  whi..).  [  have  never  for-otten 
A  young   ad  ,n  the  Montreal  (letuM-al  Hospital,  in  whose  case  I  warnuui; 
n.terested,  passe.,  through  a  tolerably  sharp  attack  of  tvphoi.l  fover      Two 
weeks  after  ttie  evening  temperature  had  been  norn.al,  and  only  a  dav  or 
wo  before  h,s  intended  discharge,  he  ate  several  n.utton  chops,  and  wifhin 
wenty-four  hours  wa«  in  a  state  of  collapse  fro.n  perforation.      \  s„,all 
tninsverse  rent  was  foutid  at  tbe  botton.  of  an  ulcer  which  was  in  j.rocess 
of  healing.     It  ,s  not  easy  to  say  why  soli.l  food,  particniarlv  meats,  should 
.  .sagree,  but  in  so  many"   stances  an  indiscretion  in  diet  is  follnvd  bv 
slight  fever,  the  so-called. /W.nV  m-nis,  that  it  is  in  tlie  best  interests  of  tbi- 
patient  to  restrict  the  diet  for  some  time  after  the  fever  lias  fallen       \n 
mdiscretion  in  diet  may  indeed  precMi,itat(.  a  relapse.     Tl.e  patient  niav 
be  allowed  to  sit  up  ^.r  a  short  time  about  the  end  of  the  first  week  o> 
convalescence,  and  the  perio.l  may  be  prolonged  with  a  gradual  return  of 
s  rength.     He  shoul.l  move  about  slowly,  and  wben  the  weatlier  is  favor- 
able should  be  in  the  open  air  as  mudi  as  possible.     He  should  be  guanlcd 
at  this  period  against  all  unnecessary  excitement.     Emotional  disturbance 
no    infrequently  IS  the  cause  of  recru.lesccnce  of  the  fever.    Constipation  is 
not  uncommon  in  convalescence  and  is  best  treated  bv  enemata.     A  pro- 
tracted d.arrhu..,  which  is  usually  due  to  ulceration  hi    the  colon,  mav 
retard  recovery.     In  such  cases  the  diet  should  be  restrh.ted  to  milk-,  and 
the  patient  should  be  confined  to  bed;  large  doses  of  bismuth  and  a  trin 
gent  injections  will  prove  useful. 

tre  Jn  '  'T'^'f  ^"!'^^^  ''^.t''^"  f"'^''"  <1'>^'«  "ot  require  special  measures.    The 
treatment  of  the  relapse  is  essentially  tliat  of  the  original  attack 

^Y^ong  the  dangers  of  convalescence  may  be  mentioned  t.ii,erculosis 
.•hich  IS  said  by  Murchison  to  be  more  common  after  this  than  aft  any 
other  fever.  There  are  facts  in  the  literature  favoring  this  view,  U  i t  s 
a  rare  sequel  in  this  country.  ' 

11.  TYPHUS   FEVER. 

Deflnition.-An  acute  infectious  disease  characterized  by  sudden 
ousc.  a  macuhited  rash  marked  nervous  symptoms,  and  a  termina  o  " 
usually  by  crisis,  about  the  end  of  tiie  secon.l  week  '"umon, 

Etiology.-The  disease  is  known  by  the  names  of  hospital  fever 
spotted  fever,  jail  fever,  camp  fever,  and  ship  fc^ver,  and  in  (iermanv  is' 
cancel  e.ro>f,^e»u,fie  typhus,  in  contradistinction  to  a/i^lo.uj  typhus    ' 

lyphus  IS  now  a  rare  disease.  Sporadic  cases  occur  from  t  mc  to  time 
m  the  large  centers  of  population,  but  epidemics  are  infrequent.     In 

W  M "n'lS^  "^i^  ''''''  *"^^^  '^^^^  ^'^^  -^  '^-  «"tbreal!::     1 
Ili;i^"aL         ^^^    '  '  "^         '"  "'"""'^  "^  ^^^^  -'"'  "'^^  J'Wl-'lolphla 

novertv  'P^;' n'^'TT''  'i"  '^''  "''"^'"^  "^  '^^P^"'«  '''  overcrowding  ami 
poveity.     As  Hirsch  tersely  puts  it,  "  Die  Geschichte  des  Typhus  ist  die 


■  l.v 


i 


a.|; 


gQ  SPECIFIC   INFECTIOUS   DISEASES, 

dos  monsfhliclion  Eloiuls."      Overcrowding,  lack   of   clcanliiu'ss,   intoni- 
poranco,  and  l)ad  food  are  predisposino;  causes.     Tlie  disease  still  lurks  in 
the  worst  (puirters  of  London  and  (ilasgow,  and  is  seen  oceaHioiuilly  m 
Now  York  and  IMiiladelpliia.    It  is  more  common  in  (ireat  Britain  and  Ire- 
l;ind  than  in  other  parts  of  Europe.     Durinji  1S97  there  were  only  :5  cases 
of  typhus  in  London  fever  hosi)itals.     Murchison  held  that  typhus  might 
originate  spontaneously  under  favorable  conditions.     This  opinion  is  sug- 
gested by  the  oi'curreiice  of  local  outbreaks  under  circumstances  which 
render  it  diilicult  to  explain  its  importation,  but  the  amilo-y  nf  other  in- 
fectious diseases  is  directly  against  it.     In  1877  there  oec-   -ed  a  lo-al  out- 
break of  typhus  lit  the  llouso  of  Kefuge,  in  Montreal,  in  whi    i  city  the 
disease  had  not  existed  for  many  ye:."s.     The  overcrowding  was  so  great  in 
the  basement  rooms  of  the  refuge  that  at  night  there  were  not  more  than 
88  cubic  feet  of  space  to  each  person.     Kleven  individuals  were  aifected. 
It  was  not  possible  to  trace  the  source  of  infection. 

Typhus  is  one  of  the  most  highly  contagious  of  fe])rile  affections.  In 
epideniics  nurses  and  doctors  in  attendance  upon  the  sick  are  almost  inva- 
riably attacked.  There  is  no  disease  Avhieli  has  so  many  victims  in  the 
profession.  In  the  extensive  epidemic  in  the  early  and  middle  part  of  tliis 
century  many  hundred  physicians  died  in  the  discbarge  of  their  duty. 
Casual  attendance  upon  cases  in  limited  epidemics  does  not  appear  to  be 
very  risky,  but  when  the  sick  are  aggregated  in  wards  the  poison  appears 
coiicentratcd  and  the  danger  of  infection  is  much  enhanced.  Bedding 
and  clothes  retain  the  poison  for  a  long  time. 

The  microbe  of  tvpl.ns  fever  has  not  yet  been  determined.  Strcpto- 
baeiUi,  diplococci,  and  an  ascomycete  liave  been  described  in  the  blood 
and  tissues,  but  the  (piestion  still  remains  open  for  investigation. 

Morbid  Anatomy.— The  anatomical  cbanges  are  those  which  result 
from  intense  fever.  The  blood  is  dark  and  fluid ;  the  muscles  arc  of  a  deep 
red  color,  and  often  show  a  granular  degeneration,  particularly  in  the 
heart;  the  liver  is  enlarged  and  soft  and  may  liave  a  dull  clay-like  lustre; 
the  kidnevs  are  swollen ;  there  is  moderate  enlargement  of  the  spleen,  and 
•  a  general  hvperplasia  of  the  lymph-follicles.  IVyer's  glands  are  not  ulcer- 
ated. Broi'ichial  catarrh  is  usually,  and  hypostatic  congestion  of  the  lungs 
often,  present.     The  skin  shows  the  petechial  rash. 

Symptoms. -Incubation.-Th is  is  placed  at  about  twelve  days,  but 
it  may  be  less.     There  mav  be  ill-defined  feelings  of  discomfort.     As  a  rule, 
however,  the  hivasion  is  "'abrupt  and  marked  by  chills  or  a  single  rigor, 
followed  by  fever.     The  chills  mav  recur  during  the  first  few  days,  and 
there  is  headache  with  pains  in  the  back  and  legs.     There  i,=  early  pros- 
tration, and  the  patient  is  glad  to  take  to  his  bed  at  once.     Tie  tempera- 
ture is  high  at  first,  and  may  attain  its  maximum  on  th  ■  -econd  or  third 
(lav.     The  pulse  is  full,  rapid,  and  not  so  frequently  dicroi-  as  in  typhoid. 
Tlie  tongue  is  furred  and  white,  and  there  is  an  early  tendency  to  dry- 
ness.    The  face  is  fiushed,  the  eyes  are  congested,  the  expression  is  dull 
and  stupid.     Vomiting  mav  be  a  distressing  symptom.     In  severe  cases 
mental  symptoms  are  present  from  the  outset,  either  a  mdd  febnle  de- 


TYPHUS   FEVEH. 


M 


^s,  inti'iii- 
11  luvks  in 
liouiiUy  in 
n  iuul  Iiv- 
ily  '.i  cii.scs 
luis  iniglu 
ion  is  siig- 
u'os  wliiih 
r  other  iii- 
L  lo^'iil  out- 
i  city  till' 
so  great  ill 
more  tliiiii 
•e  iiirocted, 

^tions.  In 
[most  iiivii- 
ims  in  the 
Kirt  of  this 
their  duty, 
[ipenr  to  he 
;on  ai)pears 
IJedding 

I.     Strcpto- 
the  hlood 
II. 

•hieh  result 
re  of  a  deep 
irly  in  the 
like  lustre ; 
spleen,  and 
e  not  ulccr- 
)f  the  lungs 

re  days,  but 
As  a  rule, 
single  rigor, 
w  days,  and 
,?  early  pros- 
le  tempera- 
)nd  or  third 
i  in  typhoid, 
ency  to  dry- 
ission  is  dull 
severe  cases 
i  febrile  de- 


lirium or  an  excited,  active,  almost  maniacal  condition,     r.ronchial  catanh 
is  common. 

Stage  of  Eruption. — From  the  third  to  tlic  fifth  day  the  eruption  ii]i- 
poars — first  upon  the  abdomen  and  upjier  })art  of  the  diest,  and  then  upon 
llie  extremities  and  face ;  developing  so  rapidly  that  in  two  or  three  days 
it  is  all  out.  There  are  two  elements  in  the  erui)tion  :  a  subcuticular  iiidt- 
tling,  "a  fine,  irregular,  dusky  red  mottling,  as  if  below  the  surface  of  the 
skin  some  little  distance,  and  seen  through  a  semi-opaque  medium  "  {\U\- 
clianan);  and  distinct  papular  rose-sjiots  whieji  change  to  pctecliia'.  In 
some  instances  the  petechial  rash  comes  out  with  the  rose-spots.  ("oUic 
describes  the  rash  as  consisting  of  three  parts — rosc-colorcd  spots  wliicli 
disappear  on  jircssure,  dai'k-red  spots  which  arc  modiiied  by  pressure,  and 
])etechia!  upon  which  pressure  produces  no  effect.  In  children  the  rash  at 
first  may  present  a  striking  resemblance  to  tliat  of  measles,  and  give  as  a 
whole  a  curiously  mottled  appearance  to  the  skin.  The  term  mulberry  rasii 
is  sometimes  applied  to  it.  In  mild  cases  the  eruption  is  slight,  but  even 
then  is  largely  petechial  in  character.  As  the  rash  is  largely  liamiorrliagic, 
it  is  permanent  and  does  not  disappear  after  death.  Usually  the  skin  is 
dry,  so  that  sudaminal  vesicles  are  not  common.  It  is  stated  by  some 
authors  that  a  distinctive  odor  is  present.  During  the  sec(md  week  the 
general  symptoms  are  much  aggravated.  The  prostration  becomes  more 
marked,  the  delirium  more  intense,  and  the  fever  rises.  The  patient  lies 
on  his  back  with  a  dull  expressionless  face,  flushed  checks,  injected  con- 
junctivae, and  contracted  pupils.  Tlie  pulse  increases  in  frequency  and  is 
feebler;  the  face  is  dusky,  and  the  condition  becomes  more  serious.  Re- 
tention of  urine  is  common.  Coma-vigil  is  frequent,  a  condition  in  which 
the  patient  lies  with  open  eyes,  but  quite  unconscious;  with  it  there  may 
l)e  subsultus  tendinum  and  picking  at  the  bedclothes.  The  tongue  is  dry, 
brown,  and  cracked,  and  there  are  sordcs  on  tlic  teeth.  Respiration  is 
accelerated,  the  heart's  action  becomes  more  and  mon;  enfeebled,  and  death 
takes  place  from  exhaustion.  In  favorable  cases,  about  the  end  of  the 
second  week  occurs  tlie  crisis,  in  which,  often  after  a  deep  sleep,  the  pa- 
tient awakes  feeling  much  better  and  with  a  clear  mind.  The  tempera- 
ture falls,  and  although  the  prostration  may  be  extreme,  convalescence  is 
rapid  and  relapse  very  rare.  This  abrupt  termination  liy  crisis  is  in  strik- 
ing contrast  to  the  mode  of  termination  in  typhoid  fever. 

Fever. — The  temperature  rises  steadily  during  the  first  four  or  live 
days,  and  the  morning  remissions  are  not  marked.  The  maximum  is  usu- 
ally attained  by  the  fiftli  day,  when  the  temiierature  may  be  105",  lOf!",  or 
107°.  In  mild  cases  it  seldom  rises  above  10;j°.  After  reaching  its  maxi- 
mum the  fever  generally  continues  with  slight  morning  remissions  until 
the  twelfth  or  fourteenth  day,  when  the  crisis  occurs,  during  which  the 
temperature  may  fall  below  normal  within  twelve  or  twenty-four  liours. 
Preceding  a  fatal  termination,  there  is  usually  a  rapid  rise  in  the  fever  to 
108°  or  even  109". 

The  heart  nay  early  show  signs  of  weakness.  Tlie  llrst  sound  be- 
comes feeble  and  almost  inaudible,  and  a  systolic  murmur  at  the  apex  is 


II 


Ko  SPECIFIC'   INPHCTlors  DISEASES. 

not  infroquont.     IIyi)ostatic  congestion  of  tlio  lungs  ocouns  in  ull  sovcit 

rases. 

Tlio  hniin  symptoms  are  usually  moro  pronounci'd  than  in  typhoid,  and 
tlie  delirium  is  more  constant. 

Tho  urine  in  typhus  shows  the  usual  fehrile  iiu-rease  of  urea  and  uric 
acid.  The  chlorides  diminish  or  disapi)ear.  Alhnmin  is  present  in  a  largo 
proportion  of  the  cases,  hut  nephritis  seldom  occurs. 

Variations  in  the  course  of  the  disease  are  naturally  common.  There 
are  malignant  cases  which  rapidly  prove  fatal  within  two  or  three  days; 
the  so-called  /ijp/iitx  xitlcraus.  On  the  other  hand,  during  epidemics  there 
are  extremely  mild  cases  in  whicli  the  fever  is  slight,  the  delirium  absent, 
and  (convalescence  is  estahlishcd  hy  the  tenth  day. 

Complications  and  Sequelae.— Broncho-pneumonia  is  perhaps  t' 
most  common  complication.  It  may  pass  on  to  gangrene.  In  cerb 
epidemics  gangrene  of  the  toes,  the  hands,  or  the  nose,  and  in  children 
noma  or  cancrnm  oris,  have  occurred.  Meningitis  is  rare.  Paralyses, 
wliicli  are  probably  duo  to  a  post-febrile  neuritis,  are  not  very  uncom- 
mon. Septic,  processes,  such  as  parotitis  and  abscesses  in  the  subcutane- 
ous tissues  and  in  the  joints,  are  occasionally  met  with.  Nephritis  is  rare, 
lla'matemosis  may  occur. 

Prognosis.— The  mortality  ranges  in  dii?orent  epidemics  from  Vi  to 
'.'()  per  cent.  It  is  very  slight  in  the  young.  Children,  who  are  quite  as 
frcfpiently  attacked  as  adiUts,  rarely  die.  After  middle  age  the  mortality 
is  high,  in  some  epidemics  M)  \K'r  cent.  Death  usually  occurs  toward  the 
close  of  the  second  week  and  is  due  to  the  tox:emia.  In  the  thin  week  it 
more  commonly  residts  from  pneumonia. 

Diagnosis.— During  an  epidemic  there  is  rarely  any  doubt,  for  tlio 
disease  presents  distinctive  general  characters.  Isolated  cases  may  be  very 
iliiticult  to  distinguish  from  typhoid  fever.  While  in  typical  instances  the 
eruption  in  the  two  alfcctions  is  very  different,  yet  taken  alone  it  may  be 
deceptive,  since  in  typhoid  fever  a  roscolous  rash  may  be  abundant  and 
there  may  be  occasionally  a  sul)cuticular  mottling  and  even  petechia". 
■  The  dilTerenco  in  the  onset,  jiarticuhirly  in  the  temperature,  is  marked; 
l)ut  cases  in  which  it  is  important  to  make  an  accurate  diagnosis  are  not 
usually  seen  until  the  fourth  or  fifth  day.  The  suddenness  of  the  onset, 
the  (greater  frequeiu'y  of  the  chill,  and  the  early  prostration  are  the  dis- 
tinctive features  in  typhus.  The  brain  symptoms  too  are  earlier.  It  is 
easy  to  put  down  on  paper  elaborate  differential  distinctions,  which  are 
practically  useless  at  the  bedside,  particularly  when  the  disease  is  not  pre- 
vailing as  an  epidemic.  In  sporadic  cases  the  diagnosis  is  sometimes  ex- 
tremely ditlicult.  I  have  seen  Murchison  himself  in  doubt,  ajid  more  than 
once  I  have  known  a  diagnosis  to  be  deferred  until  the  miio  cadrireris. 
Severe  cerebro-spinal  fever  may  closely  simulate  typhus  at  the  outset,  but 
the  diagnosis  is  usually  clear  within  a  few  days.  :\Iiilignant  variola  also 
has  certain  features  in  common  with  severe  typhus,  but  the  greater  extent 
of  the  haemorrhages  and  the  bleeding  from  the  mucous  membranes  make 
the  diagnosis  clear  within  a  short  time.     The  rash  at  first  resembles  that 


TYPHUS   FEVRR. 


63 


Jill  seven ■ 

[)lioid,  and 

a  aiid  uric 
ill  a  large 

>n.  Thrro 
liroo  days ; 
inics  tliere 
Lim  absent, 

crliaps  t't 
In  cert)  J. 
n  childroii 
Paralyses, 
■ry  unc'oni- 
snbeutaiie- 
itis  is  rare. 

from  I'i  to 
iro  quite  as 
e  mortality 
toward  the 
in    week  it 

ibt,  for  tlu! 
nay  be  very 
stances  the 
e  it  may  be 
Lindant  and 
L  petechia', 
is  marked ; 
)sis  arc  not 
I  tlie  onset, 
ire  the  dis- 
ci ier.  It  is 
,  which  are 
3  is  not  pre- 
metimes  ex- 
more  than 
)  cadfivcris. 
outset,  but 
variola  also 
ater  extent 
ranes  make 
embles  that 


of  measles,  bnt  in  the  latter  the  eruption  is  bri-jhtor  red  in  color  often 
-le-qcentic  or  irrcfTular  in  arran<,'ement,  and  appears  first  on  the  face' 

The  frequency  with  which  other  diseases  are  mistaken  for  typhus  is 
sliown  by  the  fact  that  during  and  following  the  epidemic  of  hSSl  in  Now 
^  ork  108  cases  were  wrongly  <liagnosed— one  eiirhth  of  t!i(<  entire  number 
—and  sent  to  the  Riverside  Hospital  (F.  W.  Chapin). 

Treatment.— The  general  nnmagement  of  the  disease  is  like  that  of 
typhoid  fever.  Hydrotherapy  should  be  thorougldv  and  systematically 
employed.  Judging  from  the  good  reults  which  we  liave'obtained  b'y 
tins  method  in  typhoid  cases  with  nervous  symptoms  much  may  l)e  ex- 
I)ccted  from  it.  Certain  authorities  have  spoken  against  it,  but  it  shouhl 
l)e  given  a  more  extended  trial.  Medicinal  antipyretics  are  even  less  suit- 
able (lian  in  typhoid,  as  the  tendency  to  heart-weaknes.?  is  often  mor<" 
pronounced.  As  a  rule,  the  patients  require  from  the  outset  a  supportin-' 
treatment;  water  should  be  freely  given,  and  alcohol  in  suitable  dose-T 
according  to  the  condition  of  the  pulse. 

The  bowels  may  be  kept  open  by  mild  aperients.  The  so-called  spe- 
cific medication,  by  .sulphocarbolates,  the  sulphides,  carbolic  acid,  etc  is 
not  commended  by  those  who  have  had  the  largest  experience.  The  s'pe- 
.lal  nervous  symptoms  and  the  pulmonary  symptoms  should  be  dealt  witii 
as  in  typhoid  fever.  In  epidemics,  when  the  condition,-,  of  the  climate  arc 
suitable,  the  cases  are  best  treated  in  tents  in  the  oiien  air. 

III.  RELAPSING    FEVER  {Febris  recurm,.,). 

Definition.— A  specific  infectious  disease  caused  by  the  si)irocha>te 
(spirillum)  of  Obermeier,  characterized  by  a  definite  febrile  paroxysm 
which  usually  lasts  six  days  and  is  followed  by  a  remission  of  about  "the 
same  length  of  time,  tlu>n  by  a  second  paroxysm,  which  may  be  repeated 
three  or  even  four  times,  whence  the  name  relapsing  fever. 

Etiology.— This  disease,  which  has  also  the  names  "  famine  fever  " 
and  "seven-day  fever,"  has  been  known  since  the  early  part  of  the  eight- 
eenth century,  and  has  from  time  to  time  extensively  prevailed  in  Fun)])e 
especially  in  Ireland.  It  is  common  in  India,  where  the  conditions  f(.r 
Its  development  seem  always  to  be  present,  and  where  it  lias  been  specially 
studied  by  Vandyke  Carter,  of  Hombay.  It  was  first  seen  in  this  country 
in  1844,  when  cases  were  admitted  to  the  Philadelphia  Hospital,  which  are 
described  by  Meredith  Clymer  in  his  work  on  fevers.  Flint  saw  cases  in 
^'"^f  r>?';  ,  l"A^"^  '^  prevailed  extensively  in  epidemic  form  in  New  York 
and  I  liiladelphia  ;  since  then  it  has  not  appeared. 

The  special  conditions  under  which  it  develops  are  similar  to  tho<e  of 
typhus  fever.  Overcrowding  and  deficient  food  are  the  conditions  whicb 
seem  to  promote  the  rapid  spread  of  the  virus.  Neither  age,  sex,  nor  sea- 
son seems  to  have  any  special  intliicnce.  It  is  a  contagious  disease  an.l 
may  be  communicate.l  from  person  to  person,  but  is  not  so  contagious  as 
typhus.  Murchison  thinks  it  may  be  transported  by  fomites.  One  attack 
does  not  confer  immunity  from  subsc(iuent  attacks.     In  187:3  Obermeier 


if 


i  ;i 


54 


SPECIFIC   IXFKCTIOl'S   DISEASKS. 


•Icsoribfd  an  or;.'anisin  in  the  l.lixxl  which  is  now  rccofrnizcd  as  the  8pooi(i( 
iigont.     This  spirillum,  or  more  ci.rnvtlx  spirochu'tc  is  fruin  ;5  to  (i  tinu- 
the  Icnfith  of   the  diainctcr  ol'  a   rfd  hlood-corpusclc,  and  forms  a  nurn-v, 
spiral  lilanicnt  whicli  is  readily  seen  moving  am(mg  tho  n>d  corpusck's  diir 
in-X  a  i)aroxystn.     They  arc  i)ros("nt  in  the  hlood  only  durin.uj  tho  fcvir. 
Slu.rtly  hfforf  the  crisi's  and  ii\  tho  intervals  they  arc  not  found,  thoujili 
small  "jrlisKMiinsi  hodics,  which  arc  slated  to  be  their  spores,  appear  in  thr 
blood. ""  The  disease  has  been  produced  in  luiman  beings  by  inoculation  villi 
blood  taken  during  the  paroxysm.     It  has  also  been  produced  in  monkeys. 
Med-b>igs  mav  suck  out  the  spirilla,  and  Tictin  reproduced  the  d'sease  liy 
injecting  into  a  healthy  mcmkey  blood  sucked  by  a  bug  from  an  infectcl 
mimkey.     Nothing  is  yet  known  with  reference  to  the  life  history  of  tiie 
si)irocha'te.     It  has  not  ])een  found  in  the  secretions  or  excretions. 

Morbid  Anatomy.— Tbere  are  no  characteristic  anatomical  appear- 
ances in  relapsing  fever.  If  death  takes  place  during  the  i)aroxysm  the 
sideen  is  large  and  soft,  and  the  liver,  kidneys,  and  heart  show  cloudy 
swelling.  There  may  be  infarcts  in  the  kidneys  and  .spleen.  The  bone 
niarrow^has  been  found  in  a  condition  of  hyperplasia.  Kcchymoses  are 
not  uncommon. 

Symptoms.— The  iiinilHilin,  appears  to  be  short,  and  m  some  ni- 
stances  the  attack  develops  i)romptly  after  exposure;  more  frequently, 
however,  from  live  to  seven  days  elapse. 

The  inrasin,,  is  abrupt,  with  chill,  fev(  r,  and  intense  pain  in  the  back 
and  lindis.  In  voung  persons  there  may  be  nausea,  vomiting,  and  convul- 
si(ms.  The  teinperature  rises  rapi.lly  and  may  reach  104°  on  the  evening 
<,f  the  lirst  dav.  Sweats  are  common.  The  pulse  is  rapid,  ranging  from 
11(»  to  i;}().  There  mav  be  delirium  if  the  fever  is  high.  Swelling  of  the 
s])lein  can  be  detected  early.  .Jaundice  is  common  in  some  epiilemics. 
The  gastric  symptoms  may  l)e  severe.  There  are  seldom  intestinal  .symp- 
toms. Cough  may  l)e  present.  Occasionally  herpes  Is  noted,  and  there  may 
he  miliary  vesicles  and  petechiie.  During  the  paroxysm  the  blood  inva- 
riably shows  the  spirocluttc,  ami  there  is  usually  a  leucocytosis  (Ouskow). 
After  the  fever  has  persisted  with  severity  or  even  with  an  increasing  in- 
tensity for  live  or  six  days  the  crisis  occurs.  In  the  course  of  a  few  hours, 
accoinpanied  by  profuse' sweating,  sometimes  by  diarrluwi,  the  teniperature 
falls  to  norm.il  or  even  su1)normal,  and  the  period  of  apyrexia  begins. 

The  crisis  may  occur  as  early  as  the  third  day,  or  it  may  be  delayed  to 
the  tenth  ;  it  usually  comes,  however,  about  the  end  of  the  first  week.  In 
delicate  and  elderly  persons  there  may  be  collapse.  The  convalescence  is 
rapid,  and  in  a  few  days  the  patient  is  up  and  about.  Then  in  a  wi-ek, 
usually  on  the  fourteenth  day,  he  again  has  a  rigor,  or  a  series  of  chills ; 
the  fever  returns  and  the  attack  is  repeated.  A  second  crisis  occurs  from 
the  twentieth  to  the  twenty-third  day,  and  again  the  patient  recovers 
rapidly.  x\s  a  rule,  the  relapse  is  shorter  than  the  original  attack.  A 
set'ond  and  a  third  may  occur,  and  there  are  instances  on  record  of  even  a 
fourth  and  a  fifth.  In  epidemics  there  are  cases  which  terminate  by  crisis 
on  the  seventh  or  eighth  day  without  the  occurrence  of  relapse.     In  pro- 


^ 


the  8po('iii( 
!  to  <)  tiino 

s  11  luirrov, 
)uscli's  (liir 

lllC    fl'VtT. 
111(1,  tllOll^'ll 

i])i'iir  in  tlir 
ihition  villi 
111  monkeys. 
i  (I'si'use  liy 
iiii  iutVctcil 
story  of  tlir 

)US. 

lical  iipiH'iir- 
iroxy.siu  the 
show  cloiuly 
Tlie  boiu' 
liyniorfes  arc 

in  soiiu'   iii- 
I  l'i'0(jiicntly, 

in  the  buck 
iind  eonvul- 
the  t'Vonin<i 
iinirins  i'l'oni 
;'lling  of  till' 
0  epitlomics. 
.'stinal  syniji- 
:ul  tlu'iT  may 
)  blood  inva- 
is  (Ouskow). 
ncreasing  in- 
II  few  bonrs, 
tempcratnro 
bojfins. 
M'  (lolayod  to 
rst  wot'k.     In 
ivali'sct'iicc  is 
n\  in  a  wcok, 
ries  of  chills ; 
s  occnrs  from 
iont   recovers 
il  attack.     A 
ord  of  even  a 
nate  by  crisis 
ipse.     In  i)ro- 


i;i:L.\i'siN(i  Fi:vi:i!.  kk 

;rai'rcd  rases  tlic  convalcs.'i'ricc  i<  very  tiMlimis,  as  the  patient  i<  iiiiieji  ex 
liaiisteil. 

KelapsiiiL'  fever  is  not  a  very  fatal  disea-^e.  Muivliison  states  that  the 
MKirtality  is  ahout  1  per  cent.  In  the  enfeelijed  and  ohl,  death  may  occur 
at  the  hei.Lrlit  of  the  tirst  jyaroxysm. 

Complications  are  not  frecpient.  In  some  epidemics  nephritis  and 
lia-matiiria  have  occurred.  Pneumonia  apjiears  to  lie  freijUeiit  and  mav 
interrupt  the  typical  course  of  tlie  disease.     The  acute  enlai^'cment  of  the 


lor  li 


iiii  i)° 


vy.i" 


M  I  1' 


'j&ti' 


CiiAHT  v.— Krlapsiiii,'  Ffver  (Murc'liiso 


spleen  may  end  in  rupture,  and  the  ha-morrhaire  from  the  stomach,  which 
has  been  met  with  occasionally,  is  probably  associated  with  this  enlarfje- 
lueiit.  I'ost-febrile  paralyses  may  occur.  Ophthalmia  has  followed  cer- 
tain epi(U; 'ic.;,  and  may  prove  a  very  tedious  and  serious  complication, 
.laundice  has  already  been  mentioned.  In  i»re;nriiaiit  women  abortion  usu- 
ally takes  place. 

Diagnosis.— The  onset  and  irenerarsymptoms  may  not  at  first  be  dis- 
tinctive. At  the  be<rinniii,y  of  an  epidemic  the  cases  are  usually  rejxarded 
as  anomalons  typhoid;  but  once  the  typical  conrse  is  followecl  in  a  case 
the  dia.irnosis  is  clear.     The  blood  examination  is  distinctive. 

Treatment. — The  paroxysm  can  neither  he  cut  short  nor  can  it.s 
recurrence  be  jirevented.  It  miffht  be  thonght  that  (piinine,  with  its  pow- 
erful action,  would  certainly  meet  the  indications,  but  it  does  not  seem  to 
have  the  .slightest  influence.  The  disease  must  be  treated  like  any  other 
continueil  fever  by  careful  nursing,  a  regular  diet,  and  ordinary  hygienic 
measures.  Of  special  symptoms,  pains  in  the  back  and  in  the  linibs  and 
joints  demand  opium.  In  enfeebled  persons  the  collapse  at  the  crisis  may 
lie  serious,  and  stimulants  with  ammonia  and  digitalis  should  be  given 
freely. 


5r. 


sPKciFic  ixr-'EcTiors  DIsr.ASF.S. 


' 


IV.  SMALL  POX  ( I  „;/„/„). 

Definition.— An  :u-nu-  int'.'ctiuus  disfiisc  cliiiriU'tcriscil  I'V  an  tTup- 
tion  wl.icli  imssfs  tlirou-rli  tlic  sta-.'s  ..f  imi-uIc  vcsi.lc  pusiul.'.  aiM 
crust.  The  imicous  nicmlmiiu's  in  roiitiut  with  tlu'  air  may  also  la- 
i.iTcctCl.  SovcMv  fasi's  may  W  complicated  with  cutaneous  and  visceral 
Inemorrhaires. 

Etiology.—It  lias  not  vet  been  determined  in  what  country  sma.l- 
pox  originated.  The  disease  is  said  to  have  existed  in  China  many  centu- 
ries befin'O  Christ.  The  j>rs/,i  >Hii;/>ni  descrihed  hy  <ialen  (ami  of  which 
Marcus  Aurdius  died)  is  lielievcd  to  he  snu.ll-pox.  In  the  sixth  century 
it  prevailed,  and  subse(pu'Utly.  at  the  time  of  the  Crusades,  he.ame  wide- 
spread. It  was  hroujiht  to  America  hy  the  Spaniards  early  in  the  sixteenth 
century.  The  first  accurate  account  was  L'iveu  hy  Kliazes,  an  Arahiaii 
phvsiciau  who  lived  in  the  niutli  century,  and  whose  admirable  description 
is  available  in  (ireenhiirs  translation  for  the  Sydenham  Society.  In  the 
seventeenth  centurv  a  tliorou<rh  study  of  tlie  disease  was  made  by  the  illus- 
trious Sydenham,  who  still  remains  one  of  the  most  trustworthy  authorities 

on  the  subject.  .  . 

Special  events  in  the  historv  of  the  disease  are  the  introduction  of  in- 
oculation into  Europe,  by  Lady  Mary  Wortley  Monta-u,  in  KIS,  and  the 
discovery  of  vaoeinatiou  by  Jenuer,  in  V,W>. 

Small-pox  is  one  of  the  most  virulent  of  contajrious  diseases,  and  i)er- 
sous  exi.osed,  if  uni-rotected  by  vaccination,  are  almost  invariably  attacked. 
There  are  instances  (^n  record  of  [.ersous  insusceptible  to  the  disease.  It  is 
said  that  Diemerbroeck.  a  celela'ate.l  Utrecht  professor  in  the  seventeenth 
centurv,  was  not  onlv  himself  exempt,  but  likewise  many  members  ot  his 
family"  One  of  the  nurses  in  the  small-pox  department  of  the  Montreal 
(General  Hospital  .stated  that  she  had  never  been  successfully  va.nnated, 
•md  she  certainlv  had  no  mark.  Such  instances,  however,  of  natural  im- 
niunitv  are  very  rare.  An  attack  may  not  protect  for  life.  There  are  un- 
doubted cases  of  a  second,  reputed  instances,  indeed,  of  a  third  attack. 

1  «(>  _Small-pox  is  common  at  all  a.<res,  but  is  particularly  fatal  to  youn,<,' 
children  The  Miis  in  utvm  mav  be  attacked,  but  only  if  the  mother 
herself  is  the  su"bjeet  of  the  disease.  The  child  may  be  born  with  the  rasli 
out  or  with  the  scars.  More  commonly  tlc^  fcetus  is  not  aifected,  and 
children  born  in  a  small-pox  hospital,  if  vaccinated  immediately,  may  escape 
the  disease ;  usually,  however,  they  die  early. 
.S-p,)-.— :Males  and  females  are  equally  att'ected. 

p,„re  —  \mon2  aboriginal  races  small-pox  is  terril)ly  fatal.  \\  hen  the 
disease  was  iirst  introduced  into  America  the  Mexicans  died  1)y  thousaiuls, 
and  the  North  American  Indians  have  also  been  freriuently  decimated  by 
this  pla<rue.  It  is  stated  that  the  negro  is  especially  snsceptil)le,  and  the 
mortdit"j'  is  greater-about  \-i  per  cent  in  the  l)lack,  against  :?!)  per  cent  in 

tiie  white  (W.  M.  Welch).  .-     .       i   • 

The  confaqinm  develops  in  the  system  of  the  small-pox  patient  an.l  is 
reproduced  in  the  pustides.     It  exists  in  the  secretions  and  excretions, 


SMALL-POX. 


57 


nil  cruii- 

lulc.  ami 

illsii    In- 

I  visciTiil 

try  siiii'Vl- 
iiy  cent  II- 
ul'  wliirli 
1  I'l'iituiy 
inu'  wiilc- 
sixtt'cnth 
I  Anil)iaii 
L'soriptinii 
.  In  the 
tlie  illus- 
uthoritios 

ion  of  iii- 
■!,  and  the 

;,  anil  ]wv- 
■  attackfil. 
•asi'.     It  is 
■ventecntli 
oers  of  his 
3  Montroal 
•acrinatcil, 
atural  ini- 
ere  arc  uu- 
ittack. 
il  to  younjz 
ho  niotlior 
til  the  VA^\\ 
x'cted,  and 
may  escape 


When  the 

thousands, 

inmated  hy 

le,  and  the 

per  cent  in 

ticnt  and  is 
excretioiis, 


and  in  the  exhalations  from  the  iimirs  and  the  skin.  The  dried  .scales  eon- 
stitiite  hy  far  tile  most  iiiii>ortant  eieineiit,  and  as  a  dust-like  jiowder  an- 
distriliuted  everywhere  in  tlie  room  diirinj:  convaleseeiioe,  hecomiiiLr  at- 
tached to  clotliiiiiT  and  various  articles  of  furniture.  The  disease  is  iirolja- 
lily  contairious  from  a  very  early  staj^'e,  thonjrli  I  think  it  lias  not  yet  liecn 
determined  wiietiier  the  contujrion  is  active  lud'ore  tlie  eruption  develo|is. 
Tiie  poison  is  of  unusual  tenacity  and  (ding's  to  infected  localities,  it  is 
conveyed  liy  persons  who  have  Iieen  in  contact  with  the  si(  k  and  hv  foniites. 
Durin.ir  epidemics  it  is  no  doubt  widely  spread  in  street-cars  and  pulilic 
conveyances.  It  must  not  he  foi-irottcn  that  an  unprotecti'd  person  iii;,v 
contract  a  very  virulent  form  of  the  disease  from  the  iiiihl  vai'ioloid.  'I'he 
ipiestion  of  at^rial  transmission,  of  jrrcat  importance  in  connection  with  the 
situation  of  hospitals,  can  not  he  rc.iranU'd  as  llnally  settled.  Certain  facts 
ar(>  in  its  favor,  as  those  reported  l)y  Voun,':.  Of  ;{(i  inises  whi(di  oc(iirre(I 
witliiu  .500  yards  of  tlie  ilastin.^s  small-pox  pavilion,  tlie  iicrcciita'rc  of 
small-pox  attacks  to  population  ranged  from  4. -J  witiiin  the  loo-vard  circle 
to  O.v'  in  the  400-  to  500-yard  circle. 

The  disease  smoulders  here  and  tlici'e  in  different  localities,  iiiid  when 
conditi(Uis  are  favorahle  iiecomes  eiiidcinic  Perhaps  tiie  most  rcmarkahlc 
instance  in  modern  times  of  the  raiiiil  extension  of  the  disease  occurred  in 
Montreal  in  18S,5.  Small-jiox  had  been  i>revalent  in  that  city  between 
ISTO  and  1ST5,  when  it  died  out,  in  part  owiiirr  to  the  exhaustion  of  suit- 
able material  and  in  part  owing  to  the  introduction  of  animal  vaccination. 
The  health  reports  short'  that  the  city  was  free  from  the  disease  until  l.ss.-). 
Durinir  these  years  vaccination,  to  which  many  of  the  French  C'anadii'iis 
are  opposed,  was  much  neglected,  so  tliat  a  large  unprotected  population 
grew  up  in  the  city.  On  February  -.'Stii  a  Pullman-'ar  conductor,  who  had 
travelled  from  Chicago,  where  the  disease  had  been  slightly  prevalent,  was 
admitted  into  the  Hotel-Dieu,  the  civic  small-pox  hospital  being  at  the 
time  closed.  Isolation  was  not  carried  out,  and  on  the  1st  of  April  a  serv- 
ant in  the  hospital  died  of  smuU-pox.  Following  her  decease,  witii  a  neg- 
ligence absolutely  criminal,  the  authorities  of  the  hospital  dismi.ssed  all 
patients  presenting  no  symptoms  of  contagion,  who  could  go  liome.  The 
disease  spread  like  Are  in  dry  grass,  and  within  nine  montiis  there  died  in 
the  city,  of  small-pox,  ;3,l(j4  persons. 

The  nature  of  the  rotifdc/iiim  of  small-pox  is  still  unknown.  Weiirert 
and  others  have  described  micro-organisms  in  the  jiock,  l)ut  they  are  the 
ordinary  pus  cocci,  and  the  part  which  they  play  in  the  atfectioii  is  by  no 
means  certain.  Still  less  definite  are  the  olwervations  on  the  occurrence 
of  sporozoa  in  the  pocks.  It  is  not  a  little  remarkable  that  in  a  tlisease 
which  is  rightly  regarded  as  the  type  of  all  infectious  maladies,  the  sjiecitii! 
virus  still  remains  unknown. 

Morbid  Anatomy.— A  section  of  a  papule  as  it  is  passing  into  the 
vesicular  stage  shows  in  the  refe  nuirositm,  close  to  the  true  skin,  an  area 
in  which  the  cells  are  smooth,  granular,  ami  do  not  take  tlie  staining  fluiil. 
This  represents  a  focus  of  coagulation-necrosis  due,  according  to  W'eiircrt, 
to  the  presence  of  micrococci.     Around  this  area  there  is  active  iuflamma- 


58 


SlM'.Cll'lC    INI'r.CTInlS    KISKASKS. 


t..iT  reaction,  and  in  tli''  vesicular  sta-.'i'  tlu-  ivti-  mu.'nsum  presents  re- 
liriili,  or  spaces,  wiiirli  eoiiiaiu  serum,  leueocytes,  aiitl  tihriu  tilaiiieiit<. 
The  central  ilepression  or  iiniliilication  corresponds  to  tiie  area  of  primary 
iH'cnisis.  In  the  sta^'*' <'f  maturation  the  reticular  spaces  lieeimii'  tilled 
with  iellcoeytes  and  many  of  the  cells  of  the  retc  mucosum  hecouie  Vesicu- 
lar. The  papilhe  of  tl'.e  true  skin  iielow  the  pustule  are  swollen  and  iniil- 
trated  with  eiidiryoiiic  cells  to  a  variahle  deirree.  if  the  suppuration  ex- 
lends  into  this  liiyer,  scarrin;;  iiu'vital.ly  results ;  hut  if  it  is  conlined  to 
the  ui.per  layer,  this  does  not  m-cessarily  follow.  In  the  haMin.rrhajiic  cases 
red  corpuscles  pass  out  in  larire  numliers  from  the  vessels  and  oecui.y  the 
vesicidar  spai'cs.  They  intiltrate  uUn  the  deeper  layers  of  the  epidermis  in 
the  skin  adjacent  to  the  jiapules.  Frei|uently  a  hair-follicle  passes  throUL'ii 
the  centre  of  a  papule. 

In  the  mouth  the  pu>tules  may  he  seen  ui>on  the  ton;:ue  and  the  Imoal 
mucosa,  and  on  the  palate.  The  eruption  may  lie  a))undant  also  in  the 
pharynx  and  the  upjx'r  part  of  the  o'sopha^'us.  in  exceptionally  rare  cases 
the  eruption  exti'iids  down  the  o'sopha,i:us  and  even  into  the  stomach. 
Swelling'  of  the  I'.'yer's  foUi.des  is  not  uncommon;  tiie  jmstules  have  heen 
seei'i  in  the  rectum. 

In  the  larynx  the  eruption  may  lie  associated  with  a  liiiriiious  exudate 
and  .sometimes  with  .edema.  ( iccasionully  tli.'  inllammation  penetrates 
deejily  ami  invilves  the  cartila,<res.  In  the  trachea  and  bronchi  there  may 
he  idcerative  erosions,  hut  true  pocks,  such  as  are  st'en  on  the  skin,  do  not 
occur.  There  are  no  special  lesions  of  the  lumrs,  hnt  eon<!;estion  and  hron- 
eho-pneumonia  are  very  common.  Tlie  liver  is  sometimes  fatty.  .\  ditTuse 
hepatitis,  associated  with  intense  eon.-restion  of  the  ves.sels  and  ini<,n'atioii 
of  the  leucocytes,  has  heen  descrilied  ;  Weijj;ert  has  noted  small  areas  of 

I'Oerosis. 

There  is  nothini,'  spei  lal  in  the  condition  of  the  lilood,  aiul  even  m  the 
most  maliirnant  cases  there  are  no  miiroscopic  alterations.  In  the  blood- 
drop,  however,  it  will  1)0  seen  that  the  corpuscles,  instead  of  forniing  rou- 
leaux, are  ag.irrepited  into  irre.irnhir  clumps.  An  active  leucocvtosis  is 
present.  Tlu-  heart  occasionally  shows  myocardial  chai\,<,U's,  jiarenehyma- 
tous  ami  fatty;  ondocanlitis  and  pericarditis  arc  uncommon.  French 
writers  have  described  an  endarteritis  of  the  eoromu-y  vessels  in  connection 
with  small-pox.  The  spleen  is  markedly  enlar<red.  Apart  from  the  cloudy 
swellin.U  and  areas  of  coagulation-necrosis  lesions  of  the  kidneys  are  not 
common.  Nephritis  may  o.'cur  during  convalescence.  Chiari  has  called 
attention  to  the  fre.jueiicy  of  orchitis  in  this  disease ;  there  are  scattered 
areas  of  necrosis  with  cell  iniiltration. 

In  the  luemorrhagic  form  extravasations  are  found  on  the  serous  and 
mucous  surfaces,  in  the  parenchyma  of  organs,  in  the  connective  tissues, 
and  about  the  nerve-sheaths.  In  one  instance  I  found  the  entire  retro- 
peritoneal tissue  infiltrated  with  a  large  coagiilum,  and  there  were  also  ex- 
tensive extravasations  in  the  course  of  the  thoracic  aorta.  IlaMuorrhages 
in  the  bone-marrow  have  also  been  described  by  Golgi.  There  may  be 
hcvmorrhages  into  the  muscles.     Tontick  has  described  the  spleen  as  very 


SMAI.I  -I'o.X. 


')!» 


-il'lltS    I'c- 

ilaiiu'iits. 
liriiiiarv 
nil'  tilli'il 
ic  vi'siiii- 
iinil  iiiliU 
aliiiii  f\- 

lllilltMl    tn 

ijiii-  cases 

•I'llpy  tllr 

(li'i'iiiis  in 
s  tlinpiij:ii 

111'  lill(i;il 

SI)  in  till' 

ran'  rases 

stoniaili. 

Iiave  heen 

s  exmlate 
penetrates 
tluTi'  may 
in,  ill)  nnt 
ami  Imm- 
A  (iilTnse 
mifiration 
11  areas  of 

yen  in  the 
the  l)lo()(l- 
•ming  rou- 
>cyt(>sis  is 
reiieliynm- 
1.  French 
•onnection 
the  eloiuly 
ys  are  not 
has  called 
3  scattered 

serous  and 
ive  tissues, 
iitire  retro- 
?re  also  ex- 
'inorrhages 
re  may  be 
een  as  very 


tirm  ami  han!   in  lia- rrhagic  small-|in\,  ami  si  rh  was  the  mse  in  seven 

iiislanct's  which  I  examineij.  'I'iie  liver  has  hceii  (iesci'ilicij  us  fatly  in 
tliese  rapid  ca-^es,  hut  in  "•  i.f  my  T  eases  it  was  of  normal  si/e,  dense,  luid 
tirm.  in  •.'  it  was  iarge  and  fatty;  hiil  one  man  iiad  necrosis  i.f  the  tiliia, 
ami  the  other  was  a  drunkard.  Tiie  ecchyinoses  are  scattered  over  tlie 
meninges  of  tliehniin  and  cord,  and  in  one  case  tiicrcw:i>  a  c|i,t  in  the 
rigiit  ventricle,  in  .">  of  the  cases  there  were  area.*  of  ha'iiiorrhagic  infaiv- 
tion  of  tile  lung.  In  four  instances  tlie  ju'lves  (d"  the  kidney  wdv  hh..  ked 
witii  dark  cints,  wiiicli  exicmled  into  tlie  calices  and  dnwn  the  ureter.). 
Ill  one  instance  the  coats  of  the  hladder  were  uniformly  ha-iiiorrhagic  and 
not  a  trace  of  normal  tissue  couhl  lie  seen,  'riie  extravasations  in  tiio 
mucous  memhraiu'  of  the  stonuidi  and  intestines  were  numerous  and  large. 
I'eyer's  glands  were  swollen  and  proiiiiiieiit  in  four  instances. 
Symptoms.— Three  forms  of  small-pox  are  descrihed  : 
1.   Viiriohi  irra  :  {a)  Discrete,  (//)  C'ontlueiit. 

•».   Vfiriiifd  //(niKirr/ifti/ini  ;   (ti)   i'urpura  variolosa  or  hiack   small-pox; 
(//)   Ila'iiiorrhagic  pustidar  form,  variola  ha'niorrhagica  piistulosa. 
:i.    I'lirin/iiii/,  or  small-i»ox  nioditied  hy  vaccination. 

1.  Variola  Vera— The  ail'ection  may  he  conveniently  descriiieil  nmler 
various  stages  :  {n)  hiriih(itii,,i. — "  From  nine  to  lifteeii  days  ;  ofteiie.st 
twekc."  I  have  seen  it  develop  on  the  eighth  day  after  exposure  to  in- 
fectron,  and  there  are  well-authenticated  instances  in  which  the  stage  of 
inciihatii.n  has  lieeii  prolonged  to  twenty  days.  It  is  unusual  for  iiatieiits 
to  coinplain  of  any  symptoms  in  this  stage. 

{h)  lin'ii^l(iji.—\n  adults  a  cjuU  and  in  ehildri'ii  a  coiivul>ion  are  com- 
mon initial  symptoms.  There  may  he  repeated  chills  within  the  first 
twenty-four  hours.  Intense  frontal  headache,  severe  liimhar  jiains,  and 
vomiting  are  very  constant  features.  The  pains  in  the  hack  and  in  tiiu 
limhs  are  more  severe  in  the  initial  stage  of  this  than  of  any  other  eruir 
tive  fever,  and  their  comliination  with  headache  and  voinitiiig  is  so  sug- 
gestive that  in  epidemics  precautionary  measures  may  often  he  taken  sev- 
eral days  hefore  the  eruption  decides  jiositively  the  nature  of  the  disease. 
The  tem])erature  rises  quickly,  and  may  on  the  first  day  he  lo:i  or  l(i4". 
Tile  pulse  is  rapid  aiul  full,  not  often  dicrotic.  In  severe  cases  there  may 
he  marked  delirium,  particularly  if  the  fever  is  high.  Tlie  patient  is  rest- 
less and  distressed,  the  face  is  lluslied,  atcl  the  eyes  are  hright  and  dear. 
The  skin  is  usually  dry,  though  occasionally  tliere  are  profuse  sweat.s. 
One  can  not  judge  from  tiiese  initial  symptoms  wliether  a  case  is  likely 
to  he  discrete  or  continent,  as  the  most  intense  haekache  ami  fever  may 
precede  a  very  mild  attack. 

In  this  stage  of  invasion  the  .so-called  iiutial  rashes  may  occur,  of  which 
two  forms  can  he  <listinguished— the  diffuse,  scarlatinah'and  the  macular 
or  measly  form ;  eitlier  of  whicli  may  he  associated  with  petechia' and  oc- 
cui>y  a  variable  extent  of  surface.  In  some  instances  they  are  general,  hut 
as  a  rule  they  are  limited,  as  pointed  out  by  Simon,  either  to  tlie  lower 
abdominal  areas,  to  the  inner  surfaces  id"  the  thighs,  and  to  the  lateral 
thoracic  region,  or  to  the  axilhe.     Occasionally  thev  are  found   over  the 


«■* 


no 


SPEvIFlC   INFECTIOUS   DISEASP:^^. 


it 


m'i 


extcMi.or  snrfiices,  parti-ularlv  in  tlio  iicighbovhoo-l  of  the  knees  ami  elbows. 
Thc^e  nislu's,  usiuillv  purpuric,  are  often  associated  with  an  erythematous 
or  ervsipeh.cous  blush.  The  searhitinal  rasli  may  come  out  as  early  as  the 
second  .hiy  and  be  as  ditfuse  and  viv'd  as  in  a  true  scarhitma.  The  measly 
rash  mav  also  be  dilfuse  and  ideiitical  in  character  with  that  of  measles 
Urticaria  is  o.dy  occasionally  seen.  It  was  present  once  m  my  Montreal 
cases      \pparently  these  initial  rashes  are  more  abundant  m  some  epidemics 


s         il         10        II 


13        14       IS        16        i:        19 


lOO" 


.300' 


38-0' 


37  0' 


timpm 

■HHT™" 


Initi;il  Im'vit  Erupt  iou. 


Siiiipurative  Fever. 

CiiAKT  VI.— True  small-pox. 


tl-m  in  others;  thus  thov  were  certainly  mo.e  numerous  lu  .he  Montreal 
epidemics  between  IStO  and  ISTo  than  they  were  in  the  more  extensive 
epidemic  in  1SS5.  Thev  occur  in  from  10  to  10  ""  eent^of  cases  In  the 
cas-s  under  my  care  in  the  small-pox  department  at  the  Montreal  Ceneral 
Hospital  the  percentage  was  i:5.*  A^-  •  dl  be  .absequently  mentioned  these 
initial  rashes  ..ave  considerable  diaj-nostic  value.  ,      ,      ,,     ^ 

(r)  Erupt i'>ti—(\)  In   the  lU^ercte  form,  usually  on  the  fourth  «ay, 

.ma  1  red  spots  appear  on  the  forehead,  particularly  at  ^lie  junction  w.th 

tlie  liair  and  on  the  wrists.     Within  the  first  twenty-four  hours  from  their 

..ppearance  thev  occur  on  other  parts  of  the  face  and  on  the  extremities, 

.1  .   ..-.v  are  s.'en  on  the  trunk.     As  the  rasli  con.es  out  the  temperature 

falls,  the  ueneral  svmptoms  subside,  and  the  patient  feels  com  ortable.     On 

the  fifth  or  sixth  day  the  papules  cliau.ire  into  vesie.es  with  clear  summits. 

f'  .h  one  is  elevated,  circular,  ami  presents  a  little  depression  m   he  centre, 

tile  ...-called  umbilication.     About  the  eighth  day  the  vesicles  change  into 

p,„tules,  the  umbilication  disappear.,  the  flat  top  assumes  a  globular  h.nn 

ind  becomes  grayish  yellow  m  color,  owing  to  .lie  contained  pu.s.      I  he ic 

is  an  areola  of  injection  about  the  pustules  and  the  skm  ''etwc.Mj  them    -, 

swollen.     This  matu-ation  first  takes  place  on  the  lace,  and  ioll^^^.  the 

onler  of  the  appearance  of  tlie  eruption.     The  temperature  now  n.es- 

secondarv  tVvei-and  the  gc.eral  <>mptoms  return.     The  swelling  rl.out 

the  pustules  is  attended  with  a  good  deal  of  tension  and  pa--  in  the  face, 


Tlio  initial  Uaslios  >f  Small-, i"X. 


('ana 


'  I  Medical  nnd  Suri,'ical  .(ournal.  18T3. 


vimtum 


SMALl.-l'oX. 


01 


,1,0  .vc-lids  hoc.omo  swollen  a.i.l  c-l.-s..].     TIumv  is  ii  well-nuirknl  Lurocyt..- 
is  iu'th.'  stii-.'  oi  suppuration.     In  llu-  disnrt.  form  the  temperature  of 
;,,,turuti..n   does  not  usually  ren.ain  lu^h   for  more  than  twenty-lour  or 
w  ntv-six  hours,  so  that  on  the  tenth  or  eleventh  day  the  fever  disappears 
„.l  the  sta.e  of  ..onvales..enee  he,nns.     The  pustules  rapidly  dry    jrst  on 
,;•„,,  ,Hd  then  on  the  other  parts,  and  hy  the  fourteenth  or  htteenth 
!  Iv  des.,uan,ation  n.ay  he  far  advaneed  on  the  faee.     There  maybe  in 
,,ldition  vesieles  in  the  mouth,  pharynx,  and  larynx,  eausmj:  soreness  and 
w     in^   in   these  parts,  with   loss  of  voiee.     Whether  pitting  takes  plaee 
,,,nend;  a  ,-ood  deal  upon  the  severity  of  the  disease.     In  a  ma.ior.ty  o 
;;,]!!:!  Sydenham's  statement  lu.lds  .ood,  that  "  it  is  very  rarely  the  case  that 
the  d'stinet  small-pox  leaves  its  mark."  ,,         , 

(■^)    Th'   CnnUnn,!  /'.n/^-With   the  same   initial   sympt<.ms,  though 
usu ailv  of  greater  severity,  the  rash  appears  on  the  fourth,  or,  aeeording  to 
Svdenham;  on  the  third  day.     The  more  the  eruption  shows  i  self  before 
the  fourth  dav,  the  m<.re  sure  it  is  to  beeoine  .■ontluent  (Sydenham).     J  he 
papules  at  iir^t  may  be  isolated  and  it  is  only  later  in  the  stage  of  matu- 
a  ion  that  the  eruption  is  eontUieiit.     Hut  in  severer^  ease,  the  skin  is 
swollen  and  hypenemie  an.l  the  papules  are  very  elose  together.     On    ho 
feet  and  hands,  too,  the  papules  are  thiekly  set;  more  scattered  on  the 
limbs;  and  quite  disc'rete  on   the  trunk.      Witl,  the  appearance   of   the 
eruption  the  symptoms  subside  and  the  fever  remits,  but  not  to    he  same 
extent  as  in  the  discrete  form.     Occasionally  the  temperature  tails  to  nor- 
„,,1  andthe  patient  may  be  very  comfortable.     Then,  usually  on  the  eighth 
,l,v  the  fever  a-ain  rises,  the  vesicles  begin  to  change  to  pustules,  the 
h'vperaMnia   about    tliem   becomes  intense,  the  swelling  of   the  tace   and 
Innds  increases,  and  by  the  tenth  day  the  pustules  have  fully  maturated, 
nvmv  of  them  have  coaleseed,  and  tlie  entire  skin  of  the  head  and  extremi- 
tts  "is  a  sup.>rtlcial  abs..ess.     The  fever  rises  to  10:5°  or  1W%  the  pulse  is 
from  110  to  1-20,  and  there  is  often  delirium.     As  pointed  out  by  Syden- 
him   salivation  in  adults  and  diarrluea  in  children  are  common  symptoms 
of  this  sta-^e.     There  is  usually  mu.di  thirst.     Tlie  eruption  may  also  bo 
iHvsent  in  the  mouth,  and  usually  the  pharynx  and  larynx  are  involved  and 
the  voice  is  huskv.    (ireat  swelling  of  tlie  cervical  lymphatic  glands  occurs. 
\t  this  sta^'e  the  patient  presents  a  terrible  picture,  une(iualled  m  any 
other  disease;  one  which  fully  justifies  the  horror  and  fright  with  which 
sMvill-poK  is  asso.'iated   in  the  public  mind.     Even  when  the  rash  is  con- 
tlueiit  cm  the  face,  hands,  and  feet,  the  pustules  remain  discrete  on  t.ie 
trunk      The  dan-'er,  as  pointed  out  by  Sydenham,  is  m  proportion  to  the 
,n„uber  upon  the  faee.     "  If  upon  the  fare  they  are  a.  thick  as  sand  it  is 
„  ,  •ulvanta"e  to  have  them  few  and  far  lietween  on  the  rest  of  the  body. 
h    fatal  cases,  bv  the  tenth  or  eleventh  day  the  jnilse  gets  feel)ler  and  more 
ripi'd   the  delirium  is  marked,  there  is  subsultus,  sometimes  diarrluea,  and 
xvitn 'these  svmpt>.ns  the  patient  dies.     \n  other  instanees  between  tiio 
ei^hth  aiu.  ele-enth  dav  luemorrliagic  symptoms  develop.     ^^  hen  rec.v- 
fvy  takes  place,  the  patient  enters  on  the  eleventh  or  twelfth  day  the 
period  of — 


m^ 


02 


SI'HCIFK"    IXFKCTInrs    DISKASKS. 


{(I)  Th'siiCdIitin.—'Yhc  pustuli'S  Itrciik  and  tlu'  pus  oxudos  and  forin.-, 
crusts.  Tlirmij^tlioiit  tho  third  week  the  dosi.'catioii  procoeds  and  in  ciisi  s 
of  niodoratc  severity  tlu'  seeonchiry  fever  subsides;  hut  in  others  it  may 
persist  until  the  fourtli  week.  The  erupts  in  eonlhient  siuall-pox  adlierc 
for  a  h)ng  time  and  the  jjroeess  of  searrin.ic  may  take  tliree  or  four  weeks. 
The  crusts  on  the  face  fall  off,  hut  the  tough  epidermis  of  th.e  hands  and 
foet  may  he  slied  entire.  AVe  had  in  the  small-pox  department  of  tiie 
Montreal  (ieneral  Hospital  .several  mouhls  in  ei)ithelium  of  the  hand  5  and 

feet. 

••>.  Hemorrhagic  small-pox  occurs  in  two  forms.  In  om-  t;ie  special 
symptoms  appear  early  ami  death  follows  in  from  two  to  six  days.  This 
Is  the  so-called  petechial  or  black  small-pox— y>»/7'"/v?  vdrinlnsn.  In  the 
other  form  the  case  progresses  as  one  of  ordinary  variola,  and  it  is  not 
until  the  vesicular  or  pustular  stage  that  iKcmorrhage  takes  ])lace  int<i  the 
pocks  or  from  tlie  mucous  meml)ranes.  This  is  sometimes  called  rarinht 
hrDKirrlnif/iiti  jnisfii/iisd. 

Ila-morrliagic  small-pox  is  more  common  in  some  epidemics  than  in 
others.  It  is  les.s  frequent  in  childrt'ii  than  in  adults.  Of  ^'7  cases  ad- 
mitted to  the  small-pox  department  <jf  the  Montreal  (ieneral  Hospital 
there  were  '.)  under  ten  years,  4  between  fifteen  and  twenty,  !)  between 
twenty  and  twenty-live,  T  betwei'U  twenty-tive  and  thirty-live,  :3  between 
thirty-tive  and  forty-iive,  and  1  alx.ve  fifty.  Young  and  vigorous  persons 
seem"  more  liable  to  this  form.  Several  of  my  cases  were  above  the  aver- 
age in  muscuhir  development.  Men  are  more  fre(iuently  alfected  than 
w'omen;  thus  in  my  list  there  were  il  nudes  and  only  0  females.  The 
inlluence  of  vaccination  is  shown  in  the  fact  that  of  the  cases  \i  were  un- 
vaccin.ited,  while  not,  one  of  the  i:?  who  had  sears  had  been  revaccinated. 

The  clinical  features  of  the  forms  of  lia'inorrhagic  snudl-pox  are  some- 
what ditferent. 

In  purpura  vnridliixd  the  illn"ss  st;;rts  with  the  usual  symptoms,  but 
with  more  intense  constitutional  disturlKince.  On  the  evening  of  th.e 
second  or  on  the  third  d;;y  there  is  a  ditTu-e  hypi-ru'iuic  rash,  particularly 
in  the  groins,  with  small  punctiform  he.'morrhagcs.  The  ra.-h  extends, 
becomes  more  distinctly  ha'tnorrhiigie,  and  tiie  spots  increa>e  in  size. 
Ecchymoses  appi'ar  on  the  conjunctiva',  and  as  early  as  the  third  day 
tliere"  niav  be  ha-morrhagi  s  from  the  mucous  membranes.  Death  nuy 
take  place  before  the  rash  appears.  This  is  truly  a  terrible  alle<'t ion  and 
well  developed  cases  present  a  frightful  apiiearance.  The  skin  may  have 
a  uniformly  purjtlish  lute  and  the  unforlunate  vii'tim  may  even  lotik  i»him- 
colored.  The  face  is  swollen  and  large  conjunctival  hu'iiiorrhages  with 
the  deeply  sunken  cornea'  give  a  ghasily  appearance  to  the  features.  The 
mind  may  r  ■•n.;in  clear  to  t!ie  end.  Death  occurs  from  the  third  to  the 
sixtli  day;  thus  in  thirteen  of  my  cases  it  took  place  on  or  before  this 
date.  The  earliest  death  wa^  on  the  third  day  ami  there  were  im  trac  s  of 
papuU's.  There  n\ay  be  no  mucous  ha'uiorrhages  ;  thus  in  one  ease  oi  a 
most  virulent  charaeU'r  di-ath  occurred  withcut  bleeding  early  on  the  fourth 
day.     Iliematuria  is  perhaps  most  comnu)n,  next  luematemesis,  ami  mekena 


S.MALL-l'OX. 


g;] 


^  and  fonii.s 
iiiiil  ill  cases 
hers  it  may 
l-pox  adiiti'r 
•  t'dur  weeks. 
('  liaiids  am 
ineiit  of  till 
le  liaiiil  i  am 

'  t.H'  special 
days.  Til  is 
'dsa.  Ill  the 
iiid  it  is  not 
•Uico  into  the 
•ailed  variiihi 

lilies  than  in 
'il  casos  ud- 
?val  Hospital 
y,  9  botwetn 
e,  U  between 
I  irons  persons 
ove  the  aver- 
[ilTected  than 
oinales.  The 
■s  1-i  were  nn- 
'vaceinated. 
)ox  are  soiiic- 

ymptoins,  hnt 

eiiinj;  of  tl;e 
1,  i)arti(nhirly 
ra.-li  extends, 
I'ea^e  in  sizi . 
he  thinl  (h;y 
Diatli    111;  y 

ailcctioii  and 
kin  niiiy  have 
en  lotik  iiluni- 
Drrha.ii'es  with 
eatures.     'J'he 

third  to  the 
or  lief  ore  this 
I'e  no  traci  s  of 

one  ease  of  a 

on  the  fourth 
is,  and  nielivna 


v.ii.  noticed  in  a  third  of  the  cases.  Metrorrliajjia  was  present  in  one  only 
iif  the  six  females  on  my  list.  IlaMiu'iitysis  occiirreil  in  live  ca.^es.  Tlu' 
lulse  in  this  form  of  small-pox  is  rapid  and  often  hard  and  small.  The 
respirations  are  jri'eatly  increased  in  fi'e(|ueiuy  ami  out  of  all  pidportioii  to 
t!ie  intensity  of  the  fever.  In  the  case  of  a  neirro,  whose  respirations 
t!ie  moriiin.i,'' after  admission  were  '.Vi  and  temperature  101  ,  after  examin- 
iiiir  the  hiiiLrs  and  lindinjf  nothing'  to  acconnt  for  the  relatively  rapid 
iireathinjf,  my  susjiieioiis  were  aroused,  and  even  on  the  dark  skin  I  was 
iiMe  on  earefnl  inspection  to  detect  ha'morrhai,'es  in  and  ahoiit  the  papules. 
In  rarid/K pusfitld.sd  li(riii(irrli((()icii  the  di.sease  procuresses  as  an  ordinary 
i;ise  of  severe  varicda,  and  the  lia-niorrhajfes  do  not  develop  until  theve>i(  u- 
l:ir  or  pustular  staire.  The  earlier  the  ha'morrha,i,'e  the  urcati  r  is  the  daii- 
L'er.  There  are  niidouhtedly  instances  of  recovery  when  the  hlecdine-  has 
taken  })laee  at  the  staixe  of  maturation.  Iileedini;'  from  the  niiicous  meni- 
hraiies  is  also  common  in  this  form,  and  the  ,irreat  majority  of  the  case:; 
prove  fatal,  usually  on  the  seventh,  eighth,  or  ninth  day. 

There  is  a  form  of  hiiimorrlia.tric  small-pox  in  which  hleedin^r  takes 
place  into  the  pocks  in  the  vesicular  stai^c  and  is  followed  hv  a  rapid 
ahortion  of  the  rash  and  a  speedy  recovery.  Six  instances  of  this  kind 
came  under  my  ohservation.''-  In  4  the  liieinorrhaLre  took  place  dn  the 
fourtliday;  in  'i  on  the  fifth  day,  just  at  the  lime  of  transition  of  the 
papule  into  the  vesicle.  Extravasation  took  place  chielly  into  the  jim  ks 
nil  the  lower  extremities  and  trunk,  in  only  two  instances  oceurrin<,f  i" 
those  on  the  arms.  The  eruption  in  all  proved  abortive,  and  no  patients 
under  my  care  with  an  eipial  extent  (d'  eruption  made  such  rapid  recoveries. 
With  these  eases  are  to  lie  ,iri'ouped  those  in  which  the  laemorrhap's  occur 
in  the  pustules  of  the  k\<js  in  patients  who  have  in  their  delirium  pot  out 
of  bed  and  wandered  aliout.  This  modilled  form  <if  ha'moriiia,L:i<'  sniall-iiox 
is  also  described  by  Scheliy-Buch. 

'■).  Varioloid. — This  term  is  applied  to  tlie  modified  form  of  sniall-pov 
u-liich  all'ects  pi'rs(>;is  who  have  in'cn  vaccinated.  It  iiiiiv  set  in  wiih 
ahruptness  and  severity,  the  temperature  rea.(diin,:;'  io:!'.  Mdre  conimoidv 
it  is  in  every  respect  milder  in  its  initial  syniiiloms,  though  the  headache 
ami  baekatdie  may  be  very  distressing.'.  The  papules  appear  on  the  evi  ii- 
iiiir  I  t  the  third  or  on  the  fourth  (hiy.  They  are  few  in  iiiinib(  r  and  m,-  y 
lie  confined  to  the  face  and  hands.  The  fever  drop^  at  once  aii'!  the  pa- 
tient feels  perfectly  eonifortahle.  The  vesiculation  and  maturi.'tidii  of  the 
poidss  take  place  rapidly  and  there  is  no  secondary  fev(  r.  'J'hci'e  is  ran  Iv 
;iny  scarrin,ir.  .\s  a  rule,  when  small-jiox  attacks  a  jk  rson  who  has  been 
vaccinated  within  five  (U-  six  years  the  disease  is  mild,  hul  theie  are  in- 
stances in  which  it  is  very  severe,  and  it  may  even  prove  I'alal. 

There  are  several  forms  of  rash  ;  thus  in  what  has  liei  n  Isiiovrn  a-  horn- 
pox,  crystalline  pox,  and  wart-pox  the  ]ia])ules  come  out  in  numher-  on  the 
third  or  fourth  day,  and  by  the  fifth  or  sixth  day  have  .!ried  t<>  a  hard, 
horny  consistence. 


*  CluuL'ul  N'dtos  (in  SiiiiUl-p(iN.     Mnntn'iil.  ls;(). 


II. 


i  t 


SI'ECIKIC   IXFKCTIOL'S   DISEASES, 
doinics  HI  youn^  person,  nxIu.  '''    ^  ^'^'"^^         ,^^,  ^^,^^^  backucho.     In  .  sun.  - 
""  'TZ::l      w  '     .1   '  .." 'h.H'.1  fon„  ...  .null.,,...,  r,.™Ui,>.  fro,..  ,„- 

tlu-  pl.,t..>,    I  ■  '      '|,i„„  „,,  „.,„n,ili,y  of  the  iMvnx,  it  m»y  ..ll.i.v 

;:  z:;::';'.!*-"  ..'u ..... .....^  .,ir,,a.„g..  .i,..e  t.,ey  «..„.. 

,„,„„.|,itU  ,.r  l„-.,„.-l....l...,.,n„..m,j.  ,„,„,,li.,,ti„..., 

;i::;:;;:ii;;;™;;w ;;;-'--:;  *^^.  >•• ."-...o,,. , 

sj,t,.lu-  !.inr.  .111  at  H.i   •  '"^  '  l.cricai-.litis  t..o  is  vc,-y  ili.f..i..- 

::-t:i:r;;r::;:.at^iva.;;;;un:a.a  is  vi.  eo......  p... 

'^  1;l;::;;nuvia  is  fvcMU...,  mu  tn.  nophnt.  is  vavo.     IulUuunu.tion  of 
the  testes  an.l  of  the  ovanes  .nay  "'-;";  ,^i,.,u,,tions  are  those  per- 

A,nong  the  n.ost  -^--^"'^jl    !  ,J^  ^  ^^^.^^^  1,.  are  eon.n.on.     In 
tainin,  to  the  nervous  systen.      ^  \' ."    ^^^^  ,^  ^..^  ^,,ome  violent,  a,.! 

„luUs  tho  .leliriinn  ot  the  early  .ta^e  '^'>V^}^'        -^  oeca.ionallv  me. 
,„aiy  subside  into  a  fatal  eon.a     J -t-     >    U    n^^    >  ^^  ^^^^  ^^  ^ 

^^^i-  "^":;fe::M;  :':;:w  •..;,;•  .t;:;;;vi;^  .i./intense'haeuacho  or 

r::ri;;  C'L  G  prohah,  a-.uea  .ItU  the  ..^  a.on.;n. 
Uunbar  and  crural  pains  and  .s  no,  a  '^^l^^;;^^^  n>ay  he  due  ,o 
.uished  fro.u  the  form  oeemTU,,  ''-;;  ^^     ^^  j^    tL  nc^tritis  n.ay. 

as  ,n  'lU  lit!  eiKi,  n  ol  c  p,,,udo-tahes,  or  afa.nr  vanuh>i,n 

?r'">V''h    nd  n  1  n      -> -  >-^  -^"  ^  '^  ^"^^  ^•^^^'""'^^'  ""  ""' 

Ilemnueiiia  and  .ipnaM.i  U'i>^ 

°'™m;:I;;;"l!o  most  constant  a,..l  .roul,l..so„i..  ,,,i,„,lioatio„s  of  s,„all,.... 


»  V 


SMALL- pox. 


65 


h  (Im-iuL'  ('111- 

who  pri'scm 

.     In  a  sdiui- 

liivo  iiK't  wii!i 

ting  from  in- 
forms tit  til'' 
I  it,  iilu.ut  til" 

the  carfos  an  1 
e  foci  of  siqi- 

ital  o'doina  of 
los,  produriiiLT 
;,  it  may  allow 
•e   they   oxcitr 

e'omplioations 
imonia  is  rarr. 

t  of  the  fever  a 
acarditis,  eitlnr 
is  A'cry  nncoiii- 
associated  with 

rare.  In  severe 
niting,  wliieh  i^ 
tent.  Diarrho'a 
istuntly  present 

luUamiuation  of 

lis  arc  those  por- 
re  common.     In 
ome  violent,  and 
occasionally  met 
^lany  of  the  old 
use  hackache  of 
severe  agonisinir 
;  must  he  distin- 
vh  may  he  due  to 
rhc  neuritis  may. 
iiultiple.     OFtlii^ 
afK.rir  vc rial i '/!"'■ 
tances,  'lie  result 


tions  of  small-p"'< 


are  those  involving  tlu'  skin.  iHiring  convalescence  hoils  arc  very  fre- 
iiiu'nl  and  may  he  severe.  Acne  and  eothyma  are  also  met  with.  Local 
L^angrene  in  various  parts  may  occur. 

Arthritis  in;iy  devidop,  usually  in  tlie  jieriod  of  dcsiiuannition,  and  may 
niss  on   to   snpi)uration.     Acute  necrosis  of  the  hone  is  sometimes  met 

with. 

A  remarkahle   secondary   eruption   (recurrent   small-jiox)  occasionally 

(ii'curs  after  desquamation. 

SjicridI  Si'iis('!<. — Tlie  eye  affections  whicli  were  formerly  so  common 
liiid  serious  are  not  now  so  fre(|Ucnt,  owing  to  the  care  which  is  givi'ii  to 
keeping  the  conjunctiva'  clean.  A  catarrhal  and  purulent  conjunctivitis 
i<  common  in  severe  cases.  The  secretions  cause  adhesions  of  the  eycdids, 
and  unless  great  care  is  taken  a  diffuse  keratitis  is  e.xcitcd,  which  may  go 
en  to  ulceration  and  perforation.  Iritis  is  m>t  very  uncommon.  Otitis 
media  is  an  oceasiomil  complication,  ami  usually  results  from  an  extension 
of  the  disease  througli  the  Eustachian  tuhes. 

Prognosis. — In  unprotected  persons  small-pox  is  a  very  fatal  disease. 
In  different  epidemics  the  death-rate  is  from  5J5  to  35  per  cent.  In  Wil- 
liam M.  Welch's  report  from  the  Muiiici])al  Hospital,  Philadelphia,  of 
■J,s:U  cases  of  variola,  1,5;54— i.  e.,  54.18  per  cent— died,  while  of  -.2,109 
cases  of  varioloid  only  :iS— i.  e.,  \.-i'.)  per  cent— died.  The  luemorrhagic 
form  is  invariahly  fatal,  and  a  ma.jority  of  those  attacked  with  the  severer 
confluent  forms  die.  In  young  children  it  is  particularly  fatal.  In  the 
Montreal  epidemic  of  1885  and  1S8(;,  of  :i,l(;4:  deaths  there  were  :3,717 
under  ten  years.  The  intemperate  and  dehilitated  suecumh  more  readily 
to  the  disease.  As  Sydenham  ohserved,  the  danger  is  directly  ])ropur- 
tionateto  the  intensity  of  the  disease  cm  the  face  and  Inmds.  "When 
the  fever  increases  after  the  appearance  of  the  pustules,  it  is  a  had  sign  ; 
hut,  if  it  is  lessened  on  their  appearance,  that  is  a  good  sign"  (Rhazes). 
Very  high  fever,  with  delirium  and  suhsultus,  are  symptoms  of  ill  omen. 
'I  he  disea.se  is  particularly  fatal  in  pregnant  wonu'n  and  ahortion  usually 
takes  place.  It  is  not,  however,  uniformly  so,  and  I  liave  twice  known 
severe  cases  to  recover  after  miscarriage.  Moreover,  ahortion  is  not  in- 
evitahle.     Very  severe  pharyngitis  and  laryngitis  arc  fatal  complications. 

Death  results  in  the  early  stage  from  the  action  of  the  poison  upon  the 
nervous  system.  In  tlie  later  .stages  it  usually  occurs  a1)out  tlie  eleventh 
or  twelfth  day,  at  the  height  of  tlie  eruption.  In  cliildren,  and  occasion- 
allv  ii:  adults,  the  laryngeal  and  pulmonary  comidications  jirove  fatal. 

Diagnosis. — During  an  epiilemic,  tlie  initial  ohill,  followed  by  fever, 
headache,  vomiting,  and  the  severe  }»aiii  in  the  l)ack,  are  symjitoms  which 
should  put  the  attending  physician  on  liis  guard.  Mistakes  arise  in  the 
initial  stage  owing  to  tlie  presence  of  the  scarlatinal  or  measly  rashes 
which  may  he  extremely  deceptive.  The  scarlatinal  rash  has  not  always 
the  intensity  of  the  true  rash  of  this  disease.  In  my  Montreal  experience 
I  did  not  meet  with  an  instance  in  which  this  rash  led  to  an  error,  thougli 
I  lieard  of  several  cases  in  which  the  mistake  was  made.  These  arc  douht- 
"ss  the  instances  to  which   the  older  writers  refer  of  scarlet  fever  and 


i  . 


(.g  SPECIFIC   INFECTIOUS   DISKASFS. 

sniiill-pox  opc'umn-  to-i'thor.     Tlu-   .uetisly  rasli   .-an   m.t  always  l.r  .li-- 
tiivniislu'.l  from  tnu'  measles,  iustances  of  wliidi  may  be  mistaken  lor  th, 
initial  rash.     I  found  in   the  ward  (me  morning  a  youn,-r  man   who  Ium 
been  sent  in  on  the  previous  evenin.u'  with  a  diagnosis  of  small-pox.     lb 
had  a  fa.limr  macular  rash  with  .listinet  small  papules,  winch  had  not,  how- 
ever, the  shotty  hardness  of  vari..la.     In  the  evening  tins  rash  was  le>^ 
marked  and  as  I  felt  sure  that  a  mistake  had  l)een  made,  he  was  dismte.  te.l 
•nid  sent  home.     In  another  instance  a  child  believed  to  have  small-p-.x 
was  admitted,  but  it  proved  to  have  simply  measles,     ^•elther  of  these  casts 
took  small-pox.     In  a  third  case,  whi.di  I  saw  at  the  City  Hospital,  the 
mottled  papular  rash  was  mistaken  for  small-pox  and  the  young  man  sent 
to  the  hospital.     I  saw  him  the  day  after  admission,  when  there  was  no 
(luestion  that  the  disease  was  measles  and  not  variola.     Less  fortunate  than 
the  other  cases,  he  took  small-pox  in  a  very  seven-  form.     The  general  con- 
dition of  the  patient  and  the  nature  of  the  prodromal  symptoms  are  often 
])etter  -niides  than  the  character  of  the  rash.     In  any  case  it  is  not  well,  as 
a  ruks^o  send  a  patient  to  a  small-pox  hosi)ital  until  the  characten>iir 
papuu's  appear  about  the  forehead  and  on  the  wrists. 

In  the  most  malignant  type  of  Invmorrhagic  small-pox  the  patient  may 
die  before  the  characteristic  rash  develops,  though  as  a  rule  small,  sliolty 
rainilcs  mav  be  felt  about  the  wrists  or  at  the  roots  of  the  hairs.  In  only 
ow  of  twcmty-seveii  cases  of  liamiorrhagic  small-pox,  in  which  death  oc- 
curred on  the  third  dav,  did  inspection  fail  to  reveal  the  papules.  In  three 
cases  in  which  death  took  place  on  th."  fourth  day  the  characteristic  rasii 

was  beuinniuir  to  appear.  .       ,  •  , 

The  disease  may  l)e  mistaken  for  cerebro-spinal  fever,  m  which  purpuric 
symptoms  are  not  uncommon.  A  four-year-old  child  was  taken  suddenly 
ill  with  fever,  pains  in  the  back  and  head,  and  on  the  second  or  third  day 
petecdiiie  appeared  on  the  skin.  There  were  retraction  of  the  head  an<l 
marked  ri-i.iitv  of  the  limbs.  The  haemorrhages  became  more  abundant ; 
and  iinallv  lia>niatemesis  occurre.l  and  the  .-hild  died  on  the  sixth  day.  At 
the  post  mortem  there  were  no  lesions  of  cerebro-spinal  fever,  am  m  the 
deeply  hannorrhairic  skin  the  papules  could  be  readily  seen.  The  post- 
mortem diagnosis  of  small-pox  was  unhappily  conhrmed  by  the  mother 
taking  the  disease  and  dying  of  it.  ,        v  4- 

It'  nii-ht  be  thouirht  scarcely  possible  to  mistake  any  other  disease  for 
small-pox'  in  the  pustular  stage.  Yet  I  had  an  instance  of'  a  young  nn.n 
sent  to  me  with  a  copious  pustular  eruption,  chiefly  on  the  runk  and  cov- 
ered portions  of  the  body,  which,  so  far  as  the  pustules  the.nselves  wre 
concerned,  was  almost  identical  with  that  of  variola;  but  the  history  and 
the  distribution  left  no  rpiestion  that  it  was  a  pustular  syphilide.  It  is  not 
to  be  forgotten,  however,  that  fever,  which  was  absent  in  tins  case,  may  be 
present  in  certain  instances  of  d'ffuse  pustular  syphilis.  Lastly,  chicken- 
'  pox  and  small-pox  may  be  confounded.  Indeed,  sometimes  it  ,s  not  easy 
to  distinguish  between  them,  though  in  well-defined  cases  of  varicella  the 
more  vesi.nilar  character  of  the  pustu.les,  their  irregularity,  the  short  stage 
of  invasion,  the  slight  constitutional  disturbance,  and  the  greater  intensity 


SMALL-POX. 


07 


always  lir  di- 
listaki'U  for  tin 
mail   wild  liaii 
sinall-pox.     I!' 
li  had  not,  liow- 
s  rash  was  lf>~ 
was  (lisiiit'c'(ti'(l 
have  .-iiiall-po.\ 
er  of  tht'so  oast  > 
ty   Hospital,  thf 
youiifj;  man  si'ni 
■n  there  was  no 
s  fortunate  than 
riie  ffeneral  con- 
iptoms  are  often 
it  is  not  well,  as 
le  characteristic 

the  patient  may 
Lile  small,  shotty 
I'  hairs.  In  only 
which  death  oc- 
ipules.  In  three 
laracteristic  rash 

11  which  purpuric 
?  taken  suddenly 
^ond  or  third  day 
of  the  head,  and 
more  abundant ; 
he  sixth  day.  At 
fever,  and  in  the 
seen.  The  post- 
d  In'  the  mother 

other  disease  for 
of  a  young  nnn 
le  trunk  and  cov- 
^  tliemselvcs  were 
t  the  history  and 
philide.  It  is  not 
.  this  case,  may  be 
Lastly,  chicken- 
lies  it  is  not  easy 
;es  of  varicella  the 
ty,  the  short  stage 
e  greater  intensity 


,,f  the  rash  on  the  trunk,  should  make  the  diagnosis  clear.  It  is  stated 
ihat  the  Chicago  case,  which  was  the  starting-point  in  .Montreal  of  the 
,,,'idemic  of  1SS5,  was  re>:arded  as  varicella  and  not  isolated.  If  so,  the 
n'istake  was  one  which  led  to  one  of  the  most  fatal  of  modern  outbreaks 

of  the  disease.  .       ,         ..  ,,  i  i 

(ilandersin  tlie  pustular  form  has  been  mistaken  tor  small-pox,  aii.l  1 
know  of  an  instance  (during  an  epidemic)  which  was  isolated  on  the  sup- 
niisitioii  that  it  was  variola. 

Treatment.— In  the  interests  of  public  health  cases  ot  small-pox 
.bould  invarialdv  lie  removed  to  special  hospitals,  since  it  is  impossiblo 
to  take  the  proper  precautions  in  private  houses.  The  general  hygienic 
arrangements  of  the  room  should  be  suitable  for  an  infectious  disease. 
\11  unnecessarv  furniture  and  the  curtains  and  carpets  should  be  removed. 
The  <M-eatest  care  should  be  taken  to  keep  the  patient  thoroughly  clean, 
and  the  linen  should  lie  fre<iuently  changed.  The  bedcb.tlung  should  be 
li-ht.  It  is  curious  that  the  old-fashioned  mition,  which  Sydenham  tried 
-."hard  to  combat,  that  small-pox  patients  should  be  kept  hot  and  warm, 
.till  prevails;  and  I  liave  frequeiitlv  had  to  protest  against  the  patient 
l,cin.s  as  Svdenham  ex].resses  it,  stilled  in  his  bed.  Special  care  should 
he  taken  to'  sterilize  thoroughly  everything  that  has  been  m  contact  with 

the  ])atient. 

In  the  earlv  staire  the  pain  in  the  back  and  limbs  re.|Uires  opium, 
which,  as  advised  by  Svdenham,  may  be  freely  given.  The  -liet  should 
consist  of  milk  and  broths,  and  of  "all  articles  which  give  no  trouble  to 
di.^estion."  Cold  drinks  may  be  freely  given.  Barley-water  and  the 
S,^)tch  horse  (oatmeal  and  water)  are  both  nutritious  and  palatable. 
Vfter  the  preliminary  vomiting,  wliicli  is  often  very  hard  to  check  by 
nrdiuarv  measures,  the  appetite  is  usually  good,  and,  if  the  throat  is  not 
very  sore,  ptitients  with  the  continent  form  take  nourishment  well.  In 
the  hi^imorrhagic  cases  the  vomiting  is  usually  aggravated  and  persistent. 

The  fever  when  high  must  be  kept  within  limits,  and  it  is  best  to  use 
either  cold  sponginsr  or  the  cold  bath.  When  the  pyrexia  is  combmea 
uith  delirium  anil  subsultus,  the  patiert  should  be  placed  in  a  liatli  at  ^0% 
and  this  repeated  as  often  as  every  three  hours  if  the  temperature  rises 
above  10:5°.  When  it  is  not  practicable  to  give  the  cold  Ijuth,  the  cold 
pack  can  be  employed.  These  measures  arc  much  i)referable  in  small-pox 
to  the  administration  of  medicinal  antipyretics. 

The  treatment  of  the  eruption  has  naturally  engaged  the  special  atten- 
ti.m  of  the  profession.  The  (luestion  of  the  preventing  of  pitting,  so  much 
.iis.-ussed,  is  really  not  in  the  hands  of  the  physician.  It  deiiends  entirely 
upon  the  depth  to  which  the  individual  pustules  reach.  After  trying  all 
<orts  of  remedies,  such  as  puncturing  the  pustules  with  nitrate  of  silver,  or 
treating  them  with  iodine  and  various  ointments,  I  came  to  Sydenham  s 
couclurion  that  in  guarding  the  face  against  being  disfigured  by  the  scars 
••the  only  effect  of  oils,  liniments,  and  the  like,  was  to  make  the  white 
scurfs  slower  in  coming  off."  There  is,  I  believe,  something  in  protecting 
the  ripening  papules  from  the  light,  and  the  constant  application  on  the 


t 


'111 


SPECIFIC    INFKCTlors    DISEASES, 
no 

f..,.oan.l  lK.n.l.uflmt  .oako.l  in  mM  water,  tu  whu-h  antisopti.-.  suoh  a- 

!;:-;.  't;;,j;r;;::i:«wC;;;: ;:!;::;;:  iv„.> ,,,.  ,,.1..  .oc„,n...  w,,. 

,  ,     n,..l  .tiim.L.m.  m,iv  l.o  frevlv  pv.-.i.     TIh-  .lol.nmn  .s  oc.  ,i..n.  1) 
;     ,  ;„     n,»v  ro„ui,-o  ohl.,v,..„nn,  Uu  I.T  .1.-  ..,.,..„.  --l.  -n.     ;■■ 

;:;  :  Z:^'nJ^c^^'^L,  ana  it  is  ..my  ornel  to  dr.uch  tlu-  un.n.u- 
u  te  p  t  em  witL^iron,  er,ot.  and  otluT  dvu.s.     Synjptoms  ot  o^.tm.     n 
the    irvnx  n^uallv  fr..ni  c.U'nuu  may  rail  for  tracheotomy.     In  the  1. 1. 
".        i^he'c^^ase,  should  the  patient  be  extremely  debihtated  and  the 
t£.    of  abscesso.  and  bed-sore.,  he  nu.y  be  placed  on  -J^'^;^^ 
re.  ted  by  the  continuous  warm  bath.     Dunn,v  eonva  escence  the  paU 
Ao  Idb  the  dadvanduse  carbolic  soap  freely  m  order  to  fret  v  d  of 
c      t    .1  scab.,     lie  shoitld  not  be  considered  without  danger  to  othei. 

not  favor  their  use. 

V    VACCINIA  (r.</-/»u)-VACCINAT10N. 


L"  most   suitiiliU' 
or  th"  face  it  i. 
with  oili'tl  sill< 
hem  thoroii<rlil\ 
L'lits  the  (Icsiccu- 
imrticnlavly  nsc- 
.     It  fri'qm'iitly 
lies  so  chavactci- 
roVubly  best.     11' 
bo  cut  sliort  to 
Iff  convaU'sin'UCf 
the  crusts.     The 
hi  ho  thoron^'hly 
,';is1k'(1  with  sonic 
■yolids  are  nuu'h 
hiess  that  kerati- 
kept  ('loan,  ami  if 
((Uent  iiijecticus. 
iixch  an<j;ina.     In 
Oiouhl  he  alloweil 
le  (liurrluea,  wlifn 
se  becomes  t'eelih' 
ni  is  oeca^^ioually 
lus  symptoms  the 
iges  of  the  maliu- 
•euch  the  unt'ortu- 
iiis  of  obstruction 
tomy.     In  tlie  hite 
L'l)ilitate(l  and  the 
on  a  water-bed  or 
sceuee  the  patient 
r  to  get  rid  of  the 
t  danger  to  others 
from  any  trace  of 
cities  or  the  inter- 
iibers ;   so  far  as  I 
th   the   disease  do 


ION. 

rus  of  wliicli.  inoe"- 
wilh  constitutional 
permanent,   against 

-animal  lymph — in 


VACCINIA— VArC'IXATIOX. 


69 


wliicli   the  disease  is  projiagated  at  regular  stations,  or  is  obtained   from 
persons  vaccinated  (.linmanized  ]ym]ih). 

History.  —  For  centuries  it  iiad  lieen  a  po|iular  lielief  among  farmer 
liilk  that  co\v-]io.\  ])rotected  against  small-po\.  It  is  said  tinit  the  nolorimis 
liiK  lu>s  of  Cleveland.  re|ilyi!ig  to  some  joker  \\\\i)  suggoled  that  she  would 
jii-e  her  oeenpation  if  siie  was  di.-ligiircd  with  t-mall-pox,  said  that  she  was 
not  afraid  of  the  disease,  as  she  hail  had  cow-pox.  .Icsty.  a  Dorsetshire 
larmer.  had  had  cow-]iox,  and  in  ITTl  vaccinated  successfully  ids  wife  ami 
two  sons,  riett.  in  Ilolstein,  in  Kni,  id-o  suecc»fully  vaeeinatcd  three 
cjiildren.  W'lu'n  .leiincr  was  a  stndent  a1  Sodhury.  a  young  girl,  who  came 
lor  ailvice.  wlu'ii  small-po\  was  mentioneil.  exclaimed.  "  I  can  not  take  that 
iii>easi',  foi'  I  have  had  cow-pox."  .leiiiier  suli.-eipiciitly  meiitione(l  the  suli- 
jcct  to  Hunter,  who  in  reply  gave  tiie  famous  piece  of  advice:  "Do  not 
think,  hut  try;  he  ]iaticnt,  be  accurate."  As  early  as  ITSO  the  idea  of  the 
|iroteeti\e  power  of  vaccination  was  lirndy  im|M'cs.--ed  on  Jenncr's  minil. 
The  ]irol)lem  which  oeciiiiied  his  attention  for  many  years  was  hrought  to 
a  practici  '  is>ut'  when,  on  May  1  I,  IT'.HI,  he  took  matter  fi'om  the  hand  of 
a  dairy-maid,  Sarah  Xelmes,  who  had  cow-pox.  and  inoculatt'd  a  l)oy  named 
.lames  Philips,  aged  eight  years.  On  .Inly  1st  matter  was  taken  from  a 
^iiiall-pox  i)ustule,  and  inserted  into  the  lioy.  Imt  no  disease  followeil.  In 
IT'.is  appeared  An  Inquiry  into  the  Causes  and  MlVects  of  the  N'ariola 
\'aceimc.  a  Disease  discovered  in  some  of  the  Western  Counties  of  England, 
partic  idarly  (iloucestcrshire,  and  known  by  the  Xanu'  of  Cow-pox  (jip.  iv, 
',').  four  jilates,  -Ito.  London,  K!t,s).  From  this  lime  on  vaccination  spread 
rapidly  tliroughout  the  civilized  world. 

In  the  United  States  vaccination  was  introdueeil  hy  ISenjanun  Water- 
lioiisc,  I'rofessor  of  Physic  at  Harvard,  who  on  July  S.  ISno.  vaccinated 
seven  of  his  children.  President  detferson  was  mainly  instrumental  in 
spreading  the  iiractice  in  the  Southern  States,  and  dolin  Pedman  Coxe 
introiluced  it  into  ]*hiladel|ihia. 

The  literature  id'  vaccimition  has  lieeii  greatly  enriched  by  the  pub- 
lications in  conne<'tion  with  the  .Tenner  centenary.  'Jlie  centenary  nundier 
(d'  the  P.ritish  ^ledical  .Journal  is  jparticularly  valuable.  The  re])ort  of  the 
Povai  Commission  on  vaccination,  the  exhaustive  article  in  AllbuttV  System 
by  T.  D.  Ackland  and  Coiieman,  ami  Cory's  recent  momjgrajih  on  the 
subject  atford  a  large  body  o\  material.  To  the  ])ul)lic  health  olhcials.  who 
wish  for  distribution  in  handy  shape  Facts  al)out  Small-pox  and  Vaccina- 
tion, the  leaflets  issue. i  by  the  Pritish  ^fcdical  Association  (ikitish  .Mcijical 
Journal.  1Slt8.  vol.  i.  ]).  <!:^?)  will  be  of  the  greatest  value. 

Nature  of  Vaccinia.  —  Is  cow-]iox  a  separate  independent  disease, 
or  is  it  only  snuill-]iox  modilii'd  by  passing  through  the  cow?  In  spite  of 
a  host  id'  observatioits.  this  cpiestion  is  not  yet  settled,  as  may  be  seen  in 
the  diametricallv  o]i]ioseil  views  expressed  iiy  Copeman  in  AlUmtt's  System 
and  by  P>rouardel  in  the  Tweiitii'th  Century  Practice.  The  experiments 
may  be  divided  into  two  groujis.  F'irst.  those  in  which  the  inoculation  of 
the  small-jtox  matter  in  the  heifer  ]iroiluced  ]ioeks  corresponding  in  all 
respects  to  the  vacciiu'  vesicles.  Lym])h  from  the  first  calf  inoculated  into 
a  second  or  third  produced  ;he  characteristic  lesions  of  cow-pox,  and  from 


7(1 


SPKCIFIC   INI-KiTlorS   DISEASES. 


Ill,,  fii-l.  MM-n.l.  or  lluni  iiniiiuil  lvin|.li  ii>r(1  to  van  inalc  n  fluM  i.ru.lufr,! 
a  tviMcal  lo.ali/.i'.l  vac.'iiu>  vcsiclr  willioiil  any  of  tlu>  jrcnrralixc.l  Icatun- 
.,!'  >ma!l-|«"X.  T\h'  ^'Xi-crimcnts  of  (Vcly.  ..f  r.alx'ock,  and  many  ollirr  nnav 
ir.ciit  worker-  xmi  to  Icav  no  (inotion  whatever  that  typieal  vacrmia 
,„.iv  l,e  pro.liiee.l  in  the  ealf  hy  the  inoeiihition  of  variolous  matter.  A 
.rrrat  .leal  of  the  vaeeiiie  material  at  one  time  iii  use  in  Knjrlaml  was  nl,- 
't'aiiied  in  thi^^  wav.  Seeon.lly,  a-ain>t  thi>  is  nr-vd  Chanveaii  s  Lyon^ 
exiieriment.-.  Seventeen  voiin,ir  animaU  w(  re  inoculated  with  the  vi-ns  el 
<niall-|.o\.  Small  reddish"  i-apides  oeeurred  whieh  (lisa|.|.eared  rapidly,  hiii 
the  animals  did  not  a.'Muiiv  eow-po.N.  Kil'te..n  (,f  the  seventeen  aniniaU 
M.re  aUo  vaeeinated.  Of  these  only  one  showed  a  typieal  eow-j-ox  eni|.- 
ti.m.  To  determine  the  natnre  .d'  the  original  pa|udes  one  was  e\eis,.l  and 
i,„„.,il;,lr,l  into  a  non-vaeeinale(|  eluld.  whieh  dev.do|.ed  a>  a  re-nlt  -vneral- 
iz,.,l  e.mlhient  smali-pox.  A  xrond  child  ino.ulaled  from  the  primary 
pustule  of  the  tirst  child  devch.p.d  <li^crete  Muall-iiox.  The  I'reii.di  still 
hold  to  the   Lyon-  experiment-  as  demoii.tratin-  the  duality  of  th.'  di. 

'  The  wei-ht  .d'  evidence  favors  the  view  that  cow-pox  and  horse-pox 
are  variola  mo.lilied  hv  traiiMuis<ion:  or.  a-  has  heeii  Mi--esie,l.  ••  Muall-pos 
anil  vaccinia  are  hoth  (d'  them  d.'.-cendcd  from  a  common  stock— iroin  an 
ancestor,  for  in.-tanct — which  roeiidded  vaccinia  far  more  than   it   reseni- 

hled  small-iiox"  (Copemaii).  ,    ,      ,>    •       ,,     .• 

Bacteriology  of  Vaccinia.— This.  too.  is  ^till  untitled.  (>ni>t.  Marim. 
and  Krnst  have  descrihe<l  various  micrococci.  Klein  and  Copeman  have 
independentiv  found  a  hacillus.  while  I'leillVr  and  KuilVr  have  met  witii 
l)odies  helieved  to  he  (d'  the  nature  of  p.-oro>perins.  Walter  L'eed  has  also 
met  with  peculiar  annehoid  hodies  in  the  hlood. 

Normal  Vaccination.— /V/'/m/  of  hiruhalhm.—Xx  ilr-t  then'  may 
he  a  little  irritation  at  the  site  of  inoculation.  whi(h  suhsides.     Pn-ioil  uf 
y,',.,',^,//„„._()n  the  third  day.  as  a  rule,  a  i>a]Uile  is  seen  surrounded  hy  a 
reddish  xoue.    This  p-adnally  increases,  and  on  the  iifth  or  sixth  day  sliows 
a  deiinite  vehicle,  the  niar-zins  (d'  which  are  raised  while  the  centre  is  de- 
pressed.    \\\  the  eiiihth  day  the  vesicle  has  attained  its  maximum  size.     It 
is  round  anil  distended  with  a  limjiid  fluid,  the  marjrin  hard  and  prominent, 
and  the  nmhilication  is  more  distinct.     I'.y  the  tenth  day  tlie  vesicle  is  still 
larue  and  is  surrounded  hy  an  extensive  areola.    The  contents  liave  now  he- 
come  purulent.    The  skin  is  also  swollen,  indurated,  and  often  ]iainfnl.     On 
the  eleventh  or  twelfth  day  the  hyiiera'mia  diminishes,  tlie  lyni])]i  hecomes 
more  opacpie  and  he.-iins  to  dry.     i'.y  the  end  of  the  second  week  the  vesicle 
is  converted  into  a  i)rownish  scah,  whii-h  .uradiially  hecomes  dry  and  hard, 
and  in  ahont  a  wt'ck  (that  is.  ahont  the  twenty-first  nr  twenty-fifth  day  from 
the  vaccinati(ni)  seiiarates  ami  leaves  a  circnlar  ])itted-  scar.     If  the  points 
of  inoculation  have  heen  close  loirether,  the  vesicles  fuse  and  may  form 
a   lar>re   condiint'd   vesicle.     Constitutional   symptoms   of   a   more   or   less 
marked  deizree  follow  the  vaccination.     T'snally  on  tlie  third  or  fourth  day 
the  temiwrature  rises,  and  may  ])ersist,  increasin-:  Tintil  the  ei.trhth  or  ninth 
dav.     There  is  a  marked  leiicocytosis.     In  children  it  is  common  to  jiave 
with  the  fever  rcstlessnes.s,  itartienlarly  at  night,  and  irritability;  but  as  a 


VACCINIA— VAfflNATloX. 


liM  imxliifril 
ixi'd  I'i'iituvt- 
y  (itlirr  uiin'i 
>i(.';il  Viicciiii;! 
s  inntttT.  A 
:laiul  wiis  nli- 
vcaiiV    Iaciii- 

tlu'    vi"llS    cif 

1  rit|ii(ll.v.  liiii 
itnn   animal- 

(.vW-|l(i\    iTUji- 

is  excised  ainl 
'c-iilt  ^cnd'al- 
tlie  |i:'iiuar.v 
'  rn'iicli  sliil 
y  (if  the  i\'\> 

iml  li<prsr-]ici\ 
il,  ••  >ii\alI-|"iN 
ock — fnnii  an 
liaii   il   nsciii- 

i)u\A.  Martin. 
'(i|K'niaii  liavr 
lavo  met  witii 
L'eed  lias  also 

i'~t  then'  may 
es.  Period  of 
I'l'oinKJed  liy  a 
xtli  day  shows 
"centre  is  de- 
imuni  size.  It 
.nd  jtromiiient, 
'  vesiile  is  still 
J  have  now  he- 
ll ]iaint'ul.  On 
ymph  lieeomes 
eek  the  vesicle 
dry  and  liai'd, 
-fifth  day  from 

If  the  points 
and  may  form 

more  or  less 
I  or  fourth  day 
M,irhth  or  ninth 
unmon  to  have 
aillty;  but  as  a 


inle  these  symjitoms  are  trivial.  If  the  inoculation  is  made  on  the  arm, 
the  axillary  glands  heconie  lar;:e  and  sore;  if  on  the  \v<i.  the  in^Miinal 
<:lands.  '{"he  duration  nf  the  imninnity  is  extremely  variahle,  dill'erin^' 
in  dilfereiit  indivi.lnals.  In  some  instances  it  is  i.ermaiieiit.  hut  a  majority 
(d'  ]ier!fons  within  ten  or  twelve  years  again  become  snbceiitible. 

li'cnirriiiiilinii  should  be  performed  Ix'tween  the  tenth  and  (ifteeiith 
year,  and  whenever  small-|)o.\  is  epidennc.  The  susceptibility  to  revac- 
(•illation  is  curiously  variable,  and  when  small-jiox  is  jirevaleiit  itis  not  well, 
if  iiiisiicce>.-fu|.  to  he  content  with  a  siiiLiie  attempt.  The  vesi(de  in  re- 
vacciiiatioii  is  usually  smaller,  has  less  induration  and  liy|icra'iiiia.  and  the 
resulting  scar  is  le<s  ].erfect.  Particular  care  ^hollld  he  taken  to  watch 
the  Vesicle  of  revacciiiation.  as  it  not  iiifnMpieiitly  happens  that  a  spurious 
pock  is  formed,  which  readies  ils  height  early  and  dries  to  a  scab  bv  the 
eighth  or  ninth  day.  The  constitutional  syiii]itoiiis  in  revaccination  are 
soiiietinics  (piite  severe. 

Irregular  Vaccination.— (</)  L<hvI  v„riati.,iis.—\\r  occasionally 
meet  with  instances  in  which  the  vcsi(  le  develops  rajiidly  with  much  itch"- 
ing.  has  not  the  characteristic  llatteiied  appeara-ce,  tin"-  lymph  early  be- 
comes opa(pie,  and  the  criisi  forms  by  the  seventh  or  eighth  day.  "  Tlu; 
evolution  of  the  pocks  may  be  abnormally  slow.  In  such  cases  the  operati(Hi 
should  again  he  |ierforim'd  with  fresh  lymph.  The  contents  of  the  vesi- 
cles may  be  watery  and  hloody.  In  the  involution  the  bruising  or  irrita- 
tion of  the  pocks  may  lead  to  ulceration  and  inllamniatioii.  A  verv  ratx; 
cNciit  is  the  recurrence  of  the  pock  in  the  same  place.  Sutton  rejiorts  f(Uir 
sucli  recurrences  within  six  nio!itlis. 

(/')  (Irncnilr.cil  Vnrrhiin. —  It  is  not  niicommon  to  see  vesicles  in  the 
vicinity  of  the  primary  soi'e.  Less  common  is  a  friie  generalized  pustular 
rash.  (lev(lo|mig  in  dilVerent  parts  cd'  the  body,  often  beginning  about  the 
wri>ts  and  on  the  hack.  The  secondary  pocks  may  continue  to  make  their 
apin'arance  for  li\e  or  six  weeks  afti'r  vaccinalioii.  In  i-hildren  the  disease 
may  prove  fatal.  They  may  be  most  ahiindant  on  the  vaccinated  limb, 
and  develop  usually  about  the  eighth  to  the  tenth  day. 

(r)  Cnin/ilirdliniis. —  In  nnhealthy  subjects,  or  as  a  result  of  tincleaidi- 
ncss.  or  sometimes  injury,  the  vesicles  inllame  and  deep  excavated  ulcers 
result.  Sloughing  and  deep  cellulitis  may  follow.  In  debilitated  children 
there  may  be  with  this  a  purpuric  rash,  .\cland  thus  arranges  the  dates  at 
which  the  ]Kissilde  eruptions  and  complications  may  be  looked  for: 

1.  During  the  lirst  three  days:  l-lrythema;  urticaria;  vesicular  and 
hiillous  eruptions;  invaccimite(l  erysipelas. 

•.'.  After  tlu'  third  day  and  until  the  pock  reaches  maturity:  Urticaria; 
lichen  urticatus,  erythema  multiforme;  accidental  erysipelas. 

;b  About  the  end  of  the  first  week:  (leneralized  vaccinia;  impetigo;  vac- 
cinal ulceration;  glandular  abscess;  septic  infections;  L^anjireue. 

4.  After  the  involution  of  the  pricks:  Invaccinated  diseases — i,>r  exam- 
ple, syphilis. 

[<])  "rrausmissinn  of  Disca.-!r  hi/  Varriniilinn. — Syphilis  has  undoubtedly 
been  transmitted  by  vaccination,  hut  such  instances  are  very  rare.  A  ]ar"-c 
numiier  of  tlie  c;ises  of  alleged  vaccino-syphilis  must  be  thrown  out.     The 


72 


SPFX'IFIC  IN'FKCTIOI'S  ItlSFASKS. 


m'\ 


i|iU'stioM  lias  luiw  liccdiiic  rciilly  of  iiiiiinr  iniiiDrtniicc  since  tlic  \viilcs|>rt'iiil 
use  (.f  iiiiiiiiiil  lymph.  Dr.  CoryV  sad  fxiHTiiiu'iit  may  here  he  rel'erreil  tn. 
He  vaeeiiiateil  liiiiiseU'  I'niir  times  I'roiii  syiihililie  ehihlreii.  The  first  vae- 
eiiiati.ui  fnlloucd.  imt  im  syphilis.  Tun  other  attempts  (iie.LMtive)  were 
made.  The  Iniirth  time  he  was  vaeeiiiated  Imm  a  eiiihl  the  siihjeet  ol 
foiifreiiital  syphilis.  'I'he  lymi'li  was  taken  Inmi  the  ehihTs  arm  with  care, 
avdidiii-r  aiiv  eontamiiiatioii  witli  hhiod.  At  two  of  the  points  of  insertion 
red  papules"  apjieared  on  the  twenty-lirst  day.  On  the  thirty-ei^dith  day 
a  little  nkrr  was  found,  whieh  Mr.  llutehin>on  .hcided  was  .'■yphilitii'. 
'I'he  diseased  jiarts  were  then  removed.  I'.y  the  liltieth  day  the  t^oii-titii- 
tional  syin|itoms  were  well  marked.  Amonj:  the  ditVerenees  hetweeii 
vaeeino-svpliilis  and  vaeeination  tileers  the  most  important  is  perhaps  that 
the  ehanere  never  develops  hei'ore  the  liiteeiith  day.  nsiially  not  until  from 
three  to  five  weeks,  whereas  the  ulceration  of  ordinary  vaccination  is  jires- 
ent  hy  the  twelfth  or  lifteenth  day.  The  loss  of  sultstaiiee  in  the  chaneve 
is  usiially  (piite  sui)erticial  and  the  induration  very  parchment-like  and 
specillc.  with  hut  a  sli-:ht  intlalnmatory  areola.  The  -rlaiididar  swelling:-,  too. 
is  constant  and  indolent,  while  in  the  vaccination  idcer  it  is  often  ahsent. 
or.  when  jireseiit.  chielly  intlammatory. 

Tiili<'niilos!s. — "  No  tindonhted  case  of  invaeeinateil  tuhercle  was 
Ijrouiiht  hefore  the  Hoyal  Commission  on  Vaccination  "  (Acland).  The  risk 
of  transmitting,'  tuherculosis  from  the  calf  is  so  sli<-ht  that  it  need  not  lie 
considered.  Tnhercidosis  in  the  calf  is  excessively  rare,  and  "this  almo>i 
inappreciahle  source  of  danj:er  (an  he  avoided  hy  the  simple  precaution  ol 
not  usin;.'  the  lymph  from  any  calf  until  the  animal  has  hccii  killed  and 
proved  to  he  entirely  free  from  disease"  (Acland). 

The  transmission  of  leprosy  hy  vaccination  is  also  open  to  serious  douht. 
In  a  few  instances  tetanus  has  developt'd  duiiuj.;-  vaciiuation  and   provtd 

fatal. 

(c)  TiifJtiPiirp  of  VacrliHifiiiii  upiin  other  Dlsi-osrs. — A  (piiesceii!  malady 
may  he  li}:htcd  into  activity  hy  vaccination,  'i'his  has  ha])pene(l  with  con- 
genital syi)hilis.  occasionally  with  tul)erculosis.  An  old  idea  was  preva- 
lent that  vaccination  had  a  l)eneficial  injluence  upon  existing  diseases. 
Dr.  Archer,  the  first  niedicai  grmluate  in  the  T'nited  States,  recommende<l 
it  in  whoopinfr-cough.  and  said  that  it  had  cured  in  his  hands  si.\  or  eight 
cases. 

Choice  of  Lymph. — Calf  lymph  should  invariahly  he  iist'd,  ami  it 
can  now  ho  ohtained  from  ]ierfectly  relialilc  sources.  The  practice  of  arm- 
to-arm  vaccination  with  liunumized  lymph  slnudd  he  ahandoncd.  If  hoviiie 
Ivmph  is  not  availahle,  then  the  humanized  lymph  sluudd  he  taken  on  the 
ei'dith  dav.  and  onlv  froui  nerfectlv  fornuil.  unhroken  vesicles,  which  ha\e 
had  a  ty]iical  course.  Pricking  or  scratching  tl.e  surface,  the  greatest  care 
heitig  taken  not  to  draw  hlood,  allows  the  lynii)h  to  e.xude.  and  it  may  lu' 
collected  on  ivory  points  or  in  caiiillary  tuhes.  The  child  from  which  the 
lymph  is  taken  .sliotdd  he  healliiy,  strong,  and  known  to  he  of  good  stock. 
free  from  tnhercnlous  or  syi)hilitic  taint.  All  |iossihle  sources  of  contamina- 
tion with  ])yogenic  organisms  are  now  o1ivintt'(l  by  the  use  of  the  glycerin- 
atcd  calf  Ivmph  vvliicli  should  come  into  general  use.     The  Local  (.iovern- 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


1.0 


I.I 


1.25 


IIM    1.25 


•^  IM 


Z2 

!r  1^  iliio 


I. 


U    III  1.6 


Photographic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  NY.  14S80 

(716)  872-4503 


L* 


V  ^. 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  canadien  de  microreproductions  historiques 


i\ 


"^■'v— — 


VACVINIA-VACCINATION. 


73 


inriil  J',<mnl  lias  ivinitiy  isMie'd  a  valuaLK^  ivpori  ,„i  the  Mihjoet  l)V  Tlioni.' 
iiiul  ropc'inan,  oivi,,-  lull  .k'taiLs  a.<  to  the  iiKlii.»l  „l'  pivparation.  Jn  it 
the  stateinem  is  made  that,  wh.Teas  it  was  usual  to  make  the  lvm|.h  Imm 
one  eall  >erve  lor  from  •■>uo  to  3(M»  vaeeinatioiis,  th-  jzlveerinateirivmi.h  will 
serve  lor  Iroiii  -i,U(iU  to  r),U()(i  vaeeinatioiis. 

Technique.— In  the  ]ierioriiianee  of  the  operation  that  part  of  the 
aim  aluMit  the  insertion  of  the  deltoid  is  usuallv  seleeted.  .Mothers  -in 
soeiety  "  jirefer  to  liave  girl  habies  vaeeinated  on  the  leu'.  The  skiu  should 
he  elean>e(l  and  put  ujion  tiie  streteh.  'J'heii.  with  a'laiieet  or  the  iv(,ry 
point,  eross-seratehes  should  iie  made  in  one  or  more  places.  When  tlie 
lymi)li  has  dried  on  the  ])oiiits  it  is  best  to  moist. ^n  it  in  warm  water  The 
elothmo-  „f  the  eliild  should  not  be  adjusted  uiiiil  the  spot  jias  dried  and 
It  should  he  jiroteeted  l(,r  a  day  or  two  with  lint  or  a  soft  handkereiiief 
If  erysipelas  is  jirevaleiit.  or  if  there  are  eases  of  suppuration  in  the  sanin 
house,  it  IS  well  to  apply  a  pad  of  antisep,ie  eoiton.  \'aeeiuatioii  is  u<uallv 
perlornied  at  the  seeoud  or  third  month.  If  unsueeessful,  it  !,lu)ul<l  be  n"- 
peateil  from  time  to  time.  A  person  exposed  to  the  eontajrion  of  <mall- 
l)ox  should  always  be  revaeeinated.  'IMiis.  if  siieeessful.  will  usually  pm- 
teet:  but  not  always,  as  there  are  many  instanees  in  which,  tlioimh  the 
\aeeiiiation  takes,  vm'inla  also  ajipears. 

The  Value  of  Vaccination.— Sanitation   cannot   aeeount    for  the 
•  bminution  m  small-pox  and  for  the  low  rate  of  mortalitv      Nolithui    of 
<ouise    is  a  useful  auxiliary,  but  it  is  no  substitute.     \'a"ccination  is  m.t 
claimed  to  be  an  invariable  and  permanent  preventive  of  small-pox.  but  in 
ill!  immense  majority  of  eases  successful  inoculation  renders  the  per<o„  f„,. 
many  years  insusceptible.     Communities  in  which   vaccination  and  revae- 
cmation  are  thoroughly  an<l  systematicallv  carried  (uit  are  th.we  in  which 
small-pox  has  the  fewest  victims.    On  the  other  hand,  communities  in  which 
vaccination  and  revacemation  are  i-ersistcntlv  ncylected  are  those  in  which 
cpulnmcs  are  most  ].revalent.     In  the  (u'rinan  armv  the  practice  of  revac- 
cniation  has  stamped  out  the  disease.     Xothin-  in  recent  times  has  been 
nmre  mstru.tive  in  this  connection   than  the  fatal  statistics  of  Montreal 
Hio  epidemic  which  start..!  in  lS7(i--;i  was  severe  in  Low.m-  Cana.la    an.l 
pers,M..d    m    Montreal    until    ]s:.\      A    ,^n'nt   deal    of   feelin-    h,,d  Yen 
aroused  ammi-  the  French  Canadians  I)v  the  occurrence  of  sev.'ral  «.ri.UN 
oases  ol-   ulceration,   possibly  „f  syphilitic   disease,   followini;^   vaccinath.n- 
Mu.l  s.'v.'ral  a-italors.  amon.ir  them  a  French  idivsician  of  soni.>  <taii.lin-' 
iiroused  a  ].opular  and  wid.'sprcad   prejudice  airainsf   the  practic.'      There 
were   ind.'ed   vaccination   rh.ls.     Th..   introducti.m   of  animal    Ivnipli    was 
•  listmctly  beneficial  in  exL-ndinir  the  practice  anion-  tli..  lower  .'la—    but 
coinpulsory  vaccinatum  could  not  be  carri.'d  out.     7^„.tw..en  the  y<.ar<  ISTC 
.•md  ISSI  a  eon.>^iderable  un].rote.t,.d  population  -rew  up  and  the  mat.^iTiIs 
"•.Mv  ripe  for  an  extensive  ..pi.l.MinV.     Th..  snil  h,,d  b.vn  ].repared  with  the 
f-Tcatest  care,  and  it  .mly  n..ed,.d  ih.'  intr.Klu.tioii  .,f  tli.'  s.'cd    whi.h  in  due 
time  oamo.  as  already  stat.Ml.  with  the  l'ullmaii-<.ir  conductor  from  flii- 
cao...  on  the  ?Stli  of  F..bn,ary.  ISS.'..     Within  the  next  ten  m.uith-  tlum- 
sands  ot  persons  were  stri.-k.-n  with  the  disease,  and  :^AC,l  di.-'d 

Altli.Hiol,  thp  Hl'ects  .d'  a  siii-le  vacciuatiuii  mav 'wear  out"  as  we  «'iv 


I 


iii 


74  SPECIFIC  INFECTIOUS  DISEASES. 

iuid  tln'  individual  ajrain  Ix'coiih'  sviscrpti'ik'  to  f;iiiall-]io.x.  vet  tlic  mortal- 
ity ill  sucli  cast's  is  very  iiiiich  lower  than  in  ])ersoiis  wlio  have  never  heen 
vaeciiiated.  Tiie  iiKirtality  in  persons  who  have  heen  vaeeinated  is  from 
(i  to  S  [icr  cent,  whereas  in  the  nnvaeeinated  it  is  at  least  o')  per  eeiit. 
^Marsoii  jioiiited  out  some  years  ajxo  that  tliere  is  a  detiiiite  ratio  hetween 
tile  numher  ol'  deatlis  and  tlie  nunilier  of  ^^ood  vaeeination  marks  mi  post- 
vai  cilia!  small-pox.  Willi  jiood  marks  tlu'  mortality  is  lu'twcf  ;i  3  and  4 
]ier  cent,  am!  with  indiU'ereiit  inarl<s  at  least  in  or  11  per  ct'iit.  W.  M. 
\Velcirs  stati>tics  ol'  .T.dOO  eases  on  this  point  .uive  with  ,i:ood  cicatrices  S 
per  cent:  with  fair  cicatrici's.  1  1  jier  ct'iit:  with  poor  cicatrici's.  JT  per  cent; 
jiost-vaccinal  ca>es,  Ki  per  cent:  nnvaeeinated  cases,  ."iS  jier  cent. 


VI.  VARICELLA  (Cltu/cen-pox). 

Definition. — \n  acute  contaL:ioiis  (li>ease  of  children,  cliara^'terized 
hy  an  I'rnption  id'  vehicles  on  the  >kiii. 

£jtiology.  — 'i'he  disease  occurs  in  I'pideniics,  hut  sjioradic  cases  are 
also  met  with.  It  may  prevail  at  the  same  time  as  small-pox  or  may  fol- 
low or  precede  epidemics  of  \\\\<  disease.  An  attack  of  chicken-pox  is  no 
jiroteetion  a^oiinst  small-pox.  it  is  a  disease  of  childhood:  a  majority  of 
the  ca.<es  occur  hetween  the  secoiul  and  sixth  years.  It  is  rarely  sein  in 
adults.     The  siieeiiie  germ  has  not  yet  heen  discovered. 

There  can  he  no  ijiiestioii  that  varicella  is  an  alVection  (piite  distinct 
from  variola  and  v.itliout  at  ]iresent  any  relation  whatever  to  it.  An  at- 
tack (d'  the  one  does  not  coiift-r  imimmity  from  an  attack  of  the  other. 
The  case  which  Sharkey  reported  is  (d'  special  imiiortaiice  in  this  coiiiiec- 
tioii.  A  hfiy.  a.L;cd  live.  wa>  admitted  to  St.  Thomas*  Hospital  with  a  vi'sicu- 
lar  eruption,  and  was  isolated  in  a  ward  on  the  same  iloor  as  the  siiiall-jiox 
ward.  The  disease  was  proiioiiiiced  cliicken-|iox,  liowexer.  hy  Sir  Uisdon 
lieiiiiett  and  Dr.  llristowe.  The  patient  was  then  removed  and  vaccinated, 
with  a  result  of  four  vesicles  which  ran  a  ]iretty  ncM'iiial  course.  On  the 
ei'dith  (lav  from  the  vaccination  the  child  hecame  fi'verish.  On  the  l'(d- 
lowiiiLT  dav  the  papules  appeared  and  the  child  had  a  ,', ell-developed  attack 
of  siiuill-pox  with  secondary  fever. 

Symptoms. — .\fter  a  ]ieriod  cd'  inenhatioii  of  ten  or  fifteen  days  the 
eliilil  hecomes  feverish  and  in  some  instances  has  a  sli<rht  chill.  There 
may  !)e  voniitinj:'  and  ]iains  in  the  liack  and  lejrs.  Convulsions  are  rare. 
The  eruption  usually  develops  within  tweiity-fmir  hours.  It  is  (irst  seen 
njion  the  trunk,  either  on  the  hack  or  on  the  chest.  It  may  hcfiin  on  the 
forehea<l  and  face.  At  first  in  the  form  of  raised  red  jiapnles,  these  are  in 
a  few  hours  transformed  into  heinisiiherieal  vesicles  containing;  a  clear  or 
turhid  lluid.  As  a  rnle  there  is  no  ninhilication,  hnt  in  rare  instances  the 
jiocks  are  ilattened.  and  a  few  may  even  he  timhilicated.  They  are  often 
ovoid  in  shape  and  look  more  superficial  than  the  variolous  vesicles.  The 
skin  in  the  nei,irhhorliood  is  nt'ither  inliltrated  nor  hy]ierirmie.  At  the 
end  (d'  thirty-six  or  forty-ei.Ldit  hours  the  contents  of  the  vesicles  are 
jnirnlent.     They  hegin  to  shrivel,  and  during  the  third  and   fonrth  days 


till'  iiiortal- 

e    IK'VlT    lll'l'Il 

atc'd  is  Irom 
'S'y  per  criit. 
atiu  lu'twt'on 
arks  Ml  ]i(ist- 
L'f  ;i  3  and  4 
rut.  W.  M. 
1  cicalric'cs  S 
,  '11  JUT  cont; 
lit. 


(•liaraite'i'izc'd 

(lie  cases  arc 
I  or  may  fol- 
u'li-pox  is  no 
1  iiii'.jdi'ity  of 
aivly  seen  in 

[uitc  distin;'t 

0  it.  An  at- 
of  tlu'  otluT. 

this  fonni'O- 
.vitli  a  vcsicii- 
IJK'  siiiail-iiox 
y  Sir  Uisdoii 
(I  vacoinatc'd, 
irst".     On  till! 

On  till'  fol- 
I'lopi'd  attack 

tot'ii  days  the 
cliill.  'riiiTL' 
ions  aiT  rare. 
t  is  tirst  si'on 

hi'fjin  on  tiio 
:,  tlioso  arc  in 
ng  a  clear  or 

instances  the 
hey  are  oi'ten 
^■osicles.  The 
niic.  At  the 
'   vesicles   aro 

1  fourth  days 


VAKICELLA. 


75 


are  converted  into  dark  brownish  (■rii>ts,  which  lall  oil'  and  as  a  ndc  leav.- 
no  scar.  Fresh  cro|)s  apirar  durin.i,^  the  iir-t  two  or  tliree  davs  of  tiie  ill- 
ness, s.,  that  on  the  fonrtli  day  one  can  iis„allv  .^ee  pocks  in"all  sta'-'es  of 
d.'velopnient  and  decay.  They  are  always  .li,.,'rete  and  the  niunher  may 
vary  Irom  ei>,dit  or  ten  to  several  imndrcds.  As  in  variola,  a  scarlatinal 
rasli  occasioiiiilly  precedes  the  development  of  the  eruption.  The  eruption 
may  occur  on  the  nnicous  nienihrane  of  the  mouth,  and  ()ccasi.,nallv  in  the 
larynx  ( I  >.  11.  JIall). 

'I'hcre  aro  one  or  two  modilications  of  the  rasii  wliich  are  interestin-'. 
The  vesicles  may  hecoiue  very  lar-:e  and  develop  into  re-ular  hulhe.  look- 
m^^  not  unlike  ecthyma  or  i.emphi.uns  (varicella  bullosa).  The  irritation 
oi  the  rash  may  he  excessive,  and  if  the  child  scratches  the  pocks  ul.-erat- 
mj:  sores  may  form,  uliich  on  liealin^^  leave  n-iy  scars,  indeed,  cicatrices 
alter  chicken-pox  are  more  common  than  after  varioloid.  The  fever  in 
varicella  is  sli-lit.  hut  it  do.'s  not  as  a  rule  disapp.ar  with  the  appear- 
ance <,|  the  rash.  'I'he  course  of  the  disease  is  in  a  lar^^e  majoritv  of  the 
cases  huoral.le  and  no  ill  ed'ects  follow.  The  disease  niav  rciir  in  the 
same  individual,  'i'hcre  are  instances  in  which  a  pcivoii  "has  had  three 
attacks. 

in  delicate  children,  particularly  the  tnherciilou.s,  j.an<.rrene  (varicella 
oscharotica)  may  occur  about  the  vesi.les  (Ilutcliin.son):  or  in  other  parts, 
as  the  scrotum.  ' 

Cases  have  been  (h'scribed  (Andrew)  of  ha'niorrha.iric  varicella  with 
cutaneous  ecchyiiK.ses  and   blccdinu-  from  the  mucous  membranes. 

Nephritis  may  occur,  infantile  hemipli-ia  has  developed  diiriiii:-  an 
attack  of  the  di.sea.se.  Death  has  followed  in  an  iiiicomplicated  case  from 
extensive  involvement  of  tli?  skin  (Xisbet). 

The  (iHii/iinsis  is  a.-  a  rule  easy,  i.articiilarly  if  the  patient  has  iieeii  ,<een 
from  the  outset.  When  a  case  comes  under  observation  for  the  first  tim,. 
with  the  ra.sh  well  out.  there  may  be  consideraiile  dilliculty.  'j'he  a  -iin- 
dance  of  the  rasli  on  the  trunk  in  varicella  is  most  important.  The  pocks 
in  varicella  are  more  superlicial.  more  bleb-like,  have  not  so  deeply  an 
infiltrated  areola  about  them,  and  may  usually  be  seen  in  all  sta<ies  of  de- 
velopment. They  rarely  at  the  outset  have  the  hard,  shottv  feelinrr  of  those 
of  small-pox.  The  jreiieral  symptoms,  the  nivater  intensity'  of  the  oii.set,  the 
l)roloii,u-ed  jieriod  of  invasion,  and  the  more  fre(|iient  occurrence  of  pro'i 
jiial  rashes  in  small-pox  are  important  jioints  in  the  dia<,niosis. 

No  special  tmilmrni  is  reipnred.  If  the  rash  is  aimmlaiit  on  the  fac( 
^■ivat  care  should  be  taken  to  prevent  the  child  from  .•^cratch Iiil;-  the  i.iis 
tules.     A  soothing  lotion  should  be  ajijilied  on  lint. 


VII.    SCARLET  FEVER. 

Definition.— An  infections  di.sea.se  characterized  bv  a  dilViise  exan- 
tliem  and  an  angina  of  variable  intensity. 

Etiology.— We  owe  the  recognition  of  scarlet  W'wv  n>  a  di-tinct  dis- 
ease to  Sydenham,  before  wliose  time  it  was  confounded  with  measles.     It 


ro- 


t 
1  ■ 


5     I 

i 


.i 


SPECIFIC   INFECTIOUS  DISEASES. 


is  a  \vi(lcs]>v('ii(l  iillVction,  (n ciirriiiL''  in   miirly  all  l>ai'ts  of  tlio  gloln'  ami 
iittackinj:  all  rafcs. 

'V\u'  tliscasc  occurs  simvadically  I'roin  time  to  tinio.  and  tiicii  uiuKt 
iiiikiiown  conditions  hccomcs  widcsiinad.     i-;]iidcniics  vary  in  severity. 

Anion^'  jiredisiio-iii^'  factors  ajre  is  most  inii>oi'tant.  A  lari:e  i)ro|ior- 
tion  of  the  cases  occur  licfore  the  tenth  year.  Of  an  enormous  nnnilier  of 
fatal  eases  tal)ulated  l»y  Mnnliison  over  !M>  per  cent  occurred  in  children 
under  this  ai.a'.  Adults,  houcver.  are  liy  no  miimus  excmiit.  \'ery  youn,: 
infants  are  rarely  attacked.  A  certain  numl>er  of  those  coiuin.ix  in  couiaet 
with  the  disi'ase"  escape.  In  a  family  of  Jiildren  all  more  or  le>s  exiioscd 
one  or  two  may  not  contract  scarlet  fe.er.  whereas,  as  a  rule,  in  tlie  case 
of  measles  all  tiiko  it.  The  su.<ceiitil)ility  seems  to  vary  in  families,  and  we 
meet  occasionally  with  sad  instances  in  wiiich  three  or  more  mend.>ers  of  a 
family  succiind)  in  rajnd  succession. 

^lalos  and  fonialos  arc  eiiually  alTected. 

Epidemics  iirevail  at  all  reasons.  Imt  perhaps  with  greater  intensity  in 
autumn  and  winter. 

The  contagion  of  scarlet  fever  is  prohahly  not  developed  until  the  erup- 
tiou  apjiears.  and  is  particidarly  to  he  drcailed  during  desijuamation.  No 
doui)t  the  poison  is  sjiread  largely  l.y  tiie  line  scaly  imrticles  which  are 
diffused  with  the  dust  throughout  the  room.  Mveii  late  in  the  disease, 
after  desiiuamalion  has  heen  aiipareiitly  completed,  a  patient  lu.s  cou- 
veved  the  contagion.  The  poison  clings  with  great  I'ersisteuce  to  cloth- 
ing of  all  kinds  and  to  articles  of  furniture  in  '.lie  room.  In  no  disease  is 
a  greater  tenacity  displayed.  Beilding  and  clothes  which  have  been  juit 
away  for  numtlis  or  even  for  years  may,  unless  thoroughly  disinfected, 
convey  contagion.  Physicians,  nuix's.  and  others  in  contaet  with  the  sick 
may  carry  the  ]ioison  to  ]iersons  at  a  distance.  It  is  remarkaMe  that  in 
the  case  of  ])hysiciai.s  this  does  not  more  fretjuently  occur.  I  know  of 
but  one  instance  in  which  I  carried  the  contagion  of  this  disease.  The 
poison  prohahly  is  not  widely  spread  in  the  atmosphere.  Oliservations 
have  heen  recently  made  which  indicate  that  it  mav  he  conveyed  in  milk. 
The  e])idemic  investigated  hy  Power  and  Klein  m  London  in  18.S5  w.is 
traced  hy  them  to  milk  ohtained  from  a  dairy  at  Ilendon,  in  which  the 
cows  were  found  to  he  sutl'ering  from  a  vesicular  affection  of  the  udder. 
The  nature  of  this  disease  of  the  cow  is  douljtful,  however.  C'rookshank 
holds  that  it  was  cow-pox,  and  had  nothing  to  do  with  scarlet  fever. 

Some  writers  maintain  that  scarlet  fever  may  he  associated  with  de- 
fective house-drainage.  Possihly  the  virus  may  occasionally  gain  entrance 
in  this  way. 

One  attack  does  not  necessarily  protect  permanently.  There  are  in- 
stances of  one  or  even  two  recurrences. 

Surgical  ami  puer])eral  scarlatinas,  so  called,  demand  a  word  under  this 
sectiim.  AVhile  scarlet  fever  may  attack  a  person  after  ojieration,  or  a 
woman  in  childbed,  the  majority  of  the  cases  described  as  such  belong,  1 
believe,  to  tlmse  of  sciilica'Uiia.  Tn  the  cases  which  I  have  seen  the  red 
rash  was  rarelv  so  wides|ire:iil  as  in  scarlet  fever:  the  tongue  had  not  the 
siH'cial  features,  nor  was  the  thmat  affected.    Destjuamation  is  no  criterion, 


iXlnln'    mill 

llit'ii    imdiT 
-I' verity, 
rgo  |H'i>])()r- 

luuiilicr  i>t' 
in  i-liiliiri'u 
Very  y.mn.- 
f  in  contact 
OS  I'Xjioscd 

in  the  ciise 
lies,  iuid  we 
umbers  ol'  a 


intensity  in 

il  the  eruji- 
iiiilion.  No 
;  which  are 
the  dif-easc, 
It  lii.s  eon- 
ee  In  cloth- 
lo  disease  is 
re  been  ]iut 

disini'eetetl. 
ith  the  silk 
ilile  that  in 

I  know  of 
iseaso.  Tho 
(liservatiuns 
rt'd  in  milk, 
n  LScSo  w.is 
1  whieli  the 
'  the  ndder. 
C'rooksliank 
[ever. 

ed  with  de- 
[lin  entrance 

here  are  in- 

d  nnder  this 
ration,  or  a 
cdi  belong,  1 
seen  tlie  red 
had  not  the 
no  criterion, 


SCARLET   FEVER. 


77 


as  It  occurs  whenever  liyperaiiiia  of  the  skin  has  persisted  lor  anv  Icn-th 
"I  time.  It  IS  interesting  to  imte  that  tlic>e  cases  have  become  rare  w'ith 
the  gradual  disippearance  of  septica'iiiia.  I.  K.  Atkinson  suggests  that 
in  many  cases  these  rashes  are  due  to  (luininc. 

The  >|,ecitic  germ  is  still  unknown.  Strei.tococ.a  are  found  in  the 
skm,  in  tlH>  blood  >onierinics,  and  in  the  organs  of  fatal  ca,se.s.  It  lias  oven 
liceii  urg.Ml  that  the  disea>e  is  ,uily  a  form  of  stre|.tococciis  infection.  Throat 
l.'sions  of  the  mo>f  malignant  type  may  occur  without  the  jiresence  of  the 
bacillus  (hplitheria>.  but  in  the  infectious  ]mvilions  of  hospitals  the  scarlet 
fever  cases  are  very  apt  to  be  complicated  with  true  diphtheria;  much  more 
so  than  111  private  pra.'tice.  The  streptoco<rus  jivo-enes  is  the  common 
organism  of  the  otitis  media. 

Morbid  Anatomy. —Kxcept  in  the  luemorrha-ic  form,  the  <kin 
atter  death  show.s  no  tracs  of  the  ra>h.  There  are' no  spe.Mlic  lesions 
llios..  which  occur  m  the  internal  organs  are  due  partlv  to  the  fever  and 
partly  to  infection  with  ]ni.s-organisnis. 

The  anatomical  ch.-nges  in  the  throat  aiv  those  of  simple  iiillamina- 
lion,  lollicnlar  tonsillitis,  and,  in  extreme  grades,  of  pseudo-meml)ranon.s 
angina.  In  severe  ea.<es  there  is  intense  Ivmj.liadenitis  and  much  inllain- 
inatory  (edema  of  the  tissues  of  the  neck,  which  mav  go  on  to  suppuration, 
<'r  even  to  gangrene.  Stivptoccci  are  found  abnndantiv  in  the  glands 
and  in  the  areas  „i  suppuration.  Of  changes  in  the  digestive  organs,  a 
catarrhal  state  of  the  ga>tro-iiitestinal  mucosa  is  not  uncommoiK  The 
liver  niay  show  int.-r^titial  changes  (Klein).     The  spleen  is  often  enlai;.n'd. 

i-.iidocanlitis  and  pericarditis  are  not  infre<iuent.  Mvocardial  changes 
are  less  common.  The  ivnal  changes  are  the  mo,<t  imi'.ortant,  and  lun-o 
lieen  thor.uighly  stiidie.l  by  Coats.  Klebs.  Wagner,  and  others.  The  spe- 
cial nephritis  of  scjirlet  fever  will  be  con.-idered  with  the  di.seases  of  the 
kidney. 

AlVections  of  the  respiratory  or-aiis  are  not  freipicnt.  When  death 
results  from  the  pseudo-inemliianous  angina,  broncho-pneumonia  is  not 
uiicoiinnon.     ( 'erebro-sfiinal  changes  are  i-are. 

Symptoms.— Incubation.— "  iMom  one  to  seven  davs,  ofteiiest  two  to 
four." 

Invasion.— The  onset  is  as  a  rule  sudden.  It  may  lie  preceded  liy  a 
flight,  scarcely  noticeable,  indisposition.  An  actual  cl'iill  is  rare.  Vomit- 
ing and,  in  young  children,  convulsions  are  common.  The  fever  is  in- 
tense: rising  rapidly,  it  may  on  the  first  day  reach  101=  or  even  Id.'.". 
The  skin  is  unusually  dry  and  to  the  touch  gives  a  sensation  of  very  ])u.>- 
gcnt  heat.  The  tongue  is  furred,  and  as  early  as  the  first  dav  there  may 
be  complaint  of  dryness  <d'  the  throat.  Cough  and  catarrhal  svmptom's 
are  uncommon.  The  face  is  often  iluslied  and  the  ]iatient  has  all  the  ob- 
jective f(  atures  of  an  acute  fever. 

Eruption.— Usually  on  the  second  day,  in  some  instances  within  twenty- 
four  hours,  the  rash  develops  in  the  form  of  scattered  red  points  on  a  deep 
subcuticular  flush.  It  appears  first  on  the  neck  and  chest,  and  spreads  so 
rapidly  that  by  the  evening  of  the  second  day  it  may  have  invaded  the 
entire  skin.     After  persisting  for  two  or  three  days  it  gra<liiallv  fades.     In 


i' 


^^ 


78 


SPECIFIC  INFPX'Tlors   DISKASKS. 


■ 


IB8RIIIII 
HHIIH 


lirnnoiiiK  cil  ciiM's  till'  liisli  at  its  lu'iirlit  has  a  vivid  srarlct  line,  (luitc  dis- 
tinctivo  and  unlike  tliat  seen  in  any  otluT  criiiitivc  di>casc.  It  is  cntindy 
liyiHTii'inic,  and  the  ana'inia  |iniduced  hy  jirosure  instantly  disapiicars. 
In  a  very  intense  rasli  there  may  l)e  line  imnetilVnin  ha'niorriia.u'es,  wliieii 
d(t  not  disa|i|)ear  on  pressure.  Jii  H)ine  eases  tlu'  rash  does  not  l)eeoine 
\inirorni  Init  remains  patehy,  and  intervals  of  normal  skin  se|iarate  hirj^e 
h\'|iera'niie  areas.  Tiny  ]ia|iui:ir  idevations  may  sometimes  he  seen,  hut 
thev  are  not  so  eoniinon  as  in  measles.  At  the  iieij^dit  of  the  erujition 
siidamiiial  vesicles  may  develop,  the  lluid  of  whieli  may  heeome  tnrhid. 
The  entire  .-kin  may  at  the  same  time  he  covered  witli  small  yiiiow  vesi- 
cles on  a  dee|)  red  i)aek<:round.  I'rononneed  cases  of  this  ty])o  wore  called 
])V  the  older  writers  sciirluliiiii  iiiilldriK.  The  hlood  shows  an  early  leneo- 
cytosis,  which  is  often  extreme  in  fatal  cases. 

Occasionallv  there  are  ])etechia'.  which   in   the  maliuiiant   ty|ie  of  the 
disease  heconie  widespread  ami  la.-;:e.     The  eruption  does  not  always  ap- 
pear upon  the  face.     Tln're  may 
1        334567       8!)     lie  a  jTood  deal  of  swelling:  (d'  the 

skin    which    feels    nncomfortahle 

and   tense.      The   itchini:   is   vari- 

aiile:  not  a-  a  rule  intense  at  the 

heitziit  of  the  eruption.    The  rash 

can  often  he  seen  on  the  mucous 

niemhranes    of    the     jialate,     the 

cheeks,  and  the  tonsils.  j;ivin<i  to 

these    parts   a    vivid    red,    ])uneti- 

forui    a|i|iearance.       The    lonji'iU' 

at  first  is  red  at  the  tip  and  edjies, 

furred  in  the  centre;  and  thron.uii 

the  white  fur  are  often  seen  the 

swollen    I'ed    pajiilhe.   which    <:i\(> 

the    so-calleil    "  strawherry  ""    ap- 

jiearance    to    tlie    tongue.      In    a 

few  days  the  "  fur"  des(piamates  and  leaves  the  surface  red  and  roujih.  and 

it  is  this  condition  which  some  writers  call  the  "strawherry,"  or,  lietler. 

tile  "  raspberry  "  tongue,     'i'he  breath  often  has  a  very  heavy,  sweet  odor. 

The  pharyn^'al  symiitoms  vary  extremely.     There  may  be — 

1.  Sliirht  redness,  with  swelling:  of  the  ]iillars  of  the  fauces  and  of  the 
tonsils. 

2.  A  more  intense  g'rade  of  swellinf;  and  infiltration  of  these  parts  with 
a  follicular  tonsillitis. 

3.  ^Iend)ranous  anu'ina  with  inten>e  intlamnuitioii  of  all  the  |)haryii- 
jreal  structures  ami  swelling;  of  the  plands  1)elow  tlio  jaw,  and  in  very  severe 
eases  a  thick  l)rawny  induration  (>f  all  the  tissues  of  the  neck. 

The  fever,  which  sets  in  with  such  suddenness  and  intensity,  may  reach 
10.')°  or  even  lOfi".  It  jiersists  with  slight  niornin<r  remissions,  <,n'adually 
deelininfr  with  the  (lisapitearance  of  the  rash.  In  mild  cases  the  teni])ora- 
ture  may  not  reac  ii  l(i;?°;  on  the  other  hand.  In  very  severe  eases  there  may 
bo  hyperpyrexia. the  thermometer  rejiisterinj:  108°  or  before  death  oven  lol)°. 


105-8' 


loro" 


i(wa° 


100-4= 


98 -C" 


nm 


Kruptiiin, 
t'li.vRT  VII. — Scarlet  fevtT  (Sti-iimiu'll). 


,  (itiitc  (lis- 

is  ciitiivly 

(lisiipiifiirs. 

IJIOS.  wliiili 

Kit     l)f('OIIR' 

a  rate  larj^f 

'    Sfl'M.     l>llt 

('  tTiijition 
iiu'  turl)i(l. 
iUdw  vi'>i- 
woro  callcil 
■ally  IcucD- 

ypi'  of  till' 
always  ap- 
TluTc  may 
liiijf  (if  till' 
■iiiiii'i)rtai)l(' 
wi:  is  vai'i- 
ciisf  at  till' 
Till'  rasii 
111.'  imu-niis 
talatc,  the 
;,  j;iviii^  to 
'il,  ]iuiicti- 
lir  toii.u'iic 
and  oiljit'S, 
ml  throiiiih 

11     Sl'CIl     tilt' 

ivliirli  j:i\(> 
ii'i'ry  ""  ap- 
uc.  In  a 
rouoh,  ami 
or,  licttiT. 
<\VL'i't  oilor. 

anil  of  the 

parts  with 

H'  |)liaryii- 
vrry  si'ViTi' 

may  reach 

,  firailually 

c  tempera- 

tlioro  may 

even  lot)'. 


SCAULKT   Fi:VKR. 


9 


fro,,-,  ,'-;"''  "''  ;":''!""'"^'  '••'"•"'■  ^•'""■'"•tc's.  nui^i,,.  i„  ..|n 

fro,  ,  IJ     to  J..0     or  evH,  h,irhu..     Th,.  n.spi,atio„s  .how  atilncvas 
•..o,iate  ,o  the  ,„t..n>i,y  ..f  „,„  f.,,,,,.     The  ,ast,-o.n„..„„al     v  u  „o,„ 


ililri'ii 
pro- 


'U-v  not  ,„a,'k...l  altiT  th.  initial  voi.iitin;:.  ami  f I  is  uMiallv  wll  ,-,1  ... 

n  sonn.  ,,,s,anees  ,hi.,v  a,v  ah,|o,„i„al  pa,ns.     Th.'  .-I,,.  .,,"      ,  .  ''      ^ 

H'papnhh..    Thi'i,v..risnotof,..n..nlar,..,l.     With  thi^inuialivj.,        • 

>v.n!   o,ns  a,v  p,vs,.„t  ,n  a  nu'jo.-i.y  of  th.  .-ascs:  hut  as  the  ,.,<!,  lo,,,. . 

'""    ";•■   ''7'"^-'";   "'"'    "'^'   ^li^l.t    n-t.u-nal    wan.len,,.   ,|i. .        T  . 

nnn.  has  the  o.hna.-y  f.hr.le  ehann'ters.  I..,,,  sLanty^aml   ll,   l'  .iJ.    . 

M.,!.;ht  alhinmnnna  ,s  hy  m.  means  inf,-,..,u..„t  .luri,,;,;  th.'  sta:.v  of  .,•„,. 

'-;;■     *''-'';'  -'"'ination  of  tlu.n,.i,,eshonhll.,,,a,h'evJhvTZ 
-  no  c,u,s..    or  ala,',n  ,n  the  t.'aee  of  alhmnu,  wlmh  is  so  of,.,,;  p,.  ^   t 
not  even  ,1  it  is  associate.]  with  a  IVw  tiil,..-,,,<t< 

Desquamation -With  the  .lisappcan,,,..'  .>f  th.  .-asl.  a,„l  thi.  f..v..r  th.' 
Jkin  looks  so„,..wi.atstain..,l.  is  .i.-y.  a  littl.'  ,.o.„h.  an,l  „.ailna    v  ,  u^     p    ! 

tH    n.   k  .11.1  elmst,  and  IJakrs  aiv  ,i:m.l„allv  .hlarheil.     Tii.,  .h-nve  a.i.l 
;  -racer  ..  th.'  .   's.p.a.nation  l.ar  so,,,..  ,vla„o„   to  th.'  i„t  „    ,v     f 
'""""•     ^  '"■"  ^''^'  •"'^'■•-  '-  '-••'  ve,.y  vivi.l  an.l  of  h,,,.  stan.li, l     a 
lakc.ynay  he  tlinnvn  o,r.     I„  ,,„■.  instan.-.'s  th.'  hair  and  even  the  n  d 
ave  heen  .hod.     J,  „,„st  no,   1,..  ,o,.,o„.,„  ,|,at  ti,..,'e  a,-e  .al"    ,,  m 
-  d.'s.,nan,at,.>n   has  l.e,,   pn.lo,,,...!,  a..,.onli„,  t.,  Tn.nss  •    ,.     ve 

':: ;::;;!;:;;.;f '''^ ^    Theent,..ep,.oeessias.sf,.o„,,.„.,o ,,■,....;.:; 

Tl,e,-e  a,'e   (•as.s   ..f  ex.M'ptiimal    „,il,l,K.ss   i„    whi.^l,    th.'    ra>h    n,av    h.' 
seaively  p,.e.,.t,hh'.     Du.'in,  epi.len.i.-s.  when  s..ve,.al  ..|„l.ln.„  of  ^  ho,,.: 
i"id  a,-e  at  ,.,.(...1,  ,t  so,„ot,mes  happens  that  a  .hilil  si.-k..„s  as  if  .,f  .,.,,.l„t 
l-'yvr,  and  has  a  so,v  thn.at  and  the  "  sfawhi.Tv  t.m.M,..  -  with.mt  ,!,.■  ... 
-loi;.ne,i,  ..  iany  i.sh      This  is  the  so...all...l  .;.•/./;:.,  su.  n.:!!-!!:.' 

t..^:7::;;!n.ir "' ''""'"' '-'''  '""^- '- '''--'  '^  ^'-  -•-•'-  - 

MALIGNANT  SCARLf:T   FE\'I-:R. 

Atactic  Form  -This  p,vsents  all  the  eha,-a..t..ri>,i..s  of  a„  a.„te  i,„oxi- 

n.  no,,     'J,H.  pat,ent.  .,ve,'wl,.'ln,e,I  hy  th.'  i„t..„sity  of  the  so,,,,  . 

w.tl„,i   t.x>nty-f,,nr  .n-  thi.ly-six    ho.ns.      T lis..ase   s.-ts'  i„    w  ,      "  ■,  ' 

.ev..r,ty-h,,h   fever,  o.xtren,,.  n.stlessness.   |,..a,la..h...  a„,I   .]..li,.i.„.,     ^r 
empe,-atn,-..  n,ay  r,se  t..  1..^  ..r  .'ven   l..s^  an.l  ra,-e  ..s..  hav..  h.!..,,  1 
M'H.'d  ,n  wlueh  the  th.'nno„,..ter  has  r.-ist.'>'..,I  ev.-n  hid..'.-.     i'nuvuUlnn 
;'';'.^-  •;•'■•"•  !••  Hiil.lj'en.     The  ini,ial  .l..liri„„,  rapi.lly  .iv.'s  pla.v  t..  ,.o„.a 


coiiia. 


I'h.^dyspn.ea  ,„ay  h.'  nr-.'nt;  the  pulse  ,s  v.'rv  rapi.l  a.  .1  ferhj.. 

Hemorrhagic  Form. -r,,    son,e   insta,,.-..    ha.„,orrha...s   o....„r'i„,o   the 
sK,n.        h.'n.  a,-e  ha.,natnr,a  and  ..pistaxis.     I„  the  ..,-vtl,..„,at<ms  ra^h  ,h..,v 


are^at    ii,-st   s.^atfered    p..te,.hia'.   whi.-h   -.'adually   her-o,,,,,   ,,,0,,.  ,.x,,.„hv, 

,-..,1       1 

pla.e  .)n   the  s.>rond   or  0,1   th.'  ihii'.l   ,lav. '    While 


and   ul,in,at..ly  the  ^skin   may  he   unive,'sally   involv.d.      IVath    n,ay  tak.. 

■    ha, 
pel 


"-•'■  <->"nno,,  i„  enf.'.>hK.d  ..hildivn.  1  ha^..  twi...  k„!,wn  ll'to  itti^kp^ 
sons  apparently  in  full  health.  '  '"^' 


80 


spix'iFic  ixFi-:i"rioU8  ihskases. 


Anginose  Form.— Tlio  throat  s^viiii.toins  may  ai^pcar  early  and  i.rogre^s 
rai.idlv.  The  laiurs  aiul  tonsils  are  swollen.  -Membranous  evu.  ation 
„tcurs".  It  mav  extend  to  the  posterior  wall  of  the  pharynx.  Un^.:m\  into 
the  mouth,  and  upward  into  the  nostrils.  Tiie  jrlands  of  the  neek  rapidly 
c.„lar-e  Necrosis  oecurs  in  the  tissues  of  the  throat,  the  f.etor  is  extreme, 
tiie  enn^titutional  disturiiaiiee  profound,  and  the  child  dies  with  the  clin- 
ical picture  of  a  mali-nant  diphtheria.  Occasionally  the  memlmr.ie  ex- 
tends int..  the  trachea  and  the  bronchi.  The  Hustachian  tubes  and  the 
middle  car  are  usually  involved.  When  death  doi's  not  take  place  rapidly 
fr.,ni  toxicmia  there  mav  lie  extensive  abscess  formation  in  the  tissues  ot 
the  neck  and  slon-hin-.  In  the  separation  of  deep  sl.ni<:lis  about  the  tou- 
-iN  the  carotid  arterv  mav  be  oi.eiicd,  causing  fatal  luemorrhage. 

Complications  and  Sequelae.— (»)  Xi'phrilis.-M  the  lieight  of 
tlie  fever  there  is  often  a  slight  trace  of  albumin  in  tiie  urine,  which  is 
not  of  s].ecial  significance.  In  a  majority  of  cases  the  kidneys  escape  with- 
out greater  damage  tiian  occurs  in  other  acute  febrile  all'ections. 

Nej.hritis  is  most  common  in  the  second  or  third  week  and  may  de- 
velop after  a  very  mild  attack.  It  may  be  delayed  until  the  third  or  fourth 
week.  As  a  rule,  the  earlier  it  develoiis  the  more  severe  it  is.  It  vanes 
greatlv  in  intcnsitv,  and  three  grades  ot  cases  may  bo  recognized: 

l."\'cry  severe'cases  with  supiiression  of  urine  or  the  ].assage  of  asmall 
(uiantitv  of  dark  bloo<lv  urine  laden  with  albumin  and  tube-casts.  A  omit- 
in.'  is  constant,  there  arc  convulsions,  and  the  child  dies  with  the  syiup- 
toms  of  acute  uru'inia. 

2.  Less  severe  cases  without  any  serious  acute  symiitonis.  Ihere  is  a 
l)utVv  appearance  of  the  eyelids,  witii  slight  (edema  of  the  feet;  the  urine 
is  d'iminished  in  (piantity.  smoky  in  aiipcarance.  and  contains  allmmin 
and  tnlu'-casts.  The  kidney  symptoms  then  d(uiiinate  the  entire  case,  the 
dropsy  jtersists.  and  there  may  l)e  ciVusion  into  the  serous  sacs.  The  condi- 
tion may  drag  on  and  become  chronic,  or  the  i.atieiit  may  succumb  to 
iira'mic  accidents.  Fortunati'ly,  in  a  majority  of  the  cases  the  disease  yields 
to  judicious  treatment  and  recovery  takes  jdace. 

;5.  Cases  so  mild  that  they  can  scarcely  be  termed  nephritis.  The 
nrine  contains  albumin  ami  a  few  tube-casts,  but  rarely  blood.  The  tcdema 
is  extrcmelv  slight  or  transient,  and  the  convalescence  is  scarcely  inter- 
rupted. Occasionally,  however,  in  these  mild  attacks  serious  symptoms 
may  suitcrvene.  (Kdema  of  the  glottis  may  prove  rapidly  fatal,  and  in  one 
case  of  the  kind  a  child  under  my  care  died  of  acute  elfusion  into  the 

]ileural  sacs.  .  . 

Occasionally  o'dema  occurs  without  all)uminuria  or  signs  oi  nephritis. 
Tossibly  in  some  of  these  case  the  (edema  may  be  ha>mic  and  due  to  the 
anivmia;  but  there  are  instances  in  which  marked  changes  have  been  found 
in  the  kidney  after  death,  even  when  the  urine  did  not  show  the  features 
characteristic  (d'  nephritis. 

{!))  Arlhiilis. — During  the  subsidence  of  the  fever,  rarely  at  its  height, 
pains  and  swellings  in  the  joints  may  devcdop  and  present  all  the  charac- 
t(:'ristics  of  acute  rheumatism.  In  all  im.bability  it  is  not.  however,  true 
rhenmatism,  but  is  analogous  to  goiiorrlueal  arthritis.     The  cfTusioii  may 


SCAUI.KT    I'KVEK. 


81 


aid  progrer-s 
s  I'xudatiuii 
forward  into 
iK'C'k  rapidly 
I-  i>i  fxtrt'iiu'. 
ith  tlu'  t-lin- 
I'lnlira-ie  I'x- 
ilifji  and  the 
)luce  rapidly 
1k'  tissue'!?  of 
Hint  till'  ton- 
ige. 

le  lu'iglit   I't' 
110,  which  is 
escapo  wi til- 
US. 

ami  iiiiiy  dt'- 
ird  or  I'oiirth 
is.  It  varies 
zed: 

til'  of  a  small 
iists.  A'nmit- 
th  the  syiup- 

.  There  is  a 
et;  the  urine 
ains  albumin 
itire  case,  the 
.  The  condi- 
:  siiecuiid)  to 
disease  yield>: 

pliritis.  The 
The  tedema 
eareely  inter- 
ins  symptoms 
fil,  and  ill  one 
ision  into  the 

:  of  nephritis, 
[id  due  to  the 
ve  been  f(niiid 
IV  the  feature.s 

at  its  height, 
ill  the  cliarac- 

however.  true 
'  effusion  may 


I'ass  on  to  .suppuratiiMi.  in   uhidi  (■a^e  it  mo>t  ((mimnnlv  iiivuhvs  onlv  u 
.-ingle  joint. 

((■)  Canlidc  Cuitii>liailioiis.~Sim\<k  eiidoeardilis  ii  not  uiiuommoii, 
and  many  eases  of  ehronic  valvular  disease  origiiiate  |.r(ihablv  in  a  latent 
eiidoearditis  during  this  di>ea-e.  .Malignant  end.iearditis  is'  rare.  iVri- 
earditis  is  probably  iK.t  nmre  fre(pient.  but  is  |,.>s  likrlv  to  i)e  (.verlook,.,! 
liiiin  emlnearditis.  It  uMially  (l(Vrl(.p>  during  eonvalescniee;  the  etVnsion 
may  hi-  sero-tibriiioiis  (,r  purulent.  TIr.  eardiae  complications  are  .some- 
times f.uin.l  in  asx.ciation  with  artiiritis.  Myocarditis  is  not  uiicmmon. 
('/)  ririinsii  may  fdlluw  jiiirinih>iii,i,  tlu. ugh  this  is  rare.  More  nficn 
It  orcurs  (luring  conval.'sccmr,  is  insidious  in  its  cmise,  and  as  a  rule 
purulent.  This  .-.erious  complication  of  scarlet  b'Vcr  is  not  sutliciently 
recognised.  It  was  one  upon  which  my  teaeher.  li.  I'.  Howard,*  in  Moii'- 
tri-al.  speciiijly  insisted  in  his  lectures.  Slieritf,  in  a  number  of  the  same 
journal,  reports  two  cases,  occurring  at  the  ,snne  time  in  brothers,  one  of 
uhom  dieil  suddenly  after  a  sliuht  e.vertion. 

('■)  /•;-//•  Ciinipliriilioiis. — These  are  coiunion  and  serious.  Tliev  are 
<lue  to  extension  of  the  intlammation  from  the  throat  through  the  Kn- 
stat'hian  tuiics,  and  rank  among  the  mo>t  frc(picnt  cau.ses  of  deafness.  'Hie 
severe  forms  „f  membranous  angina  are  almost  always  as.-^oeiated  witli  in- 
tlammation of  the  ini(hlle  ear,  which  goes  on  to  sup|>uration  and  to  per- 
foration of  the  drum.  The  suppuration  may  extend  to  the  labvrinth  and 
rapidly  produce  deafness.  In  otlier  in>tances  there  is  suppnrat'ion  in  the 
mastoid  cells.  In  the  necrosis  which  billows  the  middle-ear  disease,  the 
facial  nerve  may  be  involved  and  paralysis  follow,  l.nter.  still  more  seri- 
(His  complications  may  billow  the  otitis,  such  as  thrombosis  of  the  lateral 
sinus,  meningitis,  or  abscess  of  the  brain. 

(/)  Ailniili^. — In  comparatively  mild  cases  of  scarlet  b'ver  the  sub- 
maxillary lymph-glamls  m^iy  he  swollen.  In  severer  cases  the  swelling  of 
the  neck  becomes  exti'eiiie  and  extends  beyond  the  limits  of  the  irlands. 
Acute  piilegmonons  iiillammations  may  occur,  leading  to  widespread  de- 
ttriictioii  of  tissue,  in  which  vessels  may  lie  eroded  and  fatal  iueiiKU'rhairo 
ensue.  The  suppurative  processes  may  also  involve  the  retro-]iliarvnL;val 
tissues. 

The  swelling  of  the  lymjih-glands  usually  subsides,  ami  within  a  U'w 
weeks  even  the  nio.-t  extensive  enlargement  gradually  disappears.  There 
are  rare  instances,  however,  in  which  the  lymjihadenitis  becomes  chronic, 
and  the  neck  remains  with  a  glandular  collar  which  almost  olditerates  its 
outline.  This  may  ])rove  intractable  to  all  ordinary  measures  of  treat- 
ment. A  case  came  under  my  observation  in  which,  two  years  after  ,s'ar- 
let  b'ver.  the  neck  was  enormously  enlarged  and  surrounde(l  liy  a  iniM-a  of 
tirni  brawny  glands. 

(V/)  Nervous  Camplirnlions. — Chorea  occasionally  develops  in  connec- 
ti(m  with  the  arthritis  and  endocarditis.  Sudden  convulsions  bdlowed  by 
hemiplegia  may  occur.  Progressive  jiaralysis  of  the  limbs  with  wasting 
may  develop  with  the  features  of  a  subacute,  ascending  spinal   ])aralysi.s\ 


*  Canada  Medical  and  .Siirtrical  Journal,  December,  1872. 


It! 


82 


SI'KCIFIU  INFKCTIOUS   DISRASES. 


Thromliusis  ol'  tlio  ccrolinil  voins  muy  occur.    Mental  symittoms.  mania  ami 
mcliindiolia,  liavc  Itccn  (k'scril)c(l. 

(//)  Other  rare  ciiin|ilicatii)ns  an<l  siMiiU'Ia'  arc  <nlcma  nf  tlic  eyelids, 
witinmt  ne|iiirili;-  (S.  I'liilips).  syiiimetrical  jranjirene,  enteritis,  noma,  anil 
perloiation  of  the  sol't  palate  (doodall).  IVarson  ami  i-ittlewood  have 
ri'iportcd  a  case  of  dry  ;.ain^reiie  after  scarlet  fever  in  a  lioy  of  fonr,  wliicii 
developed  on  the  ninth  day  id'  the  di^'ase.  and  involved  ixith  lejrs.  neces- 
sitatinjr  am|»ntation  at  the  njipcr  third  of  the  thijrhs.     'riie  child  recovered. 

Diagnosis. — 'i'iie  diagnosis  of  scarlet  fever  is  not  dillicnlt,  imt  tliere 
are  ca>e.-  in  which  the  true  natnn'  of  the  disease  is  for  a  time  doniitfni. 
The  following'  are  the  most  common  conditions  with  which  it  may  l)e 
confounded: 

1.  Anitr  K.rfdlialiiifi  PcriHiililis. — 'Piiis  pseudo-e.xanthem  simulates  scar- 
let fever  very  closely,  it  has  a  sudden  onset,  with  fever.  The  eruption 
spreads  rapidly,  is  uniform,  and  after  |iersistin<r  for  live  or  si.\  days  he;;ins 
to  fatU'.  {''.veil  l)etore  it  has  entirely  j.Mine.  des(piamation  usually  lie;,Mns. 
Some  of  these  cases  can  not  he  distinguished  from  scarlet  fever  in  the 
sta^M'  of  eruption.  The  throat  symptoms,  however,  are  usually  absent,  and 
the  ton;,MU'  rarely  shows  the  cl)ani;es  which  are  so  marked  in  scarlet  fever. 
In  the  (les(iuamation  of  this  all'cction  the  hair  and  nails  are  commonly 
alVected.  It  is,  too,  a  disease'  lialile  to  recur.  Some  of  the  instances  of 
second  and  third  attacks  of  scarlet  fever  have  heen  eases  of  this  form  of 
dermatitis. 

•v'.  Mnislfs,  which  is  distin^niisheil  hy  the  lon<ier  period  (d'  invasion, 
the  characteristic  nature  cd'  the  prodromes,  and  the  later  appearance  of  the 
rash.  The  jrrcater  intensity  of  the  measly  rash  ujion  the  face,  the  more 
papular  character  and  the  irrejrular  crescentic  distrihution  are  distinj,nush- 
in<r  features  in  a  majority  of  the  cases.  Other  points  are  the  ahseiice  in 
measles  of  the  sore  throat,  the  peculiar  character  of  the  des(iuamation,  and 
the  ahsence  of  Unicocytosis. 

'A.  li'iilhcln. — The  rash  of  ruhella  is  sometimes  strikin;:ly  like  that  of 
scarlet  fever,  hut  in  the  <;reat  majority  of  cases  the  mistake  could  not  arise. 
In  cases  of  doubt  the  general  symptoms  are  our  host  guide. 

4.  S('iitir(iiiii(i. — As  already  mentioned,  the  so-t'alled  iiuerjieral  or  sur- 
gical scarlatina  shows  an  erujjtion  which  may  be  identical  in  appearance 
with  that  of  true  scarlet  fever. 

T).  Dipldhrrid. — The  ])ractitioner  may  be  in  doubt  whether  he  is  deal- 
ing' with  a  case  (d'  scarlet  fever  with  intense  mend)ranous  angina,  a  true 
diphtheria  with  an  erytheniatotis  rash,  or  coexisting  scarlet  fever  and 
di])htheria.  in  the  angina  occurring  early  in,  and  during  the  course  of 
scarlet  fever,  thongli  the  clinical  features  nuty  be  those  of  true  diphtheria, 
LoetllerV  bacilli  are  rarely  found.  On  the  other  hand,  in  the  mendiranons 
angina  occurring  during  convalescence,  the  bacilli  are  usually  jiresent.  The 
rash  in  dii)htlieria  is,  after  all.  not  so  C(Uumon.  is  limited  usually  to  the 
trunk,  is  not  so  ])ersistent.  and  is  gi'uerally  darker  than  the  scarlatinal  rash. 

Scarlatina  and  dijihtheria  may  coexist,  but  in  a  case  i)rescnting  wide- 
spread ervthema  and  extensive  mendirauous  angina  with  Loefiler's  bacilli, 
it  would  jiuzzle  Hippocrates  to  say  whether  the  two  diseases  eoe.xistod,  or 


<,  mania  ami 

tlic  t'Vt'liils, 
■1,  noma,  ami 
Ic'WiMid   liavc 

four,  wliicli 
1  li'jrs.  iK'ci's- 

1(1   I'ccovcrcil. 

It,  lint  tlu'iv 

IIU'    (lolliitl'lll. 

Ii    it    iiiiiy   l)t' 

imilatcs  scar- 
riio  cniiition 
c  liavs  l)t'i:iiis 
uallv  ht'^iins. 
IVviT  in  the 
v  absent,  ami 
scarlet  I'ever. 
re  commonly 
instances  of 
this  form  of 

of  invasion, 
arancc  of  the 
ce.  the  more 
■  (listinj,niisli- 
u'  alisciicc  in 
amation,  and 

like  that  of 
uld  not  arise. 

•jieral  or  sur- 
n  a])})earance 

}r  he  is  deal- 
nsxina,  a  true 
et  fever  and 
the  course  of 
le  di|)htheria. 

memliranous 
present.  The 
isually  to  the 
irlatinal  rash, 
scntinji:  wide- 
'filer's  bacilli. 

coe.\isted,  or 


SCARLET  PEVEU. 


8;j 


whether  it  was  only  an  inteiiM"  scarlatinal  ra>li  in  di|,htheria.  l)cs(iuania- 
tion  occurs  m  eitiier  case.  TJie  streptococcus  an-ina  is  not  so  apt  to  ex- 
tend  to  the  larynx,  nor  are  recurrences  .<o  common:  hut  it  is  well  to  hear 
J"  imnd  that  ;:eneral  infection  may  occur,  that  the  inemhraue  mav  -prcad 
downward  with  -reat  rapidity,  and,  la>tly.  that  all  th..  nervous  >e;,uehe  of 
the  Klehs-i.oelller  diphtheria  nuiy  follow  the  streptoco,eus  form. 

•  ;.  J'nni  h'a.shrs.—T\H>v  are  partial,  and  seldom  ,nor..  than  a  traiwicnt 
hypera'iina  .d  the  .^kin.  Occasionally  they  are  .lilfu>c  and  iuleuse.  and  in 
.-uch  cases  very  deceptive.  Th.y  arc  not  associate.l.  however,  with  the 
•  haracteristic  symptoms  of  invasion.  '|-|u.re  is  no  fever,  ami  with  care  the 
distinctum  can  usually  he  made.  They  are  moM  apt  i,,  jollow  the  use  of 
helladoiina.  (jiiiniiie,  and  iodiiie  df  potassium. 

Cwxislvncc  of  „ll,rr  />isr„sr.,.—.()i:  -Is.MUi  ,,,scs  „i  .scarlet  fever  in  the 
Metropolitan  Asylum  I'.oanl  Hospitals  whi.li  were  complicated  l.v  some 
"ther  disease,  in  l.OUt  eases  the  secondary  infection  was  diphtheria,"  in  ,s!);) 
ca.-cs  chicken-pox,  in  Td:!  measles,  in  KM  whoopin^'-coui^rh,  in  :,:>  ervsipdas, 
ni  Jl  enteric  fever,  and  in   1  typhus  fever  ( F.  F.  Cai^rer). 

J/o,r  In,,/  i.  a  ChiM  /nfcrlirr.'—V^uaWy  after  desquamation  is  com- 
ph'tc.  in  lour  or  iive  weeks  the  dan-cr  is  over,  hut  the  occurrence  of  so-called 
••return  cases"  show  that  patienK  remain  infective  <-ven  when  free  from 
des(|uamanon.  In  1S!I|,  with  -.'..-.It;}  patients  from  tli.^  (ilas-ow  fever 
hospitals  sent  to  their  homes  convaleseeiit.  fresh  cas.'s  appeared  in  70 
"{  the  houses  (Chalmers).  With  1.-,.(i(i()  cases  suhmitted  to  an  avera-o 
period  of  isolation  »(  forty-nine  days  or  under,  the  iiercenta-e  of  return 
cases  was  l.Sd:  with  an  :\\cvi\<s,>  J.eriod  of  fifty  to  liftv-six  davs,  the  per- 
centage was  lA->:  where  the  isolation  extended'  to  hetween  fifty-seven  and 
sixty-live  days,  the  perceiita.ire  (d"  return  cases  was  1  (.\eech).  This 
author  suj:,i:ests  ei,oht  weeks  as  a  minimum  and  thirteen  weeks  as  a  ina'xi- 
niiim. 

Prognosis.  — Fpidemies  dillVr  in  severity  and  tli.>  inortalitv  i<  ex- 
tremely variable.  .\inon^^  the  better  classes  tJie  death-rate  is  much  lower 
than  111  hospital  jn-actice.  There  are  physicians  who  have  treated  consecu- 
tively a  hundred  or  more  cases  without  a  death.  On  the  other  hand,  in 
hospitals  and  anion,-;  the  poorer  cla.-sts  the  death-rate  is  considerable, 
ranfiin<r  from  o  to  1(»  ])er  cent  in  mild  epidemics  to  •JO  or  :!o  per  cent  in' 
the  very  severe. 

The  yoiin-er  the  child  the  greater  the  dan,i:er.  In  infants  under  one 
year  the  death-rate  is  very  hi,<rh.  The  jzreat  iiroportioii  of  fatal  case.s 
occurs  in  children  under  six  vears  of  au^e. 

The  unfavorable  .-symptoms  are  very  liidi  fever,  carlv  mental  disturb- 
ance with  jrreat  jactitation,  the  (.cciirreiice  of  luemorrha"i:es  (cutaneous  or 
visceral),  intense  membranous  an^nna  with  cervical  bubo,  and  si;:iis  of 
laryn.u'eal  obstruction.  '^ 

Xeithriti.s  is  always  a  serious  complication  and  when  settin<r  in  witli 
suppression  of  the  urine  may  (fuickly  prove  fatal.  It  is  notewoilhy.  how- 
ever, that  a  lar>re  nia.iority  of  the  cases  of  scarlatinal  nephritis  recover. 

Treatment.— Til e  disease  can  not  be  cut  sliort.  In  the  jiresence  of 
the  severer  forms  we  are  still  too  often  lielpless.    There  is  no  disease  how- 


(  'i. 


84 


SPKCII'IC   INFECTIOUS   DISl'.ASHS. 


ever,  in  which  the  successl'iil  issue  ninl  the  avdiilaiicc  of  eoni|iIications  de- 
])en(ls  more  ii|i(iii  tiie  skilled  jud^iufiit  ol  tlic  iiliv.-iciiin  and  the  care  with 
whieii  his  iiistructiinis  are  carried  out. 

The  child  shoidd  lie  isolated  and  placcil  in  cliar<:e  of  a  couipeti-nt 
nurse.  The  teniperatnre  of  the  room  should  he  constant  and  the  ventila- 
tion thuruugh.  The  child  should  wear  a  light  ilannel  night-guwn,  and 
the  hedclothing  .should  not  ln'  too  Iumvv.  The  diet  should  consi>t  of  milk. 
hrotiis.  ami  I're.-h  fruits;  water  should  lie  freclv  j:iven.  With  tlie  fall  of 
the  temiHTature.  tiie  diet  may  he  increaM'il  and  the  child  may  ;,nadually 
rotnrn  to  ordinary  fare  When  dexiiianiaiion  iK\L;ins  the  chili'  should  he 
thorouj:hly  rubhed  every  day,  or  every  .-cidiid  day.  with  sweet  oil.  or  car- 
bolated  vasidine,  or  a  rt-per-ci'nt  hydro-naphthol  soaj),  which  prevents  the 
dryin<r  antl  the  diifusion  (d'  the  >caU's.  An  ocr  ional  warm  hath  may 
then  lie  given.  At  any  time  during  the  attack  the  skin  may  be  sponged 
with  warm  water.  The  patient  may  lie  allowed  to  get  up  after  the  tem- 
j)erature  has  been  normal  for  ten  days,  but  for  at  least  three  weeks  from 
this  time  great  care  should  lie  e.\erci.-cd  to  prevent  exposure  to  ctdd.  It 
must  not  he  forgotten,  also,  that  the  iiiial  com]ilicati()ns  are  very  apt  to 
develo})  during  the  convalescence,  and  after  all  danger  is  apparently  past. 
Ordinary  cases  do  not  reinnre  any  medicine,  or  at  the  most  a  simple  lever 
nn'.xuire,  and  during  convalescenc'c  a  liitter  tonic  The  bowels  should  be 
careiully  regulated. 

Sjiecial  symjitoms  in  the  severe  cases  call  for  treatment. 

When  the  I'ever  is  aiiove  lo;}^  tiie  extremities  may  be  s])onged  with 
tepid  water.  In  severe  cases.  ,.ith  the  temperature  ra|iidly  rising,  this  will 
not  sutlice,  and  more  thorough  measures  td'  hydrotherapy  should  lie  ]n'ac- 
tised.  With  pronounced  delirium  and  nervous  symjitoms  the  cold  pack 
shotdd  be  i\>vf\.  When  the  fever  is  rising  rapidly  lint  the  child  is  not 
delirious,  he  should  be  ]i!aced  in  a  warm  bath,  tlie  temperature  of  which 
can  be  gradually  lowered.  The  bath  with  the  water  at  HO""  is  heiielicial. 
In  giving  the  colil  ]iack  a  ruliber  sheet  and  a  thick  layer  of  blankets  should 
be  spreatl  npon  a  sofa  or  a  lied,  and  over  them  a  sheet,  wrung  out  of  cold 
water.  The  naked  child  is  then  laid  n|ion  it  and  wra]i])ed  in  the  hlaidcets. 
An  intense  glow  of  heat  ((uickly  follows  the  jireliminary  chilling,  and  from 
time  to  time  the  blankets  may  be  unfolded  and  the  child  s])rinkled  with 
cold  water.  The  good  ciVects  which  hdlow  this  ]ilan  of  treatment  are 
often  striking,  particidarly  in  allaying  the  delirium  and  jactitation,  and 
procuring  (|niet  and  refreshing  sleei).  Parents  will  object  less,  as  a  rule. 
to  the  warm  hath  gradually  cooled  than  to  any  other  forni  of  ' 
The  child   niav   be  removed    from   the   warm 


hydrotherapy, 
iiath.  placed  upon  a  sheet 
wrung  out  of  ttderahly  cold  water,  and  then  folded  in  blaid^ets.  The  ice- 
cap is  A'cry  useful  and  may  be  kept  constantly  applieil  in  cases  in  which 
there  is  high  I'ever.  ^Ie(lieinal  antipyri'ti(>  ai'e  not  of  much  service  in 
comparison  with  cold  water. 

The  throat  symiitoms.  if  mild.  <lo  not  re(|uire  nuu-h  ti'eatment.  If 
severe,  the  local  measures  mentioned  under  diphtlu'i'ia  should  be  nsed. 
Cold  applications  to  the  neck  are  to  be  pivferred  to  hot.  though  it  is  some 


times  ditlicult  to  get  a  child  to  submit  to  them.     In  connection  with 


ne 


MEASLES. 


85 


plioations  di'- 
ilic  cure  with 

a  (•(nii|H'tt'iit 
I  till'  vi'iitila- 
it-go\vii,  aiul 
iisif^t  of  milk, 
h  tiK'  lall  of 
lay  ^ladiially 
!('  siiui'lil  lie 
't  oil,  or  car- 
plVVt'lltji   tlu' 

111  hath  may 
y  ht'  !^|)o)i,i;v(l 
ftlT  tllL'  toiii- 
.'  weeks  from 
'  to  eold.  It 
_'  very  apt  to 
larently  i)ast. 
sim|ile  fever 
.'Is  t<lioukl  he 


:])onoe(l  with 
iiii:.  this  will 
mid  he  prae- 
:ie  cold   [»ack 

eliild  is  not 
lire  of  whieli 

is  heiielieial, 
inkets  siiould 
Li'  out  of  eold 
the  lihuikets. 
n,<r,  and  from 
U'inkled  with 
reatmeiit  are 
•titation,  and 
ss.  as  a  rule, 
iydrothera|)y. 
ipon  a  sheet 
'ts.  The  iee- 
ises  in  which 
•h   service   in 

eatment.     If 

uld  he  used. 
;'li  it  is  some- 
ion  with  the 


tliroaf.  the  ears  should  he  specially  looked  after,  and  a  careful  disinfeetimi 
ol  the  mouth  and  fauces  hy  suitahle  antiseptic  .-ohitions  .should  he  prac- 
tised. \\li,.n  the  inllamiuation  e.Mends  throu-h  the  tuhes  to  the  middle 
ear.  the  practiti.mer  >hoiild  either  himself  examine  dailv  the  con.lition  of 
tlH'  drum.  nr.  when  availahle,  a  fepeciali>t  .lu.ii!,!  he  called  in  to  assist  him 
111  the  ca>e.  The  careful  watching'  of  this  iiiemhraiie  day  hv  dav  and  the 
lainctiirin-  of  it  if  the  Iensi.,n  hecomes  too  -reat  mav  saVe  the  lu^irin-  <,f 
the  chil.l.  With  tJR.  aid  of  cocaine  the  drum  is  readilv  punctured  The 
op.  ration  may  he  repeated  at  intervals  if  the  pain  and"  distenti.m  return 
No  complication  of  the  disease  is  more  .serious  than  this  extension  of  the 
inllammatory  jirocess  to  the  ear. 

The  nephritis  should  he  dealt  with  as  in  ordinary  cases;  indicatir.ns 
i<'r  treatment  will  he  found  under  the  appropriate  se'c.i„n.  It  i.  worth 
mentioning  Jiowevcr.  that  .laccoud  insists  upon  the  -reat  value  of  milk  di,.i 
111  scarlet  fever  as  a  preventive  of  neiihritis. 

Anion-  other  indications  for  treatment  in  the  disease  is  cardiac  weak- 
ness, which  is  usually  the  result  of  the  direct  action  of  the  i.oison,  and  is 
hest  met  hy  stimulants. 

.Many  specifics  Jiave  heen   vaunted 
useless. 


ill   scarlet   fever,   hut   tliev  are  a 


VIII.  MEASLES. 

Definition.— An   acute,   hi-hly  infectious  dk^order,   characterized   hy 
an  initial  eoryza  and  a  rapidly  spreadin^r  erujition. 

Etiology.— ^riie  infection  of  measles  is  very  intense  and  immunity 
a-ainst  attack  not  nearly  so  common  as  in  scarlet  fever.     It  is  a  di<ea<e  o"f 

'■'"''"' 1'   ''»t   unprotected   adults  are   liahle   to   the   infection.      Indeed 

measles  is  more  freipient  in  adults  than  is  scarlet  fever.  Within  the  lir<t 
SIX  months  of  life  the  liahility  is  not  so  marked,  tliouoh  infants  of  a  month 
or  three  weeks  may  lie  attacked.  The  .«exes  are  eipiallv  ailVcted.  The  con- 
tagion IS  communicated  hy  the  hreath  and  hy  the  .secretions,  particularly 
those  of  the  nose.    It  may  he  conveyed  hy  a  third  ].erson  and  hy  fomites.  ^ 

The  disease  is  jiractically  endemic  in  lar^^e  centres  of  popiilation.  and 
Inuii  time  to  time  sj.reads  and  juvvails  epidemically.  It  occurs  at  all  sea- 
sons, hut  prevails  more  extensively  diirin.i;-  the  colder  months.  There  is 
no  infectious  disease  in  which  recurrence  is  more  Impieiit.  There  may 
he  a  second,  thin"!,  or  even  a  fourth  attack. 

Thv  niiihii/i'inii  of  the  disease  is  u.iknown.  Xo  one  of  the  various  organ- 
isms which  have  heen  descrihed  meets  the  recpiireiiients  of  Koch's  law 

Morbid  Anatomy.— :\Ieasles  itself  rarely  kills,  hut  the  complica- 
tions and  seipiehe  comhine  to  make  it  a  very  fatal  allection  in  children. 
Ihere  are  no  characteristic  post-mortem  ap|.earances.  The  skin  clian-vs 
are  those  a -sociated  with  an  intense  hyiiera'iiiia. 

There  is  a  catarrhal  cmidition  of  the  mucous  niemhrancs.  particularly 
"I  the  hr.mchi.  The  fatal  cases  show  almost  invariahjv  mth.^r  hnmcho". 
pneumonia,  capillary  hnmchitis  with  juitches  of  cnllapse.'or  less  fre,|uenily 
lohar  pneumonia.    Tlio  hronehial  glands  are  invariahly  swollen.     rieuri<y 


I 


^^ 


8G 


SPECIFIC  INFECTIOUS  DISEASES. 


is  k'i?i5  coiiiiiion.  During  fonvalosconec  from  measles  tliere  is  a  special  lia- 
hility  to  tuberculous  invasion,  and  tuherculous  broncho-pneumonia  claims 
a  iiii'^'c  nunilicr  of  victims.     Tiio  Ijroneiiial  ghuuls  may  also  be  alVected. 

Tile  gastro-intcstinal  mucosa  may  be  hy])erivmic.  .Swelling  of  IVyer's 
glands  is  not  at  all  uncommon  an<l  may  reach  a  very  intense  grade  in  the 
patches. 

Symptoms. — Incubation. — "  From  seven  to  eighteen  days;  olteiiest 
fourteen."  The  disease  has  been  fre(piently  inoculated.  In  sue!i  cases 
the  incubation  period  is  less  tlian  ten  (hiys. 

Invasion. — The  disease  usually  begins  with  symjitoms  of  a  feverish 
cold.  There  ai'e  siiiverings  (not  often  a  <lelinite  ciiili).  marked  c(U'y/,a, 
sneezing,  running  at  the  nose,  redness  of  the  eyes  and  lids,  witii  photo- 
phobia, and  within  twenty-four  hours  cough.  These  early  catarrlial  syinp- 
toins  are  more  marked  in  measles  tiian  in  any  otiier  infectious  disease  of 
ciiiidren.  There  may  lie  the  symptoms  so  connnoidy  associated  with  an 
on-connng  fever — naiist'a,  Vduiiting,  and  headache  Tlie  tongue  is  furred. 
K.xamination  of  tiie  throat  may  show  a  rcddisli  IiyperaMiiia  or  in  some  in- 
stances a  distinct  ]iunctit'oim  ra>h. 
Occasionally  tiiis  spreails  over  the 
whole  mucous  niemlirane  of  tiie 
ludutli  witli  the  exception  of  the 
tongue.  The  temperature  at  this 
stage  is  usually  iiigh.reacliing  from 
lo.T  to  1(M°.  ascending  gradually 
through  the  second  and  third  days. 
Eruption.  —  I'suaily  on  the 
fourtli  day,  wiien  the  fever  and 
general  symptoms  have  reached 
their  height,  the  rash  apjtears 
u|)on  tlie  cheeks  or  foreiiead  in 
the  form  of  small  red  ]mpules. 
which  increase  in  size  and  spread 
over  the  neck  and  thora.x.  "Wiien 
the  eruption  becomes  well  devel- 
oped the  face  is  swollen  and  cov- 
ered with  reddish  blotches,  which 
often  have  roumU'd  or  crescentic  outlines.  Here  and  there  is  an  intervening 
]iortion  of  unaffected  skin.  .\t  this  stage  the  cervical  lym])h-glands  may 
be  slightly  swollen  and  sore;  sometimes  also  the  glands  in  the  groins, 
axilla',  and  at  tiie  elbows.  The  jiapules  can  now  be  felt  with  the  finger. 
Sometimes  they  are  (|uite  shotty,  but  do  not  extend  deep  into  the  skin.  On 
the  trunk  and  extremities  the  swelling  of  the  skin  is  not  so  noticeable, 
the  color  of  the  rash  not  so  intense  ami  often  less  unifortn.  The  mottled, 
blotchy  character  of  the  rash  ajipears  most  clearly  on  the  chest  or  the  abdo- 
men. Tfie  rash  is  hypera'inic  and  di.<ap])ears  on  iiressure,  but  in  the  more 
malignant  cases  it  may  become  luemorrhagic.  "^I'he  general  symptoms  do 
not  abate  with  the  occurrence  of  the  eruption.  They  persist  until  the  end 
of  the  fifth  or  the  si.xth  day,  when  in  the  majority  of  tlie  cases  all  the  symp- 


1          a         3         4        5         G        7         8 

lOCO* 

■■■■■■■■ 

IWI" 

■■■■■■■■■ 

«■■■■■!■■ 

98  0- 
90-8° 

■■■nn 

■■■■ 

Initial  Fever. 

Cii.urr  VIII.— Meiiisli's  (Striimpcll). 


Eruptive  Fever. 
Eniption. 


llWliAMa 


\  special  lia- 
iionia  flaiins 
aUV'ctt'd. 
g  of  IVyer's 
>n'ii(K'  in  tlic 


_vs;  oftciu'st 
1    siii-h   casi's 

f  :i  IVviTisli 
rkcd  c-orv/.a, 
with  phntd- 
irrlial  sviiip- 
is  discasL'  (if 
ti'd  with  an 
IK'  is  furred. 

in  some  in- 
tifoim  rasli. 
ids  over  the 
•ane  of  tiu' 
ition  of  tile 
tiire  at  tliis 
acliini:  from 
ijf  jiradually 
1  third  days. 
ly  on  tlie 
'  fever  and 
ive  reaelied 
ish  appears 
foreliead  in 
'ed    pa|)nles, 

and  spread 
ira.x.     When 

well  devel- 
en  and  eov- 
:chcs,  whicli 

interveninjr 
-glands  may 

tlie  groins, 
1  the  finger, 
le  skin.  On 
)  noticeable, 
rhe  mottled. 
or  the  ahdo- 
in  the  more 
yinptoms  do 
ntil  the  end 
ill  tlie  symp- 


MEASLKS. 


^7 


!=;ri:;:;ri/:;;-::E--x--  ..,...„.. 

°S"'r!:-;  ;;;;,::,::;::.;:; ;;:';,:"';  '"■  "r •''  ""■  ■■■■■*  ^"''- 

i"  «*..  ivv,:,.  ''  "'■"  "'"'"■'■  ""'''"■  ""■  '■ ■»  «i,,ii,,ii„„ 

-i.'"r.'^i»^Hsl;;l  '■"""""" '""'"""'  ■'"•"■I'""' "i-ocoo  i. 

"it™;:!;*'"".,;;;;;;;;;"::;;^:;;;;''  -t  "-  • ■ •  ■'•'"■  ™* v 

;: /-''^ " ".«  "^^nC;"  ::  ;:;:;::i;;i::'''T'';i:'™r^ '■'■■  ■■" 

llm.i,.  «l„n  „i,i„v  ,,,„,  ,„,    ■.  .         I        "   ■  ■;"'  "■'.'•     •>■-  "I  "llicToMii- 

'■■■•"■  ■■<»  «"■  "Hii^ii  .>■„„„.,„    ;  j" ;*i';;i'i.  "■"■  "i:  n..  .■imi.i,™  ,„„, 

IM  no  „„,, „|,,,,,;„"  '  '      ■"■'"•"  '"'■  ""■  ''"""■r  »»  il  is  sii.l, 

.,,,iij.i  ^'J  ^itat,  and  (|,,,tli  occurs  early  from  iox- 

Complicationsand  Sequelee  ^Th,.  ,.vf  (in     i        ,.     • 

extend  into  (he  smaller  tidu's  uml  1^,1  f     "\/"'-'"'-,  ''■•'""•''itis   is  apt    t.. 
When  linuted  in  ext  ■   t       i.  ,:..,"  ^-'''''^I'^.  »"<!  bn.neho-pncMunonia. 

r'^^-^-  of  tin.  fever  (:y:;::;ni;;s;;^:;;;:;:  ^'■^  r''  r'  '"■■- 

J^  rapid:  hut  in  dehilit.tcl  ,.|,ihl,.  ^'■'"'"■"J}  'i'»ate),  ami  convalescence 

•■....org  (he  h.     .      1      ;       ,  i''''^^^  particularly  in  institutions  and 

s,.onsddc   fo  i^h   dc     h  nle''^      "  ^"^*-""l>-  K™-  and  is  re- 

-.Ho  ins(ances  llu    din^^^"  '  ^'^"^^  "Vj''^  community.      I„ 

-nit  of  a  widespread  i:;!v;::;;;\.rt '.,:,;;.  ut'%:r''-'- 

'-f  the  condition  will  he  found  under  Pr,,,,  •  ''•'•-<'ription 

-..;i»  is  1...S  o„„„„„„  „,„,  ,:,:;l;:";l!:  ,t';:,';;;;i '-  '■■■'»"■  i-- 

l^aryngitis  is  ,,„(  uncommon:  t],e  voi./heeonies  hiwlv  .,,,1  u 
oroupy  ,„  character.     (Kdema   of  (he  glotti         "      ''  .  1     ']'    "r  •■""^'' 
'"•anous  inflammaticm   of  (he   pharvnx    uid   h,  v,   ■  ^  ^  •^^''-'I'-'nem- 

'•"<al.     In  dehilitaCd  infa„(s  s  vJ  :  "  „n      ,       "  '•'  "•""''  "'"'   '•'■"^•" 

vnlvids  mav  develop  ■  t-niadtis.  nnurinn  ans,  or  ulcerative 

.«;;r;:;l  ;;rt:;-;2:--  ;;:; - 


,! 


8S 


SPECIFIC  INFECTIOUS  DISEASES. 


Nfuliritis  is  an  cxcrcdinjily  rare  coiiiiiliration.  ,     ,       •„ 

Of  till-  soquola'  or  MK'asK.s,  tiilH.r.'ul..sis  is  llio  most  important-oithor 

an  invnlv..i.R'nt  <.f  tli-  l.n.ncliial  -la.uls.  a  miliary  tuhoiriilosis,  or  a 

culdus  hroiiclio-iUK'Uinoiiia.     Arthritis  is  rare. 

to  follow  iHoaslos  in  a  chihl  of  four  year 


tuhi'r- 
1  liavi>  known  anchylosis  of 


tin.'    aw  to  iumoi  jii^...  iv^-  ■■•  ■• ^  ....  1  ,,, 

Among  the  rarer  sc.iuoke  uro  paralyses.  Ilenu,.leg>a  ,s  very  ra:e  In. 
,.as..s  of  imrapleoia  have  l.een  .]es<.rilu..l.  Thon.as  I'.arlow  reports  a  fa  a! 
oase  in  which  tlu.  svn.pton.s  oecurred  early,  the  paralysis  extended  v.^f} 
,„d  inv.dved  the  upper  lind.s,  and  death  took  phu'e  on  the  eleventh  day. 
\Iarke.l  va>eular  changes  were  found  in  the  jrray  matter  ot  the  sniual  eo,>  . 
.;,„1  ,vere  l.elleved  to  depend  on  an  early  disseminate.l  mye ht.s.  Ivxannna- 
tion  of  the  peripheral  nerves  was  not  made.  While  some  ol  these  eases  a,v 
due  to  an  ascending  myelitis,  others  are  probably  the  result  ol   a   post- 

febrile  polyneuritis.  ...  ,   ,-i    i     *     i  > 

DiagnOSiS.-From  scarlet  fever,  with   wlueh  it  is  most  hkely  to  be 
confounded,  measles  is  di>tin,uui.iu.d  by  the  hmger  initial  stage  with  char- 
acteristie  svmptoms,  and  the  blotchy  irregular  character  ot  the  rash,  ^v Inch 
is  so  nnlike  the  diiVuse  uniform  erytiu-u.a  of  scarlet  fever.     Occasionally 
in  measles,  when  tlu^  throat  is  very  sore  and  the  eruption  pretty  diilu>e, 
there  mav  at  first  be  dillicultv  in  determining  which  disease  is  iiresent   but 
:i  few  days  should  siillice  to  make  the  diagnosis  clear.      As  a   rule  there 
i.  no  leuc;.cvtosis.     It  mav  be  extivmely  dillicult  to  distinguish  from  roth.'  n. 
I   have   m.H-e  than  once"  known   practiti.uu.rs  of  large   exp.'rience   unable 
to  agree  upon  a  diagnosis.    'Vho  slmrter  prodnnnal  stage,  the  slighter  tever 
in  manv  eases,  are  perhaps  the  most  imp<n-tant  features.     It  is  d,  hcdt  to 
«l.eak  (iefinitelv  about  the  distinctions  in   the  rash,   though   ].crhaps  the 
more  uniform  "distribution  and  the  ab.sence  of  the  crescentie  a:   angement 
are  more  constant  in  riitbeln.     In  Africans  the  disease  is  easily  r.     -.nii.ed. 
even  in  the  black;  the  i.apules  stand  out  with  great   plainness,  .-      n  u, 
.rvouiw  the  hvpcraMiiia  is  to  be  seen  on  all  but  the  very  black  skins.      I  lie 
distribntiim  of  the  rash,  the  cory/.a,  au.l  the  rash  in  the  mouth  are  impor- 
tant points.  11       ,. 
The  conditions  under  which   measles  may  be  mistaken   lor  small-pox 
have  already  been  described.    Of  drug  erniiticms,  that  induced  by  eoi)aiba 
is  Ncry  like  measle<,  but  is  readily  distinguished  by  the  absence  of  fever 

and  catarrh.  .  .       ,  ,    , 

Prognosis.— The  mortality  bills  of  large  cities  show  what  a  serious 
di>;ea«e  measles  is  in  a  community.  Among  the  eruptive  fevers  it  ranks 
third  in  the  death-rate.  The  mortality  from  the  disease  itself  is  not  high, 
but  the  pulmonary  complicaticuis  render  it  one  of  the  most  serums  ot  the 

diseases  of  children. 

Tn  s.mie  epidemics  the  disease  is  of  great  s.'verity.  Tn  institutions  and 
in  armies  the  di'ath-rate  is  often  high.  The  fever  itself  is  rarely  a  source 
of  danger.  The  extension  of  th'>  catarrhal  syini>tonis  to  the  finer  bronchial 
fillies  is  the  most  serious  indication. 

Treatment.— Confinement  to  bed  in  a  well-ventilated  room  and  a 
light  diet  are  the  only  measnres  necessary  in  eases  of  uncomplicated  measles. 
The  fever  rarelv  reaches  a  danjcroiis  height.     If  it  does  it  may  be  lowered 


RUBELLA. 


su 


[ant — oitlior 

OV   il   tulllT- 

UL'luio.sis  of 

rv  I'll  re,  liut 
lorts  a  fiitiil 
idc'd  r-'piilly 
|(>v('iitli  (liiy. 
s[)iiial  c(>i\\ 
.     Kxaiiiina- 
cso  casi's  an' 
t  of  a  post- 
likely   to   1)1' 
;t'  witli  fliar- 
'  rash,  wliicli 
Occasionally 
rotty  dilVux'. 
])r('soiit.  luit 
a   nilo  there 
from  rotheln. 
ieiice    iiiial)!e 
■ijijfhtor  fever 
is  (lilliiMilt  to 
jicrha|is  the 
arrangement 
ly  r'     "'jfiiized. 
less,  '     III   in 
k  skins.     'Die 
til  are  impor- 

for  small-pox 
.m1  by  ooiniiba 
lence  of  fever 

rliat  a  serious 
L'vers  it  ranks 
If  is  not  liijih, 
serions  of  the 

istitiitions  ami 
•arely  a  sonree 
finer  bronehial 

1  room  and  a 
icateil  measles, 
nay  he  lowered 


I.y  sjion^nn;;  or  I,y  tlie  tepid  l,ath  gradually  rediice.l.  if  tlic  ra.>h  does  not 
tome  out  well,  warm  drinks  and  a  hot  l.ath  will  ha.-ien  its  maturation. 
'Ihe  howcls  should  lie  freely  oi^ened.  Il  (|,c  cough  is  distressing,  pare- 
goric and  a  niixliire  of  iiiccaciianha  wine  and  s(iiiil!s  should  he  given.  The 
patient  shoiiiil  he  kept  in  lied  for  a  ivw  days  after  the  fc\cr  sulfides.'  Dur- 
lUiT  (lesipiamation  the  skin  should  he  oiled  dailv  and  warm  l.alhs  given 
to  facilitate  the  jmiccss.  The  eomalescviice  from  mea>hs  is  the  "most 
miportanl  stage  of  the  disease.  Watclifulne.<s  and  care  mav  pivveiit  seri- 
ous ]Uilmoiiary  complications.  The  fre.pieiicy  with  which  the  mothers 
of  children  willi  simjile  or  tuhereidous  hroiicjio-piu.niiionia  tell  us  that 
-the  child  caught  cold  after  measles,"  j,iid  the  coiitcmplatiim  of  the  nior- 
tahty  hills  shouhl  make  us  extremely  careful  in  our  management  of  this 
aU'ection. 

IX.   RUBELLA  (llolhiln,  (Irnnan  Jffn.sh-.-O. 

This  exaiilhcm  has  also  the  names  of  riihrnhi  m.lhn.  or  epidemic  rose- 
ola, and,  as  it  is  supposed  to  iireseiil  features  common  to  hoth,  has  heen  also 
known  as  hybrid  measles  or  hybrid  scarlet  fever.  It  is  now  generally 
I'egarded.  however,  as  a  separate  and  distinct  all'cclion. 

Etiology.— It  is  propagated  by  coiUagion  and  spreads  wiih  great 
vapidity.  It  freipiently  attacks  adults,  and  the  occurrence  of  either  mm.sles 
or  scarlet  fever  in  childhood  is  no  protection  against  it.  Tlu!  epidemics 
of  it  are  often  very  extensive. 

Symptoms.— These  are  usually  mild,  and  it  is  altogether  a  less  seri- 
ous atrection  than  mea.sles.  Very  exceptionally,  as  in  the  epidemics  studied 
I'y  (  headle,  the  syn]])tonis  are  severe. 

The  stage  of  inculcation  ranges  from  ten  to  twelve  days. 

Tn  the  stage  of  invasion  there  are  chilliness,  hcadac'lie.  pains  in  the 
back  and  legs,  and  coryza.  1).  TI.  Hall  insists  that  slight  sore  throat  is  a 
constant  symptom,  on  which  account,  indeed,  it  was  that  il  was  originally 
regarded  as  a  hybrid,  having  the  sore  throat  of  scarlet  fever  and  tire  rash 
<.f  measles.  There  may  he  very  slight  fever.  In  :!()  per  cent  of  l-'.dwards's 
cases  the  temperature  did  not  rise  above  lOir''.  Tbe  duration  of  this  sta-n" 
IS  somewhat  variable.  The  rash  usually  a|.pears  on  the  first  day,  some 
writers  ,say  on  the  second,  and  others  again  give  the  duration  of  the  sta-re 
of  invasion  as  thre(>  days.  (Jriffith  jilaccs  it  at  two  davs.  The  eruption 
eomes  oiif  first  on  the  face,  then  on  the  chest,  and  graduallv  extends  so 
that  within  twenty-four  hours  it  is  .scattered  over  the  whole  boily.  It  may 
be  the  first  symptom  noted  liy  the  mother.  The  eruption  coiisists  of  a 
number  of  round  or  oval,  slightly  raised  spots,  ])inkisli-red  in  color,  usiialiv 
discrete,  but  .sometimes  conflnent. 

The  color  of  the  Yi\A\  is  somewhat  brighter  than  in  measles.  The 
I.atches  are  less  distinctly  cre^^centie  After  persisting  for  two  or  three 
•lays  (.somelimes  longer),  it  gradually  fades  and  there  is  a  slight  fnrfiira- 
ceons  des(iuamation.  The  rash  jiersists  as  a  rule  longer  than  in  scarlet 
fever  or  measles,  and  the  skin  is  slightly  stained  after  it.  The  lym])hn^i.- 
glands  of  the  noek  are  frequently  swollen,  and,  when  the  enipli.m  is  vcrv 
intense  and  dilfuse,  the  lymph-glands  in  tlu  otlior  parts  of  tlio  body. 


>' 


^M^ 


90 


srHCIFK"   IN'FKCTIOUS   DISEASKS. 


Tlio  (liscaso  usually  profTrcsso-; 
tliosc  r('|inrt('(l  liy  Clu'iulk',  tlic 
iiiiiiiiniria  iiiay  occur  and  even 
Ih'(  II    present    in   sonu,'  epideniies. 


There  are  no  spcciiil  cuinplieatiiins. 
i'avoral)ly;  Imt  in  rare  instances,  as  in 
nyinptonis  are  (if  {greater  severity.  A' 
nepliritis.  I'neninonia  and  colitis  have 
Icterns  lias  lieen  seen. 

Diagnosis. — The  miidness  oi'  the  case,  tlu'  sli^ditness  of  tlie  proilnmial 
syin]itonis,  the  mildness  or  the  al)sence  of  the  fever,  the  more  dill'nse  char- 
acter of  the  rash,  its  rose-red  color,  and  tiie  early  cidar^fcinent  of  the 
cervical  <,dands,  are  the  chief  jioint.s  of  distinction  hetween  rothoin  and 
measles. 

The  treatment  is  that  of  a  simple  fehrile  affection.  Tt  is  well  to 
keep  the  child  in  hed,  thon^di  this  may  he  dillicidt,  as  the  patient  rarely 
feels  ill. 

X.    EPIDEMIC    PAROTITIS  (Mumpx). 

Definition. — An  infections  disease,  characteri/ced  l)y  inflammation  of 
the  parotid  gland.  The  testes  in  jnales  and  the  o.aries  and  breasts  in 
females  are  sometimes  involved. 

Etiology. — Tlu'  nature  of  the  virus  is  nnknown. 

The  all'ection  has  all  the  characters  of  an  epidemic  disease.  It  is  said 
to  he  endemic  in  certain  localities,  an<l  jtvohahly  is  so  in  large  centres  of 
I)opnlation.  At  certain  seasons,  particularly  in  the  spring  and  autumn 
months,  the  nundier  of  cases  increases  rapidly.  It  is  met  most  fre(piently 
in  childhood  and  adolescence.  Very  young  infants  iiiul  adults  are  seldom 
attacked.  Males  are  somewhat  more  fre(iuently  alfected  than  fenmles.  In 
institutions  and  schools  the  disease  has  been  known  to  attack  over  !K)  per 
cent  of  all  the  children.  It  may  he  curiously  localized  in  a  city  or  district. 
The  disease  is  c(mtagious  ami  spreads  from  ]iatient  to  ])atient. 

A  remarkable  idiojjathic,  non-specific  ])arotitis  may  follow  injury  or 
disease  of  tiie  abdominal  or  pelvic  organs  (see  Diseases  of  the  Salivary 
Glands). 

Symptoms. — 'i'he  jieriod  of  incubation  is  from  two  to  three  weeks, 
and  there  are  rarely  any  symptoms  during  this  stage.  The  invasion  is 
marked  by  fever,  which  is  usually  slight,  rarely  rising  above  101°,  but  in 
exceptionally  severe  cases  going  up  to  10.'^  or  104°.  The  child  complain'^ 
of  pain  just  below  the  ear  on  one  side.  Here  a  slight  swelling  is  noticed, 
which  increases  gradually,  until,  within  forty-eight  hours,  there  is  great 
enlargement  of  the  neck  and  side  of  the  cheek.  The  swelling  passes  for- 
ward in  front  of  the  ear,  and  back  lieneath  the  sterno-cleido  muscle.  The 
other  side  usually  lieeomes  afTected  within  a  day  or  two.  The  other  sali- 
vary glands  are  rarely  involved.  The  greatest  inconvenience  is  experi- 
enced in  taking  food,  for  the  patient  is  unable  to  ojurn  the  mouth,  and 
oven  speech  and  deglutition  liecome  dillicult.  There  may  be  an  increa^..' 
in  the  secretion  of  the  saliva,  but  the  reverse  is  sonu^times  the  case.  There 
is  seldom  groat  pain,  but.  instead,  an  unpleasant  feeling  of  tension  and 
tightness.  There  may  be  earache,  even  otitis  media,  and  slight  impairment 
of  hearing. 

After  persisting  for  from  seven  to  ten  days,  the  swelling  gradually 


EPIDEMIC   PAROTITIS. 


01 


ly  progres-^os 
Cliradk',  tlic 
iir  and  even 
no  o|ii(k'nii(>. 

lie  iiroilnmial 
(lilTnsf  rliar- 

'incnt  of  the 
rollioin  and 

Tt  is  well  t.) 
patient  rarely 


lamination  of 
nd   breasts  in 


^e.  It  is  paid 
'}ic  centres  of 

and  antnnm 
)st  I'reiiueiitly 
ts  are  seldom 

females.  In 
k  over  !K)  per 
ty  or  district. 

o\v   injnvy  or 
tiie   Salivary 

three  weeks, 
10  invasion  is 
I  101°,  Init  in 
ild  complains 
n<T  is  noticed, 
there  is  great 
iig  ])asses  for- 
muscle.  The 
he  other  sali- 
ico  is  expcri- 
0  month,  and 
)e  an  increa^.' 
3  case.  There 
f  tension  and 
it  impairment 

ing  gradually 


>iii)si(U's  and   the  cliild   rajiidly  regains  iiis  slnngtli  and  healtli.     Kelap.se 
rarely  if  ever  occurs. 

Occasionally  the  disease  is  very  .severe  and  characterized  liy  high  fever, 
delirium,  and  great  jirostration.  'i'lie  patient  may  even  lapse  into  a  tyjiiioid 
condition. 

Oirhills. — Kxcessively  rare  heforo  imherty,  it  devcloiis  usually  as  the 
parotitis  suhsidcs,  or  indeed  a  week  or  ten  days  later.  One  or  hot h"  testicles 
may  he  involved.  The  swelling  may  he  great,  ami  occasi.Mialiy  elVusioii 
takes  place  into  the  tunica  vagiiudis.  The  orchitis  may  develop  hcfore 
the  jiarotitis,  or  in  rare  iustamcs  may  he  the  only  manifestation  of  the 
infection  {(iirhilis  pdrnli'lcd).  The  iullammation  increases  for  three  or  four 
days,  and  resolution  takes  place  gradually.  There  may  he  a  muco-pundent 
discharge  from  tlic  urethra.  Jn  severe  cases  atrophy  may  follow,  fortunately 
as  a  rule  only  in  one  organ;  occurring  in  both  hcfore  puht'rty  the  natural 
ilcvelopmcnt  is  usually  checked.  Kven  when  l)()th  testicles  are  atrophied 
and  small,  se.xual  vigor  may  he  retained.  The  proi)ortion  of  cases  of  orchitis 
varies  in  dill'cront  ei)idemies;  211  cases  occurred  in  <i!»!)  cases,  and  lu;]  eases 
of  atrophy  followed  KJl]  instances  of  orchitis  (Coinhy). 

A  vulvo-vaginitis  sometime^  occurs  in  girls,  and  the  hreasts  may  he- 
come  enlarged  and  tender.  :Mastitis  has  liecn  seen  in  hoys.  Involvement 
of  the  ovaries  is  rare. 

Complications  and  Sequelse.—Of  these  the  corel.ral  allVctions 
are  perhaps  the  most  serious.  As  already  mentioned,  there  may  he  de- 
lirium and  high  fever.  Jn  rare  instances  meningitis  has  heen  found. 
Hemiplegia  and  coma  may  also  occur.  A  maj(  rity  of  the  fatal  cases  are 
associated  with  meningeal  symptoms.  These,  of  cour.se,  are  verv  rare  in 
comparison  with  the  fre(pioiicy  of  the  disease;  yet,  in  the  Index  Catalogue, 
under  this  caption,  there  are  six  fatal  cases  menticmcd.  In  some  f\)\- 
deniics  the  cerebral  complications  are  much  nun'o  nuu'ked  than  in  others. 
Acute  mania  has  occurred,  ami  there  are  instances  on  record  of  in.sanity 
following  the  disease. 

Arthritis,  albuminuria,  even  acute  uriomia  with  convulsions,  endocar- 
ditis, facial  paralysis,  hemiplegia,  and  peripheral  neuritis  are  occasional 
complications. 

Suppuration  of  the  gland  is  an  extrenu'ly  rare  comjilioation  in  genuine 
idioi)athic  mumi)s.  (Jangreno  has  occasionally  occurred.  The  special 
senses  may  be  seriously  involved.  :Many  cases  of  deafness  have  been  de- 
scribed in  connection  with  or  following  mnmps.  It,  unfortunately,  may 
be  permanent.  Affections  of  the  eye  are  rare,  but  atrophy  of  the  optic 
nerve  has  heen  described.     The  lachrymal  glands  may  be  involved. 

Kelapse  may  occur,  even  two  or  throe,  and  chronic  hypertrophy  of  the 
gland  nuiy  follow. 

The  diagnosis  of  the  disease  is  usually  easy.  The  position  of  the 
swelling  in  front  of  and  below  the  car  and  the  elevation  of  the  lobe  on  the 
alTectofl  side  definitely  fix  the  locality  of  the  swelling.  In  children  in- 
flammation of  the  parotid,  apart  from  ordinary  nmnips,  is  excessively  rare. 

Treatment. — It  is  well  to  keep  the  patient  in  bed  during  the  "height 
of  the  disease.    The  bowels  should  be  freely  opened,  and  the  patient  given 


92 


tSI'ECIFIC  INFECTIOUS   DISKASES. 


ti  liglit  lii|iii(l  (lid.  No  iiiciliciiic  is  rciniircd  unless  llic  I'cvcr  is  Iiiyli,  in 
uliicli  ciisc  aconite  may  lie  ;,'iveii.  Cold  ioin|ire>ses  may  lie  placed  on  tlu 
;,'land,  lint  children,  as  a  rule,  iivel'er  hot  a|iiilieatiiins.  A  [lad  of  cotton 
waddiiij:  covered  with  oiled  silk  is  the  liest  ap|»]ication.  Sniipnration  i- 
lianlly  ever  t<i  lie  dreaded,  even  tliou;j;li  the  e^land  lieconie  very  tense.  Shonld 
redness  and  tenderne.-s  develoji,  leeches  may  lie  \\>^iH\.  With  delirium  and 
head  .symptoms  the  ice-ca]i  may  lie  applied.  In  a  robust  snliject,  nidc" 
the  Hi;;ns  of  constitntional  depression  are  extreme,  a  free  vcnesectio  i  may 
do  },'()()d.  For  the  orchitis,  rest,  with  sujiport  anil  protection  of  the  swollen 
filand  with  cotton-wool,  is  iisnallv  sullicii'nt. 


XI.  WHOOPING  COUGH. 

Definition. — .\  sjieeilic  all'ection  characterized  liy  convulsive  couj.'h 
and  a  lon^'-drawn  insjiiration,  during'  which  the  "whoop"  is  produced. 

Etiology. — The  disea.-e  occurs  in  epidemic  form,  Iiut  s|)oradie  <a>(- 
apjiear  in  a  community  from  tinu'  to  tinu'.  It  is  directly  conta^doiis  from 
person  to  jiersou;  liut  dwcllin;j:-rooms,  houses,  school-rooms,  and  otlur 
localities  may  lie  infected  liy  a  sick  child.  It  is,  however,  in  this  way  less 
infectious  than  oilier  diseases,  and  is  prolialily  most  often  taken  by  direct 
contact.  Kojilik,  Czaplewski,  aiul  Ilinsel  have  descrilied  a  liacilhis  in  the 
sputum,  wlii<'h  may  prohahly  lie  the  specific  or^Minism.  The  liaeilli  are  pres- 
ent in  the  mucous  chimps,  with  other  forms  as  a  rule,  hut  they  can  he  sepa- 
rated liy  proper  means.  Koplik  found  them  in  1:5  of  Ki  eases  of  whoopinj:- 
e()u<,']i.  It  is  a  small  bacillus  with  rounded  ends,  a  little  larj,a'r  than  the 
influenza  bacillus.  It  is  a  facultative  aiia'robe,  and  is  pathofrenie  for  mice. 
There  are  .still  doubtful  points  n^^arding  the  or{j;aiiism.  K])i(!emics  prevail 
for  two  or  three  months,  us\ially  durinjx  the  winter  and  sjirinf:,  and  have 
a  curious  relation  to  other  diseases,  often  jjreceding  or  following  e|)ideniies 
of  measles,  less  freipiently  of  scarlet  I'ever. 

("hildren  between  the  first  and  second  dentitions  are  commoidy  alTectcd. 
Sucklings  are,  however,  luit  exenijit,  and  I  have  seen  very  se>'ere  attaeks 
in  infants  under  six  weeks.  It  is  stated  that  girls  are  more  subject  to  the 
disease  than  boys,  .\dults  and  (Id  people  are  sometimes  attackml,  and  in 
the  aged  it  may  be  a  very  serious  affection.  Many  persons  jiossess  immu- 
nity against  the  disease,  and.  though  fre(|uently  exjiosed,  escape.  As  a 
rule,  one  attack  protects.  Deliiate  ana'uiic  chiidren  with  nasal  or  bron- 
ehial  catarrh  are  more  subject  to  the  disease  than  others.  According  to 
the  rt,:'ed  States  Census  Kejiorts.  the  disease  is  more  than  twice  as  fatal 
in  the  negro  race  than  in  others. 

Morbid  Anatomy. — Whoo]iing-cough  itself  luis  no  special  patho- 
logical cluniges.  In  fatal  cases  ]iuhnonary  complications,  particularly 
broncho-pneumonia,  are  usually  ])rcsent.  C(il]a|ise  aiul  compensatory  em- 
physerna,  vesicular  and  interstitial,  are  found,  and  the  tracheal  and  bron- 
chial glands  are  enlarged. 

Symptoms. — Catarrlud  and  i>aroxysnial  stages  can  be  recognized. 
There  Ip  a  variable  jieriod  of  incubation  of  from  seven  to  ten  days.     In 


\vii()oi'iN(i-roi'(in. 


03 


:•  is  liiyli,  in 
liU'cil  on  till 
nl  of  coltcn 
|ipnriiti(in  i- 
•nsc.  Slionld 
Icliriiini  and 

l)j('ct,    Ulllcr- 

'scctiti  )  miiy 
'  tilt"  swollen 


ilsivi'  cou^'li 
n'oiiuccij. 
loiailic  <iis(- 
ii^noiis  i'roui 
,  and  other 
liis  way  le^-s 
■n  ])}•  direct 
I'ilhis  in  the 
illi  are  pres^- 
ean  lie  se|ia- 
t'  vvhoopiii^'- 
;er  than  the 
lie  for  iiiiee. 
inies  i)revail 
fj,  and  have 
ly  t'pidoniies 

nly  alTeeted. 
vero  attack^ 
hjeet  to  the 
ked,  and  in 
ssess  iinmu- 
•ape.  As  a 
:al  or  hron- 
coordin<i  1<> 
.ico  as  fatal 

>oial  patho- 
partieularly 
nsatory  eni- 

I  and  hron- 

recofjnized. 

II  days.     In 


the  cnlnrrhnJ  slar/r  the  eliild  has  the  syiii|itonis  ol'  an  ordinary  cold,  which 
may  he;,'in  with  slif,dit  fever,  rnnnin;i  at  the  nose,  injection  of  the  i'\i'>. 
and  a  hroncliial  eon<,di,  nsuaily  diT.  and  sonietiniis  ;,nvin;,'  i;idiciiiions  id'  a 
spasmodic  character.  The  fever  is  usuidiy  not  hi;:li.  and  >li-lit  attention 
is  paiil  to  tlu'  symptoms,  which  are  tlioii;rIit  to  i)e  tho>e  of  a  simjile  catarrh. 
Alter  lasting;  for  a  week  or  ten  chiys,  instead  of  suhsidin<,%  the  conjrii  he- 
eonies  worse  and  more  convidsive  in  character. 

The  /iiinut/.sinnl  slai/r,  marked  hy  the  characteristic  co>if,d),  dates  from 
the  first  appearance  of  the  "  whoop."  '{'he  lit  he^rins  with  a  series  of  from 
lifteen  to  twenty  short  coMi,dis  of  increasing'  intensity,  and  then  with  a 
deep  inspiration  the  air  is  drawn  into  the  Innj^^s,  makinj,'  the  '*  wh()()|»,"' 
which  may  he  heard  at  a  distance  and  from  which  the  disease  takes  its 
name,  'i'liis  loud  inspiratory  sound  may  .sometimes  preci'de  the  serit-s  of 
spasmodic  expiratory  ell'orts.  Several  e<iu<,'hin<;-lits  may  sueei'ed  each  other 
until  a  tenacious  mucus  is  ejected.  'I'his  may  hi'  small  in  amount,  hui 
after  a  scries  of  eou^diitifi-tits  a  eonsideralde  (piantity  may  he  expec- 
torated. Not  infre(|uently  it  is  hrouj,dit  up  l.y  voniitini;  or  hy  a  condona- 
tion of  cou^di  and  rej^u rental  ion.  There  may  he  oidy  four  or  live  of  these 
attacks  in  the  day,  or  in  severe  cases  they  may  recur  I'very  half-hour.  Dur- 
inj;  the  paro.xysni  the  thorax  is  very  stron<:ly  compressed  hy  the  powerful 
expiratory  eiforts,  and,  ns  very  little  air  passes  in  thron^di  the  jilottis,  there 
are  siyns  of  defective  ai'ration  of  tlie  hlood;  tlie  face  hecomes  swollen  and 
conjiested,  th;'  veins  iire  prominent,  the  eyehalls  protrude,  and  the  con- 
junctiva' heeonie  deeply  en^-or;,'((l.  Sulfocatioii  indeed  seems  imminent, 
when  with  a  deep,  crowin,i,'  inspiration  air  enters  the  Iun<;s  and  the  color 
is  (piickly  ri'stored.  Children  are  usually  terrilied  at  the  onset,  and  run 
at  once  to  the  mother  or  nurse  to  l)e  suppcu'ted  durini;'  the  attack.  Few 
diseases  are  more  painful  to  witness,  in  severe  paroxysms  vomiting  is 
fre()uent  and  the  sj)hincters  may  he  o|)ene(l.  The  uriiU'  is  said  to  he  of 
hi-;h  siieciiic  j,M'avity  (in'^>','-l();it.'),  pale  yellow,  and  to  cuilain  much  uric 
acid. 

An  ulcer  under  the  tongue  is  a  very  common  <'veiit.  and  was  thought 
at  one  time  to  be  the  cause  of  the  d isea.se. 

During  the  attack,  if  the  chest  be  examined,  the  resonance  is  defective 
in  the  expiratory  stage,  full  and  clear  during  the  dee|),  crowing  inspiration; 
hut  on  auscultation  during  the  latter  there  may  be  no  vesicular  murmur 
lieard,  owing  to  the  slowness  with  which  the  air  passes  the  narrowed  glot- 
tis.    JW-oncliial  rales  are  occasionally  heard. 

Among  eirc'unistanees  which  precipitate  a  jiaro.xysm  are  emotion,  such 
as  crying,  and  any  irritation  about  the  throat.  Kven  the  act  of  swallowing 
sometimes  seems  sxiflieient.  In  a  close  dusty  atmosphere  the  coughing- 
fits  are  more  frequent.  After  lasting  for  three  or  four  weeks  the  attacks 
become  lighter  and  finally  cease.  In  cases  of  ordinary  severity  the  course 
of  the  disease  is  rarely  under  six  weeks. 

The  comidieations  and  sequela'  of  wh()0|)ing-cough  are  important.  Dur- 
ing the  extensive  venous  congestion  lurmorrhages  are  very  apt  to  occur 
in  the  form  of  petechia-,  parti<'ularly  about  the  forehead,'  eechymosis  of 
the   eonjunetivop,   epistaxis,    and    occasionally    ha-inoptysis.      Ilivmorrliao-e 


( 


U4 


SPFCIFir  INFRfTIOUS  DISEASES. 


Iroiii  tlic  liMUcIs  is  nirc.  ('iniviiUiniis  iirc  iiut  \,tv  iiinniiiinnii.  diK-  porlinps 
to  tlic  cxtrciii"  cii^ror^'ciiicMt  nl'  the  <rrclniil  cortex.  W-ry  rarely  lieiiii|ile<iiii 
or  iii()iioi)le;j:iii  follows.  Siidcleii  ileal li  lias  heeii  caused  liy  extensive  sid)- 
diiral  lia'iii()rrliaj,'e.  \Vlioo|iiii;r-conuli  inii>t  lie  rej,'arded  as  a  very  muisiial 
cause  of  cereliral  Jialsy  in  children.  It  was  associated  witli  ;{  of  my  series 
of  r.M)  cases,  Imt  m  none  (d'  them  did  the  hemiplejiia  come  on  diirinij  the 
paroxysm,  as  in  a  caw  reported  liy  S.  West.  Hernliardt  has  dcscrihed  an 
acutely  devclopin^f  spastic  jiara|)lej.na. 

The  persistent  vomiting'  may  iiidnee  markeil  anaemia  and  waslinjr.  The 
jiidmonar/  complications  which  follow  whoopint,'-con<,di  are  extreiiiely  seri- 
ous. Dnrin^r  the  severe  cun>,diin;.'-spells  interstitial  em|)hysema  may  ho 
induced,  more  rarely  pneumothorax.  I  saw'  one  instance  in  which  rupture 
occurred,  evidently  near  the  root  of  the  lunjx,  and  the  air  passed  rlonjr  the 
trachea  and  reached  the  sul>cutaneous  tissues  of  the  neck,  a  condition 
which  has  lieen  !;nown  to  hecoiue  general.  I'roncho-pneumonia,  with  its 
aceompanyinj,'  c(dlapse.  is  the  most  freinieiit  pulmonary  complication  and 
carries  olf  a  lar;:o  nuiuhcr  of  children.  It  may  he  sim|)le,  hut  in  a  con- 
siderahle  projtortion  :d'  the  cases  the  ]irocess  is  tuherculous.  Pleurisy  is 
sometimes  met  with  and  occasionally  lohar  pneumonia.  I'lnlargemeut  of 
the  bronchial  ghinds  is  very  common  in  whoopin^^-cou^di  and  has  been 
tlioufiht  to  cause  the  disease.  It  may  sometimes  he  sutlicient  to  jiroduee 
dulness  over  the  manuhrium.  During,'  tlie  spasm  tlie  radial  pul.so  is  sTuall, 
the  right  heart  enjiorjied,  and  during  and  after  the  attack  the  cardiac  action 
is  very  much  disturbed.  Serious  dauuige  may  result,  and  ])ossib]y  some 
of  the  cases  of  severe  valvular  disease  in  children  who  have  had  neither 
rheunuitisin  nor  scarlet  fever  may  be  attributed  to  the  terrible  heart  strain 
during  a  jirolonged  attack  of  whooping-cough.  Ko])lik  regards  the  swelling 
about  the  face  and  eyes  as  an  important  sign  of  the  heart  strain.  Serious 
renal  complications  are  very  uncommon,  but  albumin  not  infreiiuently 
and  sugar  oecasioiuilly  is  fcumd  in  the  urine.  An  unusmdly  marked  leuco- 
cytosis  ajijiears  early,  chiefly  of  the  lyni])hocytes  (Meunier). 

Diagnosis. — So  distinctive  is  the  "  whooj)  "  of  the  disease  that  the 
diagnosis  is  very  easy;  but  occasionally  there  ari'  doul)tful  cases,  jmrticu- 
larly  during  eitidemics.  in  which  a  series  of  expiratory  coughs  occurs  with- 
out any  inspiratory  crow. 

Prognosis. — Taken  with  its  complications,  whooping-cough  must  l)e 
regarded  as  a  very  fatal  afTection.  According  to  T>o!an,  it  ranks  third 
among  the  fatal  diseases  of  children  in  England,  where  the  death-rate  ])er 
1,()0(),()00  from  this  disease  is  5,000  annually.  The  yoi'Kn'^r  the  infant 
the  greater  is  the  probability  of  serious  complications.  The  deaths  are 
chiefly  among  children  of  the  poor  and  among  delicate  infants. 

Treatment. — Parents  should  be  warned  of  the  serious  nature  of 
\vhoo])ing-cough,  the  gravity  of  which  is  scarcely  a]ipreciated  by  the  pub- 
lic. I'articular  care  should  bo  taken  that  children  suspected  of  the  disease 
.ire  not  sent  to  the  public  schools  or  exposed  in  any  way  so  that  other  chil- 
dren can  become  contaminated.  There  is  more  reprehensible  neglect  in 
connection  with  this  than  with  any  other  disease.  The  patient  should  be 
isolated,  and  if  the  paroxysms  are  at  all  severe,  at  rest  in  bed.    Fresh  air, 


lie  porlmp^ 
lu'nii|)l(';iiii 
I'lisivc  siili- 
ry  imiisiiiil 
r  my  siTit's 
duriii};  tlic 
L'sorihed  an 

-I  ill  jr.  Tlio 
viiu'Iy  scri- 
im  iiiiiy  lie 
it'll  riiptiiro 
1  rl<>n<(  tlic 
I  condition 
ia,  with  its 
ication  ami 
t  ill  a  ('i)ii- 
I'lcurisy  is 
rgcmont  of 
1  has  l)0(>n 
to  produce 
sc  is  small, 
■diac  action 
"sihly  some 
lad  neither 
loart  strain 
he  swelling 
n.  Serious 
nfre(iuently 
rked  leuco- 

se  that  the 
es,  jiarticu- 
ccurs  with- 

:]i  must  lie 

ranks  third 

ith-rate  ])er 

the  infant 

deaths  are 

natnre   of 

)y  the  pub- 

tlic  disease 

other  chil- 

neglect  in 

t  should  1)0 

Fresh  air, 


iN'i'Lrr.NZA. 


1)5 


ni^lit  and  day,  is  a  most  essentiiil  ciemeni  in  the  treatment  of  the  disease. 
The  medicinal  treatment  of  wlion|iini,f-coiij:li  is  mnsi  uiisatisfactoi'y.  In 
the  catarrhal  slaj;e  when  there  is  iVver  tlie  cliilil  shoidd  lie  in  lied  and  a 
saline  IVvcr  mixture  administered,  if  the  ciiniih  is  distressing,',  iju'caciiaiihu 
wine  and  parcj^oric  may  lie  jriven.  l'"or  thi'  paro\ysuiiil  sta;;t'  a  suspiciously 
long  list  of  remedies  lias  hcen  recommended,  twenty-two  in  one  popular 
te.xt-hodk  on  therapeutics.  If  the  disease  is  due,  "is  seems  prohalile,  to  a 
•jerni  growing  upon  and  irritating  the  hronchial  mucosa,  a  gcrmiciilal  plan 
of  treatment  seems  highly  rational,  ami  persistent  attempts  should  i)e  made 
to  discover  a  suital)Ie  remedy.  (Quinine  is  one  of  the  best  drugs.  One 
sixth  of  a  grain  may  he  given  three  times  a  day  for  each  month  of  age, 
and  U  grain  for  each  year  in  children  under  five  years.  Kesorcin 
in  a  l-per-cent  solution,  swahhed  fretpicntly  on  the  throat;  '^  or  ;J  grains 
of  iodolorni  to  an  ounce  of  starch  powder;  a  spray  of  carholie  acid 
— have  all  lieen  warmly  reconunended.  ,].  Lewis  Smith  advises  the  use  of 
the  steam  atomizer  with  a  solution  of  carholic  acid,  chlorate  of  ])otassium, 
and  hromide  of  ]iotassiuni  in  glycerin.  I>romoforiu,  in  doses  of  1  to  5 
minims  suspended  in  syruji,  has  heen  warmly  recommended  of  late.  Jacohi 
regards  hclladonna  as  the  most  satisfactory  remedy,  lie  gives  it  in  full 
doses,  as  inucli  as  one  sixth  of  a  grain  of  the  extract  to  a  child  of  six  or 
eight  months  three  times  a  day.  It  should  hi'  given  in  suilicient  doses  to 
]n'oduce  the  cutaneous  Hush.  I'or  the  nervous  element  in  the  disease  aiiti- 
])yrin  has  liccn  used  with  apparent  success. 

After  the  severity  of  the  attack  has  pass(>d  and  convalescence  has 
hegun,  the  child  should  he  watched  with  the  greatest  care.  It  is  just  at 
this  period  that  the  fatal  broncho  pneuinonias  are  apt  to  develop.  The 
cough  sometimes  ])ersists  for  months  and  the  child  remains  weak  and  deli- 
cate. Change  of  air  should  he  Iriid.  Such  a  jialient  should  he  fed  witli 
care,  and  given  Ionics  and  cod-liver  oil. 

XII.    INFLUENZA  (La  Gnpp,). 

Definition. — A  pandemic  disease,  appearing  at  irregnlar  intervals, 
characterized  by  extraordinary  rapidity  of  extension  and  the  large  number 
of  people  attacked.  Following  the  pandemic  there  are,  as  a  rule,  for  sev- 
eral years  endemic  or  epidemic  ontbreaks  in  dilfcreiit  regions.  Clinically, 
the  disease  lias  ju-otean  as]iects,  bnt  with  a  s])ecial  tendency  to  attack  the 
res]>iratory  mucous  membranes. 

History. — Crcat  jiandemics  have  been  recognized  since  the  sixteenth 
opntnrv.  There  have  been  four  with  their  succeeding  epidemics  during 
the  present  century— 1S;iO-;?;5,  lSr.(;-";iT.  ISIT-'IS,  and  1S8!)-"1)0.  The 
last  pandemic  began,  as  others  had  done  before,  in  some  of  the  distant  prov- 
inces of  Russia  (hence  the  name  "Russian  fever)  in  October,  and  by  tho 
beginning  of  Xovember  it  had  reached  "Moscow.  ]\y  tlie  middle  of  Xovcm- 
ber  Berlin  was  attacked.  By  the  middle  of  December  it  was  in  London, 
and  by  the  end  of  the  month  it  had  invaded  Xew  York,  and  was  widely 
distributed  over  the  entire  continent.  Within  a  year  it  had  visited  nearly 
all  parts  of  the  earth. 


\} 


J)fi 


SPRCIFK-   IXFKrTIOlS   r»ISKASKS. 


:  I 


'I'lu'  (luralidti  i>l'  ail  i'|)iiltiiiif  in  any  unc  locality  is  from  six  to  ci^'lit 
ivcck.-.  With  the  cMciition.  pfi'liaps.  ot'  ilciijinc.  there  is  no  disease  whieh 
attarks  intliseriininately  so  hir.iie  a  pro|iortion  of  the  inlialiitanls.  l-'or- 
lunately,  as  in  den^jne,  the  rate  of  mortality  is  very  low.  hut  the  ia^t  ei>i- 
(lemie  tan<rlit  ns  to  reeojinize  in  inllnenza,  partienlarly  its  M'tpiels  ami  cnm- 
lilications,  one  of  the  most  serious  of  all  s|ieei(ie  diseafcs.  'I"he  o]i|iorlunit,\ 
for  studying'  the  disease  in  the  last  epidemie  has  thrown  miu  h  li;,dit  upon 
many  luohlems.  Amon^'  the  most  notahle  produ<tions  were  the  work  id' 
IMVilTer  in  discovering.'  the  speeilie  <,'erm,  the  elahorate  lierlin  report  hy  von 
Leyden  and  Senator,  and  the  l.oeal  (iovernmeiit  IJoard's  report  hy  I'arsons. 
Leiehtenstem's  article  in  Notlina;.'ers  llaiulhnch  is  tlie  most  masterly  and 
systematic  consideration  of  the  disease  in  the  literature. 

Etiology.— What  relation  has  the  epidemic  inllnenza  to  the  ordinary 
inllnenza  cold  or  catarrhal  fever  (commoidy  also  called  the  f/n'/'/^c),  which 
is  constantly  present  in  tlie  cofiiinnnity?  Leichtenstern  answers  this  ipn'>- 
lion  hy  making;  the  followin<,Mlivisions:  (1)  Kpidenue  iit/litnr.n  irni,  caused 
l.y  JM'eill'er's  hacilUis;  (V)  ondeniic-eiiidemic  iu/ltivn:a  vera,  whieh  often 
develojis  for  several  years  in  succession  after  a  |iandemic.  also  caused  hy  the 
same  hacillus;  (:'.)  endemic  inliiiniui  iin.^lnis,  pscudo-inlluenza  or  catarrhal 
fever,  commonly  called  tiie  ///•//'/*(■.  wliich  is  a  special  disease,  still  of  un- 
known etiolojry,  and  which  Ix'ar-^  the  same  relation  to  the  true  inllnenza  as 
cholera  nostras  does  to  Asiatic  cholera. 

The  epi<lemics  which  f(dlowed  the  ;:rcat  paiulcmic  of  lSS!)-'!)0  dnrin<,' 
the  years  1S!»1  to  IS!*,')  varied  in  intensity  and  extent  in  dilfercnt  localities. 

The  disease  is  liifihly  eonta^iions;  it  spreads  with  remarkable  rapidity, 
wliich,  however,  is  not  ^'reater  than  modern  methods  of  conveyance.  In 
the  {ireat  jmndemic  of  1S.S!»-'!I()  some  cd'  the  lar^'c  prisons  escaped  entirely. 
The  outbreak  of  epidemics  is  in(le])endent  of  all  seasonal  and  meteoroloifical 
conditions,  thoiij.di  the  worst  have  been  in  the  colder  seasons  of  the  year. 
One  attack  does  not  necessarily  jtrotect  from  a  subse(|iient  one.  A  few 
persons  appear  not  to  be  liable  to  the  disease. 

Bacteriology. — In  l^i'v  rfcillVr  isolated  a  bacillus  from  tlic  iia>al 
ami  bronchial  secretions,  wliicii  is  reco<.'nized  as  the  cause  of  the  disease. 
It  is  a  small,  non-motile  or/ianism.  which  stains  well  in  T.oefller's  mothyleno 
blue,  or  in  a  dilute,  ]iale-rcd  solution  id'  carbol-fiichsin  in  water.  On  cul- 
ture media  it  },'rows  only  in  the  iireseiice  of  luemofilobin.  The  bacilli  are 
present  in  enormous  numbers  in  the  nasal  and  lironchial  secretions  of 
patients,  in  the  latter  almost  in  ))ure  cultures.  'IMiey  jiersist  often  after 
the  severe  symptoms  have  subsided. 

The  much-discussed  (juestion  whether  during'  the  ])resenro  of  an  epi- 
demic human  influenza  attacks  animals  must  be  answered  in  the  negative. 
In  great  iiandemics  of  influenza  the  general  rule  holds  good  that  other 
diseases  do  not  ]irevail  to  the  same  extent,  .\nders  has  hrought  forward 
statistics  to  indicate  that  the  outbreaks  <d'  inalaria  are  very  much  dimin- 
ished during  the  prevalence  of  influenza. 

Symptoms. — The  incuhation  ])eriod  is  "  from  one  to  four  days;oftcn- 
cst  tl  ree  to  four  days."  The  onset  is  usually  abrupt,  with  fever  and  its 
associated  phen(miena. 


INFM'EXZA. 


U7 


six  to  ('i;.'Iit 
incase  wliicli 
tants.      Fni- 

tlic    lll>t    t'lli- 

cls  ami  cniii- 

ii|i|inrlllllit} 

ll    \\'^\\l    llpnll 

tlic  work  of 
i'|)itrt  hy  voii 
t  l)y  I'arson-. 
masterly  ami 

tlic  onliiiaiy 
•ipiir),  wliidi 
M's  this  ipio- 
1  vera,  L'a\isc(l 
which  ol'teii 
•aiist'd  hy  the 
or  catarrhal 
,  still  of  iin- 
•  intliicii/.a  as 

0-90  ilurin}; 
cut  localities, 
iblc  rapidity, 
veyaiu'o.  1  n 
i|ic(l  entirely, 
leteorolojrical 
:  (if  the  year, 
one.     A   few 

ini  the  iia>al 
f  the  disease, 
r's  methylene 
ter.  On  ciil- 
he  hacilli  are 
secretions  of 
•t  often  after 

OP  of  an  p|H- 
thc  negative. 
)tl  that  other 
light  forward 
much  dimin- 

ir  days;  often- 
fevor  and  its 


Types  of  the  Disease. — The  iMaiii''e>tatinn<  arc  so  extraordinarily 
rom|ilc.\  that  it  is  hot  in  (Icscrihe  them  under  types  of  the  di>casc. 

1.  Itisiiirtiliini. — 'I'lic  mucous  ineinluaiic  of  the  respiratory  tract  from 
the  nose  to  the  air-ccl!>  of  the  lungs  nniy  he  regarded  as  the  siat  of  election 
of  the  inlliicn/a  hacilli.  In  the  simple  forms  the  disease  sets  in  with  cory/.a, 
and  presents  the  fiatiires  of  an  a<'iite  catarrhal  fever,  with  perhaps  rather 
more  prostration  ami  dchility  than  is  usual.  In  otlnr  (a>e>  the  catarrhal 
symptoms  persist.  Itroiichitis  devi-lops,  the  fever  continues,  there  is  de- 
liriiim  and  much  prostration,  and  the  picture  may  even  he  tliul  (d'  severe 
typhoid,  '{'he  graver  respiratory  coiiditiinis  are  hroiichitis,  pleurisy,  and 
pneumonia.  The  hronchitis  has  really  no  special  peculiarities.  The  .spiitiim 
is  su|»poscd  liy  many  to  he  distiiu'tive.  Sonietimes  it  is  in  extraordinary 
amounts,  very  thin,  and  <'ontaining  juirnlci  masses.  I'fcilfcr  regards 
sputum  of  n  greenish-yellow  color  and  in  coir  I'ke  luni|)s  as  almost  char- 
acteristic id"  iiilliiciiza.  In  other  cases  there  may  he  a  d.irlv  rcil,  iijoody 
sputum.  One  of  the  most  distressing  scipiels  (d'  the  iiillucnza  lironchitis 
is  diiriise  hronchicctasis,  of  which  I  have  seen  at  least  one  instance.  It 
occasionally  happens  that  the  lironchitis  is  of  great  intensity  and  rearhes 
the  liner  tiiiics.  so  that  the  patient  hccoiues  cyaiiosed  or  even  asphyxiated. 

Inllueii/.a  pneumonia  is  (uie  of  tlie  most  serious  iuaiiil'e>talions.  and  may 
depend  n|ioii  Pfeill'cr's  haeilliis  itself,  or  is  tlu'  result  of  a  mixed  infection. 
The  true  inlluenza  pnciiiuonia  is  most  commonly  loluilar  or  catarrhal.  lc.-< 
often  croupous.  Much  of  the  mortality  of  tlie  disease  depends  U|)on  the 
fatal  character  of  this  (Munplication.  The  clinical  cour.se  of  tlie  cases  is 
often  irregular  and  the  symptoms  are  ohsciire  or  masked. 

Inlluenza  pleurisy  is  more  rare,  hut  cases  of  primary  involvement  of  the 
pleura  are  reported.  It  is  very  apt  to  lead  to  empyema.  I'lilmonary 
tuhercniosis  is  usually  iiiueli  aggravated  liy  an  attack  of  inlluenza. 

'i.  Nervous  /'(//'//(.--Without  any  catarrhal  symptoms  there  nuiy  ho 
severe  headache,  pain  i:i  the  hack  and  joints,  with  jirofouud  pro.stration. 
Many  remarkahle  nervous  nianifestations  were  noteil  during  the  last  epi- 
demic. Among  the  more  serious  may  he  mentioned  meningitis  and  en- 
cephalitis, the  latter  leading  to  lienii])legia  or  monoplegia.  Alwess  of  the 
brain  has  followed  in  acute  cases.  All  forms  of  ucuiitis  are  m)t  uncom- 
mon, and  in  some  cases  aic  characterized  liy  markcil  distuiiiaiice  of  motion 
and  sensation.  Judging  from  the  accoun*  in  the  literature,  almost  every 
form  of  disease  of  the  nervous  system  ma_\   follow  inlluenza. 

To  involvement  of  the  nervis  may  he  ascrihed  some  of  the  common 
cardiac  symptoms,  such  as  persistent  irregularity,  tachycardia  or  iirady- 
cardia,  and  attacks  of  angina  pectoris.  Amoni,''  the  most  important  of  the 
nervous  sequche  are  depression  of  sjiirits.  melancholia,  and  in  some  eases 
denu'ntia. 

.1.  Oastro-inlrsliiuil  Fcrm. — With  the  onset  of  the  fever  there  nuiy  Ije 
nausea  and  vomiting,  or  the  attack  may  set  in  with  abdominal  pain,  profuse 
diarrluea,  and  collapse.  Tn  some  epidemics  jaundice  has  been  a  common 
symptom.  Tn  a  considcrahle  numher  of  the  oases  there  is  enlargement  of 
the  s])leen.  depending  chietly  upon  the  intensity  of  the  fever. 

4.  Febrile  Form. — The   fever  in   influenza   is   verv   variable,   but   it   is 


98 


SPIX'IFIC   IXFKCTIOUS  DISEASES. 


iiiil)or(ant  to  rcoo^riiixe  lliut  it  may  lio  tlic  only  iiinnil'ostation  of  the  dis- 
oast'.  It  is  .soinotiiiu's  iiiarkedly  ri'iiiittcnt,  with  cliills;  or  in  rare  cases 
there  is  a  protraeled,  eontiniied  IVvi^r  oT  several  weeks  duration,  whieh 
siniidates  typhoid  closely. 

While  these  are  ])erha]>s  tlie  most  common  forms  with  their  comjdiea- 
tiiins,  there  are  many  others,  amonfj;  which  may  he  mentioned  the  follow- 
\U'^:  \'arious  rt'oal  aifections  have  heen  noted,  (i.  liaunij^^arten  lias  calK'd 
attention  to  tiie  I'reiiuency  of  neithritis  in  the  recent  epi<Iemic.  Urciiitis 
has  l)een  also  seen,  l-hulocarditis  and  pericarditis,  piilehitis  and  thrond)()sis 
111'  tlu'  varions  vessels  arc;  reported.  Herpes  is  common.  A  diirn:;e  erythema 
sometimes  occurs,  occasionally  purpura.  Catarrhal  conjunctiviti:-;  is  a  fre- 
(pu'iit  event.  Iritis,  and  in  rare  instances  optic  neuritis,  have  been  met 
with.  Acute  otitis  media  v,as  a  common  complication.  I  have  seen  severe 
and  persistent  vertip)  follow  inlluenza,  prohaMy  from  involvement  of  the 
labyrinth. 

Since  the  late  severe  epidemics  it  has  been  the  fasliion  to  date  various 
ailments  or  chronic  ill-lu'alth  from  inlluenza.  In  many  cases  this  is  cor- 
rect. It  is  astonishing^  the  number  of  pcojile  who  have  been  crippled  in 
health  for  years  after  an  attack. 

Diagnosis. — i>urinjf  a  pandemic  the  cases  ofTer  hut  slight  dilTiculty. 
The  jirofoundness  of  the  ])rost  ration,  out  of  all  ])roportion  to  the  intensity 
of  the  disease,  is  one  of  the  mo.^t  characteristic  features.  In  the  resj)iratory 
form  the  diagnosis  mav  be  made  hv  the  bacteriolomcal  examination  of  the 
s])nt)nn,  a  ])rocedure  which  should  be  resorted  to  early  in  a  suspected  c|)i- 
demic.  The  diil'erentiation  of  the  various  forms  has  been  already  sulll- 
ciently  considered. 

Treatment. — Is(dation  should  be  ])ractised  when  ])ossil)le,  and  old 
l)e()j»le  should  be  guarded  against  all  possible  sources  of  infection.  The 
secretions,  nasal  and  broiuhial,  slioulil  be  tluiroughly  disinfected.  In  every 
case  the  disease  should  be  regarded  as  serious,  and  the  ])atient  should  be 
confined  to  bed  until  the  fever  ha-;  completely  disappeared.  In  this  way 
alone  can  serious  comjilications  be  avoided.  From  the  outset  the  treatment 
should  be  supporting,  and  the  jmtient  should  be  carefully  fed  and  well 
nursed.  The  bowels  should  be  opened  by  a  dose  of  calrmel  or  a  saline 
draught.  At  night  10  grains  of  Dover's  powder  may  bo  given.  At  the 
onset  a  warm  bath  is  sometimes  grateful  in  relieving  the  pain  in  the  back 
and  limbs,  but  great  care  should  be  taken  to  have  the  bed  well  warmed, 
and  the  ])atient  should  be  given  after  it  a  drink  of  hot  lemonade.  If  the 
fever  is  high  and  there  is  delirium,  small  doses  of  antipyrin  may  be  given 
and  an  ice-cap  apjdied  to  the  head.  The  medicinal  antipyretics  should  be 
used  with  caution,  as  ]irofound  prostration  sometimes  develops  in  these 
cases.  Too  much  stress  should  not  be  laid  upon  the  mental  features.  De- 
lirium may  be  marked  even  with  slight  fever.  Tn  the  cases  with  great  car- 
diac weakness  stimulants  should  be  given  freely,  and  during  convalescence 
strychnia  in  full  doses. 

The  intense  bronchitis.  ])nenmonia.  and  other  complications  should 
receive  their  appropriate  treatment.  The  convalescence  requires  careful 
management,  and  it  may  be  weeks  or  months  before  the  patient  is  restored 


DENGUE. 


99 


II  of  the  (lis- 
iii  rare  cases 
ation,  which 

rir  coiiiiilicii- 

I  tlie  I'oHow- 
,'11  has  called 
lie.  Orchitis 
(1  thrombosis 

II  :;e  erythema 
.'iti:-;  is  a  fre- 
ve  been  met 
e  seen  severe 
-'jiient  of  the 

dale  various 
5  this  is  cor- 
1  crippled  in 

:ht  diniciilty. 
the  intensity 
le  resi)iratory 
lation  of  the 
iispected  epi- 
ilready  sulll- 

ble,  and  old 
eetion.  The 
.'d.  In  every 
lit  should  bo 

In  this  way 
he  treatment 
fed  and  well 
1  or  a  saline 
:eii.     At  the 

in  the  back 
veil  warmed, 
lade.  If  the 
aay  be  given 
OS  should  be 
ops  in  these 
matures.  De- 
th  great  car- 
onvalescence 

lions  should 
aires  careful 
it  is  restored 


to  full  health.  A  gdod  nutritious  diet,  change  of  air,  and  pleasant  sur- 
rduiidiiigs  are  essential.  'J'he  depression  of  spirits  following  thi  disease 
is  one  of  its  most  uniileasant  and  olistinate  features. 


Xm.  DENGUE. 

Definition.— An  acute  infectious  disease  of  trojiical  and  subtropical 
regK.ns,  characterized  by  febrile  jiaroxysms,  pains  in  the  joints  and  imis- 
clcs,  an  initial  erythematous,  and  a  terminal  polymorphous  eruption. 

Ft  is  known  as  hreal--hi)iu'  fever  from  the  atrocious  cliaraeter  of  the  pain, 
and  (laiiiln  fern-  from  the  still",  dandified  gait.  The  word  dengue  is  sup- 
posed to  lie  derived  from  a  Spanish,  or  possibly  llindoostaiiee,  e.piivalent  of 
the  word  dandy. 

History  and  Geographical  Distribution.— The  disease  was  first 
recognized  in  KTi)  in  Cairo  and  in  Java,  where  i'.rylon  described  the  out- 
l)reak  in  liatavia.  The  description  by  I5enjamin  "HiisIi  of  the  epidemic 
in  rhiladel])liia  in  irso  is  one  of  the  first,  and  one  of  the  very  best  ac- 
counts of  the  disease,  lletweeii  ISV  I  and  lSt>S  it  was  ]u'eva!ent  at  intervals 
in  India  and  in  the  Southern  States.  S.  Jl.  J)ickson  gives  a  graphie  de- 
scription of  the  disease  as  it  ajipeared  in  Charleston  in  18-.'8.  Since  that 
date  tiiere  have  been  four  or  live  widespread  eiiideiiiics  in  tropical  coun- 
tries and  on  this  continent  along  the  (iulf  States,  the  last  in  the  summer 
of  1897.  Xone  of  the  recent  epidemics  have  extended  into  the  Northern 
States.^but  in  1SS8  it  prevailed  as  far  north  as  Virginia. 

Etiology.— '{'he  rapidity  of  dilfusion  and  the  jiandcmic  character  are 
the  two  most  ini|iortant  features  of  dengue.  There  is  no  disease,  not  oven 
inlluenza,  which  attacks  so  large  a  jirojiortion  of  the  population.  In  (ialvos- 
ton,  in  18;iT,  '.^0,OOU  peojile  were  attacked  within  two  months.  1|  ajipears 
to  belong  to  the  group  of  exanthematic  fevers,  and  has  their  highly  infec- 
tious characters.  A  micrococcus  has  been  found  in  the  blood  of  patients  by 
McLaughlin,  of  Texas. 

As  the  disease  is  rarely  fatal,  no  ol)servati(ms  have  been  made  upon  its 
pathological  anatomy. 

Symptoms.— Til e  ]ieriod  of  incubation  is  from  three  to  five  days 
during  which  tiie  jiaticiit  feels  well.  The  attack  sets  in  su.ldcnly  wi'tii' 
headache,  chilly  feelings,  and  intense  aching  jiains  in  the  joints  and  mus- 
cles. The  temperature  risi's  gradually,  and  may  reach  10()°  or  lO?".  Tiio 
inilse  is  rapid,  and  there  are  the  other  phenoinena  associated  with  acute 
fever— loss  of  appetite,  coated  tongue,  slight  nocturnal  delirium,  and  con- 
centrated urine.  The  face  has  a  suffiised,  bh)ated  appearance,  the  eyes  are 
injected,  and  the  visible  mucous  membranes  are  Hushed.  There  is  a  con- 
gested, erythemalous  state  of  the  skin.  l?ush"s  description  of  the  ])ains  is 
worth  (pioting.  as  in  it  the  ejiithet  break-bone  occurs  in  the  literature  for 
the  first  time.  "The  pains  which  accompanied  this  fever  were  ex(|uisitelv 
severe  in  the  head,  back,  and  limbs.  The  pains  in  the  head  were  sometimes 
in  the  back  jiarts  of  it,  and  at  other  times  they  occupied  only  tlie  eveballs. 
In  some  jieople  the  pains  were  so  acute  in  their  backs  and  Jiips  that  they 
could  not  lie  in  bed.     In  others  the  pains  affected  the  neck  and  arms,  so 


tfa^ 


I 


100 


SPECIFIC  INFECTIOUS  DISEASES. 


fis  to  ])n)(1iic('  ill  Olio  iiistaiuc  a  (linicultv  of  moving-  tlic  fin-ror?  of  tlio  ri^lit 
liaml.  'J'licy  all  coiiiiilaiiicd  iiiort'  or  k'ss  of  a  soreness  in  the  seats  oi'  these 
|iaiiis,  i)artieiilarly  when  they  oeenjiied  the  head  and  eyelialls.  A  few  coiii- 
plaiiied  of  their  liesli  heini,'  sore  to  the  toneli  in  every  part  of  llio  Ijody. 
From  these  eireiiinstances  the  disease  was  .sometimes  helieved  to  1)0  a  rlieii- 
matism,biit  its  more  pMieral  name  among  all  classes  of  people  was  the  l)reak- 
l)one  fever.""  'l"he  large  and  small  joints  are  ail'ei't"(l,  sometimes  in  suc- 
cession, and  lieeome  swollen,  red,  and  painful.  In  some  eases  eutanoous  liy- 
poi'a\stliosia  ha.s  heeii  noted.  Jliumorrliago  from  the  miieous  meml)ran>s  was 
noted  by  Uush.    JUack  vomit  has  al.so  been  de.<eribed  by  several  oli.servers. 

The  fever  gradually  reaehes  its  maximum  by  the  tliinl  or  fourth  day; 
the  patient  tlu'ii  enters  uj)on  the  apyretie  period,  whieii  may  last  from  two 
to  four  days,  and  in  whieli  he  feels  prostrated  and  still".  A  seeoiul  paro.xysm 
of  fever  then  oecurs,  and  the  ])ains  return.  In  a  large  numiier  of  cases  an 
eruption  is  eomnion,  wiiieh,  judging  from  the  deseri|ition,  has  nothing 
distinetive,  being  sometimes  niaeular,  like  that  of  measles,  .sometimes  dif- 
fuse and  searlatiniform,  or  ])apular,  or  lieher.-like.  In  other  instances  the 
rash  has  been  described  as  urticarial,  or  even  vesicular.  Certain  writers 
describe  intlammation  and  liy|)ei'a'mia  of  the  mucous  menibrinie  of  the 
nose,  mouth,  and  pharynx.  Knlargemeiit  of  the  lymjih-glands  i.s  not  un- 
eomiium.  and  may  persist  for  weeks  after  the  disappearance  of  tiie  ivwr. 
Convalescence  is  often  jtrot raited,  and  there  is  a  degree  of  mental  and 
physical  prostration  out  of  all  proportion  to  (he  severity  of  the  ]irimary 
attack.  The  jiains  in  the  joints  or  muscles,  sometimes  very  local,  may  per- 
.sist  for  weeks.  J{nsh  refers  to  the  former,  stating  that  a  young  lady  after 
recovery  said  it  should  be  called  break-heart,  not  break-bone,  fever.  The 
average  duration  of  a  moderate  attack  is  from  seven  to  eight  days.  Dengue 
is  very  seldom  fatal.    Dickson  saw  three  deaths  in  the  Charleston  epidemic. 

Complications  are  rare.  In.somnia  and  occasionally  delirium,  resem- 
bling somewhat  the  alcoludic  form,  have  been  observed,  and  convulsions 
in  children.     .\  relajise  may  occur  even  as  late  as  two  weeks. 

The  (liiiipidsla  of  the  disease,  ])revailing  as  it  does  in  epidemic*  form 
and  attacking  all  clas.<cs  indiscriminately,  rarely  offers  any  special  dilTiciiltv. 
Isolated  cases  might  be  mistaken  at  first  for  acute  rheumatisiu.  The  im- 
portant (juestion  of  the  differentiation  between  yellow  fever  and  dengue 
will  l)e  considered  later. 

Treatment.— This  is  entirely  syni]itomatic.  Quinine  is  stated  to  he 
a  prophylactic,  but  on  insuiricient  grounds.  Hydrotherapy  may  be  em- 
jiloyed  to  reduce  the  fever.  The  salicylates  or  antijiyrin  miiy  be  tried  for 
the  pains,  which  usually,  however,  reipiin'  opium.  During  convalescence 
iodide  of  potassium  is  recommended  for  the  arthritic  ])ains,  and  tonii?s  arc 
indicated. 

XIV.  CEREBROSPINAL    MENINGITIS. 

Definition. — A  specific  infections  disease,  occurring  sporadically  and 
in  epidemics,  caused  by  the  diplococcus  intracelhilaris,  cliaracterized  by 
inflammation  of  the  ccrcbro-spinal  meninges  and  a  clinical  course  of  great 
irregularity. 


'U. 


CFRRBRO-SIMN'AIi   MKNIMUTIS. 


lol 


)!'  the  riiilit 

iltri  Oi'   tllL'SO 

X  few  coin- 
t'  llio  body. 

1)0  a  rlioii- 
^  the  l)roak- 
iK's  in  !<ii('- 
tiuicous  liy- 
ilji'iiius  was 
)I)S('rvi'rs. 
ruiirtli  day; 
't  ii»m  two 
il  i)aroxysiii 
of  cases  an 
as  notliiii^- 
letinies  dil'- 
stanees  the 
ain  writers 
line  of  the 

is  not  un- 
•  tile  fever, 
nental  and 
lie  i)riniary 
I,  may  per- 
:  lady  alter 
'over.  The 
<.  Denfrne 
1  epidciiiie. 
ini,  resein- 
•onviilsions 

cmie  form 
1  dilTiciilty. 
,  The  im- 
iid  dengue 

ated  to  he 
ay  he  em- 
e  iried  for 
ivaleseenee 
tonics  arc 


lieally  and 
'terized  hy 
se  of  great 


The  affoetion  is  also  known  by  the  mimes  of  malignant  purpuric  fever, 
petechial  fever,  and  spotted  fever. 

History,  — Vieusseiix  lirst  described  n  small  outbreak  in  (iciieva  in 
ISon.  Jn  ISOO  j,.  J)aniel.son  and  K.  Mann  (.Medical  and  Agricultural 
hVgistcr,  n.iston)  gave  an  account  of  "a  singular  and  verv  mortal  di.sease 
wliich  lately  made  its  appearaii.'e  in  Medlord.  .Mass." 

The  di.sea.se  attracted  iiiiirli  atti'iitioii  and  was  the  subject  (»f  -everal 
very  careful  .-tiidie.<.  Tlie  Massaeliusetts  Medical  Society,  in  iSOil,  ju.- 
pointed  dames  Jackson.  Tli.mias  Welch,  and  .1.  C.  Warren  to  inve>tigate  it 
Khsha  North's  little  book  (l.sll)  gives  a  full  account  of  the  early  epi- 
demics. Stille's  monograph  (iSdT)  and  the  elaborate  section  in  vol.  i  of 
doseph  Joins'  works  contain  details  of  the  later  American  outbreaks.  The 
history  of  the  disea.>-e  in  Kiirope  and  el.sewhere  is  to  be  found  in  ilirscirs 
(ie()graphical  I'athology,  and  a  detailed  statement  of  the  epidemics  in  the 
I'nited  Kingdom  is  given  as  an  appendix  by  Ormen.d  in  hi.-,  article  in  .\11- 
l)iitt"s  System.  IIir.<ch  divides  the  outbreaks  into  four  periods:  Froiu  ISO") 
to  l,s;i(),  ill  which  the  disea.se  was  nio.4  prevalent  throughout  the  ruite.l 
States;  a  second  period,  from  1S:5T  to  1S:,().  mIicii  the  disea.^c  prevailed  ex- 
tensively in  France,  and  there  were  a  few  outbreaks  in  the  I'liited  States; 
a  third  period,  from  IS.-*!  to  iS^j,  when  ''  >  were  outbreaks  in  JMirope 
and  several  extensive  epidemics   in   this  ny.      During  the  civil   war 

there  were  comparatively  few  cases  of  the  (li..,,ise".  It  prevailed  extensively 
in  the  Ottawa  \'alley  early  in  the  .-eventics.  in  the  fourth  period,  from 
isr.-)  to  (lu'  iircsciit  time,  the  di.sease  has  broken  out  in  a  great  many 
regions.  There  was  a  serious  epidemic  in  western  Maryland  in  is!)>>  and  in 
Xew  York  in  lS!t;5.  From  the  spring  of  1S!)(!  to  the  date  of  writhig,  April, 
1S!»S.  the  di.-ease  has  prevailed  in  I'.oston  and  the  neighboring  towns,  and' 
has  been  made  the  subject  of  careful  study  by  Coiincilman.  :^^allory,  ami 
Wright,  whose  monograph,  issued  by  the"  ^rassacliu,<eits  Stale  I'.oard  of 
Health,  is  the  most  important  (>ontribulion  made  in  this  couiitrv  to  the 
])athol()gy  of  e])ideniic  meningitis. 

Etiology.— Cerebro-spinal  meningitis  presents  s(>veral  remarkable 
l>eculiarities.  The  outbreaks  are  localized,  occurring  in  certain  regions, 
and  are  rarely  very  widespread.  As  a  rule,  country  districts  have'^been' 
more  alllicted  than  cities.  The  ei)ideniics  have  occurred  most  freiincntly  in 
Vw  winter  and  spring.  The  concentration  of  individuals,  as  of  troops  in 
large  barracks.  .<cems  to  be  a  sj)ecial  factor,  and  ciiidcmics  on  the  Conti- 
nent show  how  liable  recruits  and  young  soldiers  are  to  the  disease.  In 
civil  life  children  and  young  adults  are  most  susceptible.  Over-exertion, 
long  marches  in  the  heat,  depressing  mental  and  bodily  surroundings,  and 
the  nii.<ery  and  sipialor  of  the  large  tenement  houses  "in  cities  are 'jjredi.s- 
posing  causes.  The  disease  seems  not  to  be  directly  contagious,  and  is 
probably  not  transmitted  by  clothing  or  the  excretions.  Tt  is  very  rare 
to  have  more  than  one  or  two  ca.<es  in  a  house,  and  in  a  citv  epidemic  th(> 
distribution  of  tlie  eases  is  verv  irregular,  rouncilman  lias"  found  five  in- 
stances in  which  the  same  individual  is  reported  to  have  had  the  disease 
twice. 

Sporadic  cases  occur  from  time  to  time  in  the  larger  cities  and  country 


102 


SPECIFIC  INFECTIOUS  DISEASES. 


districts  on  lliis  tontiiu'iit.  A  Tut  tlu'  iirst  i'|ii(lcinic  in  Montival  in  187:? 
(iL'CiiHioiiiii  instanci'S  (it-ciirrcd.  In  I'iiiladi'liiliia,  t^incf  its  a|)|icaiancc  in 
l.s(i;5,  thoiv  have  been  cases  rcpoiti'd  cvcrv  year  in  tiie  mortality  bills. 
Witliout  antop.sy  ibo  (liaf,niosis  ot  many  ui'  tlioso  is  cxtromcly  doubtl'nl;  but 
tliorc  can  bo  no  <iiiostion  that  the  dist'a.si',  thoii>:h  rare,  still  linjrcrs.  thidg- 
ing  from  my  own  cxiu'ricncc  in  tiirco  of  the  hosjiitals  of  that  city,  in 
Avhich  in  live  years  I  saw  only  three  instances,  1  wonld  regard  it  as  very 
ninch  less  frecjuent  than  the  rejiorts  of  the  Health  Ollice  would  seem  to  in- 
dicate. 

It  is  grt'atly  to  be  desired  that  observers  hereaiter  pay  very  special  atten- 
tion to  these  eases,  jiarticularly  to  the  bacteriological  study,  in  order  to 
determine  the  character  of  the  exciting  organism. 

Bacteriology. — In  1887  AVeichselbaum  described  an  organism,  the 
Diphcucais  iiihvrclliihiris  ineiiiinjilidb,  which  was  proliai)ly  the  same  as 
one  ])revionsly  found  by  Leichtenstern.  In  the  tissues  the  organism  is 
almost  constantly  within  the  ]iolynuclear  leu<-ocytes.  In  cultures  it  has 
well-cliaracterized  features,  and  is  distinguishable  from  the  pneumoeoccus. 
Since  Weichselbaunrs  ol)servations  this  is  the  organism  which  has  usiuilly 
been  met  with  in  the  carefully  studied  ei)idemics  of  the  disease,  particu- 
larly by  Jiiger.  In  the  recent  Boston  outbreak,  in  35  of  the  cases  on  which 
I)ost-mortem  examinations  were  made,  the  diidococci  were  demonstrated  in 
all  but  4,  in  one  of  which  they  had  jn'eviously  been  found  in  lluid  withdrawn 
by  sjiinal  jtuncture.  The  other  3  cases  were  chronic.  Cultures  may  fail  to 
give  the  organism  even  wlien  alnmdantly  present,  as  shown  on  cover-slips. 
In  7  cases  the  pneumoeoccus  was  found  in  connection  with  the  di]»lococ- 
cus  intracellularis,  and  once  Friedliinder's  bacillus.  Lumbar  puncture  was 
performed  in  55  cases,  in  38  of  which  dii)lococci  were  found. 

Morbid  Anatomy.— In  maligiumt  cases  there  may  be  no  characteris- 
tic changes,  the  lirain  and  spinal  cord  showing  only  extrenu'  congestion, 
which  was  the  lesion  descril)cd  by  ^'ieussi.■u^:.  In  a  majority  of  the  acutely 
fatal  cases  death  occurs  within  the  first  week.  There  is  intense  injection  of 
the  ])ia-arachnoi(i.  The  exudate  is  usually  fibrino-purulent,  most  nuirkeil  at 
the  base  of  the  brain,  where  the  meninges  may  be  greatly  thickened  and 
plastered  over  with  it.  On  the  cortex  there  may  be  mu<'h  lymph  along 
the  larger  lissures  and  in  the  sidci;  scnnetimes  the  entire  cortex  is  covered 
with  a  thick,  purulent  exudate.  It  deserves  to  be  recorded  that  Danielson 
and  Mann  made  five  autopsies  and  were  the  first  to  describe  "  a  fluid  resem- 
bling ]»us  between  the  dura  and  i)ia  mater."  The  cord  is  always  involved 
with  the  brain.  The  exudate  is  more  abundant  on  the  posterior  surface, 
and  involves,  as  a  rule,  the  dorsal  and  lumbar  regions  more  than  the  cervical 
portion. 

In  the  nu)re  chronic  cases  there  is  general  thickening  of  the  meninges 
and  scattered  yellow  patches  mark  where  the  exudate  has  been.  The  ven- 
trich's  in  the  acute  cases  are  dilated  and  contain  a  turbid  fluid,  or  in  the 
])osferior  cornua  ]>nre  pus.  In  the  chronic  cases  the  dilatation  may  bo  very 
great.  The  brain  substance  is  usually  a  little  softer  than  normal  and  has 
a  ]>inkish  tinge;  foci  of  luemorrhage  and  of  encephalitis  nuiy  be  found. 
The  cranial  nerves  are  usually  involved,  i)articularly  the  second,  fifth,  sev- 


I 


CEREDRO-yPINAL  MENINGITIS. 


103 


ul  in  187:? 
I'iirancc  in 
ality  hills, 
ihtl'ui;  Init 
'VS.  Judj:- 
it  I'ily,  in 
it  as  very 
;oein  to  iii- 

H'ial  at  ten - 
11   order  ti) 

[Uiisiii,  the 
10  saiue  as 
rj,'anisni  is 
ires  it  lias 
iiniofoce'US. 
las  usually 

0,  partic'U- 
s  on  which 
iistrated  in 
withdrawn 
may  fail  to 
covor-slips. 
0  diplococ- 
ncture  was 

•haractoris- 
oony't'stioii, 
the  acutely 
njc'ction  of 

marked  at 
'kened  and 
uiph  aloufi 

is  covered 
;  Dauielson 
luid  reseiii- 
ys  involved 
ior  surface, 
the  cervical 

0  nioningc's 
'J'he  ven- 

1,  or  in  tho 
nay  bo  very 
lal  and  has 

bp  found. 
,  fifth,  scv- 


f. 


i 


cnth,  and  eighth.     The  .spinal  nerve  roots  are  also  found  imbedded  in  the 
e.xnchite. 

i\Iit:roscopi(ally,  the  exudate  consists  largely  of  polyiuiclear  leucocytes 
closely  packed  in  a  fllirinoiis  material,  {•"lexncr  and  I'.arker  describe  larger 
cells,  from  two  to  eight  tinii's  the  diameter  of  a  leucocyte.  The  lesions  in 
the  tissue  of  the  brain  and  ccu'd,  acording  to  Councilnian,  are  more  marked 
in  this  than  in  other  forms.  They  consist  chiclly  in  iiililtration  of  the 
tissue  with  |)iis  cells,  which  extend  downward  in  the  perivascular  spaces.  In 
some  instances  there  are  foci  of  purulent  infiltration  and  haMuorrhage. 
The  neuroglia  cells  are  swollen,  with  largt>,  clear,  iuid  vesicular  nuclei. 
The  ganglion  cells  show  less  marked  changes.  Diploeocci  are  found  in 
variable  numbers  in  the  exudate,  being  niori'  numeroiis  in  the  brain  than  in 
the  cord. 

Lesions  in  Other  Parts.— In  one  of  the  I'.oston  cases,  examination 
of  the  na.sil  secretion  during  life  showed  dijilococci,  and  in  this  instance 
there  was  found  post  mortem  a  imrulent  iiililtration  of  the  mucous  mem- 
brane.    Jn  two  other  cases  this  membrane  was  normal. 

Linitjs. — rneumonia  and  jileurisy  have  been  described  in  the  di.sease. 
Councilman  ri'ports  that  in  the  recent  epidemic  in  l.S  cases  there  was  con- 
gestion with  (edema,  in  7  bronclio-pneumonia,  in  •.>  characteristic  crou|(ous 
pneumonia  with  jmeiimococci;  in  S  |moumonia  due  to  tho  diplococcus  intra- 
cellularis  was  jiresent. 

Sl)k'ni. — The  organ  varies  a  good  deal  in  size.  In  only  three  of  the 
r>oston  fatal  cases  was  it  found  much  enlarged.  The  llirr  is  rarely  abnormal. 
Acute  iicphrilis  is  sometimes  |ircseiit.  The  intestines  show  sometimes  swell- 
ing of  the  follicles,  but  this  was  not  iiresent  in  any  of  the  IJoston  cases. 

Symptoms. — Cases  differ  remarkably  in  their  characters.  Many  dif- 
ferent forms  have  been  described.  These  are  perhaps  best  grouped  into 
three  classes: 

1.  Malignant  Form.— This  fulminant  or  apoplectic  type  is  found  with 
variable  frecpieiicy  in  epidemics.  It  may  occur  sporadically.  The  onset 
is  sudden,  usually  with  violent  cliills,  headache,  somnolenc(\  spasms  in  the 
muscles,  great  depression,  moderate  elevation  of  temiierature,  and  feeble 
pulse,  which  may  fall  to  fifty  or  sixty  in  the  minute.  I'sually  a  purpuric 
rash  develops.  In  a  Philadeliibia  case,  in  ISSS,  a  young  giri,  a])parently 
quite  well,  died  within  twenty  hours  of  this  form.  There  are  cases  oil 
record  in  which  death  has  occurred  within  a  shorter  time.  Stille  tells  of 
a  child  of  five  years,  in  whom  death  occurred  after  an  illness  of  ten  hours; 
and  refers  to  a  case  reported  by  G(U-don,  in  which  the  entire  duration  of 
the  illness  was  only  five  hours.  Two  of  Vicusscu.x's  cases  died  within 
twenty-four  hours. 

2.  Ordinary  Form.— The  stage  of  incubation  is  not  known.  The  dis- 
ease usually  sets  in  suddenly.  There  may  be  ])reinonitory  symptoms: 
headache,  jKiins  in  the  back,  and  loss  of  a|)petite.  ]\Iore  eomnionly,  the 
onset  is  with  headache,  severe  chill,  and  vomiting.  The  temperature  rises 
to  lOr  or  102°.  Tho  pulse  is  full  and  strong.  An  early  and  imjiortant 
symptom  is  a  painful  stiffness  of  tho  muscles  of  the  neck.  The  headache 
increases,  and  there  are  photophobia  and  groat  sensitiveness  to  noises. 

7 


^^^ 


'I 

! 


1U4 


SPECIFIC  INFECTIOUS  DISEASES. 


C'liildi'cii  hi'conu'  very  irritalilc  iiiid  restless.  In  scvitc  cases  tlic  conirac- 
i'lon  of  tlir  imiselcs  ol'  tlio  neck  sets  in  early,  tlie  lieail  is  drawn  l)aek,  and, 
when  the  ninseU's  of  the  hack  are  also  involved,  there  is  orthotonos,  which 
is  more  coininon  than  oi>isthol()nos.  The  i)ains  in  the  hack  and  in  the 
iimhs  may  he  very  severe.  Tiie  motor  symptoms  are  most  ehuracleristie. 
Tremor  of  the  mnscles  may  he  preset  '  ith  tonic  or  clonic  sj)asms  in  the 
arms  or  lejrs.     Kijiidity  of  the  must  ilie  hack  or  neck  is  very  com- 

mon, and  the  imtient  lies  with  the  [»■  tiif  and  the  head  drawn  so  far 
hack  that  tiie  occiput  may  he  hetween  the  shoidder-hlades.  Except  in 
early  childhood  convulsions  are  not  common.  Strahismus  is  a  frequent 
and  important  symptom.  Spasm  of  the  muscles  of  the  face  may  also 
occur.  Cases  have  l)cen  descrihed  in  which  the  f^eneral  rij^idity  and  stitV- 
ness  was  such  that  the  hody  could  he  moved  like  a  statue.  Paralysis  of 
the  trunk  muscles  is  rare,  hut  paralysis  of  the  muscles  of  the  eye  and  the 
face  is  not  uncommon. 

Of  sensory  sym])tonis,  headache  is  the  most  donunant  and  persists  from 
the  outset.  It  is  chiefly  in  the  hack  of  the  head,  and  the  ])ain  extends 
into  the  neck  and  hack.  There  may  he  great  sensiti\eness  along  the  si)ine, 
and  in  many  cases  there  is  marked  hypera'sthesia. 

The  psychical  sym]tti)Uis  are  ])ron()unced.  Delirium  occurs  at  the  onset, 
occasionally  of  a  furious  aiul  maniacal  kind.  The  patient  may  display  at 
the  start  nuirked  erotic  symptoms.  The  delirium  gives  ])lace  in  a  few  days 
to  stupor,  which,  as  the  effusion  increases,  deejtens  to  coma. 

Tiu'  teni])erature  ir-  irregular  and  variahle.  Remissions  occur  frequently, 
and  there  is  no  uniform  or  typical  curve  during  the  disease.  In  some  in- 
stances there  has  l)een  little  or  no  fever.  In  others  the  temperature  may 
reach  lO.'i"  or  10(>°,  or,  hefore  death,  ]<1S°.  The  pulse  may  he  very  ra])iil 
in  children;  in  adults  it  is  at  first  usually  full  and  strong.  In  some  cases 
it  is  reniarkahly  slow,  and  may  not  he  more  than  fifty  or  sixty  in  the  minute. 
Sighing  resi>irations  and  ("heync-Stokes  hreathing  are  met  with  in  sonu^ 
instances.  Unless  there  is  pneumonia  the  respirations  are  not  often  in- 
creased in  frequency. 

The  cutaneous  symptoms  of  the  disease  are  important.  Herpes  occurs 
with  even  greater  fretpu'ucy  than  in  imeumonia  or  in  intermittent  fever. 
The  ]ietechial  rash,  which  has  given  the  name  spotted  fever  to  the  dis- 
ease, is  very  variahle.  Stille  states  that  of  98  eases  in  the  Philadel- 
phia Hospital,  no  eruption  was  ohserved  in  37.  In  the  Montreal 
cases  petechia'  and  pnr])le  s])()ts  were  common.  They  a])])ear  to  have  heen 
more  fre(|uent  in  the  epidemics  on  this  continent  than  in  Kurope.  The 
]ietecliia'  may  he  numerous  and  cover  the  entire  skin.  An  erythema  or 
dusky  umttling  may  he  ])resent.  In  some  instances  there  have  heen  rose- 
colored  hypera'mic  spots  like  the  typhoid  rash.  Urticaria  or  erythema  no- 
dosnm,  ecthyma,  pemphigus,  and  in  rare  instances  gangrene  of  the  skin 
have  heen  noted. 

There  is  a  leucocytosis,  a  point  which  may  help  in  the  diagnosis  from 
typhoid  fever.  In  the  recent  Boston  epidemic  hlood  counts  were  made  in 
33  cases.  The  highest  numher  of  leucocytes  in  any  one  was  31,000.  The 
increase  is  chiefly  in  the  polynuclcar  variety. 


^ 


rKHKRUO-SPIXAL   MKNIXCITIS. 


105 


he  contrac- 
1  hiK'k,  ami, 
onos,  which 
ami  in  the 
anu'toristii'. 
asuisi  in  tiio 
i  very  coni- 
rawn  so  far 
Except  in 
a  frequent 
e  may  also 
y  and  tstitV- 
I'aralysis  of 
eye  and  the 

ersists  from 
uin  extends 
'^  the  sjune, 

it  the  onset, 

y  display  at 

a  few  days 

frequently, 
[n  some  in- 
n-ature  may 
very  rapid 
some  cases 
the  minute. 
Ill  in  some 
it  often  in- 

'rpes  occurs 
ttcnt  fever. 
to  the  dis- 
e  Philadel- 
'  Montreal 
)  have  heen 
irope.  The 
rylhenia  or 
'  heen  rose- 
ythema  no- 
of  the  skin 

tjnosis  from 
M'e  made  in 
1,000.    The 


As  already  staled,  vomiting;  may  he  a  sjiccial  feature  at  the  onset;  hut, 
as  a  ruk',  it  <:radiially  sniisides.  In  some  iii.-taiiccs,  however,  it  persists 
and  lie<(>mes  the  most  f.erioiis  and  distressing'  of  tiie  .-ymptoins.  Diarriuea 
is  not  common.  The  iiowcis  are  usually  loiilined.  The  alidomcn  is  not 
tender.     In  the  acute  form  the  spleen  is  usually  enlar^^cd. 

The  urine  is  sometiuu's  aliiuininous  and  the  (piaiitity  may  he  increased. 
Glycosuria  has  heen  noted  in  some  instances,  and  in  the  mali<;nant  types 
luematiiria. 

The  course  (d'  the  disease  is  extri'nudy  variahle.  llirsch  ri;:htly  states 
that  it  nuiy  rauire  hetwecn  a  few  hours  and  .several  months.  .More  than 
half  of  the  di'aths  occur  within  the  first  live  days.  In  favorahle  cases, 
after  the  symptoms  have  jicrsisted  for  five  or  six  days,  improvement  is  in- 
dicated hy  a  lesseninjr  of  the  spasm,  reduction  of  tlie  fever,  and  a  return 
of  the  iidcllijrence.  A  sudden  fall  in  the  temperature  is  of  had  omen.  Con- 
valescence is  extremely  tedious,  and  may  he  interrupted  hy  complications 
and  se(|m'lii'  to  he  noted. 

3.  Anomalous  Forms. 

((()  Ahoiiire  Ti/pc. — The  attack  sets  in  with  jrreat  severity,  hut  in  a 
day  or  two  the  symptoms  suliside  and  convalescence  is  rapid.  Striinipell 
would  distinjriush  hetween  'this  ahortive  variety,  whicli  lie;;ins  with  such 
intensity,  and  the  mild  amindant  cases  descriiied  hy  certain  writers.  lie 
reports  a  case  in  which  the  menin^^'al  symptoms  set  in  with  the  jrreatest 
intensity  and  iiersisted  for  four  days,  the  temi)eralure  risinix  to  40. 'J°  C. 
On  the  fifth  day  the  patient  entered  upon  a  rapid  and  satisfactory  con- 
valescence. In  the  mild  cases,  as  distinguished  from  the  ahortive,  the  pa- 
tients complain  of  headache,  nausea,  sensations  of  discomfort  in  the  hack 
and  limhs,  and  stiffness  in  the  neck.  There  is  little  or  no  fever,  and  only 
moderate  vomitiufr.  These  cases  could  he  recognized  only  during  the 
prevalence  of  an  epidemic. 

(b)  All  Iiilcniiillrnl  Tijpc  has  heen  ohscrved  in  many  e|iidemics,  and  is 
recognized  hy  von  Ziemssen  and  Stifle.  It  is  characterized  hy  exacerlja- 
tions  of  fever,  which  may  recur  daily  or  I'very  second  day,  or  follow  a  curve 
of  an  intermittent  or  remittent  character.  Tiie  pyrexia  reseinhles  that  of 
pyivmia  rather  than  iiialaria. 

{(■)  Clininir  Funn. —  lleuluier  states  that  this  is  a  relatively  frequent 
form,  though  it  does  iiot  seem  to  he  recognized  hy  many  writers  on  the 
sniiject.  .\n  attack  may  he  protraete<l  for  from  two  to  five  or  even  six 
months,  and  may  cause  the  n\o-^t  intense  marasmus.  It  is  characterized  hy 
a  series  of  recurrences  of  the  fever,  and  may  present  the  most  complex 
syni])tomatology.  Tt  is  not  improlialile  that  these  protracted  cases  dejiend 
upon  chronic  liydroceplialus  or  ahscesses  of  the  hrain.  This  form  differs 
distinctly  from  the  intermittent  tyite.  A  very  remarkahle  instance  of  it  is 
descrihed  hy  Worthington.  in  which  the  disease  lasted  for  fourteen  weeks. 

Complications. — I'leurisy,  pericarditis,  and  parotitis  are  not  un- 
common. 

Pneumonia  is  descrihed  as  fre(|uent  in  certain  outhreaks.  Immermann 
found,  during  the  Krlangen  e]tidemic.  many  instances  of  the  comhination 
of  pneumonia  with  meningitis,  hut  it  does  not  seem  iwssible  to  determine 


100 


SI'IICIKK"   INFIUTIorS    DISKASES. 


wlu'tlicr,  in  such  cases,  iinciinioiiiii  is  liic  priiimrv  disease  and  llic  iiieiiiiijj;itis 
t-ucoiulary,  or  rice  rcrsd.  The  rriM(iicn(v  witii  which  iiillanmiatioii  of  tlie 
incniiifjcs  of  tlic  i)raiii  c()iii|ilicatcs  imeiiiininia  is  well  kiiouii.  Coiiticil- 
iiiaii  siijr^^'sts  lluit  the  i>iicnnioiiia  n\'  the  disease  is  not  tlio  true  croupous 
form,  luit  (hie  to  the  diplococcus  iueiun;fiti(ns.  This  was  found  in  eifxlit 
of  tlie  IJoston  cases,  and  in  one  it  was  so  extensive  that  it  couhl  have  heeii 
mistaken  for  tiie  ordinary  croupous  jmeMnKUiia.  Arthritis  has  lieen  tlie 
most  frequent  compHcation  in  certain  epi(h  inics.  Many  joints  are  air"cted 
simultaneously,  and  there  are  swellini:,  |iain,  and  e.xudatiou,  sometimes 
serous,  sonu'tinu's  |iurulent.  This  was  lirst  ohserved  hy  Janu's  .lacuson,  Sr., 
in  the  epiilcuiie  which  he  dcscrilicd.     hlnteritis  is  rare. 

Headache  nuiy  jiersist  for  months  or  years  after  an  attack.  Chronic 
liy(lrocc'|)halus  develops  in  (crtain  instances  in  children.  'I'lie  symptoms 
of  this  are  "  paroxysms  (d'  .<evcre  headache,  ]iains  in  the  neck  and  extremi- 
ties, vomit  in^^  loss  of  consciousness,  convulsions,  and  involuntary  discharjics 
of  fivces  and  urine  "  (von  Zicmssen).  \'on  Ziemssen  re,i:ards  chronic  hydro- 
cephalus as  hy  no  means  a  rare  seciuela.  Mental  feehloncss  and  a[)hasia 
have  occasionally  heen  noted. 

Paralysis  of  individual  cranial  nerves  or  of  the  lower  extremities  may 
])ersist  for  some  time,  in  some  (d'  tlic-^o  eases  there  may  lie  periplioral 
neuritis,  as  ]\lills  su^rj^csted. 

Special  Senses. — /w/^'. — These  are  due  to  three  causes:  First,  neuritis 
followiiifi  involvement  of  the  nerve  in  the  exudation  at  the  hase.  This  may 
alfect  the  third  nerve  or  the  optic  nerves,  leadinj,'  to  acute  pajiillitis,  whicli 
was  found  in  (!  out  of  10  cases  examined  hy  Randolph.  Secondly,  the 
inllannuation  may  extern]  directly  into  the  eye  alon^  the  pia-araclnu)id  of 
the  o]>tic  nerve,  cansinir  purulent  choroido-iritis  or  even  keratitis.  Thirdly, 
a  lUMiritis  of  the  (ifth  nerve  may  he  followed  hy  keratitis  and  i)urulent 
conjunctivitis, 

l''(ir. —  DeafiH'ss  very  often  follows  inflammation  of  th(>  lahyrinth.  Otitis 
nu'dia,  with  mastoiditis,  may  devclo])  from  direct  extension.  In  (Ji  ca.^os 
of  meningitis  which  recovered,  ^loos  found  that  55  ))or  cent  were  deaf.  IIo 
sufrgosts  that  the  ahortive  form  of  the  dis(>ase  may  he  res]>r>nsihle  for  many 
cases  of  early  ac(juired  deafness.  In  children  this  not  iufreijuently  leads 
to  deaf-mutism.  A'on  Ziems.son  states  that  in  the  deaf  and  dumh  institutions 
of  l?atnher<r  and  Xurendier<r,  in  ISTl,  a  nuijority  of  the  ]n\\nh  had  hecomo 
deaf  from  e])idemic  cerehro-s])inal  meningitis. 

Nose. — Coryza  is  not  infre(pu>nt  early  in  the  di.^ease,  and  Striimpell  says 
that  in  many  of  his  eases  nasal  catarrh  ])reeeded  the  nienin<,nti.s.  lie  .suji- 
pests  that  the  latter  may  he  caused  hy  infection  from  the  nose.  Certainly 
the  nasal  secretion  appears  freciuently  to  cojitain  the  diplocoeei — in  18  cases 
cxann'ned  hy  Scherrcr,  and  in  10  out  of  15  of  the  Boston  eases. 

Diagnosis. — Is  cerehro-spinal  nienin<ritis  present?  This  is  not  always 
easy  to  answer.  Tn  certain  manifestations  tyjihoid  fever,  tvphus  fever,  and 
])nenmonia  closely  simulate  cerehro-spinal  meningitis.  I  am  (juitc  certain 
that  many  cases  reported  to  the  health  hoards  as  the  last-named  disease 
helonjr  to  the  cerehral  form  uf  ty])hoid  fever  or  pneumonia.  Such  eases 
present  high  fever,  delirium,  retraction  of  the  neck,  tremor,  and  rigidity 


^S^ 


CKUHIJltU  .SI'INAL   MKNlNCilTIS. 


107 


iii('iiiiij,MtiHi 

tiim  of  tliu 

Ciuincil- 

('    Cl'OUpOllS 

111  ill  oifilil 

llilVO   llClMl 

s  liccii   tlif 

iR'  iill'i'dt'd 

soiiictiiiics 

uksoii,  Sr., 

.  el  ironic 
symptoiiis 

111  t'Xtrciiii- 
(liscliiir^H's 

)iiic  liyilro- 

nd  ii[ili<isi!i 

initios  Miiiy 

IKTiplKTill 

•st,  Ticiii'itis 
'i'iiis  iiiiiy 
litis,  wliich 
■iiiiilly,  till' 
iiclmoid  of 
.  Thirdly, 
d  purulent 

nth.  Otitis 
u  (il  cases 
'  deaf.  Ho 
i>  for  many 
cntly  leads 
institutions 
lad  heeonie 

inipoU  says 

.    Jlo  su,u- 

Cortainly 

■in  18  cases 

not  always 
fever,  and 
lite  certain 
led  disease 
Such  cases 
nd  rigidity 


of  the^  iiiusilcs,  and  a  certain  dia<:nosis  may  only  he  made  at  autopsy. 
Siokcs  .statement,  thai  •"  there  is  no  single  ncr\oiis  symptom  which  may 
not  and  does  not  occur  indcpeiidi'ntly  of  any  appreciahle  lesion  of  the  l)rain, 
nerves  or  .-jiinal  cord,"  can  not  hi-  too  olicn  rc|ic,ii,.(|.  j  Imve  already  re- 
ferred to  the  fact  that  the  niali;4ii:inl  fnriii  of  .-mail-iiox  may  he  mi.-takcn 
for  ccrchi'o-spinal  mcnin;,Mtis. 

The  second  question,  is  the  disease  cen nro-.-pinal  IV'ver?  is  usuallv  easy 
to  answer  when  an  epidemic  is  prevailing,  as  the  practitioiu'r  thcii  .soon 
learns  to  recognize  the  dillVrcnt  types  of  wiiicli  I  have  spoken.  The  chief 
(lillicnity  is  in  dilVereiitiating  s|ioiailic  caMs  of  ceivliro-spinal  fever  from 
otiicr  forms  of  meningitis,  'i'lu-  matter  i>  of  imjioiiance  chiclly  wiiii  reier- 
ence  lo  the  prognosis,  which  is  so  mui  h  moiv  lavoraMe  in  cereliro-spinal 
fever.  .Xeither  the  luherculons  nor  liie  slre|itoco(  lus  forms  oil'cr,  as  a  rule, 
s|iecial  ilillicullies.  'i'he  pneiimocoeciis  nicningili.s  may  occur  alone  or  as  a 
compliiation  of  a  pneumonia,  latent  or  manifest.     Lciciitenstern  states  that 

"in    meningitis    following    | nmonia   contraction    of   the    muscles   of   the 

neck  is  oFten  alisent.  while  in  epidemic  meningitis  it  is  almost  invariahly 
present,      rneuinonia-meningitis  soon   leads   to  delirium  and   coma,  while 
in  the  epidemic  form  the  sensorium  may  he  normal  throughout  the  entire 
course,      i'ncnmonia-meningitis,  moreover,  is  rapidly   falal.  while  the  epi- 
deinie  form  is  frciiiieiitly  recovered  from.''     Councilman  eonchides  that  the 
diU'ereiUH'  hetwivn  the  clinical  history  of  |)iu  iimococcus  meningitis  as  com- 
pared with  the  epidemic  form  is  the  ahseiice  or  slight  dcvelojunent  in  the 
former  ui  .-symptoms,  pointing  to  extensive  infection  of  the  meninges  of  the 
cord  and  of  the  roots  of  the  spinal  and  cranial  nerves,     i'roliaiily  the  most 
relia!)]e  method  in  diagnosis  is  Quincke's  Ii;mhar  puncture,  which  is  easily 
]ierl'ormcd  and   free  from  danger.     In  the  recent    I'.ostoii  epidciiiic  it   was 
carried  out  in  o,")  ea.'^cs,  and  diplococei  were  foiiiiil  in  ;>S.    The  negative  cases 
were  chiclly  early  in  the  outhreak.     Toward  the  end  of  the  epidemic  there 
were  lU)  negative  resulls  when  the  sjiinal  puncture  was  made  early,  and  the 
tulies  were  inoculated  with   a   large  amount    of   material,     'i'he   puncture 
sliouh.  he  made  liet    ecu  the  second  and  third  or  the  third  and  fourth  lum- 
liar  vertehra'  with  an  ordinary  exploratiu'y  or  "  antitoxine '"  needle.     At  a 
depth  of  ahout    1  cm.  in  children  and  T  or  S  cm.  in  adults  the  needle  jiasses 
through  the  mcmluanes,  and  the  tluid  comes  out  drop  hy  drop.     Jt  is  not, 
as  a  rule,  lu'ce.-sary  to  use  aspiration.     l''or  hacteriological  study  from  o  to 
10  cc.  should  pass  into  a  ])erfcctly  sterilized  test-tiihe,  which  should  then 
he  stoppered  with  cotton.     The  experience  of  F.  II.  AVilliams  and  of  Weiit- 
worth  in  llostoii  shows  that  jmncture  is  iH)t  only  harmless,  hut  the  results 
are  sometimes   positively  heneficial.     Hereafter  this   jiroccdnre  should   ho 
used  early  in  all  sporadic  cases,  and  careful  studies  made  of  the  organisms. 

Prognosis. — Tlirseh  states  (hat  (he  mortality  has  ranged  in  various 
ei)ideniics  from  20  to  To  ])er  cent.  In  children  the  d.;'ath-rate  is  much 
hiuher  than  in  adult.<.  Cases  with  deep  coma,  repeated  conviilsions.  and 
high  f(>ver  rarely  recover.  The  outlook  in  the  jirotrai  ted  cases  is  not  szood, 
though  Heuhner  gives  an  instance  of  a  lad  of  seven,  who  was  ill  from  the 
end  of  Fehruary  until  the  end  of  Juno,  with  repeated  recurrences,  was 
worn  to  a  skeleton,  and  yet  completely  recovered. 


M* 


i 


I 


I 


108 


SPtX'IFIC  INFKCTIOUS  DLSKASES. 


Treatment. — 'I'lic  lii;:li  rale  nf  inortality  whidi  has  existed  in  most 
Cl)iiit'iai(s  iii(li(jit<'S  the  I'lilihtv  nl'  the  various  tiiera|ieiiti(iil  ai.n'iits  which 
liuve  been  recoiiiiiieiitk'd.  When  we  eoiisidrr  the  iiatiiii'  of  tlie  local  dis- 
ease and  the  J'aet  tliat,  so  i'ar  as  we  know,  siiniilc  or  tul)crcuioiis  cereljro- 
ti|iinal  nieniii^Mtis  is  iiivariaiilv  lata!,  we  may  wonder  rather  that  recovi'ry 
follows  in  any  well-developed  ease. 

Jn  stronj,'  rol)iist  patients  the  l:,cal  alistractioii  oi'  Mood  hy  wet  enps 
on  the  nape  id'  tiie  neck  relieves  the  pain.  (Jeiieral  hioodlctlin;,'  is  rarely 
indicated.  Cold  to  the  head  and  spine,  which  was  nsed  in  the  lirst  epi- 
demics hy  New  I'ln^jland  |ihysicians.  is  ol'  <;reat  service.  A  liladch  r  of  ioo 
to  the  head,  or  an  ice-cap,  and  the  spinal  iec-i)aj,'  may  he  continuously  em- 
ployed. The  latter  is  very  benefieial.  Jndffinjj;  from  the  remarkable  elFects 
(d'  tlu'  j^eneral  bath  in  typhoid  with  pronounceil  cerebro-siiimd  symptoms, 
hydrotherapy  should  he  systematically  employed  if  the  temperature  is  above 
10'^.')°.  In  ))rivate  ))raetice  the  cold  pack  or  sponginj,'  may  be  substituted. 
If  any  counter-irritation  is  thou,i.dit  lU'cessary,  the  skin  of  the  back  of  the 
neck  may  l)e  lif,ditly  touched  witii  the  racpielin  thermocautery,  lilister.s, 
which  have  been  used  so  much,  are  of  doubtful  benefit.  Of  internal  reme- 
dies opium  may  be  jriven  freely,  best  as  morphia  hypodermically.  Stillo 
recommends  },dvinfj  a  jxrain  of  o|  Mini  every  hour  in  severe  cases  or  every 
two  hours  in  cases  of  moderate  severity;  von  Ziemssen  advises  the  hypo- 
dermic injection  of  morphia,  from  one  third  to  one  half  jxrain  in  adults. 
]\lercury  has  no  s|)ecial  influence  on  meninireal  inllammation.  Iodide  of 
])otassium  is  warmly  recounnended  by  some  writers.  (Quinine  in  larye  doses, 
ergot,  belladonna  and  Calaliar  bean  have  had  advocates.  I>romide  of  potas- 
sinm  may  be  emjdoyed  in  the  milder  cases,  but  it  is  not  so  useful  as  mor- 
])hia  to  control  the  spasms. 

The  diet  shoidd  be  nutritions,  consisting  of  nnlk  and  strong  broths 
vhile  the  fever  ])ersists.  ^laTiy  cases  are  very  diflicult  to  feed,  and  Heubner 
n'commenils  forced  alimentation  with  the  stomach-tube.  The  cases  seem  to 
bear  stimulants  well,  and  whisky  or  brandy  may  be  given  freely  when  there 
are  signs  of  a  failing  heart. 


XV.   LOBAR    PNEUMONIA. 

{Croupoxis  or  Fibrinous  Pneuinonin;  Piieumonilis;  Lung  Fever.) 

Deflnitioil. — An  infections  di.sease  characterized  l)y  inflammation  of 
the  hnigs.  toxa'mia  of  varying  intensity,  and  a  fever  that  terminates  ab- 
ruptly by  crisis.  Secondary  infective  ])roce,>^ses  are  common.  The  micro- 
coccus lanceolatus  of  Fraenkel  is  present  in  a  hirge  proportion  of  the  cases. 

Incidence. — Pneumonia  is  tlie  most  widespread  and  the  most  fatal 
of  all  acute  diseases.  Tn  the  Tnited  Slates  during  the  census  year  18!)0 
there  died  of  it  ?n.4nfi.  a  death-rate  per  100.000  of  ])opnlation  of  18().94. 
"  ^fore  deaths  are  attributed  to  it  than  to  any  single  form  of  disease  except 
consumption  "  (Census  I{e])ort).  T)nring  the  year  1807  there  died  of  ]meu- 
nionia  in  Baltimore  H-l  I  persons.  It  canu^  next  on  tlie  list  to  pulmonary 
tuberculosis.    The  Census  Reports  of  1870,  1880,  and  1890  show  that  pneu- 


L 


LUUAU   rNKlMONIA. 


hJ'J 


iiifniin  a.'  a  cause  o(  death  lias  increased  Imt  .li;.'litl}'.  ('.  K,  l^'olsitm  lias 
lin>M;,dit  I'liiwurd  cvidnni'  to  sliow  that  in  the  Shile  of  .Ma»aehii>ells  tiiere 
has  liccii  iietweeii  hsTil'  mid  IcSUl  a  |ii(ij:ressive  iiicrea>e  in  tlie  dealii-rale 
I'roiii  piiciiiiioiiia.  '{"lie  suiiie  is  true  for  the  litv  of  (iiasirow.  On  the  other 
iiaiiil,  ill  i-liijilaiiil  there  is  a  sii^dit  diiiiiniitioii.  ilos|)ital  statistics  .••how 
that  the  ratio  of  [iiieiiiiioiiia  to  oilier  admissions  is  in  the  |iroj)ortioii  of  ^'d 
to  ;!(i  |icr  l.OOO. 

Etiology. — Af/r.—'Vii  the  sixtli  year  llie  predi^iinsition  in  |ineiiinoiiia 
is  niarkeil;  it  diminishes  to  the  iil'tcentii  year,  hut  then  for  eaeli  siihsc(|iifiit 
(hiade  it  increases.  l''or  children  ll(dt"s  statistics  iti  oOO  vases  jjive:  First 
year.  l.">  per  cent;  from  the  second  to  the  sixth  year,  i'ri  ]ier  cent;  froni  the 
seventii  to  the  eleventh  year,  1:^1  jter  cent;  fioni  tlie  twelfth  to  the  I'oiir- 
teeiith  year,  '-i  per  cent.  !,oliar  |iiieiinioiiiu  has  lieen  met  with  in  the  new- 
horn.  The  relation  to  a;:e  is  well  shown  in  the  last  Ceiisiis  Ifejiort.  'J"lu," 
death-rate  in  |»er.«ons  from  liftirii  to  forty-live  years  was  Idd.tt.j  per  lOd.ddO 
of  population;  from  forty-live  to  si.\ty-live  years  it  was  '^'(i;!.!-..';  ami  in  per- 
sons sixty-live  years  of  af.^'  and  over  it  was  ?:!;). TT.  I'neuiiionia  may  well 
be  called  llie  friend  of  the  a<,^'d.  'J'aken  oil'  hy  it  in  an  acute,  short,  not 
often  jiainful  illness,  the  old  man  escapes  those  "cold  <;radations  of  decay  " 
so  distrosin;;  to  himself  and  to  his  friends. 

iSV.c. — Males  are  more  fre(iuently  all'ectcd  than  females.  The  Census 
T{ei»ort  for  lM!)d  ^mvcs  Iv'.r;!',*  males  af,'ainst  ;{;5,?a7  females. 

Hare. —  In  this  country  |meumoiiia  is  more  fatal  in  the  colored  race  than 
anioiii;  the  whites,  the  death-rate  heinj;  'v'TS.'.)?  a;.'ainst   l,S'^.'.Jl. 

Social  ChHilitiitn. — The  disease  is  more  common  in  the  cities.  Tlu! 
census  (ij,nires  fiive  v'iil.d?  deaths  per  IdO.ddd  of  population  for  the  cities 
ajrainst  M1.d!»  for  rural  districts.  Individuals  who  are  niiich  exposed  to 
hardship  and  cold  are  jiarticularly  liahle  to  the  disease.  Xew-comers  and 
inimij.;rants  are  stated  to  he  less  susce|itil)Ie  than  native  inhahitants. 

I'crsiiiKi}  ('oiiditidii. — Dehilitatiuf!  causes  of  all  sorts  render  individuals 
more  susce|itihle.  Alcoholism  is  jn'rliaps  the  most  potent  predisposing 
i'actor.     Hohiist.  healthy  men  are.  however,  often  attacked. 

I'lrvimiK  Altdck. — No  acute  disease  recurs  in  the  same  individual  with 
such  frcijueiicy.  Instances  are  on  record  of  individuals  who  have  had  ten 
or  more  attacks.  The  percenta^'c  of  recurrences  has  heen  ]tlaced  as  hi;,di 
as  50.  Xotter  <:ives  it  as  ;?!.  and  he  has  collected  the  statistics  of  eleven 
ohservers  who  jilaee  the  jjcrcentajre  at  'Hi.H.  Amoiijr  the  hifrhest  li;iiires  for 
recurrences  are  those  of  Hcnjamin  Kush.  'iS,  and  Andral.  U!. 

Trouiiia. — Oi'casionally  the  disease  directly  follows  an  injury,  jiarticu- 
larly of  the  chest.  IJtten,  who  has  deserihed  these  coiihtsidii-jiiiciiuinnlir, 
saw  14  cases  in  the  course  of  six  years.  Jiirgensen,  however,  met  with  only 
one  case  anionjr  'i'^>8  pneuniouia  patients.  There  can  he  no  (piestion  that  an 
acute  inflammation  of  the  lun^rs  may  follow  immediately  11)1011  injury  to 
the  chest  without  fracture  of  the  rihs.  Harris  has  re[)orted  a  remarkalile 
case  in  which  a  pneumonia  of  this  kind  appears  to  have  heen  infected  from 
ohsolesccnt  tuherciilous  foci  in  the  same  lung.  Workers  in  certain  jilios- 
})hate  factories,  where  they  breathe  a  very  dusty  atmosphere,  according  to 
Ballard,  are  particularly  prone  to  jineumonia. 


110 


SI'HCll'K'   INFKCTIOI'8  DISKASRS. 


('('/(/  lias  liccii  I'nr  vt'jir.-i  rc^jiinldl  ns  iiii  iiii|Mirtaiit  (•tinl();:ical  factnr.  Tin* 
friMjiiciil  occiirri'iiic  of  an  initial  cliill  lias  liccii  niic  nasnii  t'(ir  this  widc- 
i-|iiTa<l  lii'licl'.  .\>  tn  the  close  association  ol'  |>iiciiiiioiiia  with  c\|M)«iirc  then- 
can  lie  Mil  i|iic«ti()ii.  \Vc  mc  the  discas cnr  cither  |iroiii|itlv  alter  a  wet- 
ting or  a  chiliiii;;  ihie  to  some  iiniisiial  c\|io,-.iire,  or  coiiie  on  alter  an  onli- 
liary  oatari'h  of  one  or  tuo  days'  duration,  ('ohi  i>  now  re^jarded  sim|ily 
i\.i  a  I'actor  in  loueiin;,'  tiic  resi.-taiice  ol'  the  hroiiehiil  and  pulinonarv 
tissues. 

('limiih'  mill  Snisnii. — Cliinate  does  not  appear  to  haxc  very  nuieii  in- 
flni'Mce,  as  |inennionia  prevails  cipially  in  hot  and  cold  countries.  It  is 
i>tatcd  to  lie  nuire  prevalent  in  (he  Soutiu'rii  than  in  the  Northern  Statis. 
but  uii  e.vainination  of  the  I  ,1  Census  l{eport  shows  tiuit  there  i.>  very  little 
(liU'erenee  in  the  various  Stale  jxi'^'M"^- 

Much  more  important  is  the  inlluenee  of  srusdn.  Statistics  are  unani- 
juiius  in  placiiif,'  the  hijihest  ineideme  of  the  disease  in  tiie  winter  and 
fpriiij;  months.  In  Montreal  January,  the  coldest  month  of  the  year,  hut 
with  steady  tem|)erature,  has  usually  a  eoniparatively  low  death-rate  from 
pm'unionia.  The  lar<:e  statistics  of  Seitz  from  Munich  and  of  Seihert  of 
.\\  w  \()\k  </\\v  the  iii^ihcst   perccnta^'e  in  Kchniary  and  March. 

Bacteriology  of  Acute  Lobar  Pneumonia. — (n)  Tin'  MiirnriH-- 
nis  hinri'iiliil iin,  I'lii'iniKinicciis  nr  Di jtlncufius  I'liriiiiiuiiiir,  nf  Fniniki'l. — 
In  Septemlu'r,  ISSO,  Sternherg  inoeiilated  rahliits  with  liis  own  saliva  and 
isolated  a  micrococcus.  The  puldication  was  not  made  until  April  .'!0.  ISSI. 
I'asteur  discovered  the  .same  orj^anism  in  the  saliva  of  a  child  dead  of  hydio- 
plioliia  in  Dereiidier,  1SS0,  ami  the  jiriority  of  the  discovery  helonirs  to  him. 
as  his  pulilication  is  dated  .January  IS.  ISSl.  'J'here  was,  however,  no  sus- 
jiiciou  tiuit  this  or;;anism  was  eonccrnei]  in  the  etiology  of  iohar  ]ineunionia, 
and  it  was  not  really  until  .\piil.  ISSl.  that  A.  Fraenkel  determined  that 
the  ori^anism  found  liy  Steridieri,^  and  I'asteur  in  tlie  .sdiva,  and  known  as 
the  eoecus  of  s|iutum  sejitica'mia,  was  the  most  frequent  orijanism  in  acute 
jmcumonia.  At  first  there  was  a  jiood  deal  of  confusion  iietween  this  and 
the  orjzanism  descrilied  l)y  I'-ricdiriiidcr.  Xovi'inher.  ISSM,  and  which  is  now 
known  ns  the  ]'neunu)-hacillus.  The  snliseipu-nt  investijfations  of  Fracidvcl 
and  those  of  Weieliselhaum  liave  dcnionstrated  that  in  a  very  larj,'e  pro- 
jinrtion  of  all  ca.ses  of  croupous  pm-umonia  the  diploooccus  is  present. 

The  orjianism  is  a  somewhat  elliptical,  laneo-shaiied  coccus,  usually 
occnrring  in  jiairs;  hence  tho  term  diplococcus.  It  is  readily  demon- 
strated in  cover-<flass  preparations  with  the  nsual  solutions  and  liy  the 
Gram  method.  .Miout  tlie  orjianism  in  the  spiitum  a  Ciipsule  can  always 
he  demonstrated.  Its  cultural  and  1iio1o<,neal  properties  present  many 
variations,  for  a  consideration  of  which  the  stndont  is  referred  to  the  te.xt- 
hooks  on  hacteriol(\<fy.  Scarcely  any  pi'culiarity  is  constant.  A  lar;j;e  nuin- 
h.T  of  varieti'.'s  have  heen  cultivalei].  Its  kinshi])  to  the  strejitococcus 
]n'o<:enes  is  re<jarded  hy  many  as  very  close. 

Dislrlhtifioii  in  Ihi'  Biuhj. — Tn  the  bronchial  secretions  and  in  the  af- 
fected hinfi  it  is  readily  demonstrated  in  cover-sli])s,  and  in  the  latter  in 
sections.  Dnring  life  in  cases  of  pnenmonia  the  organism  has  been  isolated 
from  the  blood  in  a  number  of  cases,  in  -4  out  of  32  by  Kohn. 


actor.  I  III' 
!•  tills  widc- 
losiii'i'  there 
iit'ter  a  wet- 
li'r  ail  ordi- 
rdeil  siiii|ily 
Iiiiliiiniiarv 

v  iiiucli  iii- 
trii'.s.  It  is 
IllTIl  States. 

is  Vl'IT    little 

;  are  iinaiii- 
wiiiter  ami 
10  year,  l)nl 
li-rate  from 
I'  Seihert  of 

'/('  M  irrornr- 
Friicnkcl. — 
1  saliva  ami 
ril  ;50.  1SSI. 
1(1  of  liydro- 
)ii,i:s  to  him, 
vcr.  no  siis- 
]iiieiimoiiia. 
rniiiied  that 
d  known  as 
sm  in  aeiiti' 
en  this  anil 
hieli  is  now 
of  FraenKel 
'  large  pro- 
prospiit. 
"lis,  usually 
lily  deinon- 
and  hy  the 
can  always 
I'seiit  many 
to  the  text- 
lai';j;e  num- 
reptococcus 

I  in  tlio  af- 
ho  latter  in 
een  isolated 


liOlJAIl  PNKLMoMA. 


ill 


Mi<fitr„rcuA  hnirciihiliis  iiiultr  tillirr  <'„iiililinii!<.~]n  this  rninu'ction 
a  very  iinporlani  point  is  the  presence  of  the  orj:ani>m  in  the  mouih  ami 
iironrhial  xiretions  of  healthy  individuals — 'io  per  cent,  aiditdin;:  to 
.Netler's  ohservalioiis.  It  jieisists  for  immths  or  even  for  years  in  the  .sdi\a 
of  persons  who  have  had  pneumonia. 

///  ('//„•/•  Pisidsrs. — The  ori.'anism  is  very  widely  di>trihnte(l,  ami  is 
louml  in  many  other  conditions  hesides  croiijioiis  ptieiinioiiia.     It  has  iieen 

met  with  in  pure  cultures  in  tiie  inllaminations  of  the  serou>  uiemliranes 

pleurisy,  pericarditis.  inenin>,ntis,  peritonitis,  acute  synovites  and  in  cmht- 
canlitis,  etc. 

An  acute  jieneial  infection  with  llie  niierneoeciis  laiiceolaliis  without 
localized  foci  may  prove  rapidly  fatal,  i  onsiituliii;;  a  l'nnuiinri,(ru!<  scjili. 
nrmld  comparahle  to  the  typhoid  septici>mia  already  dcMrii.e.l.  'I'ownsemI 
has  reixirted  a  remarlsai)le  caM-  cd'a  niil  a^ed  six.  who  hail  jiain  in  the  alido- 
meii,  vomitinj:,  and  a  temperature  of  liil.-J\  'i'here  was  no  cxiidile  in  the 
throat.  'I'weiity-foiir  hours  from  the  heuiiiniii;,'  of  the  .■symptoms  >lie  had 
a  convulsion  and  died  six  hours  later.    'I'here  was  found  a^reiieral  infection 

with   the  pneiimocoecMs.  which  occurred   in  the  Id |.  Iun;;s,  spleen,  and 

kidneys,  in  i'"le\ner's  study  of  terminal  infections  the  microcoeeus  lanceo- 
latus  was  found  four  times  in  acute  ]ieritonitis,  cdeven  times  in  acute  peri- 
laiditis.  live  times  in  acute  endocarditis,  three  times  in  acute  ])leiiii>y.  and 
three  times  in  acute  meninijitis. 

()iihi,lr  llir  hnilji  the  oriraiiism  has  liecii  found  in  the  du-t  and  sweepim^s 
of  rooms. 

|/')  I'liv  lltirilhis  piii'iniiiinid'  t,f  Frliilliiiiiln: — 'I'his  is  a  larirer  ofiranism 
than  the  |ineiimococcus.  and  apjiears  in  the  form  id'  small,  short  rods.  It 
also  shows  a  capsule,  hut  jiresents  marked  hiolojiical  and  cultiii'al  diil'er- 
eiices  from  FraenkcFs  pneumoeoccus.  It  is  not  found  iiearlv  so  often 
in  the  liinjj  as  the  pneiimoeneens.  It  occurred  in  '.)  of  Weichselliaiinrs  P.'K 
cases.     Its  etiolotrieal  relation  to  the  disease  is  still  in  question. 

('■)  Ollirr  Orfiniiisnis. — In  a  variahle  nnmher  of  eases  of  pi;ct;monia 
the  stapliyloeneens  and  the  strejitoeoeens  ])yo<:eiies  occur,  rarelv  alone,  usu- 
ally in  association  with  the  ]>neumococcns.  The  streptococcus  pvo^feiies 
may  he  the  only  orsanisni  ])reseiit.  particularly  in  children,  hut  this  tyjte  of 
l>neninonia  ])rohahly  dilVers  froTu  the  true  iihimoiis  form.  Other  or<ranisms 
have  heeii  met  witii  in  ])neumonia — the  hacillus  typhosus,  the  liacillns  diftli- 
theria>.  and  the  inllucnxa  hacillus. 

Clinically,  the  infrrlinii:^  iiahirr  of  pneumonia  was  reco;:nized  loni,'  hefore 
ve  knew  anytliin-r  of  the  inienmococcus.  Anioiifi  the  features  which 
favored  this  view  were  the  followinj::  First,  the  disease  i.s  similar  to  other 
infections  in  its  mode  of  outhreak.  It  may  occur  in  endemic  form,  local- 
ized in  certain  houses,  in  harracks,  jails,  and  schools.  As  many  as  ten 
oecu])ants  of  one  hnnse  have  heen  attacked,  and  in  hospital  practice  it  is 
not  infreipieiit  to  have  2  or  .3  rases  admitted  from  the  .same  house.  I  have 
seen  three  memhers  of  a  family  ennsecutively  attacked  with  a  most  mali;^. 
iiant  type  of  pneumonia.  Amontr  the  more  remarkahle  endemic  onthreaks 
is  that  reported  hv  W.  B.  Rodman,  of  Frankfort.  T\y.  In  a  prison  with 
a  population  of  735  there  ocenrrod  in  one  year  118  case.s  of  pneumonia 


112 


SPECIFIC  INFFX'TIOUS  DISEASES. 


with  '2ii  (loatlis.  At  tlio  lu'iiitentiary  at  AihIrtj:  diiriiip  a  period  of  five 
inoiitlis  llieic  were  Kil  eases,  with  a  mortality  ai)ove  'JS  |icr  ifiit.  The 
disease  may  assume  i'iii(k'mie  proportions.  In  the  .MichUeslioroiigh  epi- 
dciuic,  so  farel'uily  studied  l)y  I'.allard,  there  were  (iS".*  persons  attaeked 
witii  a  mortality  oi"  •.'!  jier  cent.  Duriujj;  some  years  |iiieumoiiia  is  so  jjreva- 
leiit  that  it  is  praetiially  paiulemie.  Direct  eonta^Moii  is  su<r<,'estt'd  hy  the 
iaet  that  a  patient  in  the  next  bed  to  a  pneumonia  ease  may  lake  the  (lis- 
ea*.,  or  "-'  or  'A  cases  may  follow  in  rapid  sueeession  in  a  ward.  It  is  very 
exeeptional,  however,  for  nurses  or  doetors  to  he  attaeki'd. 

Secoiully.  the  elinieal  course  of  the  disease  is  that  of  an  acute  ini'eetion. 
It  is  the  very  type  of  a  self-limited  disease,  running  a  delinite  cycle  in  a 
way  seen  oidy  in  infeetions  disorders. 

'riiirdly,  as  in  other  acute  infeetions,  the  constitutioniil  symptoms  may 
hear  no  jiroportion  whatever  to  the  severity  of  the  local  lesion.  As  is  well 
known,  a  patient  nuiy  have  a  very  small  apex  pneumonia  which  does  not 
seriously  im])air  tlie  hreathinj.'  capacity,  but  which  may  he  accompanied 
with  the  most  intense  toxic  features. 

JiiDinniili/  and  ScriDii  Thcrapji. — The  ol)servations  of  the  Klemperers, 
Foa,  AVashiiourn,  and  otliers  on  tiie  i)rodiuti(m  of  immunity  and  on  the 
cure  of  the  disease  are  of  frreat  importance.  The  Klemperers  found  that 
immunity  was  readily  obtained  in  animals  either  by  subcutaneous  or  intra- 
venous injections  of  larjre  (piantities  of  the  filtered  bouillon  cidtures,  or 
l)y  the  injection  of  the  <,dycerine  extract.  The  immunity,  though  rarely 
lasting  more  than  six  months,  was  transmitted  to  the  od'spring  l)orn  within 
this  ])eriod.  Still  more  interesting  are  their  observations  u|)on  tlu'  ciu'e 
of  the  exi)erimentally  produced  disease.  They  found  tliat  the  sertim  and 
lluids  of  the  body  of  an  aninud  wliich  had  been  reiulercd  immune  had  the 
])ro|)erty  not  only  of  |>roducing  immunity  when  introduced  into  tlie  circu- 
lation of  another  su.-eeiitible  animal,  but  actually  of  curing  the  disease 
after  infection  had  been  in  ))rogress  for  s<mie  time.  In  infected  animals 
with  a  body  temperature  of  from  40°  to  -11°  C,  the  fever  fell  to  normal 
in  twenty-four  hours  after  tlie  injection  of  serum  from  another  animal 
which  ])ossessed  immunity.  They  believe  that  the  pneumoeoecns  produces  a 
])oisonous  alluimin  (])neuinotoxin)  which  when  introduced  into  the  circi- 
lation  of  an  animal  causes  elevation  of  temiieratnre  and  the  sub.«e(pient 
production  in  the  body  of  a  substance  (antipnenniotoxin)  which  ])osses«es 
the  ])ower  of  neutralizing  the  ])oisonous  albumin  which  is  formed  by  the 
hacteria.  In  man  they  hold  that  during  tlie  |)neumonic  ])rocess  there  is  a 
constant  absorption  into  the  circulation  of  this  poisonous  all)umin  pro- 
duced by  the  hacteria  in  the  lungs.  This  continiu's  until  eventually  the 
same  antidotal  suhstaneo  is  ])i'odnced  in  the  circulation  that  has  Ix'cn  seen 
to  occur  experimentally.  It  is  then  that  tlu^  crisis  occurs.  The  bacteria 
are  neither  destroyed  nor  is  their  p<nver  to  produce  the  poisonous  albumin 
lessened;  hut  the  third  factor,  tlic  antitoxic  element,  now  exists  and  neu- 
tralizes the  toxic  substances  as  they  are  iiroduced.  They  demonstrated 
that  the  sernm  of  the  hlood  of  patients  after  the  crisis  of  pneumonia  con- 
tained the  antitoxic  sidistance  and  was  capable,  in  a  fair  number  of  cases, 
of  curing  the  disease  when  injected  into  infected  animals. 


riod  of  five 
cfiit.  Tin.' 
)r()Mfj;h  opi- 
iis  iittiK'kod 
is  so  provii- 
sU'd  l)y  the 
ike  till'  (lis- 
It  is  very 

le  inl'eetion. 
'  cycle  in  a 

iptoms  imiy 

As  is  well 

I'll  does  not 

iCcoin|)anied 

Klcinjierers, 
and  on  the 

fonnd  that 
ins  or  intra- 
cultures,  or 
oiigh  rarely 
horn  within 
)n  the  cnre 

serum  and 
nie  had  the 

0  the  circii- 
tlie   disease 

ted  animals 

1  to  normal 
ther  aninnil 
s  prodnces  a 
I)  the  eircM- 

snb.secpient 
eh  jiossesses 
med  by  the 
-s  there  is  a 
l)nniin  ])ro- 
'ntnally  the 
IS  l)een  seen 
riie  bacteria 
)ns  all)umin 
ts  and  nen- 
enionstrated 
mionia  eon- 
jer  of  cases, 


LOHAR  PNEUMONIA. 


113 


Not  mnch  propres?  has  as  yet  1)een  made  in  establishin':  a  satisfai'tory 
sernm  tiierapy  for  tlie  disease  in  men.  WasidM.urii  iias  diiiained  large  tjuau- 
tities  of  the  sernm  l)y  immimizinji  jionies,  imt,  so  far  as  1  can  ascertain,  a 
trustworthy  antipneiimocociic  scrinn  is  at  present   not  in  the  market. 

Morbid  Anatomy. — Since  the  time  of  Laennec,  p.itholojrists  have 
recognized  three  stages  in  the  inllanied  lung — engorgement,  red  hepatiza- 
tion, and  gray  hepatization. 

In  the  stage  of  fiH/f'niciiinit  the  lung  tissue  is  deep  red  in  color,  firmer 
to  the  touch,  and  more  solid,  and  on  section  the  surface  is  bathed  with 
hlood  and  scrum,  it  still  crepitates,  though  not  so  di.-tinctly  as  healthy 
lung,  ami  excised  ]iortions  lloat.  The  air-cells  can  he  dilated  hy  insnilla- 
tion  from  tie  bronchus,  ^licroscopical  examination  shows  the  capillary 
vessels  to  lie  greatly  distended,  the  alveolar  e|iitlielium  swollen,  and  the 
air-cells  occupied  hy  a  variable  number  of  Idood-corpuscles  and  detached 
alveolar  cells.  In  the  stage  of  inl  hi'paH:ulinn  the  lung  tissue  is  solid,  lirm, 
and  airless.  If  the  entire  lobe  is  involved  it  looks  volumimins,  and,  shows 
indentations  of  the  ribs.  On  section  the  surface  is  dry,  reddish  brown  in 
color,  and  has  lost  the  deeply  congested  appearance  of  the  lirst  stage.  (Jne 
of  the  most  remarkable  features  is  the  friability;  in  striking  contrast  to 
the  healthy  lung,  which  is  torn  with  dilliculty,  a  hepatized  organ  can  he 
readily  broken  t)y  the  linger.  Careful  ins])ection  shows  that  the  surface 
is  distinctly  granular,  the  granulations  representing  lihrinous  plugs  tilling 
the  air-cells.  The  distinctness  of  this  appearance  varits  greatly  with  the 
size  of  the  alveoli,  which  are  about  0.10  nun.  in  diameter  in  the  inl'ant, 
0.15  or  O.K!  in  the  adult,  and  from  0.",J0  to  (t.V*.")  in  old  age.  On  scraping 
the  snrface  with  a  kniiV'  a  reddish  viscid  serum  is  removed,  containing  small 
granular  masses.  The  snudler  bronchi  often  contain  fibrinous  plugs.  If 
the  lung  has  been  removed  before  the  heart,  it  is  not  uiu'ommon  to  fii'd 
solid  monlds  of  clot  filling  the  blood-vessels.  Microsco|iii'ally,  the  air-cells 
are  seen  to  be  occnjiied  hy  coagulated  fibrin  in  the  meshes  of  which  are  red 
blood-e(n-])nscles,  ])olynnclear  leucocytes,  and  alveolar  epithelium.  The 
alveolar  walls  are  infiltrated  and  lencocytes  are  seen  in  the  interl(d)ular 
tissues.  Cover-glass  preiiarations  from  the  exu(hitc.  ;ind  thin  sections  show, 
as  a  rule,  the  diplococci  already  referred  to,  many  of  which  are  contained 
within  cells.  Staidiylocoeci  and  streptococci  may  also  be  seen  in  some 
ca.ses.  In  the  stage  of  r/m//  livpaliialuni  the  tissue  has  changed  from  a 
reddish-brown  to  a  grayish-white  color.  The  snrface  is  moister,  the  exudate 
obtained  on  scrajiing  is  more  turbid,  the  granules  in  the  acini  are  less  dis- 
tinct, and  the  Inng  tissue  is  still  more  friable.  IIist(dogically,  in  gray 
hepatization,  it  is  seen  that  the  air-c(dls  are  densely  filled  with  leucocytes, 
the  fibrin  network  and  th(>  red  blood-cori)uscles  have  disa])peared.  A  more 
advanced  condition  of  gray  he]iatization  is  that  known  as  purulent 
ill  fill)  .iliou,  in  which  the  Inng  tissue  is  softer  and  l)athed  with  a  ])urident 

fluid. 

The  stage  of  gray  heiiatization  appears  to  he  the  first  step  in  the  process 
of  rrxdhiHtni.  The  exudate  is  softened,  the  cell  elements  are  disintegrated 
and  rendered  callable  of  absorption.  When  the  jiurulent  infiltration  of 
the  lung  tissue  reaches  the  grade  sometimes  seen  post  mortem,  it  is  i)rob- 


lU 


.SPECIFIC   INFECTIOUS   IJISEASHS. 


altlo  tliat  rosoliitioii  could  iiol  take  place.  Si, nil  al)srcss  cavities  may  aii:»o, 
uiid  liy  their  fusion  lar^^er  ones.  Oi'ten  in  one  lunjj,  or  even  in  one  lol)c, 
the  various  stages  of  the  process  may  bo  seen,  ami  the  passajie  of  tlie  en- 
"•ori'i'nient  into  red  iiciiati/aliun  and  of  the  hitter  into  the  yray  stage  can 
he  readily  traced. 

The  "<;('"'■'■"'  <l^'hiils  of  the  morliid  anatomy  of  pneumoiua  may  he 
g:itheri'd  frnm  the  lolinwing  huts.  I.ased  on  100  autopsies,  made  hy  me  at 
The  (ieneral  Hospital.  Mon;real:  in  'il  cases  the  riglil  lung  was  alVeeted; 
in  ;i-.'.  tiu'  left:  in  K,  hoth  organs.  In  •>':  cases  iL"!  entire  lung,  v.-ith  tiie 
exception,  pcriuips,  of  a  narrow  margin  at  the  ajiex  and  anterior  border, 
was  coiisolidalcd.  In  ol  cases,  tiie  lowt'r  lobe  alone  was  involved;  in  l:> 
cases,  tiie  upper  lolie  alone.  When  doiilile,  the  lower  lobes  were  usually 
alVected  together,  but  in  thre(>  iostanci's  the  lower  lobe  of  one  and  the 
npj.cr  lobe  of  tin-  other  were  attacked.  In  three  t'ases  also,  lioth  upper 
lobt'S  were  all'ectcd.  Occa.-iniially  the  disease  involves  the  greater  part  of 
hoth  lungs;  thus,  in  one  instance  the  let!  organ  with  the  excepti(Mi  of  the 
anterior  border  was  uniformly  heiiatixeil,  while  the  right  was  in  the  stage 
of  gray  hepatization,  excei)t  a  still  smaller  ])orlion  in  the  corrtspoiiiliug 
region.  Jii  a  third  of  the  cases,  red  and  gray  hc])atizalion  existi'd  together. 
In  ■.".'  instances  tlu'rc  was  gray  hepatization.  As  a  rule  the  unall'ected  jior- 
tion  of  the  lung  is  congested  or  (edi'inatoi  s.  When  the  greater  jiortioii  of 
a  lobe  is  attacked,  the  nninvolved  part  may  be  in  a  state  of  almost  gelati- 
nous (edema.  The  unalVected  lung  is  usually  congested,  ]iarticularly  at 
the  posterior  ]iart.  This,  it  must  be  remembt'red,  may  ''c  largely  due  to 
post-mortem  subsidence.  The  niiinilanied  ]iortions  are  not  always  con- 
gested and  (edematous.  The  ujiper  lobe  may  be  dry  and  bloodless  when 
the  lower  lobe  is  unirormly  consolidated.  The  average  weight  of  a  normal 
lun<'-  is  about  (loO  grammes,  while  that  of  an  inllamed  organ  may  ho  1,500, 
5i,00(>,  or  even  '^,5t)0  grammes. 

'J'ho  bronchi  contain,  as  a  rule,  at  the  time  of  death  a  frothy  serous 
fluid,  rarely  the  tenacious  mucus  so  characteristic  of  ])neuinonic  sputum. 
The  mucous  membrane  is  usually  reddened,  rarely  swollen.  In  the  airected 
areas  the  smaller  bronchi  often  contain  fibrinous  plugs,  which  may  extend 
into  the  larger  tubes,  forming  jterfect  casts.  The  bronchial  glands  arc 
fiwollon  and  may  even  be  soft  and  ])ul]>y.  The  ])leural  surface  of  the  in- 
flamed lung  is  invariably  involved  when  the  ]n-ocess  hecomes  superficial. 
Commonly,  there  is  only  a  thin  sheeting  of  exudate,  ])roducing  slight 
turbidity  of  the  membrane.  In  only  two  of  the  hnndred  instances  the 
])leura  was  not  involved.  In  some  cases  the  flbrinons  exudate  may  form  a 
creamy  layer  an  inch  in  thickness.  A  serous  exudation  of  variable  amount 
is  not  uncomnKUi. 

Lesions  in  other  Organs. — The  heart  is  distended  with  firm,  tenacious 
CQagnla,  which  can  he  withdrawn  from  the  vesscds  as  dendritic  moulds. 
In  no  other  acute  disease  do  we  nuH't  with  coagula  of  such  solidity  and 
firmness.  The  distention  (tf  the  right  cliambcM's  of  the  heart  is  jiarticu- 
larly  marked.  The  left  chnmlK^'s  are  rarely  distended  to  the  same  degree. 
The  sjileen  is  often  enlarged,  though  in  only  ."15  (,f  the  100  cases  was  tlic 
weight  above  20p  grammes.     The  kidneys  show  paronchymatons  swelling, 


LOHAlt   1'NKLM(jMA. 


115 


I's  may  avi^o. 

in  uiu'  lnl)(', 

je  ol'  lliu  I'li- 

•iiy  ftngc  can 

>iiia  may  lii' 
ulf  l)y  mi'  at 
was  aH'irti'd; 
111;.%  with  tlu' 
terior  bonliT, 
•olvod;  in  l:! 
wiTi'  usually 
dill'  and  till' 
,  both  upin'r 
•catiT  part  (>( 
('[itidii  of  the 
;  in  the  staj;o 
•orrispondini; 
sti'd  to^ictlicr. 
iiail'ccti'd  pur- 
er portion  ol' 
almost  gclali- 
articularly  at 
arjj;('ly  due  to 
;  always  con- 
loodlt'ss  when 
t  ol'  a  normal 
may  he  l.-MK), 

frothy  serous 
loiiie  sputum. 
11  the  aU'ected 
h  may  extend 
al  filands  arc 
iiee  of  the  in- 
es  superficial, 
ducing  slight 
instances  the 
e  may  form  a 
riable  amount 

irm,  tenacious 
Iritic  moulds. 
1  solidity  and 
irt  is  particu- 
'  same  degree, 
cases  M'as  tlie 
itons  swelling. 


lurhidity  of  the  cortex,  and,  in  a  very  considcrahjc  proiiortii>n  of  the  cases 
-  --•.'.'>  per  cent— cliroiiic  inteislilial  changes. 

i'ericarditis  is  imt  iiifriMpieiii.  ;ind  occurs  m,,re  particiilarlv  with  pneii- 
luunia  of  the  left  side  and  with  doiihic  piieuinonia.  In  :>  of  tlii'  Itio  aiitop- 
,-ies  it  was  |iresent.  and  in  1  of  tlicni  the  lappet  of  lung  overlying  the  peii- 
cardiiim  with  its  pleura  wa.-  invoKcd.  I'jujocardilis  is  more  freipieiil  and 
occurred  in  Hi  of  the  Kit)  lases.  in  .")  of  tlie.-e  the  eiiducarditis  was  nf  tjie 
.-iiiiple  characler:  in  11  the  lesions  were  ulcerative.  I'atty  degciieialiun 
of  the  heart  i>  not  coninioii  except  in  protracted  ca.ses. 

Meningitis  is  not  infreciiieiilly  fniind.  and  in  many  cases  is  associatiMJ 
with  malignant  endocarditis.  It  \\a>  procnt  in  S  of  the  KIO  atilo|isies. 
Of  -Ji)  ca>c>  .if  meiiingilis  in  ulcerative  endocarditis  1-")  occurred  in  pneu- 
monia.    The  meningeal  iiillammalioii  in  thoe  cases  is  usuallv  cortical. 

Cnuipoiis  or  diphlheritii'  iiillaminalion  may  occur  in  other  parts.  .\ 
crou|ious  colitis,  as  pointed  out  hy  I'.ristowe,  is  not  very  uncomnion.  Il 
occurred  in  .")  of  my  llKt  post-nioiiems.  It  is  usually  a  "thin,  llaky  exuda- 
tion, most  marked  on  the  tops  of  the  folds  of  the  niucous  memhraiie.  In 
1  case  there  was  a  patch  (d"  croupous  gastritis,  covering  an  area  of  IV  hy 
.^  cm.,  situated  to  the  left  of  the  cardiac  orilice. 

The  liver  shows  parcnchyiiiatous  changes  and  often  extrcnu'  etn'orge- 
mciit  of  the  lie|)atic  veins. 

SymptOiaS. —('nil IS,  of  thr  Di^cisr  in  Tiipicdl  Ctsrx. — We  know  liut 
little  of  the  incnliatioii  period  in  loiiar  piu'umoiiia.  it  is  prohahly  verv 
short,  'i'here  are  sometimes  slight  catarrhal  symptoms  for  a  day  or  two. 
As  a  rule,  the  disease  sets  in  ahriiptly  with  a  severe  chill,  which  lasts  from 
fifteen  to  thirty  minutes  or  longer.  In  no  acute  disea.se  is  an  initial  chill 
so  constant  or  so  severe.  The  patient  may  he  taken  ahruptly  in  the  midst 
of  his  work,  or  may  awaken  out  of  a  sound  sleep  in  a  rigor.  'I'lie  tempera- 
ture taken  during  the  chill  shows  that  the  fever  has  already  begun,  if 
seen  shortly  after  the  onset,  the  patient  has  usually  features"  of  an  acute 
fever,  ami  complains  of  headache  and  general  pains'.  Within  a  i'vw  hours 
])ain  in  the  side  develo|is,  often  of  sin  agonizing  character;  a  short,  drv, 
jiainfiil  cough  begins,  and  the  respirations  are  increa.sed  in  frecpiency. 
When  seen  on  the  second  or  third  <Iay.  the  picture  in  typical  pneumonia 
is  ipiite  pathognomonic;  more  so,  perhaps,  than  that  |)resented  by  any 
other  acute  disease.  The  i.atieni  lies  Hat  in  bed,  often  on  the  affected 
side;  the  face  is  flushed,  jiarticnlarly  one  or  both  cheeks;  the  breathimr  is 
hurried,  accompanied  often  with  a  short  expiratory  grunt;  the  ahe  nasi 
dilate  with  each  inspiration;  herpes  is  usually  jjresent  on  the  lips  or  nose; 
the  eyes  are  bright,  the  expression  is  anxious,  and  there  is  a  freipient  short 
cough  which  makes  the  patient  wince  and  Indd  his  side.  The  exiu'ctora- 
tion^  is  blood-tinged  and  extremely  tenacious.  The  tem|)erature  may  be 
101°  or  K).-)".  The  pulse  is  full  and  bounding  and  the  pulse-respiration 
ratio  much  disturbed.  Examination  of  the  lung  shows  the  physical  signs 
of  consolidation — blowing  breathing  and  fine  rales.  After  ])ersisting  7or 
from  seven  to  ten  days  the  crisis  occurs,  and  with  a  tV.ll  in  the  teini)eratiire 
the  patient  passes  from  a  condition  of  extreme  distress  and  anxiety  to  one 
of  comparative  comfort. 


rta* 


IIG 


SI'FXMl'IC    INl'KCTlors    lUSKXSKS. 


Special  Features.       'I'lic  frm-  rises   rii|>i{lly.  ami    ll:c   liriL;ht    inav  lie 
10  1"  or  J(»r)°   witliiu   twelve   lnuirs.      Ilaviui;-   reaelied    llie    ^a^l  i,L;imn,   it    is 


Jan.   tn  ff  /?  n  u  t 


BLACK,  TEMPEHATUHE  I  RED,  PULSE  ;  BLUE,   RESPIRATION. 

CiiAKT  IX.- — l""('V('r.  |nilsc.  and  ivspinitions  in  loliar  piioiumiiiiii. 

ronuirkalily  coiiKlaiit.     Ol'ton  llio  two-liour  teiii|)c'ratiire  rliart  will  not  ^\w\\ 
for  two  (lavs  more  tliaii  a  (leirri'c  of  variation.      In  eliildrt'n  and   in  cases 


t    in:iy  lie 
mn,   it    is 


t 

14 

1  not  show 
1(1   in  cast's 


LOBAU   PXKl'MOXIA. 


ii: 


witliniit  ohil]  ilio  rise  is  nioiv  <:riiiliiiil.  lii  old  lursons  and  in  diiinkanis  tlio 
Icinpcratnri'  ran.uc  is  lower  than  in  chihh'cn  and  in  licalthv  induidnals; 
in(h't'd,  oiu'  occasionally  inccls  with  an  atVlirilc  ]mciinionia. 

'I'lir  Crisis. — After  the  fever  has  persisted  for  from  live  to  niiic  or  tcii 
days  there  is  an  ahrnpi  di'o|),  known  as  the  crisis,  whicli  is  perhaps  the 
nio.-t  characteristic  feature  of  iohar  pneumonia.  'I'he  day  of  llio  crisis  is 
variahle.  It  is  very  uncommon  hefore  the  third  dav.  and  rare  after  the 
twclftii.  I  have  twice  seen  it  as  early  as  the  third  day.  From  the  tinu'  of 
JlipiHH-rates  it  has  hccn  thonjrht  to  he  more  fre(|uent  on  the  uneven  days, 
jiarticularly  tlie  fifth  and  seventh.  A  jirecritical  rise  of  a  de;;ree  or  two 
jnay  occur.  In  one  case  tiie  temperature  rhse  from  l(t.')'  to  nearlv  ln;\  and 
then  in  a  f.  hours  fell  to  normal.  Not  even  after  the  chill  in  malarial 
fever  do  we  see  such  a  prompt  and  rapid  dro])  in  the  temperature.  The 
nsnal  time  is  from  five  to  twelve  hours,  ])ut  often  in  an  hour  there  may 
occur  a  fall  of  six  or  ei,L;lit  de,^n'ees  (S.  West).  The  temperature  may  he  snh"- 
normal  after  the  crisis,  as  low  as  ixr  or  !tr.  I'sually  with  the  erisi.s  there  is 
an  ahundant  sweat,  and  the  patient  sinks  into  a  eomlortahle  sleep.  The 
day  after  the  eri>is  there  may  he  a  slight  post-critical  rise.  A  pseudo- 
crisis  is  not  very  unconnuon,  in  which  on  the  fifth  or  sixth  dav  the  tempera- 
t\ire  drojis  from  104°  or  ]0r)°  to  102°,  and  then  rises  a^^ain.  "Wh.en  the  fall 
takt's  place  <:radually  within  twenty-four  liours  it  is  called  a  protracted 
crisis.  If  the  fever  jiersists  heyomi  the  twelfth  day,  the  fall  is  likely  to  he 
))y  lysis.  In  children  this  mode  of  termination  is  common,  and  occurred 
in  one  third  of  a  series  of  1S;{  cases  reported  hy  ^Forrill.  Occasionally  in 
dehilitated  individuals  the  teinjjerature  drop.s  rapidly  jnst  hefore  death; 
more  frequently  there  is  an  ante-mortem  elevation.  In  ea,«e.s  of  delayed 
resolution  the  fever  may  persist  for  weeks.  The  crisis  is  the  most  reniark- 
ahle  sin^de  ])henomenon  of  ])nenmonia.  With  the  fall  in  the  fever  the 
respirations  ))eeonio  reduced  almost  to  normal,  the  pulse  slows,  and  the 
])atient  ])asses  from  i)erhaps  a  state  of  extreme  hazard  and  distress  to  one 
of  safety  and  eomfort,  and  yet.  so  far  as  the  ]ihysical  examination  indicates, 
there  is  with  the  crisis  no  special  chan<re  in  the  local  condition  in  the  luni,'. 

Pain. — On  the  affected  side  th.ere  is  early  a  sharp,  a<ronizin<j;  pain,  •Gen- 
erally referred  to  the  region  of  the  nijiple  or  lower  axilla.  It  is  much  a^-'jira- 
vati'd  on  deep  ins])iration  and  on  coughing'.  It  is  associated  with  the  ac- 
com])anyinnr  <li'.V  jdenrisy  of  the  disease.  It  is  ah.sent  in  central  pneumonia, 
and  mnch  less  freipient  in  a|)e\-  pnennionia.  In  exce|)tional  cases  the  pain 
is  in  the  a1)domen,  and  I  have  twice  known  the  susi)icion  of  appendicitis 
rai.^'d  hy  the  sudden  acute  onset  of  the  pain,  once  in  the  re^jjion  of  the  navel 
and  once  low  on  the  ri<,dit  side.  The  pain  may  ho  severe  enough  to  re(iuire 
a  hy))odermie  injection  of  morphia. 

Di/spiin^n  is  an  almost  constant  feature.  Even  early  in  the  disease  the 
res])iratio]is  may  he  30  in  the  minute,  and  on  the  second  or  third  day  be- 
tween 40  and  50.  The  movements  are  shallow,  evidently  restrained,  and 
if  the  ])atient  is  asked  to  draw  a  deep  breath  he  cries  out  with  the  pain. 
Kxi)iration  is  frequently  interrupted  by  an  audible  grunt.  At  first  with  the 
increased  res])iration  there  may  he  no  sensation  of  distress.  Later  this 
may  be  present  in  a  marked  degree.     In  children  the  resi»irations  may  be 


^■^ 


118 


SPECIFIC   INFECTIOUS  DISEASES. 


80  or  I'vt'ii  100.  ]\Iaiiy  factors  combine  to  produce  the  shortncfs  of  breath— 
the  |)aiii  in  tiie  side,  tiie  toxivniia,  tlie  fever,  and  the  h)ss  of  funelion  in  a 
(■(insi(K'ralik'  area  of  tlie  liniK  tissue.  Sometimes  tliere  appear  to  be  nerv- 
ous iaetors  at  worlv.  Tiuit  it  (h)es  not  (k'pend  upon  tlie  consoli(hition  is 
shown  by  tiie  fact  tliat  after  tlie  crisis,  witliout  any  clian>ie  in  the  local 
condition  of  the  Inii^s  the  niimher  of  respirations  may  drop  to  normal. 
The  ratio  between  the  respirations  and  the  pulse  may  l)e  1  to  2  .  r  >  ven  1  to 
1..'),  a  disturbance  rarely  so  marked  in  any  other  disease. 

Coi„lli, — This  usually  comes  on  with  the  jiain  in  the  side,  and  at  first  is 
dry.  hard,  and  without  any  expectoration,  i.ater  it  becomes  v(  ry  charac- 
t^,,'.isti( — fre(pient,  short,  restrained,  and  associated  with  ^n-eat  pain  in  the 
side.  In  old  persims.  in  drunkards,  in  the  terminal  pneumonias,  and  some- 
times in  younji  ciiildren  there  may  be  no  cou<,di.  After  the  crisis  the  couj^h 
usually  becomes  much  easier  and  the  expectoration  more  easily  expelled. 
The  C()U<:h  is  sometimes  iiersistent,  continuous,  and  by  far  the  most  afjfira- 
vated  and  distressing  symptom  of  the  disease.  Taroxysms  of  coughinji  of 
great  intensity  after  the  crisis  suggest  a  pleural  exudate. 

Simhiiii. — A  brisk  luemoptysis  may  be  the  initial  symiitom.  At  first 
the  sputum  may  be  mucoid,  but  usually  after  twenty-four  hours  it  becomes 
blood-tinged,  viscid,  and  very  tenacious.  At  first  (piite  red  from  the  un- 
changed blood,  it  gradually  becomes  rusty  or  of  an  orange  yellow.  The 
tenacious  viscidity  of  the  sputum  is  remarkable;  it  often  has  to  be  wiped 
from  tlie  lips  of  the  imtieiit.  and  a  spit-cup  half  full  may  be  inverted  with- 
out spilling.  In  low  tyjies  of  the  disease  the  sinitiim  may  be  fluid  and  of 
a  dark  brown  color,  resembling  i)rune  juice.  The  amount  is  very  variable. 
In  children  and  in  old  jieojile  there  may  be  none,  and  even  in  adults  cases 
are  not  very  uncommon  in  which  from  beginning  to  close  there  is  no  ex- 
jH'ctoration.  A  c(miinon  amount  is  from  l.-)0  to  tiOO  cc.  daily.  After 
the  crisis  the  cpiantity  is  variable,  abundant  in  some  cases,  absent  in  others. 

IMieroscoiiically,  the  sputum  consists  of  leucocytes,  mucus  corpuscles, 
red  blood-corpuscles  in  all  stages  of  degeneration,  and  bronchial  and  alve- 
olar epithelium.  Ila-niatoidin  crystals  are  occasionally  met  with.  Of  micro- 
organisms the  pneumococcus  is  usually  present,  and  sometimes  Friedliinder's 
bacillus.  Very  interesting  constituents  are  small  cell  moulds  of  the  alveoli 
and  the  fibrinous  casts  of  the  bronchioles;  the  latter  may  be  very  plainly 
visible  to  the  naked  eye.  and  sometimes  may  form  good-sized  dendritic 
casts.   Chemically,  the  cxjiectoration  is  ]iartieularly  rich  in  calcium  chloride. 

Physical  Signs. — Iiisjinlidn.—Tlw  ]H)sition  of  the  patient  is  not 
constant.  He  usually  rests  more  comfortably  on  the  affected  side,  or  he 
is  ju'opped  u])  with  the  spine  curved  toward  it.  OrthopncTa  is  not  nearly 
so  fre(pient  as  in  heart-diseasi 

Inspection  of  the  thorax  may  show  at  first  no  din"erences  between  the 
two  sides;  usually  if  the  lower  lobe  of  a  lung  is  involved  the  movement  is 
less  on  the  affected  side.  Later  this  deficient  expansion  is  marked,  and 
may  be  both  seen  and  felt.  The  comiiensatory  increased  movement  on 
the  sound  side  is  sometimes  very  noticeable  even  before  the  patient's  chest 
is  bared.  The  intercostal  si)aees  are  not  usually  obliterated.  When  the 
cardiac  lappet  of  the  left  upper  lobe  is  involved  there  may  be  a  marked 


R  of  breath — 
'unction  in  a 
['  to  ho  norv- 
isoli(hitinn  is 

in  the  \wa\ 
|)  to  nonnal. 

nv  I  ven  1  to 

nid  at  iirst  is 
very  I'harao- 
[  pain  in  tlic 
IS,  and  sonu'- 
sis  tlie  cough 
sily  oxjH'llcd. 
!  most  agfira- 
cougliing  of 

)m.  At  first 
rs  it  heconics 
from  tlio  un- 
ycllow.  The 
1  to  be  wiped 
nverted  witii- 
'  thiid  and  of 
very  variable. 
1  adults  cases 
lere  is  no  ex- 
laily.  After 
ent  in  others. 
IS  corpuscles, 
lial  and  alve- 
h.  Of  micro- 
Friedliinder's 
of  the  alveoli 
'  very  ])lainly 
zed  dendritic 
'ium  chloride, 
atient  is  not 
'd  side,  or  he 
is  not  nearly 

J  between  the 

movement  is 

marked,  and 

movement  on 

latient's  chest 

I.     When  the 

be  a  marked 


LOHAIl   PN'KUMOMA. 


11!) 


increase  ,n  the  area  of  visible  cardiac  pulsation,     rulsati.u,  of  (),.  alVedcd 
lung  niay  cause  a  marked  nrnvcmeut  of  the  ch,.st   wall   ((iravcs).     OtluT 
points  to  be  noticed  in  the  insp,.,,,on  arc  the  frcjucncy  of  the  respiration 
the  action  oi  the  accessory  muscles,  such  as  the  slornolclei.lo-mastiids     ,  d 
scalein,  and  the  dilatatmn  of  the  n.,stri]s  with  each  inspiration 

.Vvnsuralu,,,  may  show  a  dciinite  .ncrea.^c  in  the  volum.  of  the  side 
alloeted,  rarely  more,  however,  than  1  or  l.V  cm 

ral/H,liou.~Th,  huk  of  expansion  on"  the' alfected  side  is  sometimes 
non^  rea. hly  pe,ve,vcd  by  touch  than  by  sight.     The  pleural  friction  n  ^ 
be  lelt      On  asking  the  j.afent  to  count,  the  voice  fremitus  is  greatly  in- 
mised  in  ..omparison  with  the  corresponding  point  on  the  healthy  ^side 
It  IS  to  be  remembered  that  if  the  brom-hi  are  tilled  with  thick  secVetion 

exui'ile  Tbi   t"n  "f"  ^^/""^^'^-^  pneumonia,  they  are  tilled  with  (ihriium 
exudate,  the  tactile  Iremitus  may  be  diminished,     it  is  always  well  to  ask 
the  i)atient  to  cough  before  testing  the  fremitus  ' 

Fercussion.-h^  the  stage  of  engorgement  the  note  is  higher  pitched 
;  ^,"'"-t;'-''  "  "T^^"^  tyn.panitic  quality,  the  so-calle.l  Skoda's  reso- 

X-  ted     ,;.      W     '\  "  'I''''^'''^'^---  <!"■  '""^^  tissue  just  above  a  eon- 
solKlated  a.ea.     ^Vhon  the  lung  is  hepati/ed,  the  per.ussion  n..te  is  dull 
the  quality  varying  a  good  deal  from  a  note  whieh  has  in  it  a  certain  tvm-' 
pan.tic  quality  to  one  of  absolute  llatness.     There  is  not  the  wood...  i    t- 

ess  o    el  usion  and  the  sense  of  resistance  is  not  so  great.     During  resolu- 
t.on  the  tympanitic  quality  of  the  percussion  note  usually  returns      For 

r  tVT'l  ;'"'\"'''"'"'"""  ^'•"■^'  "'">'  ''^  '  I'i^luM-pitched  note 
on  the  allected  side.  Among  variations  to  be  notice.I  are  that  Wintrieh's 
ehange  in  the  percussion  note  when  the  mouth  is  open  may  be  v.-rv  well 
marked  ,n  pneumonia  of  the  upper  lobe.  Occasionally  tlu.R.  is  an  almost 
metallic  .piality  over  the  consolidated  area,  and  when  this  exists  with  a 
very  pronounced  amphoric  qnality  in  the  breathing  the  presence  of  a  .-avity 
may  be  suggested.  In  deep-seated  pneuuK.nias  there  may  be  for  s..vera"l 
days  no  change  in  the  ],erciissi(.n  note,  and  in  a  few  rare  "cases  percussion 
sliows  no  change  thronghout  the  disease. 

AnsniUa/lon.—Quu'U  suppressed  breathing  in  the  alfected  part  is  often 
a  marked  leature  in  the  early  stage,  and  is  alwavs  suggest iv(>      \er-  .^nrly 
there  IS  heard  at  the  end  of  inspiration  the  fine"<.repitant  rale,  a  series  „> 
minute  cra<.klings  heard  close  to  the  ear,  and  perhaps  not  audible  until  a 
iull  breath   is  drawn.     This  is  probably  a  fine  i.l.-ural  crepitus,  a<  J    R 
Learning  maintained;  it  is  usually  believed  to  be  produced  in  the  air-cells 
and  finer  bronchi  by  the  se,.aration  of  the  sticky  exudate.     At  this  sta.r,> 
before  conso hdation  has  occunvd.  the  bn-ath-sounds  may  be,  as  before  niHi- 
tioned,  much  feebler  than  in  health,  but  on  drawing  "a  long  breath  thev 
may  have  a  harsh  quality,  to  which  the  term  broncho-vesicular  has  been 
npplH'd.     In  the  .<tage  of  red   hepatization  and  when  dulness  is  well  d.«- 
hned.  the  respiration  is  tubular,  similar  to  that  heard  in  health  over  the 
Larger  bronchi.     A\,th  this  blowing  breathing  there  may  be  no  rales    and 
1     may  present  an   int..nsity  unknown   in  any  other  i)u"lmonarv  affection 
IS  simply  the  propagation  of  the  laryngeal  and  tracheal  sounds  thron-h 
the  bronchi  and  the  consolidated  lung  tissue.     The  permeability  of  the 


120 


srEClFIC  INFECTIOUS  DISEASES. 


l,r„iulii  is  essential  to  its  i)rocliietion.  Tulmlar  l^reathing  is  absent  v.\  cer- 
tain eases  of  massive  i.neiinKMiia  in  wliicii  llie  larger  hronehi  are  eonipletely 
jilled  with  exndation.  When  resuhitiun  l)egins  iniRons  rales  of  all  sizes  eaii 
be  heard.  At  lirst  they  are  small  and  have  been  called  tiie  mliix-orinlits. 
Tiie  voice-sounds  are  transmitted  tlirongh  the  eons.didated  lung  with  great 
inten«itv  This  bronchoiiliuny  niav  have  a  curious  luisal  (luality  to  whu'h 
the  term  a'-ophoiiv  lias  been  given.  There  arc  cases  in  which  the  consoli- 
dation is  deeply  seated— so-called  central  pneumonia,  in  which  the  pliys- 
ieal  signs  are  slight  or  even  ab.^ent,  yet  the  ccmgh,  the  rusty  expeeU.raliuii, 
and  general  I'eatures  make  tiie  diagnosis  certain. 

Circulatory    Symptoms.— During  tiie  chill  the  pulse  is  small,  Init  in 
the  succeeding  fever  it  becomes  full  and  bounding.     In  cases  of  moderate 
severity  it  ranges  from  100  to  llti.     It  is  not  often  dicrotic.     In  strong, 
liealthy  individuals  and  in  children  there  may  be  no  sign  of  failing  imlso 
throughout   tlie  attack.     Witli   extensive   consolidation   tlio   left  ventricle 
may  receive  u  verv  much  diminisiied  amount  of  blood  and  the  pulse  in 
conscipieiice  may  be  small.     In  the  old  and  feeble  it  may  be  small  and 
rai)id  from  tlie  outset.     Tlie  inilse  may  be  full,  soft,  very  dece].tive,  and  of 
no  value  whatever  in  jirognosis.     The  hcart-soit litis  are  usually  loud  and 
clear.     During  the  intensity  of  tlie  fever,  particularly  in  children,  bniUs 
are  not  uncommon  both  iii  tiie  mitral  and  in  tlie  ])uliiionie  areas.     Tiie 
second  sound  over  the  ]iulnionary  artery  is  accentuated.    Attention  to  tins 
sign  gives  a  valuable  indication  as  to  the  condition  of  the  lesser  circula- 
tion.''with  distention  of  the  right  chambers  and  failure  of  the  right  ven- 
tricle to  empty  itself  comiiletely  tlie  pulmonary  second  sound  becomes  much 
less  distinct.     ^Vlu'n  the  right  heart  is  engorged  there  may  be  an  increase 
in  the  dulness  to  the  rightOf  the  sternum.     With  gradual  heart  weakness 
and  signs  of  dilatation   the  long  pause  is  greatly  shortened,  the  sounds 
approach  each  otluT  in  tone  and  have  a  fu-tal  character  (embryocardia). 

There  may  lie  a  sudden  early  collapse  of  the  heart  with  very  feeble, 
rajiid  pulse  and  increasing  cyanosis.  I  have  known  this  to  occur  on  the 
third  day.  Even  when  these  "symptoms  are  very  serious  recovery  may  take 
jilace.  i  saw  with  Dr.  Ilollyday  a  robust  man  of  thirty-six  who  at  the  end 
of  the  second  week  of  a  severe  pneumonia  had  two  serious  attacks  of  heart 
weakness,  in  which  the  pulse  became  exceedingly  feeble,  scarcely  percepti- 
ble; there  was  marked  pallor,  an  ashy  appearance  of  the  face,  and  profuse 
sweating,  l^oth  attacks  ai>i)eared  to  be  most  critical,  but  he  recovered 
perfectly.  In  other  instances  without  any  special  warning  death  may 
occur  even  in  robust,  ]ireviously  healthy  men.*  Endocarditis  and  pericar- 
ditis will  be  considered  under  complicatior- 

7j/,,„(?._Ana>mia  is  rarely  seen.  V>o  ger  has  called  attention  to  an 
oliga'mia  due  to  the  large  amount  of  exudate,  and  thinks  that  the  collapse 
feahires  are  in  part  due  to  it.  There  is  in  most  cases  i  >ncocytosis,  wdiich 
appears  early,  iiersists,  and  disaitpears  with  the  crisis.  The  leucocytes  may 
numl)er  from  12,000  to  40,000  or  50,000,  or  even  more,  per  cubic  millimetre. 
The  fall  in  the  leucocytes  is  often  slower  than  the  drop  in  the  fever,  par- 


*  For  ilhistrative  cases  sec  Prognosis  in  Pneumonia,  Am.  Jr.  Med.  Sci.,  Jan.,  1897. 


ibscnt  in  cor- 
ri'  iiiinplc'toly 
1'  all  i^'v/A'i  I'iiii 
rdu.f-crcjiiltts. 

U'^  with   glH'Ul 

ility  Id  wliicli 
li  tiie  ooiisoli- 
icli  till'  pliv^- 
expcfloraliuii, 

small,  but  in 
s  ol'  inodoralo 
2.  In  strong, 
'  failing  ]nilsL" 

loft  vent  rifle 
.  the  pnlso  in 

be  small  and 
•ejitive,  and  of 
ally  loud  and 
liildren,  ^r»i7.s 
le  areas.  The 
tentiou  to  this 

lesser  circula- 
the  right  ven- 
beeomes  much 
be  ail  increase 
leart  weakness 
;d,  the  sounds 
ibryocardia). 
th  very  feeble, 
)  occur  on  the 
)very  may  take 
vlio  at  the  end 
ttacks  of  heart 
ircely  percepti- 
ve, and  profuse 
t  he  recovered 
ng  death  may 
:is  and  pericar- 

ittention  to  an 
lat  the  collapse 
ocytosis,  W'hich 
leucocytes  may 
due  millimetre, 
the  fever,  par- 

ici.,  Jan.,  1897. 


l.dliAU    I'NIUMdNI  A. 


i-Jl 


liruhiily  wlicii  nMihilidii  is  delayed.  The  aniU'Xcil  chart  Inmi  ,1.  S.  Hillings" 
|,,i|„,,.  ^'.1.  II.  II.  liiilletin.  N(.."-l;i)  shdws  well  the  ((.incident  dn.).  in  the 
(Vvcr  and  in  the  iinnil.cr  of  the  leucocytes.  .\  point  ol'  considerate  prog- 
nostic importance  is  that  m  malignant  pncnnionia  the  Icueocytosis  may 
he  absent,  and  in  any  ease  the  eonlinuons  absence  may  be  regarded  as  an 
iinlavoraiile  si'ni.     <M'  .")()  eases  shown  in  my  clinic  during  the  sessions  of 


I'.l..,  IS'.lll 

"  16         1         17         1         13         1         1«         1        20        1         21         1         22 

tl 

,,,     i;    1  .    II     ,„    0    !■;     li    Ml    6    v:    0    Ml     II    I'.'    il     111    li     1-    1'     111     ''    1-    '>     1"   " 

KM 

Itt-i       — 

104        - 

io;i 

101 

100 ' 
99' 
98' 

1  "^ 

1 

-    \~r     \- 

tx  T 

:_ . :  J_. 

r 
1 

T — I" 
I  1 

i   L, 

1      ■ 
--1 — ' 

^"rr 

1 

l|     [-  iT 

n-/ 

1 

i         1 

m,ow      — 
tu.ooo 

1      ' 

1 

..  

— 

-— 

■-]    -  ' 

I 

_-.- 

1 

'■ 

^rr 

"p't    '  r  i 

1 

\--i-- 

i 

1 

1 

+--— 1 — 

"Vr- 

"■|  t^ 

p 

1 

i  1 

p 

30,0(K) 

20,(X)0 
18,0(KI 
1(!,(X)0 
It  000 

T 

! 

1  1 

p 



i,M- 

-• 

' 

1 

-\l 

;    ■ 

|— ( — ^■ 

1 

\i 

\  j-'j— ' 

[-  - 

V  r 

'< 

r 

1 

\ !       ! 

1         1 

i  '  ! 

H 

1 

1                      ; 

i 

i 

1 

I 

;._ 

--]    -  - 

1 

-- 

V 

x:  s 

1 -1 — 

-  -^'-r 

13,000 
10,000 
8,000 
(j  000 

1 

'^i    1    i 

-1-    ^  1  ' 

1 

_^^  1 

T~ 

^    ^ 

,              i 

1 

A 

sj^~-p 

1,000 
2,000 



-t  - 

-— •— 

1 

1  ' 

~     r— r-,    r 

' 

'      ' 

("llAHT    X. 

l«;)()-"!tr  and  1S1);-"'.IS.  the  highest  leiicoeyto^is  was  (i;!.0<l(>,  the  lowest 
^^),•>()^).  A  striking  feature  in  the  blood-slide  is  the  richness  and  density  ol" 
th('  fibrin   network.     This  corresponds  to  the  great    increase  in  the   tibrin 


1-J-J 


Sl'Kl  IKIC    INI-'KCriorS    DISKASKS. 


clciiiriil.-.  uhicli  liiis  Inn;:-  liccii  kriDUii  \n  (irciir  in  imciiiiKtiiiiK  tlic  prcipor- 
lidll  lislllj,'  Irolll  I  tn  l"  jiiirls  jicr  IIiuiimIIIiI.  IhlVclll  (li'M-rilica  the  lilnod- 
[iliitcs  as  j^rciitl.v  incrciiscd.  Tlic  iiiiciucdcti  i  an  v.tv  lairlv  lie  (liiiinii- 
stralfil   ill  llir  liloDil. 

Digestive  Organs.  -'I'lic  tniii^uc  is  whit^'  ami  I'liircil.  ;•  il  in  scvon- 
t(i.\ir  ca.-cs  ra|Hillv  lircdincs  drv.  N'miiiliiii:-  is  iwd  iiiicoiiiiiuni  at  tin'  nii,-ci 
ill  iliildrt'ii.  'I'iic  a|i|iflil('  is  lust.  ( 'un>ti|iaticm  is  niuif  ((1111111011  lliaii 
diarrliti'a.  A  distivssiii;;  and  sonictinio  danpToiis  >viii|it(ini  i>  in'icori^iii. 
Oil  several  (iccasions  I  liave  t-viw  <;reat  distri'ss  lidiii  the  eiilarjzcd.  tviii- 
|iaiiitie  alMldiiieii  iiiisliiiiji  ii|)  the  dia|pliiii;;iii.  'i'lie  >|ileeii  •.-  ii.-iiallv  eii- 
lai-ged,  and  the  edjic  can  he  lelt  duriii;^-  a  deep  in>iiirati(in.  With  eMr( me 
eiij:()r<reiiient  oi'  the  rijilit  heart  there  may  lie  |ieree|)tihle  inereasi'  in  the 
volume  (»r  the  liver. 

Skin.— Anion;:  nilniiciiiis  symi>toms  one  (d'  the  most  interesting'  is  the 
association  of  herpes  with  pneiiinonia.  Not  e\eeptin,i:  malaria,  we  see 
jahial  herpes  more  l're(iiieiitly  in  this  than  in  any  other  disease,  (nciirrin^-. 
as  it  does,  in  from  I'.'  to  Hi  per  cent  of  the  eases,  it  is  supposed  to  he  of 
favorahle  prognosis,  and  li^zures  have  hc'ii  (pioted  in  proof  (d'  this  as,<er- 
lioii.  It  iiiav  also  occur  on  the  no.-e.  .i;cnitals.  and  anus.  Its  siuMiilieance 
and  relation  to  the  disease  are  iinkiiowii.  It  is  scarcely  necessary  to  men- 
tion till'  theory  which  has  heeii  advanced,  that  it  is  an  external  e.\pressioii 
(d'  a  neuritis  which  involves  the  imeiimo^aslrie  and  indnces  the  pneumo- 
nia. \\  the  height  of  the  disease  sweats  are  not  eoiuiiioii,  Imt  at  the  crisis 
they  may  lie  profuse.  U'edness  (d'  one  cheek  is  a  plieiionieiioii  loii^f  recou- 
iiizt'd  in  connection  with  pneiiiiioiiia,  and  is  usually  on  the  .same  side  as 
the  disease. 

Urine.  —  I'.arly  in  the  disease  it  presents  the  usual  febrile  cliaracter.s 
of  lii^h  color,  lii^'li  specific  ^'ravity,  and  increased  acidity.  A  trace  of  alliii- 
niin  is  very  coiiimou.  There  may  he  tiilie-casts  and  in  a  few  instances  the 
o.xisteiice  of  allnimin.  tube-casts,  and  lilood  indicate  the  presence  (d'  an 
acute  nephritis.  In  a  lar>;e  proportion  of  all  eases  the  albumin  is  a  febrile 
or  toxic  feature.  The  urea  and  uric  acid  are  usually  increased  at  first,  but 
may  be  nnicli  diminished  before  the  crisis,  to  increase  ^n'catly  with  its  onset. 
The  chlorides  are  absent  or  greatly  reduced  during'  the  height  of  tlio  fever, 
owin^-  to  the  amount  exuded  in  the  hejiati/ed  lun^'.  At  the  crisis  there  may 
he  a  marked  increase  in  the  amount  of  urine,  which  is  heavily  laden  with 
urates  and  extractives.  When  jaundice  occurs  there  is  bile  i)i^nnent.  I 
saw  profuse  liaMiiaturia  (ui  the  seventeenth  day  of  a  severe  ]inenmonia.  The 
bov  liad  recently  had  eonorrluea. 

Cerebral  Symptoms.  —  Headache  is  common.  Convnlsions  occur 
fre(piently  al  the  outset  in  children.  Apart  from  nienin,L:itis.  which  will 
l)e  e(Uisidered  separately,  one  may  ,i;rou|)  the  cases  with  marked  ci'rebral 
features  into — 

First,  the  so-called  cerebral  pneiinionias  of  children,  in  wlircli  the  dis- 
ease sets  in  with  a  convulsion  and  there  are  hi.ah  fever,  lu^adache.  delirium, 
^nvat  irritability,  muscular  tremor,  and  perhaps  rctraeiion  of  the  head 
and  neck.  The  dia^niosis  of  meiiinaitis  is  usually  made,  and  the  local 
all'ection  may  be  overlooked. 


LOBAR   rXKlMONIA. 


12;} 


Iliil.  the  jJl'Djinr- 
•rilics  tilt'  lilooil- 

irclv     111'    (Irliinll- 

(1,  i'  il  ill  severe 
nm  lit  till'  niiM't 
e  ('(illlinnil  tluiii 
nil  is  iiM'tenrisiii. 
'  eiiliirjzcil.  tyiu- 
11  '.-  ll.-Uilllv  ell- 
Willi  cMreini' 
increase  in  the 

iiteresiinji  is  the 
iiiuliiriii.  we  see 
isease.  i/cciirriii*,'. 
ii|i|i()S('(l  to  lie  of 
of  (if  this  asser- 
Its  siuiiilicaiiee 
oeessary  to  iiieii- 
ternal  expression 
ces  tlu'  |ineuiiio- 
lint  at  tiie  crisis 
'lion  ioiij,'-  reiMi;;- 
tlie  same  side  as 

elirile  cliaraeters 
A  trace  of  alliii- 
'c\v  instances  the 
'  |ireseiice  of  an 
uiiiin  is  a  ft'lirile 
■ased  at  (irst,  Imt 
ly  with  its  onset, 
yht  of  the  fever. 
'  crisis  til  ere  may 
■avily  huleii  witli 
liile  pijjrinent.  I 
)neiiiiioiiia.    The 

nnviilsimis  occur 
.i:itis.  whicli  will 
marked  cerebral 

11  wlirch  the  dis- 
adache,  delirium, 
ion  of  the  head 
e.  and  the  local 


Secondly,  the  oaf^es  with  maniacal  symiitom.-J.  Those  may  occur  at  the 
\(i'V  outset,  and  I  once  |ierforiiied  an  aiitn|psy  on  a  case  in  which  there  was 
III)  suspicion  whatever  that  the  disease  was  other  than  acute  mania.  'I'iie 
JMiiise  pliysician  slioidd  ;:ive  iiistructi<ins  to  the  nurses  to  watch  such  cases 
very  carefully.  On  March  '^'i,  Istlj.  a  jiatient  who  hail  heeii  doiii;,'  very 
well,  with  the  exception  of  >li;^ht  delirinm.  while  the  orderly  was  out  of  the 
niom  for  a  few  moments,  j^ot  up.  raised  the  window,  and  jnnipcil  out.  siis- 
laininj:  a  fracture  of  the  \v'^  and  of  the  iijiiier  lumliar  vertebra',  of  which 
he  died. 

'i'liirdly,  alcoholic  cases  with  the  features  of  delirium  tremens.  It 
^hiiidd  lie  an  invariable  ride,  even  if  fever  Ih'  not  present,  to  I'xamiiu,'  the 
Imiirs  in  a  case  of  nuiiiin  a  jmlii. 

{•"oiirthly,  cases  with  toxic  features,  resenililiiiix  rather  those  of  iira'inia. 
Without  a  chill  and  without  coiiLdi  or  |iaiii  in  the  side,  a  patient  may  de- 
velop t'ever,  a  little  shortness  of  breath,  and  then  irra-lually  '^row  dull  men- 
tally, and  within  three  days  be  in  a  condition  of  probnind  toxa'iuia  with 
liiw,  mutteriii;,'  delirium. 

Il  is  stated  that  apex  pneumonia  is  more  often  accompanied  with  severe 
delirium.  Occasionally  llu'  cereiiral  symptoms  develo|i  immediately  after 
tiie  crisis.  .Mt'iital  disturbance  may  persist  diirini:  and  after  convalescence, 
anil  in  a  few  instances  delusional  insanity  follows,  the  outlook  in  which  is 
favorable. 

Complications. — Compared  with  tyiilmid  fever,  ]ineumonia  has  but 
trw  com|ilications  and  still  fewer  seipiela'.  'l"he  most  important  are  the 
!'ollowin<r: 

PIciirisi/  is  an  inevitable  event  when  the  inllammation  reaclu's  the  sur- 
face of  the  lun;,',  and  thus  can  scarcely  be  ternii'd  a  comiilicalion.  Ilut  there 
are  oases  in  which  the  pleuritic  features  take  the  (irst  place — cases  to  which 
the  term  pleuro-pneumonia  is  applicable,  '{'he  exudation  may  be  sero- 
librinoiis  with  copious  eifusion.  dilVeriiiff  from  that  of  an  ordinary  acute 
pleurisy  in  the  <rreati'r  richness  of  the  fibrin,  which  may  form  thick, 
tenacious,  curdy  layers.  I'neumonia  on  ono  side  with  extensive  pleurisy 
on  the  other  is  sometimes  a  jiuzzlinji;  complication  to  dia,s,Miose  and  an 
as|iirator  needle  may  be  required  to  settle  the  ipiestion.  'I'lie  bacterioIo;,dcal 
cxamiiuition  of  the  iluid  has  demonstrated,  in  a  larjre  number  of  cases,  the 
presence  of  the  pneumococcus.  I'^mpyema  fi.'piently  follows  pneunionia. 
The  jileurisy  caused  by  the  streptococcus  is  much  more  (lanjicrous  and  is  a 
not  infreipieiit  fatal  complication.  Klfiision  may  not  have  been  suspected 
diiriii<r  the  hei^dit  of  the  disease,  l)ut  after  the  tem])erature  has  been  normal 
for  some  days  a  slijrht  ri.se  occurs  and  an  irre^qdar  fever  persists.  Dulness 
continnos  at  the  base,  or  may  have  extended.  The  breathing  is  feeble 
and  there  are  no  rales.  Such  a  condition  may  be  closely  siimdated,  of 
course,  by  the  thickeiu'd  pleural  layers  which  are  so  commonly  found  after 
the  ])nounionia.  The  ipiesti>,n  should  be  settled  at  once  by  the  introduc- 
tion of  the  needle.  It  is  liy  no  means  an  nncominon  com])lication,  and 
many  cases  of  emiivema  su])|)osed  to  be  primary  are  in  reality  secondary  to 
a  sli<rht  inieumonia.     The  persistence  of  the  leucocytosis  is  an  important 

tioint. 

8 


^^ 


124 


srKcn'ic  iNFKcTiors  diskasks. 


I 'ni  run}  ills  is  iiiori'  cuiniiinii  in  I  lie  iinciimniiiii  of  cliililron.  piirtion- 
larlv  "lif'i  «l<>iil)lc.  iiiul  it  is  said  willi  llif  inicimioiiia  nf  tlw  Id't  side.  It 
is  itarticiilarlv  n|)t  to  joilnw  or  to  lie  assnciattil  witli  acutf  rlifimiati.-iii.  It 
was  jn'c'sciit.  as  I  statrd.  in  :>  nf  m,v  ino  aiitn|isii's.  'I'liini;.'li  nsuallv  i>lastif. 
llirrc  iiiav  III'  much  scnms  clVnsinn.  'riicn'  is  rardv  any  iliHicultv  in  tlic 
dia^'Miisis,  l»iit  wlicn  tin'  |inciini<inia  involves  the  portion  of  Inn;,'  covcrin;; 
ihc  pcricardintn,  tlitTc  may  !•»'  dillicnlty  in  dftcrininin}:,  l>y  pliysiial  sij^ns, 
the  existence  of  tlnid.  The  increase  in  the  dysjanea.  the  ;:reater  I'eelileness 
nf  the  pnlse,  and  the  >rradiia!  sn|(pres>ion  of  the  heart-sonnds  will  ;:ive  the 
iiKtst  vainahle  indications.  In  some  instances  the  tlnid  is  pnrnlent.  'riion^ih 
a  very  serions  event,  it  is  surprising,'  how  often  recovery  tidies  place  even 
in  the  most  desperate  cases  of  pnennioina  coniplicated  with  pericarditis, 
a  point  to  wiiieli  I  have  heard  Murcliison  refer. 

KitdiHiinlitix  is  still  more  frctpicnt,  and  in  my  HiO  autopsies  was  pres- 
ent in  111.  I  called  attention  in  the  (iulstonian  lectures  for  IS.s.")  to  the 
great  frecpicney  of  this  complication.  Of  v'Oii  cases  of  mali^inant  endo- 
carditis collected  from  the  literature,  a  I  occurred  in  this  disease.  Suh- 
seciucnt  ohservatioiis  have  fully  coiilirnu'd  this  statement.  Kanthack  found 
an  antecedent  imeunionia  in  M.".'  jier  cent  of  all  instances  of  infective  endo- 
earditis.  It  is  much  more  common  in  the  left  heart  than  in  the  '•ij.'ht. 
it  is  particularly  liaMe  to  attack  per>ons  with  old  valvular  disease.  The 
|»neumococcus  has  liein  found  in  the  ve.L'etations.  'I'here  may  he  no  symp- 
toms indicative  of  this  complication  even  in  very  severe  cases.  It  may. 
liowever,  he  suspected  in  cases  (1)  in  whicli  the  fever  is  iirotracted  and 
irrej^ular;  ('i)  when  signs  of  .sejitic  mischief  arise,  such  as  chills  and  sweats; 
(;j)  when  emholic  ]>henoniena  appear.  The  freipient  comiilii'ation  of 
meningitis  with  the  endocarditis  of  pneumonia,  which  has  already  heeii 
mentioned,  gives  prominence  to  the  eerehral  symptoms  iu  these  cases.  The 
])hysieal  signs  may  he  very  deceptive.  There  are  instanc<'s  in  which  no 
cardiac  nnirmurs  have  heen  heard.  In.  others  the  development  under 
ohservation  of  a  loud,  rough  murmur,  particularly  if  diastolic,  is  extremely 
suggestive. 

Mijorarditix  is  rare. 

Hi'drl-cliits. — Ante-mortem  coagnla  are  uncommon  in  ])ni'Uinonia,  even 
in  extreme  grades  of  dilatation  of  the  right  chamhi'r.  In  not  a  single  in- 
stance of  my  autopsies  were  there  globular  throndii  in  the  auricles  or  in 
the  apices  of  tl)(>  ventricles.     In  protracted  case  '"An  occasionally  i'lU'iu 

in  the  veins.     A  rare  complication  is  I'liilx.listi'  if  the  larger  arteries. 

1  saw  in  Montreal  an   instance  of  endior  femoral  artery  at  the 

lieiglit  of  pneunuinia.  whicli   lU'cessital  , cation  at   the  thigh.     The 

|iatient  recovered.     Ajiliasid  has  l)ee)i  n  .ih  in  a  few  instances,  setting 

in  abruptly  with  or  without  hemiplegia. 

}ft'iiii>(iih'x  is  perhnjis  the  most  serious  eomplication  of  pneumonia.  It 
varies  very  m\wh  at  diil'erent  tinu's  and  in  diiferent  regions.  My  Montreal 
o.xperienoo  is  rather  exce])ti(mal,  as  S  jier  cent  of  the  fatal  cases  had  this 
eomplication.  It  usually  conu's  on  at  the  height  of  the  fever,  and  in  the 
nuijority  of  the  eases  is  not  recognized  uidess,  as  before  mentioned,  the 
base  is  involved,  whicli  is  not  common.     ^leiiingitis  may  develop  later  in 


LOHAK   I'MU'MOXFA. 


125 


.  partion- 
sidf.  It 
Dtisiii.  It 
l_v  plastic. 
Ity  ill  till- 
;  CDVcriii^' 
ical  siffiis, 
rcclilciu'ss 
1  ;:iv('  tlic 
.  'riinii-h 
ilacf  even 
'ricanlitis, 

was  pfcs- 
iS.")  to  tilt' 
ant  ciiilii- 
isc.  Suh- 
ack  I'diiiid 

•tiVL'  I'lulo- 

tlic  ''i^lit. 
•asc.     Tlie 

no  synip- 
It  may. 
■acted  and 
lid  sweats; 
icatioii  of 
cadv  l)ocn 
ascs.    The 

which  no 
eiit    under 

extivinely 


oiua,  even 
sinji'le  in- 
iclcs  or  in 
iially  form 
er  arteries, 
erv  at  the 
ii<;"h.  The 
•es,  setting 

inoiiia.  It 
V  Montreal 
's  had  this 
and  in  the 
tioned,  the 
op  later  in 


the  disease,  and  is  then  iiK.re  easily  diagno>e.I.     In  snme  nises  i(   is  assoei- 

at.'d   with    inl.Mlive  ciidorarditis.     The   pn-imi ecus   has   h.vn    foinid    in 

the  exudate. 

rrri/,l,n„l  nmrilis  \<  i,  raiv  cniMplication.  of  uhich  sevral  ca^.^  Imve 
I'ccn  <l..scnlM.d.  I  siw  .,n..  \vell-n,arl<..d  instance  followjn-  pn..nn.nMia  and 
inthieMza  in  the  sprin-  of  IS!M..  There  \wis  neuritis  of  th..  I,.ft  „rin  uith 
(onsiderahle  wastiiij:. 

(loslrir  rn,nplin,ll„ns  aiv  rare.  A  croupous  ;rastritis  has  already  h.rn 
"'<'iH'""<'d  III.,  rrnnpnas  mlili,  uuxy  indii.e  severe  diarrh.ea.  ./mni^lirv 
IS  on."  .d  th..  most  inl..r..stin-  coniplicati.ms  uf  pn..iinionia  and  o,.urs  with 
curious  niv-iilarity  in  .lillVrent  outhivaks  of  the  .lisea.se.  It  s..ts  j,,  ,.nrlv 
IS  raivly  vry  inf.nse.  ami  has  n..t  Hie  ..haracfrs  ,>(  ol,..trii.tiv..  jaiin.lic"..' 
•••■re  are  ..as.-s  ,n  whi,.h  it  assunH.s  a  vry  >erious  f.,rn!.  Th..  mo.ie  .,f  m-.- 
'liK-t.on  IS  not  well  as.rrtained.  It  .lo,.s  not  app..ar  to  l,..ar  any  .lelinite 
'■'■iation  t..  the  dejrn.e  of  hepatic  ..nn.„..vni,.nt  an.l  it  is  c.rtainlv  n..t  .liio 
to  catarrh  oi  the  .lu.ts.     P.,ssil.ly  it  may  I.e.  in  -ivat  part.  ha.mato-,.noMs 

/</n-/,/,s.  ..ccasionally  oc.-ur.s,  co. ,nly   in   ass.u-iation   with   <.n.|..car- 

diti.s.     In  chihlren  nii.l.l!..-..ar  .lis,.as,.  is  not  an  ii.fr...pu.nt  c..mpli..ati.,n 

hni/hls  disntse  .Iocs  m,f  often  f..ll.nv  pneumonia.  J'n'ihmitis  is  ...v- 
ceedingly  rare. 

The  n.lations  ..f  rhi'iiiiHilIsm  and  pn..iini..nia  are  very  interesfin.r  The 
arthritis  may  pivc...!.-  th..  oMs,.t.  and  the  pne.im.mia.  p..ssihly  with' ,.ndo- 
.•iirditis  and  p!..,insy.  may  o.nir  as  a  .•omplication  of  the  rlH.umatism  In 
"Iher  iiistaiic..s  at  lli..  h..i-ht  ..f  an  ..r.linary  pneum.mia  on.,  or  two  joints 
may  heconi..  r,..l  an.l  sor...  ()„  the  other  liaii.l.  after  the  .'risis  has  ..cc'iirred 
jiaiiis  and  sw..|ling  may  come  ..u  in  the  joints. 

Relapse.— Tii..re  are  eases  in  whi.'h  fr.M.i  th..  ninth  t..  th..  ..I,.v..nlh 
day  tlie  l.-ver  siil.si.le.s,  and  after  the  tempera! uiv  Iims  1,..,.|,  „„rmal  f..r  i 
day  or  tw..  a  rise  occurs  and  fever  may  persist  lor  another  t.^n  -lays  or  vwn 
two  we..l<s.  TI1..UKI1  this  mi-ht  be  terme.l  a  r..iaps..,  it  is  nior..  "correct  to 
repird  It  as  an  instance  of  an  anomalous  ,„urse  of  .|..lay...l  r..solution 
Wa-ner.  who  ha.s  studied  the  sul.ject  caivfiiliy,  savs  that  in  his  jar-o  e.x- 
1-erience  ol  l.KJO  case.s  he  m..t  with  oidv  ;5  .loubtful  case.s.  Wli..n  it  does 
oc'iir.  the  attack  is  usually  ahorliv..  an.l  mild.  In  the  ca,<e  of  Z  l{  (Medical 
N".  I-.".';!*,  with  pneunmnia  of  the  ri-ht  lower  lohe.  crisis  occurre.l  ..'n 
the  seventh  day.  and  after  a  iioimal  ten;peratnre  for  thirteen  days  he  wis 
discharged.  That  ni-ht  he  had  a  shakin-  chill.  follow,.d  l.y  fev.'.r  ami  he 
iiad  murrin^r  ch.lls  with  reapp..arance  of  the  pm.un.onia:  In  a  second 
case  (Medical  No.  4r.;5S)  crisis  occurred  on  the  third  .lay,  and  there  wis 
recurn.nce  of  pneumonia  on  the  thirteenth  dav. 

Ucrunrnrr  is  more  common  in  pnc.umonia  than  in  any  other  acute 
dis(^ase.  l?ush  -ives  an  instance  in  which  there  were  'iH  attacks  Other 
authoriti..s  narrate  cases  of  8.  10.  and  even  more  attacks. 

Convalescence  in  j.neumonia  is  u.sually  prompt  an.l  rapid,  and  .so.niela. 
are  rair.  S..me  authors  sp..ak  of  a  su.l.len  fatal  collapse  wh..,,  the  patients 
are  alh.wed  to  pet  up  and  -..  about  too  soon.  With  the  onset  of  fever  and 
l.ersistence  of  the  leucocytes  the  a(r..cted  sid..  sh.mld  be  very  carefully 
ex-ammed   for  pleuri.sy.      AVitli   a   persistence  of  the  dulne.ss  the   i.hysica'l 


V2G 


SPECIFIC  INFECTIOUS  DISEASES, 


signs  may  he  oliseuro,  \nii  tlu-  iis(>  of  a  siiiall  exploratory  noodlo  will  1)0 
I'otmd  vcr\  satisfactory. 

Clinical  Varieties.  —  1 .  l-'H-al  variation  arc  rrsiionsiliK'  for  sonic  of 
the  most  marked  deviations  from  the  nsnal  type. 

Apcr  piii'iiiiionia  is  said  to  lie  more  often  associated  with  adynamic 
features  and  with  marked  cerebral  symptoms.  The  expectoration  and 
cou;;ii  may  lie  slight.  1  can  not  say  that  in  my  experience  the  cerebral 
sym^ptoms  in  adults  iiave  lieeii  more  marked  in  this  form,  nor  do  1  tliink 
it  necessarily  graver  than  if  situated  at  the  base.  ^ 

Miiinilon/  or  rrccpiiuj  pnnimuuia,  a  form  which  succossively  involves 
one  lobe  after  the  other. 

])(iuhl('  pncumunia  has  no  peculiarities  other  than  the  greater  danger 
connected  with  it. 

Mdssirc  pnnntiouia  is  a  rare  form,  in  which  not  alone  the  air-cells  but 
the  bronchi  of  ar.  entire  lolie  or  even  of  a  lung  are  lilled  with  the  librinous 
exudate.  The  auscultatory  signs  are  absent;  there  is  neither  fremitus  nor 
tubidar  breathing,  and  on  percussion  the  lung  is  abs(dutely  Hat.  It  closely 
resend)les  jileurisy  witii  elVusion.  Tiie  ni"  Is  of  the  bronchi  may  ije  ex- 
pectoratt'd  in  violent  tits  of  coughing. 

Central  Piunnnonui. — The  ■ntlammation  may  be  deep-seated  at  the 
root  of  the  lung  or  centrally  placed  in  a  lol)e.  ami  for  several  days  tiie  diag- 
nosis may  be  in  doubt.  It  may  not  be  until  the  third  or  fourth  day  tiiat  a 
pleural  fi'iction  is  detected,  or  that  dulness  or  blowing  breathing  and  rales 
are  recognized.  1  saw  recently  with  ])r.  Henry  Adler  and  Dr.  Chew  an 
instance  in  which  at  the  end  of  the  fourth  day  in  a  young,  thin-chested 
girl  all  the  usual  symptoms  of  imeumonia  were  iiresont  without  any  phys- 
ical signs  other  tium  a  few  clicking  rales  at  the  left  ajiex  behind.  The  thin- 
ness of  the  jiatient  greatly  facilitated  the  examlnaticm.  The  general  fea- 
tures of  ]ineumonia  continued,  ami  the  crisis  occur'X'd  on  the  seventh  day. 

2.  Pneumonia  in  Infanlx. — It  is  sometimes  seen  in  the  newborn.  In 
infants  it  very  often  sets  in  with  a  convulsion.  The  summit  of  the  lung 
seems  more  frequently  involved  than  in  adults,  and  the  cerebral  symptoms 
are  more  marked.  The  t(U'])or  and  cmna.  iiarticularly  if  they  follow  con- 
vulsions, and  the  preliminary  stage  of  excitement,  may  lead  to  the  diag- 
nosis of  meningitis,     rneumonic  sjiutuni  is  rarely  seen  in  children. 

3.  Pncnniouia  in  the  Af/rd. — The  disease  may  he  latent  and  set  in  with- 
out a  chill;  the  cough  and  expectoration  are  slight,  the  ])liysical  signs  ill- 
defined  and  changeable,  and  the  constitutional  symptoms  out  of  all  pro- 
])ortion  to  the  extent  of  the  local  lesion. 

4.  Pnnimonia  in  Alrolialir  Snhjrdx. — The  onset  is  insidious,  the  symp- 
t(uiis  masked,  the  fever  slight,  and  the  clinical  ])icture  usually  that  of 
delirium  tremens.  The  thermometer  alone  may  indicate  the  ])resencc  of 
an  acute  disease.  Often  the  local  condition  is  overlooked,  as  the  ])atient 
makes  no  complaint  of  pain,  and  there  may  bo  very  little  shortness  of 
breath,  no  cough,  and  no  sjmtum. 

5.  Terminal  Pneumania. — The  wards  and  the  post-mortem  room  show 
a  very  striking  contrast  in  their  pneumonia  statistics,  owing  to  the  occur- 
rence  of  what   may  be   called   terminal  pneumonia.     During  the   winter 


LOBAR  PNEUMONIA. 


Ilo  will  1)0 

n'  soiiu'  (if 

ailyiiiuiiic 
■ation  and 
ic  i'ori'i)ral 
ilo  1  tliiuk 

ly  involves 

t^'^  dangi-r 

ir-ct'lls  l)iit 
iC  lilii'imuis 
eniitns  nor 
It  closely 
may  bo  ex- 
tod  at  the 
•s  tlio  diajr- 

day  that  a 
ir  and  rales 
;•.  Chow  an 
hin-chostod 
:  anv  ])hvs- 
Tho  thin- 
;onoral  foa- 
^■enth  day. 
whom.  In 
)!'  the  Inng 
1  syinptomr^ 
follow  con- 
0  the  diag- 
Iren. 

set  in  with- 
al signs  ill- 

of  all  i)ro- 

,  the  svnip- 
dly  that  of 
])rosenee  of 
the  ])atient 
ihortness  of 

room  show 

)  the  oeeur- 

tho   winter 


12; 


inonth.s  i>ationts  with  ehronio  pnlnionarv  tuhoreulosis,  artorio-.leroM. 
l.oart  disease.  Jlright's  disease,  and  diabetes  are  not  in]iv.|ne„|lv  .arri,.! 
oil  by  a  pnennionia  whieh  may  give  Jew  or  no  si-ns  of  its  presenee  There 
inay  be  a  slight  elevation  of  temperature,  with  in-rease  in  the  respiration. 
l">t  the  pafent  is  near  tlio  end  and  p.rhaps  not  in  a  condition  in  which' 
a  thon.ngj,  j.hysical  examination  can  be  made.  The  antopsy  may  show 
pneumonia  oi  the  greater  part  of  one  louvr  lob,,  or  of  the  apex,  which  had 
entirely  escaped  notice.  In  diabetic  patients  the  disease  often  runs  a  rapid 
and  severe  course,  and  may  end  in  abscess  or  gaiM'rcno 

Some  of  the  most  remarkable  variations  in  tlu"  clinical  course  of  pneu- 
monia depend  probably  npon  the  severity,  possiblv  upon  the  nature  of  tho 
nilectiyc  agent.  Further  investigation  may  enable  us  to  sav  how 'far  the 
a.ssociated  organisms,  so  olteii  present,  may  be  responsible  for  the  diU'er- 
oncos  111  the  clinical  course. 

6.  Snondarn  J'»rummnas.~'V]w,c  are  met  with  clii,.|lv  in  the  specific 

fevers,   i.nl,cularly  diphtheria,   typhoid  fever,  typhus,  iiuhuMiza,  and   the 

phig.ie.     Anatomically,  they  rarely  present  the  typh^al  ior,„  „f  ,-,.,1  or  -n'ay 

lopati^atioii.     I  he  surface  is  smoother,  not  so  drv.  an.l  it  is  oft.-n  a  p.eudo- 

lobar  condition,  a  consolidaticm  caused  by  closelv  set  areas  of  lobular  in- 

-Ivenient      ll,stol.>gicalIy,  they  are  c.linracterl.cd  in  nianv  instancvs  bv  a 

niore  ce  lular,  less  hbrnious  exudate,  which  may  also  inliltnite  tho  alveolar 

Malls      Lactonologically,  a  large  number  of  diUVivnl  ..rganisms  have  been 

found    the  specific  microbe  of  the  primary  di..oaso,  usually  in  association 

ith  the  sreptococcus  pyogenes  or  the  staphylococcus;  in  .some  instances 

0  colon  bacillus  has  been  ,.rcsent.     Finkler  has  attempted  to  separate  a 

pocial  form   which  h.  calls  the  amir  rrllular  pncnnonia,  to  which  most  of 

these  secondary  types  conform  and  which  have  the  liistological  characters 

already  relerred  to  (Die  Acuteii  LungenentzundunL'en,  ]S!)l) 

The  symptoms  of  the  secon.lary  imeumonias  "often  la<d<  the  striking 
<ieiinitoness  ot  the  primary  croupous  pneumonia.  Th,-  pulmonary  features 
may  bo  latent  or  masked  altogether.  There  may  be  no  ,.ough  and  only  u 
slight  increa,.o  in  the  number  of  respirations.  The  lower  lobe  of  one  lun^^ 
IS  m..st  commonly  involved,  and  the  ,.liysical  signs  are  obs.-uro  and  rarolv 
amount  to  more  than  impaired  resonance,  feeble  breathing,  and  a  few 
crackling  rale.s.  In  some  instances  when  the  consolidation  is  ext,>n.ive  the 
breathing  IS  distinctly  tubular. 

7.  Epuhmlr  pimiwonia  has  already  been  referred  Ux.  It  is  as  a  rule 
more  fatal  and  often  displays  minor  con.i.lieations  wliic^h  dill'er  in  dilfor- 
ent  outbreaks.  In  some  the  cerebral  manifestations  are  very  marked;  in 
others,  the  cardiac;  in  others,  again,  the  gastro-intestinal 

8  Larval  JWrnnnma.-^VM,  abortive  types  are  seen,  ,,arti<.ular]v  in 
nstitu  lons  when  pneumonia  is  prevailing  extensivelv.  A  ,.atient  may 
have  the  nntial  symptoms  of  the  di,«ease,  a  slight  ch'ill,  moderate  feve; 
a  few  mderimte  local  signs,  and  her,,os.  The  whole  process  may  only  last 
for  two  or  tliree  days;  some  authors  recognize  even  a  on.Mlay  piuMunonia. 
f).  Aslhnnc,  ],,nr,  or  Tj,phn!,l  P„n,nmun.~'Vh,.  toxaMiiio  features 
dominate  the  scene  throughout.  The  local  lesions  may  bo  slight  in  extent 
and  the  subjective  i.henomena  of  tho  disease  absent.  "The  nervous  svmp- 


128 


SPECIFIC  INFECTIOUS  DISEASES. 


tonis  usually  prodominate.  There  arc  tielirium,  prostration,  ami  early 
weakness.  \ery  frecjuently  there  is  jaundiee.  Gastro-intestinal  syiuptonis 
may  l)e  jireseiit,  jiarticularly  diarrluea  and  meteorism.  In  such  a  case,  seen 
about  the  end  of  the  first  weelv,  it  may  l)e  dillicult  to  say  whctlier  the  con- 
dition is  one  of  asthenic  i)neum()nia  or  one  of  typhoid  fever  whicli  has  set 
in  with  early  localization  in  the  lun<f.  Here  the  Widal  reaction  would  be 
an  important  aid.  In  these  cases  there  is  really  a  i)neumot-occus  septi- 
caMuia,  and  the  organisms  may  sometimes  l)e  isolated  froui  the  blood. 
Possibly,  too,  there  is  a  mixed  infection,  and  the  stre])toc(K('Us  pyogenes 
may  be  in  large  i)art  responsil)le  for  the  toxic  features  of  the  di>ease. 

10.  Associalion  uf  I'neumunia  irith  other  Diseases. — {a)  ir///(  Mulario. 
—A  malarial  jmeumonia  is  described  by  many  observers  and  thought  to  lie 
]mrticularly  ])revalent  in  some  parts  of  this  country.  One  hears  of  it,  in- 
deed, even" where  true  malaria  is  rarely  seen.  With  our  large  experience  in 
malaria,  amounting  now  to  nearly  ^,000  oases,  and  a  consi(leral)le  nuMd)er 
of  })neumonia  patients  every  year,  we  have  only  had  a  few  cases  in  which 
the  latter  disease  has  developed  during  malarial  fever,  or  vice  versa.  In 
either  case  the  malaria  yields  promi)tly  to  the  action  of  quinine.  So  far  as 
the  Southern  States  are  concerned,  the  (piestion  of  a  sjiecial  form  was 
thrashed  out  years  ago  in  a  discu.«sion  between  ]\Ianson  and  W.  T.  Jloward, 
and  was  decided  in  the  negative.  A  form  of  pneumonia  directly  dependent 
njion  tiie  malarial  ])arasite  is  nnknowti.  We  have  not  heen  able  to  recog- 
nize here  a  pneumonia  which  is  iidluenced  in  any  way  hy  the  malarial 
])oison.  Such  a  case  as  the  following  we  see  occasionally:  A  ]tatient  was 
admitted,  March  10,  18!»1,  with  tertian  lualarial  fever.  'J'he  lungs  were 
clear.  A  pneumonia  began  thirty-six  hours  after  admission.  (Quinine  was 
given  that  evening,  and  the  malarial  organisms  rapidly  disappeared  from 
the  blood.  There  was  successive  involvement  of  the  right  lower,  the  middle, 
and  the  left  lower  lobe.  The  temperature  fell  by  crisis  on  the  '^'Ith,  and 
there  were  no  features  in  the  disease  whatever  suggestive  of  malaria.  In 
other  instances  we  have  found  a  chill  in  the  course  of  an  ordinary  ])neu- 
mouia  to  he  associated  with  a  malarial  infection,  and  (|uiniiu>  has  rai)idly 
and  promptly  caused  the  disappearance  of  the  parasites  from  the  Ivlood. 

(h)  Puenmonia  and  .\cute  liheuntatisvi. — We  have  already  spoken  under 
complications  of  this  association,  wliich  is  more  fre(|Uenlly  seen  in  children. 

((■)  I'linniKiiiia  and  Tiibercalo.tis. — ^lany  subjects  oi'  chronic  pulmonary 
tuhercidosis  die  of  an  acute  croupous  pneumonia.  A  point  to  i)e  specially 
borne  in  mind  is  the  fact  that  acute  tuberculous  ])neumonia  may  set  in 
with  all  the  features  and  physical  signs  of  fibrinous  ])neumonia  (see  page 
•^t)0). 

For  the  consideration  of  tlio  association  of  pneumonia  with  typhoid 
fever  and  influenza,  the  reader  is  referred  to  the  sections  on  those  diseases. 

11.  Post-ftpernlion  Pneiininnia. — Before  the  days  of  anaesthesia,  lobar 
pneumonia  was  a  well-recognized  cause  of  deatli  after  surgical  injuries  and 
operations.  Xorman  Cheevers,  in  an  early  number  of  the  (iuy"s  Hospital 
Reports,  calls  attention  to  it  as  one  of  the  most  frequent  causes  of  death 
after  surgical  procedures,  and  Erichser  states  that  of  41  deaths  aft(>r  sur- 
gical injuries  23  cases  exhibited  signs  of  pneumonia.     The  lobular  form 


LOBAR  PXEL'MOXIA. 


129 


1,  and  early 
al  syiuptoius 
1  a  case,  soon 
tlior  the  oon- 
ihioli  has  sot 
ion  would  bo 
oucoiis  sopti- 
1  tho  blood. 
[■us  pyogenos 
i>oaso. 

'///(  Maltirii'. 
liou<rlit  to  1)0 
'ars  of  it,  in- 
pxporionce  in 
;-al)lo  nnnibor 
isos  in  whioh 
ce  versa.  In 
10.  So  far  as 
ial  form  was 
.  T.  Howard, 
:ly  dopendont 
iblo  to  rocof,'- 
tlio  malarial 
L  pationt  was 
0  hull's  woro 
(Quinine  was 
ppoarod  from 
r,  liio  middlo, 
ho  ^'Ith,  and 
malaria.  In 
•dinary  pnou- 
0  has  rapidly 
tho  l<lood. 
spokon  undor 
n  in  cliildron. 
ic  pulmonary 

0  1)0  sjx'c  ially 
a  may  sot  in 
Ilia  (soo  page 

with  typhoid 
thoso  disoasos. 
'sthosia,  lobar 

1  injurios  and 
uy"s  Hospital 
msos  of  doath 
tlis  a  ft  or  snr- 

lobular  form 


is  the  most  frequent.     I  have  already  roforrod  to  tho  eontnsion-pnoiimonia 

1  "I  11  T      •   J    . 


(h'SO 


ribod  by  Litton 


]'-i.  Ellivr  I'licitiiiuiiid. — Tho  qnostion  of  a  direct  relation  between  ether 
narcosis  and  i)noumonia  has  been  much  discussed  within  tho  past  year, 
having  lieen  raised  by  ^Mr.  Lucas,  of  (iuy"s  Hospital.  The  statistics  are  by 
111)  means  unanimous,  rrescott,  of  Jioston,  in  -lO,!)!)!)  eases  found  only  3 
of  acute  lobar  pneumonia.  Tho  London  ana'sthotists,  partii.-ularly  ilewilt 
and  Silk,  seem  also  to  have  had  a  fortunate  o.xperieneo.  Silk  having  found 
among  .-),U()0  eases  lli  of  pneumonia:  S  of  tlieso  were  tongue  or  jaw  cases. 
The  (iorman  exporioneo  is  very  diiferent.  \'oii  iUrk  states  that,  owing  to 
'he  injurious  after-eireets  ujion  the  respiratory  tract,  the  use  of  ether  has 
been  largely  restricted  in  Czerny's  clinic.  (Jurlt  reports  r)"J,17T  cases,  with 
:>U  cases  of  pneumonia  and  lo  deatlis.  On  the  surgical  side  of  tlie  Johns 
ilojikins  Ilos[)itaK  Dr.  Uloodgood  tells  me  there  have  boon  15  eases  of 
|incumonia  following  ana'stliesia;  \'i  of  those  have  been  broncho-pnen- 
iiionias;  T  deatiis  and  S  recoveries;  7!)  jior  cent  of  the  eases  followed  ab- 
dominal section  or  hernia  operations.  Czorny  suggests  that  the  relation 
of  those  other  pneumonias  to  abdominal  operations  is  associated  with  tho 
})ain  on  coughing,  which  loads  to  an  accumulation  of  secretion,  aiul  through 
this  to  retention  or  as])iration  pneumonia.  Among  the  various  views 
brought  forward  to  account  for  it  are  tho  rapid  evaporation  of  the  other, 
causing  cliilling  of  the  ])ulnionary  tissues,  chilling  of  the  patient  at  the 
time  of  ojioration,  infection  from  the  inhaler,  and  direct  action  of  (he 
ether. 

The  probability  is  that  the  jirolonged  etherization  lowers  the  vitality 
of  the  tissues  of  the  liner  bronchi  and  permits  the  pathogenic  organisms 
(which  are  almost  always  present)  to  <lo  their  work.  The  pneumonia  is 
more  fre(|uently  lobular  than  loiiar.  Xeuwerck,  ami  subsecpicutlv  Whifnov, 
have  suggested  thorough  disinfection  of  tho  mouth  and  throat  before 
operation. 

lo.  Drhtiiril  li'i'si.h(Hi)ii  in  Piictiiiioiild. — Tho  lung  is  restored  to  its  nor- 
inal  state  partly  by  the  expectoration  of  the  exudate,  partly  by  its  li(piefae- 
tion  and  al)sori)tion.  '^riiore  are  eases  in  which  resolution  takes  place  rapidly 
without  any  increase  in  or,  indeed,  without  any  exiuu'toration;  on  the 
other  hand,  during  resolution  it  is  not  um'omnmn  to  tlnd  in  the  sputa  tho 
little  plugs  of  iii)rin  and  leucooytos  which  have  been  loosened  from  the 
air-eells  and  expelled  by  coughing.  In  a  majority  of  cases  both  processes 
are  jirobably  at  work.  A  variable  time  is  taken  in  tho  restoration  of  tho 
lung.  Sometimes  within  a  week  or  ten  days  tho  dtdness  is  greatly  dimin- 
ished, the  breath-sounds  become  clear,  and,  so  far  as  physical  signs  are 
any  guide,  the  lung  seems  ])orfectly  re.«torod.  Tt  is  to  be  remembered  that 
in  any  case  of  ])nenmoiiia  with  extensive  pleurisy  a  certain  amount  of 
dulness  will  ))orsist  for  months,  owing  to  thickening  of  the  jtloura. 

Delayed  resolution  is  a  condition  which  causes  much  anxiety  to  the 
physician.  While  it  is  ])erhaps  more  frecpient  in  debilitated  persons,  yet 
it  is  mot  with  in  robust,  jireviously  healthy  individuals,  and  in  eases  which 
have  had  a  very  ty])ical  onset  and  course.  Tho  ootMlilion  is  stated  to  he 
most  frequent  in  apex  pneumonia.     Yencsection  has  been  assigned  as  a 


.1: 


I'l 


130 


SPBX'IPIC  INFECTIOUS  DISEASES. 


c•lUls^c.  There  is  no  question  that  tlie  solid  exudate  can  jx'Tsist  for  weeks 
and  yet  llie  integrity  ol'  the  lung  may  idliinately  ho  restored.  (Jrissole  de- 
Herihes  the  lung  I'roin  a  jiatient  who  died  on  the  sixtieth  day,  in  which  the 
uU'eeted  |mrt  showed  a  eondition  not  uidike  that  oi'  the  aeute  stage. 

Clinieally,  there  are  several  groups  of  eases:  First,  those  in  wiiieh  th.' 
crisis  occurs  naturally,  the  temperature  falls  and  remains  normal,  hut  the 
local  features  ])ersist— well-nuirked  llalness  with  tuhular  lireathmg  and 
rales.  Kesolution  may  occur  very  slowly  and  gradually,  taking  from  two 
to  three  weeks.  Jn  a  second  group  of  cases  the  temperature  falls  hy  lysis, 
and  with  the  persistence  of  the  local  signs  there  is  slight  fever,  s(,metimes 
f^weats  and  rajtid  i)ulse.  The  condition  may  i)ersist  for  three  or  four  weeks, 
or,  as  in  one  of  my  c«ses,  for  eleven  weeks,  and  ultimately  perfect  resolution 
occur.  During  all  this  time  there  may  l)e  little  or  no  sputum.  The  jirac- 
titioncr  is  naturally  much  exercised,  and  he  dreads  lest  tuberculosis  should 
supervene.  In  a  third  grou})  the  crisis  occurs  or  the  fever  falls  hy  lysis, 
but  the  nmsolidation  persists  and  there  may  be  intense  Immchial  breath- 
ing, with  few  or  no  rales,  or  the  fever  may  recur  and  tlH>  ].atient  may  die 
exhausted.  In  1  of  mv  100  autopsies  a  i)atient,  aged  lifty-eight,  had 
died  on  the  thirty-second  day  fnm.  the  initial  chill.  The  right  lung  was 
solid,  grayish  in  color,  firm,  and  presented  in  places  a  translucent,  semi- 
homogeneous  as]K"ct.  In  these  areas  the  alvec.lar  wails  were  ihickeiuMl.  and 
the  phigs  filling  the  air-cells  were  undergoing  transformation  into  new 
connectiv(>  tissue.  This  fibroid  induration  may  })roceed  gradually  and  l>e 
associated  with  shrinkage  of  the  affected  side,  and  the  gradual  prodr.ction 
of  a  cirrhosis  or  chronic  interstitial  ])neumonia. 

Ordinary  fibrinous  pneumonia  never  terminates  in  tul)erenlosis.  The 
instances  of  caseous  ])neunionia  and  softening  which  have  followed  an 
acute  pneumonic  process,  have  been  from  the  outset  tuberculous  (see  page 

290). 

14.  Trrmliialinii  in  Ahsrrss.—Thii^  occurred  in  -I  of  my  100  autopsies. 
Usually  the  Inng  breaks  down  in  limited  areas  and  the  abscesses  are  not 
large,  hut  they  may  fuse  and  involve  a  considerable  pro])orti(m  of  a  lobe. 
The  condition  is  recognized  by  the  sputa,  which  is  usually  abundant  and 
contains  ])us  and  elastic  tissue,  sometimes  cholesterin  crystals  and  luenia- 
toidin  crystals.  The  cough  is  often  iiaroxysmal  and  of  great  severity; 
usually  the  fever  is  remittent,  or  in  protracted  eases  intermittent  in  char- 
acter, and  there  may  be  ]ironounced  hectic  symptoms.  When  a  ease  is 
seen  for  the  first  time  it  may  be  dinieult  to  determine  whether  it  is  one 
of  abscess   of  the   lung   or   a   local   eini>y:enia   which   has   ])erforated    the 

lung. 

15.  Ganqrcnc. — This  is  most  commonly  seen  in  old  debilitated  ])ersons. 
Tt  was  i)resent  in  3  of  my  100  autojisies.  It  very  often  occurs  with  abscess. 
The  gangrene  is  assoc"  ted  with  the  growth  of  the  saprophytic  bacteria  on 
a  soif  m;nle  favorable  by  the  presence  of  the  pneumococcus  or  the  strepto- 
coccus. Clinically,  the  gangrene  is  rendered  very  evident  by  tlie  horribly 
fetid  odor  of  the  expectoration  and  its  characteristic  features.  In  some 
instances  the  gangrene  may  be  found  ]>ost-mortcni  when  clinically  there 
has  not  been  any  evidence  of  its  existence. 


It 

1  I 

:i! 


LOBAR   PNEUMONIA. 


i;]i 


for  weeks 
rissole  dc- 
wliieli  the 

wliieli  the 
1,  hut  the 
liiiig   and 

i'roin  two 
ri  l)y  lysis, 
si.iuetimes 
Diir  weeks, 
resolution 
Tlie  prae- 
)sis  should 
s  hy  lysis, 
ial  hreat li- 
lt may  die 
L'if^lit,  iiad 
;  lung  was 
'ent,  senii- 
kcned,  and 

into  new 
Hy  and  ho 
prodi'.etion 

losis.  The 
illowed  an 
s  (see  page 

I  autopsies, 
ses  are  not 
of  a  lohe. 
mdant  and 
luid  ha'uia- 
it  severity; 
ut  in  ohar- 
1  a  ease  is 
'r  it  is  one 
I'o rated    tiie 

ed  ]iersons. 
ith  al)seess. 
haeteria  on 
(lie  strejito- 
he  horrihly 
In  sonic 
ically  there 


Prognosis. — Pnenmonia  is  the  most  fatal  of  all  aeute  diseases,  killing 
more  than  (njiiiliieria,  and  ranl<ing  next  to  consumption  as  a  cause  of  dcatli. 

Ilos|)ital  statistics  show  tiint  tiie  mortahty  ranges  from  I'O  to  Id  |icr 
cent.  Of  l.ol:.*  ca.<es  at  the  Montreal  (ieneral  Hospital,  the  morlality 
was  20. \  jicr  cent.  It  appears  to  lie  somewhat  more  fatal  in  southi'rn 
climates.  Of  ;5,U(J!)  eases  ti'cated  at  tiie  Cliarily  ilosiiital,  New  Orleans,  the 
death-rate  was  38.01  per  cent.  Of  tlie  lirst  T.M  eases  admitted  to  or  devel- 
oping in  the  Johns  Hojikins  Hospital,  lu  died,  a  mortality  of  v!!).S  per  cent. 
Jii  TOl  cases  at  tlie  J'ennsylvania  Hospital  tlie  mortality  was  'J!)  per  cent. 
At  the  lioston  City  llosjiital  in  l,ll;5  cases  the  mortality  was  vMt.l  jier  cent. 
Jt  has  licen  urged  that  the  mortality  in  this  disease  has  heeii  sti'adily  iii- 
crea-Miig.  and  attempts  have  been  made  to  connect  this  increase  with  the 
expectant  ]ilan  of  treatment  at  present  in  vogue.  I'lut  the  careful  and  thor- 
ough analysis  hy  C  X.  Townsend  and  A.  Coolidge,  Jr.,  of  1,000  cases  at 
the  Massachusetts  (ieneral  Jlosi)ital  indicates  clearly  that,  when  all  cir- 
cumstances are  taken  into  consideration,  this  conclusion  is  not  justilied. 
They  found  that  when  all  fatal  cases  over  (i!'ty  years  of  age  were  omitted, 
and  those  patients  who  were  delicate,  intemperate,  or  the  suhject  of  some 
complication,  there  was  very  little  variation  from  decade  to  decade,  and 
that,  excluding  these  eases,  the  rate  was  hut  little  over  10  per  cent.  In 
answer  to  the  assertion  that  tlie  moditied  treatment  is  in  part  responsihle 
for  the  increased  mortality,  these  authors  show  clearly  that  the  rise  in 
death-rate  took  place  in  the  period  jirior  to  18G0,  when  the  treatment  was 
entirely  or  in  great  part  heroic. 

According  to  the  analysis  of  TOS  cases  at  St.  Thoniiis's  Hospital  hy 
Iladden,  H.  W.  (J.  ^IcKeiizie.  ami  \V.  W.  Ord,  the  mortality  progressively 
increases  fnun  the  twentieth  year,  rising  from  'A.7  per  cent  under  that  agt> 
to  "22  per  cent  in  the  third  decade,  ;50.S  p(>r  cent  in  the  fourth,  17  per  cent 
in  the  fifth.  51  per  cent  in  the  sixth,  (!.")  p(>r  cent  in  the  seventh  decade. 
Of  '.>'i;5,T;iO  cases  collected  hy  Wells  from  various  .sources,  10,'JT(1  died,  a 
mortality  of  1S.1  per  cent. 

Tlie  mortality  in  private  ]iraetie(>  varies  greatly.  Jv.  P.  Howard  treated 
ITO  cases  with  only  (!  per  cent  of  deaths.  Fiussell  has  recently  reported  I'M 
eases  with  a  mortality  of  17.!)  per  cent.  The  mortality  in  children  is  some- 
times very  low.  ]Morrill  has  recently  reported  G  deaths  in  I'i'.i  ea.s(>s  of  frank 
pneumonia.    On  the  other  hand,  Goodhart  had  25  deaths  in  liiO  cases. 

The  following  are  among  the  eircnmstanees  which  influence  the  'rog- 
nosis: 

Age. — As  Stnrges  remarks,  the  old  are  likely  to  die,  the  young  to  re- 
cover. Tender  one  year  it  is  more  fatal  than  between  two  and  five.  Fus- 
sell  lost  5  out  of  H  eases  in  yearlings.  At  alioiit  sixty  the  death-rate  is  very 
high,  aimmnting  to  (10  or  80  jier  cent.  So  fatal  is  it  in  this  country,  at  least, 
that  one  may  say  that  to  die  of  ])neunionia  is  the  natural  end  of  old  jieojilo. 

As  already  stated,  the  disease  is  more  fatal  in  the  negro  than  in  the 
white  race. 

Previous  hahits  of  life  and  tlie  condition  of  hodily  health  at  the  time 
of  the  attack  form  the  most  important  factors  in  the  jirognosis  of  pneu- 
monia.   In  analyzing  a  series  of  fatal  cases  one  is  very  much  impressed  with 


H' 


132 


SPECIFIC  INFECTIOUS  DISEASES. 


the  miinlicr  of  cases  in  wliich  the  orfrans  sIidw  signs  of  (Icgcnoratioii.  In 
'.\")  of  my  1(10  iiiitoiisics  at  the  Montreal  (Jeneral  Jlospital  the  kidneys 
sliowed  extensive  interstitial  eiianges.      IiKJividuals  del)ilitaled    from  siek- 

iiess  or  poor  i' I,  hard  drinkers,  and  that  large  elass  of  hospital  patients, 

coniposed  of  rohust-looking  lal)orers  hetween  the  ages  of  forty-Iivo  and 
sixty,  wiiose  organs  show  signs  of  wear  and  tear,  and  who  iuive  hy  excesses 
in  alcoiiol  weakened  the  reserve  power,  I'all  an  easy  prey  to  tlie  disease. 
\'erv  few  fatal  cases  occur  in  rohnst,  healthy  adults.  Some  of  the  statistics 
given  hy  army  surgeons  show  hetter  tlum  any  cithers  tiie  low  mortality 
Irom  ]»neuinonia  in  healthy  picked  men.  The  death-rate  in  Mie  (ierman 
army  in  over  ^O.OOO  cases  was  only  ;{.(!  \)vt  cent. 

('ertain  r(mij>liniliiiiis  and  terminations  are  jiarticularly  serious.  The 
meningitis  of  pneumonia  is  |irol)ahly  always  fatal.  Kndocarditi.s  is  ex- 
tremely grave,  much  more  so  than  jieriearditis.  Ajmrt  from  these  serious 
complications,  tiie  fatal  event  in  ])nenmonia  is  due  either  to  a  gradual 
toxa'mia  or  to  nu'chanical  interference  with  the  respiration  and  circulation. 

Toxivmia  is  the  important  jmignostie  feature  in  the  disease,  to  which  in 
a  majority  of  tlie  cases  the  degree  of  ])yrexia  and  the  extent  of  consolidation 
are  entirely  snhsidiary.  It  is  not  at  all  proportionate  to  the  degree  of  lung 
involved.  A  severe  and  fatal  toxu'mia  may  develop  with  the  consolidation 
of  only  a  small  ]mrt  of  one  lohe.  On  the  other  hand,  a  patient  witii  com- 
])lete  solidiiication  of  one  lung  may  have  no  signs  of  a  general  injection. 
The  (luestion  of  individual  resistance  seems  to  he  the  most  important  one, 
and  one  sees  even  most  robust-looking  individuals  fatally  stricken  within 
a  few  days. 

!Mucli  stress  has  been  laid  of  late  upon  tlie  factor  of  Icurnriitosis  as  an 
clement  in  the  ])rognosis.  A  very  slight  or  complete  absence  of  a  leuco- 
cytosis  is  regarded  as  very  unfavm-able.  Of  the  'i'i  eases  from  my  wards 
re])orted  by  Billings,  only  1  showed  a  complete  absence  during  the  entire 
course  of  the  disease.  In  (5  fatal  cases  there  was  an  absence  of  leucoeytosis 
at  some  period  of  the  disease.  As  a  rule,  it  may  be  said  that  the  continuous 
absence  of  leucoeytosis  is  unfavorable. 

Death  from  direct  interference  with  the  function  of  res])iration  is  rare. 
It  may  hapjien  in  extensive  doid)le  ]nieunionia.  but  even  with  involvement 
of  a  very  large  section  of  bf)th  lungs  recovery  may  take  ])lace.  A  very  im- 
portant element  in  the  prognosis  is  the  condition  of  the  heart,  from  failure 
of  which  (juite  as  many  die  as  from  the  intoxication.  The  heart  weakness 
nuiy  be  due  either  to  the  specific  action  of  the  poison,  to  the  prolonge<l  fever, 
or  to  over-distention  of  the  right  chambers.  All  three  factors  may  be  at 
work  together.  T  have  already  referred  to  the  sudden  onset  of  serious  car- 
diac weakness;  more  ccmimonly  there  is  a  gradually  increased  ra])idity  with 
increasing  weakness  of  the  heart  muscle.  The  pulse  is  not  always  a  safe 
guide;  since,  as  I  mentioned  before,  it  may  lie  full  and  soft  and  not  very 
rapid  within  a  few  hours  of  a  fatal  termination,  even  in  cases  witliout  pro- 
nounced toxremia. 

Diagnosis. — Xo  disease  is  more  readily  recognized  in  a  large  majority 
of  the  cases.  The  external  characters,  the  s])nta,  and  the  physical  signs 
combine  to  make  one  of  the  clearest  of  clinical  pictures.     After  a  study 


LOUAll   I'NKrMONIA. 


r:,[\ 


noratioii.     In 

tlio   kidncvs 

■(I   I'roiii  sick- 

)itiil  patient!*, 

orty-livo  and 

,1'  ])\  cxc'i'Sfict; 

»  the  (list'iii-o. 

tlu'  statistics 

low   mortality 

Mk'  (irrnuin 

sfi'ioiis.  The 
arditis   is  ex- 

tlii'so  serious 

to  a  <i;ra(lual 
id  eireulation. 
3,  to  whith  in 

consolidation 
k'jrrcc  of  hinjf 

consolidation 
Mit  witli  coni- 
■ral  infection. 
n|)ortant  one, 
ricken  within 

■nriiloxis  as  an 
•e  of  a  k'uco- 
om  my  wards 
in<x  the  entire 
)f  leucocytosis 
he  continuous 

ration  is  rare. 
1  involvement 
.  A  very  im- 
,  from  failure 
cart  weakness 
olon<:'e<l  fever, 
irs  may  he  at 
if  serious  car- 
ra])idity  with 
always  a  safe 
and  not  very 
;  without  ])r()- 

lar<re  majority 
physical  sipns 
After  a  study 


in  the  post-mortem  room  of  my  own  ami  others"  mistakes,  I  think  that 
the  ordinary  lobar  pneumonia  of  adults  is  rarely  overlooked,  i-'.rrors  are 
jiarticularly  lial)le  to  occur  in  the  iiitercurreiil  pneumonias,  in  those  com- 
plicating' chronic  all'ections,  and  in  the  disease  as  met  with  in  ciiildren.  tlie 
;',<a'd,  and  (lruid<ards.  'l'iihei(nlo-|ineumonie  phthisis  is  freipieiitly  con- 
ionndi'd  with  pneumonia.  Pleurisy  with  elfusion  is,  1  helieve,  not  often 
mistaken  except  in  children.  The  diagnostic  iioints  will  he  referred  to 
under  pleurisy. 

In  diabetes,  l'>ri>rht's  dist'ase,  chronic  heart-disi'ase.  pnlmnmiry  jihthi^is, 
and  cancer,  an  acute  pneumonia  often  ends  the  scene,  and  is  fre(piently 
overlooked.  In  these  cases  the  temperature  i^  perhaps  the  i)est  index, 
and  should,  more  particularly  if  cough  develops,  lead  to  a  carefid  examina- 
tion of  the  lungs.  The  absence  of  expectiu'ation  and  of  pulmonary  symp- 
toms may  make  the  diagnosis  very  dillicult. 

In  children  there  are  two  special  sources  (d'  error;  the  disease  may  he 
entirely  masked  by  the  cerebral  symi)toms  and  the  case  mistaken  for  one 
of  meningitis.  It  is  remarkable  in  these  cases  how  U'w  indications  there 
are  of  pulmonary  trotible.  The  other  condition  is  jileurisy  with  elfusion, 
which  in  children  often  has  deceptive  physical  signs.  The  breathing  may 
he  intensely  tubular  and  tactile  fremitus  may  be  jiresent.  The  exploratory 
needle  is  sometimes  recpured  to  decide  the  (piestion.  In  the  old  and  de- 
bilitated a  knowledge  that  the  onset  of  jjucunionia  is  insidious,  and  that 
the  symptoms  are  ill-dedned  and  latent,  shoidd  i)ut  *he  practitioner  on  his 
guard  and  make  him  very  careful  in  the  examination  of  the  lungs  in  doubt- 
ful eases.  In  chronic  ahoholism  the  cerebral  symptoms  mny  predominate 
and  completely  mask  the  local  jn'ocess.  As  nientioiu'd,  the  disease  may 
assume  the  form  of  violeid  mania,  hut  more  commoidy  the  symptoms  are 
those  of  delirium  tremens.  In  any  case  rapid  pulse,  rapid  res|)iration,  and 
fever  are  symjitoms  which  should  invariably  excite  susjjicion  of  inllamma- 
tion  of  the  lungs.  Tnder  cerebro-siiinal  meningitis  will  be  found  the  |)oints 
of  dilferential  diagnosis  between  piu'umonia  and  that  disease. 

I'lieumonia  is  rarely  confounded  with  ordinary  consumption,  but  to 
dilTerentiate  acute  tubc'rculo-]>iicumonic  jihthisis  is  often  dillicult.  The 
case  may  set  in  with  a  chill.  It  may  he  imjiossible  to  determine  which 
condition  is  |  eseiit  until  softening  occurs  and  elastic  tissue  and  tuberch! 
hacilli  ajjpear  in  the  s])utum.  A  sin.iilar  mistake  is  sometimes  made  in 
children.  With  typhoid  fever,  ]ineumonia  is  not  infrecpicntly  confounded. 
There  are  instances  of  imeumonia  with  the  local  signs  well  marked  in 
which  the  jialient  ra])idly  sinks  into  what  is  known  as  the  typhoid  state, 
Avith  dry  tongue,  rapid  i)ulse,  and  diarrhoea.  T'nless  the  case  is  seen  from 
the  outset  it  may  he  very  dillicult  to  determine  the  true  nature  of  the 
malady.  On  the  other  hand,  there  are  cases  of  tyjdioid  fever  which  set  in 
with  symptoms  of  lobar  ])neumonia — the  so-called  ))i\'umo-typh us.  It  may 
he  imixissiblr  to  make  a  dilTerential  diairnnsis  in  such  a  case  unless  the 
characteristic  eruption  develops  or  the  Widal  reaction  be  found. 

Prophylaxis. — The  (pu'stion  of  the  prevention  of  imeumonia  is  a 
difTicult  one.  which  has  hardly  yet  come  within  the  sphere  of  practical 
knowledge.     ^Nlore  care  should  be  taken  with  pneumonic  sputum  than  has 


'  *f 


I 

111 
M 


134 


SPEflFIC   INFI'XTIOUS   DISEASKS. 


Ix'cn  (lone  heretofore,  nnd  it  sitoiild  l)e  ciireriilly  (lisinfcctcil.  Iiidividiinls 
who  hiive  lifid  |iiieuinoiiiii  f-lioiild  lie  ^|ie(iidl_V  ciirel'id  to  keep  the  mouth 
and  throfit  thonm^ddy  eleiiiised,  and  any  house  in  whieii  several  eases  of 
pnenMioiiia  have  oeeurred  in  rapid  siieiission  should  he  thonm^ddy  dis- 
inl'eeted. 

Treatment.-i'uennionia  is  a  sell'-liiuited  disease,  which  can  lU'ither 
he  ahorled  nor  cut  short  hy  any  known  means  at  our  command.  I'iveii 
under  the  most  unl'av(U'ahle  circumstances  it  may  terminate  aliruoMy  and 
naturally,  without  a  dose  of  nu'diciiie  having,'  lieen  administered.  .'■.  patient 
was  admitted  into  the  l'hilad(dphia  Hospital  (Ui  the  eveninir  ol'  Ihe  .seventh 
day  after  the  chill,  in  which  he  liad  heen  seen  hy  one  of  my  assistants,  who 
had  ordered  him  to  ;:o  to  a  hospital,  lie  remaine<l,  however,  in  his  house 
alone,  without  assistance,  takin;,'  nothing:  hut  a  little  milk  and  hread  and 
whisky,  and  was  leou^iht  into  the  hospital  hy  the  police  in  a  condition  of 
active  delirium.  That  nitrht  his  temperature  was  lo.")"  ami  his  |)ulse  ahove 
1"^().  In  his  delirium  he  came  near  escaping'  throu<rli  the  window  of  the 
ward,  '{'he  followini;  morniiifx — tiie  ei^dith  day — the  crisis  occurred,  and 
at  ward  class  Jiis  temperature  was  helow  !I<S°.  'I'iu'  entire  lower  lohe  of  the 
ri<:lit  side  was  found  involved,  and  he  entered  upon  a  rapid  convalescence. 
So  also,  uiuler  the  favorin<i  eircumstanecs  of  good  nursin<r  and  careful 
diet,  tiu'  experience  of  nuiny  jihysieians  in  diU'erent  lands  has  shown  that 
pneumonia  runs  its  course  in  a  delinite  tinu',  ternnmitiny  soim'times  spon- 
taneously on  the  third  or  the  fifth  dav,  or  continuing  until  the  tenth  or 
twelfth. 

There  is  no  speciiic  treatment  for  ]iiu'umonia.  The  young  jiractitioner 
may  hear  in  mind  that  patit'uts  are  more  often  damaged  than  hel])ed  by 
the  prondsc  iKuis  drugging,  which  is  still  only  too  ])reval(Mit. 

1.  (InirrnI  M<ni(iiiniiciil  af  a  Ctisc. — 'I'he  sanu'  carcd'ul  hygiene  of  the 
hed  and  of  the  sick-room  should  he  carried  out  as  in  ty|)hoid  i'ever.  The 
patient  should  luit  he  too  much  hundled  up  with  clothing.  For  the  heavy 
llannel  undershiits  should  lie  siihstituted  a  thin,  light  llaiinel  jacket,  open 
in  front,  which  eiiahies  the  ])hysieian  to  make  his  examinations  without 
uniu'cessarily  disturiiing  the  patient.  The  room  should  he  hright  and 
light,  letting  in  the  sunshine  if  possible,  ami  thoroughly  well  ventilated. 
Only  one  or  two  jiersons  sliould  he  allowed  in  the  room  at  a  time,  l-'.ven 
when  iu(t  called  lor  on  ace<iunt  of  the  high  I'ever.  the  patient  should  he 
carefully  sponged  each  day  with  tejiid  water,  'i'his  should  ])e  doiu"  witli 
as  little  disturl)ance  as  possible.  Special  care  should  be  taken  to  keej)  the 
mouth  and  gums  cleansed. 

2.  Diet. — I'lain  water,  a  pleasant  table  water,  or  lenmnade  should  be 
given  freely.  When  the  iiatient  is  delirious  the  water  should  he  given  at 
fixed  intervals.  The  food  should  be  li(piid.  consisting  chiefly  of  milk, 
either  alone  or,  better,  ndxed  with  food  prepared  from  sonu'  one  of  the 
cereals,  and  eggs,  either  soft  boiled  or  raw. 

Ii.  S/irrinl  Tirfiliiicnt. — Certain  measures  are  believed  to  have  an  indu- 
eiu'c  in  arresting,  controlling,  or  cutting  short  the  disease.  It  is  very  diiri- 
cidt  for  the  practitioner  to  arrive  at  satisfactory  conclusions  on  this  ques- 
tion in  a  disease  so  singularly  variable  in  its  course.     How  natural,  when 


LOBAR  PNEUMONIA. 


185 


.     Individual^ 

'])    tlic    lllOlltll 

vcral  ciiscs  of 
(ir(iiij:lil_v  (lis- 

li  can  lU'itiicr 
iiiiaiid.      I'ivcii 

ai)niii'i_v  and 
m1.  .'■.  patient 
)!'  I  he  t^cvfiitli 
ssistanls.  wiio 
.  ill  liis  house 
ml  lircail  and 
I  condition  ol' 
is  pulse  above 

iiidow  ol'  the 
oceiiiTod,  and 
er  lol)C'  oi'  the 
'onvalescenee. 
r  and  careful 
IS  shown  that 
netinies  spon- 

ttie  tenth  or 

LT  ]>raetitioner 
an  holi)ed  by 

^•<rieiie  of  the 
1  fever.  The 
^or  the  lieavv 

jacket,  open 
(ions  witlioiit 
;'  briicht  anil 
'11  ventilated. 

time.  l-',ven 
■lit  should  be 
be  done  with 
1  to  keep  the 

de  should  bo 
1  be  <j;iven  at 
efly  of  milk, 
e  one  of  tlie 

lavo  an  inllu- 

is  very  diili- 

on  this  ques- 

latnral,  when 


on  the  lliird  or  fourth  day  tlie  crisis  occurs  and  convalescence  set  in,  to 
attribute  the  happy  result  to  the  elVect  (d'  some  special  me(lieationI  How 
easy  to  forget  that  the  same  unexpected  early  rccoverio  occur  uiidi'r  other 
((iniliti(Uis!  'I"he  following-  are  ainoiiji-  the  measuri's  which  arc  believed  by 
many  to  be  of  beiielit: 

((/)  llli'rdiitij. — The  I'l'id'oach  of  \'an  ilcliuont.  that  "a  bloody  .Moloch 
presides  in  the  chairs  of  meilicine,"  can  not  be  broiiiiht  against  this  \iv\\- 
eration  of  physicians.  IJcfore  liOiiis*  iconoclastic  paper  on  l)leedin^r  in 
))neumoiiia  it  would  have  ln'cii  rejianled  as  almost  crimimd  to  treat  a  case 
without  venesection.  We  em|iloy  it  nowadays  inucli  more  than  we  did 
a  few  years  a<ro,  but  more  often  late  in  the  disease  than  early.  'I'o  bleed 
at  the  very  onset  in  robust,  lu'althy  individuals  in  whom  the  disease  sets 
in  with  ^reat  intensity  and  Iiifili  fever  is,  I  believe,  a  fzooil  |iractice.  1  have 
seen  instances  in  which  it  was  very  lieiieficial  in  relievin;^  the  pain  and  the 
dys|in(ea.  reducinj,'  the  temperature,  anil  allayinji  the  cerebral  symptoms. 

[b)  Pnii/s. — Certain  drujrs  are  credited  with  the  power  id'  rediicini;  the 
intensity  and  shorteniiii:'  the  duration  of  the  attack.  .\moii,i,^  them  vera- 
Iriiin  viriih-  still  holds  a  place,  doses  of  ill  ii-v  of  the  tincture  i^iveii  every 
two  hours.  Tartar  emetic — a  remedy  which  had  ^rcal  xonuc  soiue  years 
ajio — is  now  very  rarely  emiiloyetl.  To  a  third  ilriiii'.  dijiilalis.  has  been 
attributed  of  late  great  ])ower  in  controlling;;  the  course  of  the  disease. 
I'etresco  gives  at  one  time  as  much  as  from  1  to  \-i  grammes  of  the  pow- 
dered leaves,  and  claims  that  these  colossal  doses  are  specially  ellicacious 
in  shortening  the  cour.so  of  the  di.-ease  and  diminishing  the  mortality. 

((■)  AiilijiiiciiDKiiuc  Scniiii. — Tlii.s  is  still  in  the  trial  stage.  The  Klemp- 
crcr  brothers,  Auld,  Washbonni,  and  others  have  reported  favorable  re- 
sults. The  serum  is  injected  into  the  subcutiiiieous  tissues.  Washbourn 
recommends  as  a  doso  20  cc,  and  thinks  it  is  well  to  make  an  injection 
twice  a  day  until  the  patient  is  convalescent.  Fortunately,  the  serum  ap- 
pears to  be  harmless.    1  have  no  jicrsonal  c.\])erienco  with  it. 

4.  Sipiiiiloiiititir  Treatment. — {a)  T«  irliere  tlie  Pain. — The  stitch  in 
tlio  side  at  onset,  which  is  sometimes  so  agonizing,  is  best  relieved  by  a 
livpoilermic  injection  of  a  (juarter  of  a  grain  of  iuor]»hia.  When  the  pain 
is  less  intense  and  dilfuse  over  one  side,  the  i'aipiclin  cautery  applied  lightly 
is  very  ellicacious,  or  hot  or  cold  a])|)lications  may  be  tried.  When  the  dis- 
ease is  fairly  estaldished  the  pain  is  not.  as  a  rule,  distressing,  except  when 
the  i)atient  coughs,  and  for  this  the  Dover's  powilt'r  may  be  used  in  r)-grain 
doses,  according  to  the  patient's  needs.  Hot  poultices,  formerly  so  much 
in  use.  relievo  the  ]min,  though  not  more  than  the  cold  applications.  For 
chihlren  they  are  often  jirefcrable. 

(}>)  To  comt)at  ilie  To-rainvt. — Tlorcin  lies  onr  chief  weakness  in  dealing 
with  ])neunioiiia.  We  have  as  yet  no  s])0cific.  either  drug  or  the  product  of 
the  hacteriological  laboratory,  which  safely  and  surely  neutralizes  the  jioison 
of  the  disease.  We  may  reasonaldy  ho]ie  that  such  a  remedy  ere  long  will 
1)0  forthcoming,  but  meantime  wc  must  be  content  with  measures  which 
aim  at  keeiting  up  the  strength  of  the  iiatient  in  his  fight  against  the  pro- 
gressive toxivmia. 

(r)  The  third  and  all-important  indication  in  the  treatment  of  pncu- 


IVA) 


SI'KCIFIC   IXFKCTIOUS   DISRASKS. 


riiuiiia  is  Id  siippnrl  Hit'  hnirl.  'IMic  pnictilioiicr  must  I'vcr  lie  on  tlio  aliTt 
to  [H'l'vciit  tlic  niist't  ol'  c'iinliac  wnikiifss,  iiinl  to  treat  il  should  that  coiuli- 
tioii  arise. 

Til  inrrciil  llic  Oiisrt  of  Ciinlidc  Wi'dL-iicss. — We  can  not  at  present  sopa- 
lale  the  ell'i'cts  ol'  the  t'ever  tVoni  tliose  of  tiie  poisons  cii'dilatini;  in  tlio 

hi 1.      It    is   ]ios>ihle.   indeed,  as  some  sMp|iose,   tliat    the   i'ever  itself  may 

he  henelieial.  rndonhtedly.  however,  hij:!!  and  prolonj^ed  pyrexia  is  dan- 
},feroiis  to  the  heart,  and  shonid  he  condiated.  For  this  our  most  tru.-ty 
weapon  is  lii/dnillicni/n/,  wiiieh  in  pneumonia  is  used  in  several  dill'erent 
ways.  Tlie  ice-ha^^  to  the  atl'eett'd  side  is  one  ol'  the  most  convenient  and 
servieeaMe.  Its  j^ood  ell'ects  have  heen  stroniily  insisted  upon  hy  ^lays.  I 
Inive  y\>i'i\  ice  .systematically  in  my  wards  I'or  the  past  six  or  seven  yi'ars.  It 
allays  the  pain,  reduces  the  i'ever  sli^^htly,  and,  as  a  rule,  the  ]iatient  says 
)h'  t'<'els  very  much  more  comfortahle.  liroad.  Hat  ice-l)a<rs  are  now  ea.sily 
ohtaiiied  for  the  ])iirpose,  and  if  these  are  not  availahle  an  ice  poultice  can 
he  readily  made,  and  hy  the  use  of  oil-silk  the  clothm^i'  and  heddin<x  of 
the  jiatient  can  ho  protected  from  the  water.  Cold  spon^dn^r  should,  I 
think,  he  em|iloyed  as  a  routine  measure  in  cases  of  |)neumonia.  When 
done  lind)  hy  lind>  the  patient  is  hut  little  dislurl)ed,  and  it  is  nd'reshinir 
and  henelieial.  With  very  pronounced  nervous  symptoms  and  persistent 
liifih  temperature,  or  with  hyper])yrexia,  a  cold  hath  of  ten  minutes"  dura- 
tion may  he  "jfiven.  \'on  .liirfiensen,  one  of  ihe  liest  of  livin<,f  students  of 
the  disease.  siron;;ly  advises  it  under  these  conditions.  Personally,  my 
expeiienci'  with  the  full  cold  hath  is  not  lar<,''e  euon<,di  to  eiialde  me  to 
e.xprcss  a  positive  opinion.  In  this  country  we  have  not,  I  think,  used  it 
sutliciently  in  the  to.\ic  cases,  in  which  in  typhoid  fever  we  see  such  good 
results. 

Of  meiliciiud  antipyretics,  (iiiiiiiiir  has  heen  much  vaunted  in  doses  of 
from  'M)  to  (III  <rrains  daily.  Tnfortunately,  it  is  apt  to  disturh  the  stomach 
and  cause  unpleasant  rinj.dn<f  in  the  ears;  accordinjx  to  some,  also,  it  is  very 
de])rcssin<r,  hut  I  must  say  I  have  never  seen  any  injurious  elfects  from  it, 
thonj,di  I  have  not  used  it  for  some  years.  Aiili/ii/rln.  unlifrhnii.  ami 
jiheHiuclin  have  heen  thoronfi;hly  tried  in  pneumonia,  and  the  ireneral  opin- 
ion at  present  is  decidedly  aj^ainst  their  systematic  employment. 

AlroJiiil  may  he  used  with  henefit  in  a  majority  of  oases  of  pnonmonia. 
In  moderate  doses  it  diminishes  slightly  the  temperature,  increases  the  appe- 
tite, oliviates  the  tendency  to  heart  weakness,  and  is  a  conservator  of  eiu'rgy, 
hoinjr  itself  consumed  in  su])]ilyinf>-  heat  in  place  of  the  hody  tissues.  Two 
or  three  ounces  of  good  whisky  in  the  twenty-four  hours  may  he  used  in 
ordinary  cases. 

To  ireat  Urart  ]V<'(il-iii'xst  wlirn  P/v.sy///. — Xow  the  resources  and  judg- 
ment of  the  jihysician  are  taxed  to  the  utmost.  Ts  the  heart  weakness  duo 
to  ]irogressive  distention  and  overdlling  of  the  right  heart?  This  is 
usually  indicated  hy  increasing  cyanosis,  increasing  shortness  of  breath, 
signs  of  (rdematous  infdtration  in  the  nninv(dved  imrts  of  the  lung,  and  a 
small  and  feohle  radial  jmlse.  Tnder  the.se  circumstances  a  free  irnrscrfion 
is  sometimes  helpful,  though  T  must  say  that  my  personal  experience  luis 
not  heen  very  satisfactory.     T  have,  however,  within  the  past  three  years 


I 


LOBAR  PXHIMONIA. 


i;'.; 


II  tlio  alert- 
lliat  I'oiuli- 

t'Sl'Ilt  H'\M\- 

iiiy  in  tlio 
itsL'lf  may 
xia  is  (laii- 
K'st  trusty 
il  (lillVrcnt 
ciMciit  and 
y  .Mays.  I 
I  years.  It 
aticiit  says 
now  easily 
oiiltice  can 
jc'ddinjr  of 
slioidd,  I 
ia.  When 
rofroshin^ 
])ersistent 
utes"  dnni- 
itudents  of 
)nally,  my 
d»Ie  me  to 
\k,  nsed  it 
such  ji'ood 

n  doses  of 
10  stomach 
I,  it  is  very 
ts  from  it, 
chriii.  and 
iieral  opin- 

monnionia. 
s  the  appe- 
of  enei';,'y, 
-uos.  Two 
be  nsed  in 

and  jndfj- 
[dvness  duo 
This  is 
of  hroath, 
iinir.  and  a 
irnrsertiDH 
>rionce  has 
hreo  years 


>oon  '2  eases  in  which  it  seemed  to  he  timely,  even  life-.siviiijf.  'i'oo  oflcii 
ihe  pro;:rcssive  ennliae  a>lhenia  is  due  to  the  action  of  the  fever  and  of  the 
poi.<ons,  partly  upi.ii  the  heart  ninscle  itsi'lf,  partly  u|inn  the  nerve  eeiitros, 
nirdiac  and  res|iiratory.  An  iiureiise  in  the  amount  of  nlmhul  is  advisahlo 
when  the  pulse  heenmi'S  Muall.  freipient,  and  feelile  or  very  compressihlo. 
and  when  the  hoart-sounds,  jmrticularly  the  second  pulmonic,  begin  to  lo>c 
iheir  foice.  The  amount  will  vary  with  the  age  of  the  jiatient  and  with 
his  habit.-.  It  may  be  iiu'reased,  if  necos.<ary,  to  Vi  or  1(1  ounces  in  the 
twonty-i'onr  hours.  Slri/rlniiit  is  a  most  valnal)le  cardiac  tonic  in  pneu- 
monia, it  may  l)e  given  in  doses  of  from  one  si.vtieth  to  one  thirtielh  of  a 
gi'ain  Iiypodermieally,  or,  if  the  heart's  action  beconu's  more  b'cblc.  in  still 
larger  doses,  up  to  one  twentieth  or  even  otu'  twi'lfth  of  a  grain  every  three 
KV  four  hours.  The  precise  indications  lur  the  use  of  ilii/lliilis  in  |)iu'U- 
monia  are  not  easy  to  estimate.  I  rarely  u^v  it  unless  the  heart's  action 
liccomes  very  rapid,  or  if,  as  above  stated,  there  is  a  sudden  (Uisct  of  cardiac 
weakness,  indicated  i)y  a  very  (piick  and  irregular  pulse.  Then  it  mav  bo 
givi'U  freely,  either  in  the  form  of  the  tincture,  lo  or  •■>{)  minims  every 
two  hours  nr.til  '.'  drachms  are  given,  or  a  good  digitalin  Iiypodermieally 
in  doses  of  from  a  thirtieth  to  a  twentieth  of  a  grain.  (Mlier  remedies  still 
much  in  u<c  are  the  aromatic  s|)irits  of  ammonia,  camphor,  musk,  and  the 
hypodermic  injections  of  other.  Two  other  ineasuros  may  bo  referred  to 
under  this  section. 

Ori/tirii  <!,!.•<. — It  is  doubtful  whether  the  inhalation  of  oxygon  in  jmou- 
mouia  is  really  beiiclicial.  I'ersonally,  when  called  in  consultation  to  a  ea.so, 
if  I  see  the  oxygen  cylinder  at  the  bedside  I  feel  the  prognosis  to  be  ex- 
tremely grave.  It  does  sometimes  seem  to  give  tiansitory  relief  and  to 
iliniinish  tlio  cyanosis.  It  is  jiarmlo.-^s,  its  exhibition  is  very  simple,  and 
the  jirocoss  need  not  bo  at  all  disturbing  to  the  patient.  'I'lie  gas  may  lie 
allowed  to  ilow  gently  from  the  iiozxle  directly  under  the  nostrils  of  the 
patient,  or  it  may  be  administorecl  every  alternate  fifteen  minutes  throiiLrh 
a  mask.  .\s  already  stated,  l>ollinger  regards  the  heart  weakness  as  in  part 
due  to  an  oliga'mia  from  the  loss  of  a  large  amount  of  solid  exudate  in  the 
lung.  The  use  of  sdliiic  iiiji'dioiis  hypodtTinically  has  been  advocated.  I 
havo  seen  it  do  good  in  hel|iiiig  to  tide  over  a  critical  [wriod  of  cardiac 
depression.  As  much  as  a  c(Ui|ile  of  pints  may  be  allowed  to  run  beneath 
the  skin  by  gravity,  a  rublier  bag  and  either  a  large  hypodeiniic  or  a  middle- 
sized  as|)irator  needle  being  used.  The  injection  may  bo  made  in  the  ilanks 
or  in  the  thighs. 

Tiraliiiciif  (if  CoDiplirnHiiiis. — Tf  the  fovor  jiersists  it  is  important  to 
look  out  for  pleurisy,  particularly  for  the  meta-pnenmonic  em|)yoma.  The 
exploratory  needle  should  bo  nsed  if  necessary.  A  soro-fibrinous  elTusion 
should  lie  as])irated,  a  purulent  opened  and  drained.  In  a  complicating  jieri- 
carditis  with  a  largo  effusion  aspiration  may  bo  nociwary.  Delayed  roso- 
^'itinn  is  a  diflicult  condition  to  treat.  1?iess  has  recommended  pilocarpine, 
which  I  have  tried  in  one  or  two  cases  without  much  benefit. 


^^ 


i;58 


srKCIFlC    INKKCTlolS    MISKASI'.S. 


XVI.    DIPHTHERIA. 


Doflnition. — A  siiccitic  inlVctidii-  discnsc,  cliiinictfri/.nl  liv  ii  lodil 
liliiiniiiis  (Xiidiiti',  ii.-inilly  iipfiii  a  imicDiis  incinliniiic,  iiiid  liy  (  nii>lil  iitidiial 
Kyiii|)tiiiiis  due  to  toxins  |irodii(cd  at  tlic  site  of  tlic  loion.  'I'lic  picsciui' 
of  till-  KIclis-I.ocllIcr  liacilliis  is  the  ctiolo^iical  critcrioii  liy  wlii.li  true 
di|ilitlu'ria  is  distiiijiiiisiu'il  from  other  forms  of  mcmliraiioiis  iiilliimma- 
tiot). 

'I'lic  clinic;!!  and  liactcriolojrical  conceptions  of  diplitlicria  are  at  present 
not  in  full  accord.  On  the  one  hand,  tlicre  are  cases  of  sinijiU'  sore  ('u'oat 
whicii  the  hacterioloi'iists,  lindiii^'  the  KU'lis-LoetUer  hacilliis,  call  true 
diplitlicria.  On  the  other  hand,  cases  (>(  memliranotis,  slou^diin<;  an^rina, 
dia.L'iiosed  hy  tlie  jihysician  as  diphtheria,  are  calleil  hy  the  liacteriolo^'ists, 
in  the  alisencc  (d'  tlii'  Klehs-l  .oclller  iiacilliis,  pscudo-diphthe:ia  or  diph- 
theroid anjiina. 

'i'he  term  tliiilillicniid  may  lie  used  for  the  present  to  desiirnate  those 
forms  in  which  the  Klelis-Loctller  liacillns  is  not  present.  'i'lioii,i;h  usually 
milder,  severe  constitutional  di>turhanci',  and  even  paralysis,  nuiy  follow 
tlicse  so-called  |iseudo-diplitlieritic  jirocesses. 

Historical  Note. — The  disease  was  known  to  Areticus  and  to  (ialcn. 
l''|iideniics  occurred  throui^hout  the  middle  ages.  It  a]i|ici;red  early  anion;,' 
the  settlers  cd'  New  Knj,dand,  and  accounts  are  extant  (d'  epidemics  in  this 
country  in  the  seventeenth  and  ei<,diteenth  centuries.  Huxluim  and  Fother- 
frill  <:ave  excellent  descriptions  of  the  disease.  An  admirable  account  was 
given  by  Samuel  Hard,*  of  New  Y(U'1\,  whose  essay  is  one  of  the  most  solid 
contriluitions  made  to  medicine  in  America.  It  was  reserved  for  Pierre 
liretonneau,  of  Tours,  to  grasp  the  fact  that  (UKjiiia  siilfonilird.  "  riinditchi' 
viali<iii(i"  the  "  putrid."  an<l  other  forms  of  malignant  sore  thmat,  wero 
one  niul  the  same  disease,  to  which  he  gave  the  name  ''  iliphllK'rllr." 

Etiology.^ — 'I'hc  disease  is  endemic  in  the  larger  centres  of  poiiulation, 
-nd  becomes  epidemic  at  certain  seasons  of  the  year.  While  other  con- 
tagious diseases  have  diminished  within  the  ])ast  decade,  diphtheria  has  in- 
creast'il,  particidarly  in  cities.  It  has  ])revaile(l  also  with  great  severity  in 
country  districts,  in  which  indeed  the  ailVction  seems  to  ho  sjiecially  viiu- 
lent.  A  close  relation  hetwceii  imperfect  drainage  or  a  ])olluted  watcr- 
»uj)ply  and  diphtheria  has  not  been  determined. 

l)i|)litheria  is  a  higlily  contagious  disease,  readily  communicated  from 
])erson  to  person.  The  bacilli  may  be  received,  '"  (1)  from  the  nu'iubranous 
exudate  or  dis(>harges  from  diphtheria  ]iatients:  (•.')  from  the  secretions 
of  tlu'  nose  and  throat  of  e(Mivalescer.t  cases  of  diphtheria  in  which  the 
virulent  bacilli  persist;  (;!)  from  the  throats  of  liealthy  individuals  who 
have  ac(piired  tlio  bacilli  from  being  in  contact  with  others  having  virulent 
germs  on  their  person  or  clothing:  in  such  cases  the  bacilli  may  sometimes 
live  and  develop  for  days  or  weeks  in  the  throat  without  causing  any  lesion  " 
(I'ark  and  Bcehe).  In  the  tenement  districts  of  Xew  York  these  authors 
recognized  two  varieties  of  local  e])idemics.     In  one,  the  cases  were  evi- 


*  Transactions  of  tlie  Ainorican  Pliikistiphical  Sociuty,  vol.  i,  Philadelphia,  1770. 


I 
! 


DIPHTriKHIA. 


l:j'.> 


liy    a    lixiil 

ISlillltilllllll 
IC  pICSCllll' 
iVllicll     tllic 

iiilliiiniiui- 
■  lit  in'csciit 

KdlV    t'Toilt 

,  call  tnii,' 
ii;j;  anjiiiia, 
U'i'i()liij,M>ls, 
a  or  (liiili- 

rnatc  (liiisc 
\>s.\\  usually 
may   I'oilnw 

1  to  (iah'ii. 
arly  anion;,' 
hies  in  this 
mil  {''otlicr- 
c'foiiiit  was 
'  most  solid 

I'or   i'icrrt,' 

'•  ciiinuuhe, 
iii'oat,  wore 
•ilrr 
]io|iulation, 

otiiiT  con- 
iTJa  has  in- 

scvciity  in 
'cially  viru- 
iteil  water- 

icatcd  from 
K'nihranons 
^  pocrctioiis 
which  the 
idnals  who 
n,ir  virulent 
'  somi'timt's 
finy  lesion  " 
ose  authors 
s  were  evi- 

hui.  17:0. 


<  rntly  from  iu.i;:h»,o,hoo.l  infection;    while  in  the  other,  the  infeetinn  \saH 

'''■''"■7   ''■'""  ^;' ^'  •^'"'■•'  "    "l'"l<"  "listriet    wouhl  su.McnIv   hecome   the 

seat  (.    Hcatlere,!  eases.     '•  At  times  in  a  crtain  area  of  the  city,  from  which 
M'veral  schools  ,lrew  their  scholars,  all  .he  eases  of  .liphtheria  wonM  occur 

<as  investigation  sl,o^^e,l)  in   fan.ilies  whos,.  Hnhlren  atten.hd  one  s.l I 

""•  '••"hire,  ot  the  other  schools  hein-  for  the  time  exem|.t  " 

No  disease  ,d'  leni|u.rale  r.-ions  proves  „ion.  fatal  to  |.hvsi.ians  and 
nurses  here  seems  to  l„.  particular  dan^^-r  in  Ih..  examinaii.m  and  swah- 
hm;:  of  th,.  throat,  lor  in  Ihe  f;a-in.r.  con^d,in,^  an.l  splntl..ri,m  Hforts 
'"•  I""h;>'I  ■".-.v  con;;!,  mn.ns  and  Hakes  .d'  median.,  into  the  plusician's 
l^"«'.  .  I  he  vnns  aUa.hes  itself  to  the  dothin;;-.  the  l,eddi„;r.  ami  li,e  room 
'"  "'"'■''  «'<■  patient  has  live.l,  and  has  in  mai  y  instan.es  displayed  .Mvat 
l-^ni'-dy.     It  has  been  found  to  live  on  hh.od  serum  for  one  hundre.l  and 

ilty-hve  days,  in  ;;e!M(i„  for  ei^rjitcen  months,  dri. n  silk  threa.ls  for  one 

l"iudn.d  am   seventy-two  days,  on  1,  child's  plaything;  which  had  he,..,  k.pt 

■"  ii  dark  place  for  (iv..  months,  an.l  in  hits  (d'  dri.Ml  mhnm,,  for  from 

-urteen  to  twenty  weeks.     An  iixta.uv  has  heen  irporled  ((i.dav)  in  whi.h 
iH'  hacilli  were  present  in  the  throat  for  three  hundred  ami  sixty-two  days 
).irin-  tins  p,.riod  there  were  three  acute  relaps.  s.     They  have  h.^ii  foun.]' 
'<"•-  111  the  dii.st  of  a  diphtheria  i)uyilion,  and  in  Ihe  hair  and  elothin<r  „f 
the  nurses  in  att..n.lame  upon  diphthcia  bahies  (Wright  and  Kmers"n) 
iM.rl.es  isolated  diphtheria  hacilli  from  a  ves.sel  which  was  regarded  as  the 
cause  01  the  .lisease  in  twenty-four  families.     The  hacilli  <^vov.-  readily  in 
milk  without  chanoin-  its  aj.peara.:ce.     From  cheese  which  was  ma.le  on 
"  larin  on  which  diphtheria  prevailed,  pure  cultures  of  diphtheria  hacilli 
were  obt:iined  (Xcw  York  JJoard  of  Jlealth  ]{eport,  I.SIM). 
The,  disease  ma;   he  transmitted  hy  inoculation. 

('alves,  cats,  and  fowls  are  subject  to  conla-ious  mendu'auous  disease- 
which  are,  liowever,  not  identical  with  diphtheria  in  man  and  are  not  com- 
municable to  liiin. 

As  in  other  infectious  disorders,  individual  susceptibility  plays  an  im- 
I'ortant  role.  Not  only  do  very  many  of  those  exposed  escape,  hiil  even  of 
those  in  whose  throats  the  bacilli  lodge  and  grow. 

Of  predisposing  causes  age  is  one  of  Ihe  most  important.  A'ery  voun-r 
oliildren  arc  rarely  attacked,  hut  Jacobi  slates  that  he  has  seen  three  in'^ 
stances  of  the  disease  in  the  newly  born.  Between  the  second  and  the  fif- 
teenth year  a  large  majority  of  lh<.  cases  occur.  In  this  period  th,.  -nratest 
number  ol  deaths  is  between  the  s.'con,!  and  the  fifth  years,  clrls  are 
attacked  ,n  larger  num])ers  than  boy>.  probably  because  they  are  brought 
into  closer  contact  with  Ihe  sick.  Adults  are  fre,iuently  atrect,,]  The 
disease  is  most  prevalent  in  the  cold  autumn  weather.  The  secondary 
I>seudo-niemhranous  inflammations,  caused  usually  by  the  streptocx.'ns 
attack  debilitated  persons,  the  subj,.cts  of  fever.s;  pa'rli,ularlv  of  scarlet 
iever,  ty[)lioid,  and  measles. 

Cailh^  regards  as  special  predisposing  elements  in  children  eniar-red 
tonsils,  chronic  naso-pharyng,.al  catarrh,  carious  teelh,  and  an  unhealthy 
condition  of  the  mucous  membrane  of  the  mouth  and  throat 

Epidemics  vary  in  intensity.     While  in  some  the  alfection  is  mild  and 


140 


SPECIFIC   INFECTIOUS   DISEASES. 


raivly  fatal,  in  ddicrs  it  is  cliaractorizod  l)y  wide  extension  of  tlio  mem- 
liraiic.  and  shows  a  siu'cial  tendency  to  attaeiv  the  hirynx. 

The  Kllebs-Loeffler  bacillus  oeeurs  in  a  larire  percentage  of  all 
suspected  cases.  It  is  found  ciiietly  in  the  false  niend)rane,  and  does  not 
extenil  into  the  sulijaccnt  mucosa.  In  tiie  majority  of  instances  the  organ- 
isms are  localized,  and  only  a  few  penetrate  into  the  interior.  In  excep- 
tional instances  the  bacilli  are  found  in  the  blood  and  in  the  internal 
organs.  It  may  be  the  iiredoininating  or  sole  organism  in  the  Ijroiicho- 
])ireuinonia  so  common  in  the  disease.  Outside  the  throat,  the  common  site 
of  its  morbid  action,  the  Klelis-Loelller  bacillus  has  been  I'uund  in  diph- 
theritic conjunctivitis,  in  otitis  media,  sometimes  in  wound  diphtheria,  in 
tilirinous  rhinitis,  and  in  an  attenuated  condition  by  Howard  in  a  ease  of 
idcerative  endocarditis. 

Morphological  Characters.— The  bacillus  is  non-motile,  varies  from  3.0 
lit  :')  /i  in  leng.h,  and  from  0.5  to  0.8  /i  in  thickness.  It  aiipears  as  a  straight 
or  slightly  lient  rod  with  rounded  ends;  irregular,  bizarre  forms,  such  as 
rods  with  One  or  both  ends  swollen  and  siin])le  branching  forms,  are  more 
or  less  common.  The  bacillus  stains  in  sections  or  on  the  cover-glass  by 
.  the  (iram  metiiod. 

It  grow.s  best  njion  a  mixture  of  glucose  bouillon  and  blood  serum 
(LoclHer),  forming  large,  elevated,  grayish-wliite  colonies  with  o])a(iue  cen- 
tres. It  grows  also  upon  all  the  ordinary  culture  media.  The  growth 
usually  ceases  at  temperatures  below  "..'O"  C. 

Tl'ie  bacillus  is  very  resistant,  and  cultures  have  been  made  from  a  bit 
of  nu'inbrane  preserved  for  live  months  in  a  dry  cloth.  Incorporated  with 
dust  and  kept  moist,  the  bacilli  were  still  cultivatable  at  the  end  of  eight 
weeks;  kept  in  a  dried  state  they  no  longer  grew  at  the  end  of  this  period 
(Hitter). 

Variation  in  Virulence.— F^r  testing  the  virulence  the  guinea-pig  is 
used,  being  most  suscep1il)le  to  the  poison.  An  amount  of  a  forty-eight 
hour  bouillon  culture  eiiualling  one  half  per  cent  of  the  weight  of  the  ani- 
mal is  injected  subcntaneously.  "A  fully  virulent  culture  is  one  wMcR' 
causes  the  death  of  a  guinea-])ig  within  three  days  or  less;  a  culture  of 
medium  vindence  one  which  causes  the  death  of  the  animal  in  from  three  to 
live  days.  Ctdtures  which  only  produce  local  necrosis  and  ulceration  or  death 
after  a  greater  number  of  days  may  be  considered  as  of  slight  virulence" 
(.1.  11.  Wright).  At  the  seat  of  the  inoctdation  there  is  local  necrosis  with 
fibrinous  exudate  which  contains  the  bacilli,  and  there  is  also  a  more  or 
less  extensive  (vdema  of  the  stdieidan(>ons  tissue.  The  Klebs-Loefller 
bacillus  evidently  has  very  varying  grad(>s  of  virulence  down  oven  to  com- 
]ilete  absence  of  ])athogenic  ell'ects.  The  name  pseudo-bacillus  of  diph- 
tlieria  shotdd  not  be  given  to  this  avirulent  organism. 

The  Presence  of  the  Klebs-Loeffler  Bacillus  in  Non-membranous  Angina 
and  in  Healthy  Throats. — The  liacillus  has  bceu  istdated  from  cases  which 
show  nothing  more  than  a  simjile  catarrhal  angina,  of  a  mild  tyjie  withoul 
any  membrane,  with  diffuse  redness,  and  ]ierha])s  huskiness  and  signs  of 
catarrhal  laryngitis.  In  other  cases  the  anatomical  picture  may  be  that  of 
a  lacunar  tonsillitis. 


ion  of  the  moiii- 

lereeiitage  of  all 

no,  and  does  not 

tanci's  tilt'  organ- 

t'lMor.     in  cxci'])- 

in   the   inti'i-nal 

in  thf  bronclio- 

tlic  ooninion  site 

1  t'ounil  in  di|ih- 

lui  di|ihlheria,  in 

vai'd  in  a  cat^e  of 

t',  varies  from  5.5 
lears  as  a  straight 
I'e  forms,  sucli  as 
:  forms,  are  more 
he  cover-glass  by 

[iiid  blood  scrum 
with  o])a<tue  ccn- 
lia.     The  growth 

made  from  a  bit 

ncorporatcd  with 

th(>  end  of  eight 

'lid  of  this  period 

the  guinea-pig  is 
t  of  a  forty-eight 
veight  of  the  ani- 
ure  is  one  wMcT!' 
ess;  a  culture  of 
il  in  from  throe  to 
ilcoration  or  death 
slight  virulence  " 
ocal  necrosis  with 
is  also  a  more  or 
ho  Kh'lis-Loelllor 
own  oven  to  C(un- 
-bacillus  of  diph- 

jmbranous  Angina 

from  oases  whicli 
mild  type  without 
noss  and  signs  of 
re  mav  bo  that  of 


DI  PUT  11  Eli  I  A. 


141 


During  tlic  iirovaloneo  of  an  epidemic  the  organisms  may  be  mot  with 
in  [lorfoctly  liealthy  throats,  paiticularly  in  persons  in  the  same  house,  or 
10  ward  attendants  and  nurses  in  fever  hospitals. 

Following  an  attack  of  diphtheria  the  bacilli  may  persist  in  the  throat 
after  all  the  membrane  has  disap[ioared  for  weeks  or  months.  Schiiler 
iiotes  a  case  in  which  they  wore  present  six  months  aftiT  the  attack,  and 
in  a  nurse  in  my  ward  the  bacilli  jiersistod  for  oighty-ruur  days. 

Toxlne  of  the  Klebs-Loeffler  Bacillus. — Koux  and  Yorsin  showed  that 
a  fatal  result  following  the  inoculation  with  tln'  bacillus  was  not  caused 
by  any  extension  of  the  micro-organisms  within  tlu  body;  anil  they  wore 
ciiabied  in  ijouillon  cultures  to  separate  the  bacilli  from  the  ])oison.  The 
iiixine  so  sc|iai'ati'd  killed  with  very  much  the  same  ilVoets  as  those  t'aiised 
\i\  the  inoculation  of  the  bacilli;  the  pseudo-membrane,  however,  is  not 
lornied.  'I'liose  results  wore  conlirmed  by  many  observers,  i>articiilarly 
l)y  Sidney  Mai'tin,  who  separated  a  toxic  alliumose.  The  precise  composi- 
tion of  the  body  and  whothor  it  is  a  proteid  at  all  is  still  doubtful. 

Production  of  Immunity.— Susceptible  animals  may  be  rendered  ini- 
iiiuno  from  dijihtheritic  infection  by  injecting  weakened  cultures  of  the 
Ijacillus  or,  what  is  bettor,  suitable  doses  of  the  diphtheria  toxino.  The 
result  (d'  the  injections  is  a  febrile  reaction  which  soon  jiasses  away  and 
leaves  the  animal  loss  susceptible  to  the  poison  or  the  living  bacilli.  ]5y 
lepeating  and  gradually  increasing  the  (piantity  of  jioison  injected  a  high 
degree  of  immunity  can  ))e  produced  in  largo  animals  (goat,  horse).  Dur- 
ing tho  reaction  f(dIowing  the  injections  the  immunity  tenipoiarily  falls 
only  to  exi'oed  the  ])revious  degrt'o  at  its  end.  This  form  of  iiiimuuity,  do- 
iiiiminated  antitoxic,  is^associated  with  the  development  of  a  curative.'  sub- 
stance, which  is  contained  within  tho  huniors  and  cells  (d'  tho  Imdy,  and 
in  the  form  of  the  jireserved  serum  of  the  blood  (horse)  is  known  com- 
mercially as  diphtheria  antitoxine.  It  has  the  power  to  neutralize  the  eH'octs 
of  the  toxino. 

The  Bacteria  associated  with  the  Diphtheria  Bacillus. — The  most  com- 
mon is  the  streiitococciis  pyogenes.  Others,  in  addition  to  the  organ- 
isms constantly  found  in  the  mouth,  are  the  micrococcus  lancoolatus,  the 
bacillus  coli  communis,  and  tho  staphylococcus  aureus  and  alhus.  Of  these, 
probably  the  streptococcus  ])yogones  is  the  most  imjiortant,  as  cases  of 
general  infection  with  this  organisin  have  boon  found  in  dijihthoria.  Tho 
suppuration  in  the  lymph-glands  and  the  broncho-pneumonia  arc  usually 
(tluHigh  not  always)  caused  liy  this  organism. 

Pseudo-Diphtheria  Bacillus. — x\s  mentioned  above,  the  Klobs-Loefllor 
bacillus  varies  very  much  in  its  virulence,  and  it  exists  in  a  form  entirely 
devoid  of  jiathogonic  ])ropertios.  This  organism  should  not  be  designated 
the  ])seudo-di]ihthcria  liacillns.  The  name  "should  bo  coniined  to  bacilli 
which,  though  resembling  the  diphtheria  liacillus,  ditl'er  from  it  not  only 
by  alisenco  of  virulence,  but  also  by  cultural  ])oculiaritios,  the  most  iinjior- 
tant  of  the  latter  being  greater  luxuriance  of  growth  on  agar,  and  the  pres- 
ervation of  the  alkaline  reacticm  of  the  bouillon  cultures  '"  (Welch),  \eissor 
has  just  pro])osed  a  differential  method  of  staining  to  discriminate  between 
these  organisms  that  gives  useful  results. 


I 


142 


SPECIFIC  INFECTIOUS  DISEASES. 


Diphtheroid  Inflammations.— riulfi-  tlio  term  diphtheroid  may 
l)e  gr(nii)od  those;  mfml)raiH)Us  iiitliinimatioiis  wliicli  arc-  not  associated  with 
the  Klel)H-LnomcT  Ijacilhis.  It  is  pcrliajis  u  more  suitahle  desigiuition  than 
pseudo-diplitlioria  or  socondary  diphtlu'ria.  As  in  a  great  majority  of  eases 
the  streptocoeeiis  jiyogeiies  is  tlio  active  organism,  the  term  "  streptocoeeiis 
diiditheritis  "  is  often  emph)yed.  The  name  "  diplitheritis  "'  is  l)est  nsed  m 
an  anatomical  sense  to  designate  an  inlhuiimation  of  a  mucous  memlirane 
or  integumentarv  surface  cliaracterized  hy  necrosis  and  a  ilhrinoi's  exudate, 
wliereas  the  terni  "  dijihtheria  "  sliould  he  limited  to  the  disease  caused  hy 
tlie  Kleljs-Loelller  hacilliis.  Tlie  ])roportion  of  cases  of  diiditlieroid  iii- 
ilammation  varies  greatly  in  the  dilVercnt  statistics.  Of  tlie  large  numher 
of  ohservations  made  l,y  Paik  and  Heel)"  (5,(ni)  in  New  York,  40  per  cent 
were  diphtheroid.  Figures  from  otiier  sources  do  not  show  so  high  a  per- 
centage. 

It  is  not  to  he  inferred  from  these  statistics  that  any  consideralile  num- 
her of  tlie  cases  wliich  i)resent  tlie  appearances  of  typical  ami  characteristic 
l)rimarv  dijihtheria  arc  due  to  otiier  micro-organisms  tlian  the  Klehs- 
Loeiller  hacilhis.  Nearly  all  such  cases,  when  carefully  examined  hy  a  com- 
l)etent  hactcriologist,  are  found  to  he  due  to  the  diphtiieria  bacillus.  It 
is  the  less  characteristic  cases,  witii  more  or  less  suspicion  of  di[)htheria, 
Avhicii  are  most  likelv  to  he  caused  hy  otiier  bacteria  than  the  Klel)s- 
Loefller  bacillus.  It  is  also  to  he  remenil)cred  that  in  the  routine  exam- 
ination of  a  large  nniiil)er  of  cases  for  boards  of  health  and  diphtheria 
wards  of  hosi)itals.  some  cases  of  genuine  dii>btlieria  may  escape  recog- 
nition from  lack  of  such  re])eated  and  thorough  bacteriological  tests  as  are 
sometimes  required   for  the   detection   of  cases   presenting   unusual   difli- 

culties. 

Conditioiifi  under  whidi  the  Dlphlhemid  Afj'rrHnii  orntrf<.—0^  ■b'iO  cases 
(Park  and  ]k>ehe),  ;?(»<)  oceiirred  in  tlie  autumn  months  and  150  in  tlie 
spring:  108  occurred  in  chihlren  from  tlie  first  to  the  seventh  year.  In  a 
large '"in-o])ortion  of  all  the  casts  the  disease  develops  in  childien,  and  can 
only  be  diirerentiated  from  diphtheria  jn-oiier  by  the  bacteriological  ex- 
amination. In  many  of  the  cases  it  is  simply  an  acute  catarrhal  angina 
with  lacunar  tonsillitis. 

The  diphtheroid  inflammations  are  particularly  prone  to  develop  m 
connection  with  the  acute  fevers. 

(a)  Scarlet  Fever. — In  a  large  proportion  of  the  cases  of  angina  in  scar- 
let fever  the  Klehs-Loeffler  bacillus  is  not  ju'esent.  llooker  has  rep-:rted 
11  cases  comiilicating  scarlet  fever,  in  all  of  which  the  streptococci  were 
the  predominant  organisms.  Of  the  -l.^O  cases  of  Park  and  Beebe,  43  com- 
plicated scarlet  fever.  The  angina  of  this  disease  is  not  always,  however, 
due  to  the  streptococcus.  Where  diphtheria  is  prevalent  and  ojiportunities 
are  favorable  for  exposure,  a  large  jiroportion  of  the  cases  of  membranous 
throats  in  scarlet  fever  may  be  genuine  diphtheria,  as  is  shown  by  the  sta- 
tistics of  Williams  and  :Nb")rse  in  the  Poston  City  nos])ital.  Here,  of  97 
cases  of  scarlet  fever,  membranous  angina  was  present  in  3ri;  in  13  with 
the  Klebs-T.oefTler  bacillus,  and  in  2.'?  with  other  organisms.  Aforse  rejiorts 
99  cases  of  angina  in  scarlet  fever  in  which  7fl  were  diphtheritic.     This 


y;; 


■■ 


DIPIITIIEUIA. 


143 


liplitheroid  may 
associated  with 
k'signation  than 
iiajority  of  cases 
1  "  sti'e})toco(;Tiis 
"  is  best  used  in 
icons  mombraiK! 
l)rin()i's  exudate, 
lisease  caused  l)y 
oiplitheroid  iii- 
lic  larpe  number 
'ork,  40  per  cent 
V,-  so  high  a  por- 

uisiderable  iium- 
nil  cluiracteristic 
tlian  the  Klebs- 
niiiu'd  l)y  a  com- 
eria  bacillus.  It 
)n  of  di[)htheria, 
than  the  Klehs- 
le  nnitine  exam- 
1  and  diphtheria 
ay  escape  recog- 
)gical  tests  as  are 
ig  unusual  dilli- 

rs.—Of  4 no  cases 
■  and  150  in  tlu> 
i'cnth  year.  In  a 
children,  and  can 
lactei'iological  ex- 
catarrhal  angina 

ne   to   develop   in 

of  angina  in  scar- 
;)ker  has  rep-rted 
streptococci  wen; 
id  Reebe,  A2  corn- 
always,  however, 
and  opportunities 
re  of  membranous 
shown  by  the  sta- 
ital.  Here,  of  1)7 
in  35;  in  13  with 
ns.  Aforso  reports 
iplitheritic.     This 


large  proportion  of  cases  in  which  scarlet  fever  was  associated  with  true 
iliphliieria  is  attributed  to  local  conditions  in  the  hospital. 

(h)  J/ ('((.y/t',s.— [Membranous  angina  is  much  less  comnum  in  this  disease. 
It  occurred  in  (5  of  the  450  dii)litheroid  cases  in  New  York,  Of  I  cases 
with  severe  meud)ranous  angina  at  the  iJoston  City  Hospital,  1  only  pre- 
.-fUted  the  Klebs-Loeiller  bacillus. 

(r)  WkonpiiKj-coiKjh  may  also  be  complicated  with  membranous  angina. 
The  bacteriological  examinations  have  not  been  very  numerous.  Kschericli 
uives  4  cases,  in  all  of  which  the  Klebs-LoelUer  bacillus  was  found. 

((I)  'I'lipliuid  Fever. — :Membranous  inilammatious  in  this  disease  are  not 
very  inlrcipient;  they  may  occur  in  tlu;  throat,  the  pelvis  of  the  kidney, 
tin/ bladder,  or  the  intestines.  The  complication  may  be  caused  by  the 
Klebs-Loeillor  bacillus,  \\\\'\v\\  was  present  in  4  cases  descrilied  by  ^lorse. 
ft  is  fre(iuently,  however,  a  streptococcus  infection. 

Krnst  Wagner  has  remarked  upon  the  greater  frciiucncy  of  these  mem- 
branous inllammations  in  typhoid  fever  when  diphtheria  is  [(revailing. 

Clinical  Features  of  the  Diphlheroid  Affection. — The  cases,  as  a  rule, 
are  milder,  aiul  the  mortality  is  low,  only  :..'.5  per  cent  in  the  450  cases  of 
I'ark  and  Beebo.  The  diphtheroid  iidlammations  complicating  the  specilic 
fevers  are,  however,  often  very  fatal,  and  a  general  stre])to(!occus  infection 
is  by  no  means  infrecpient.  As  in  the  Klebs-I.oelller  angina,  there  may 
r,e  only  a  simple  catarrhal  iiroccss.  In  other  instances  the  tonsils  are  cov- 
ered with  a  creamy,  pidtaceous  exudate,  without  any  actual  nieml)rane. 
An  important  grou])  may  begin  as  a  simple  lacunar  tonsillitis,  while  in 
others  the  (>ntire  fauces  and  tonsils  are  covered  by  a  continuous  membrane, 
and  there  is  a  foul  sloughing  angina  with  intense  constitutional  disturb- 
ance. 

Are  the  dii)litheroid  cases  infectious?  (Jcncral  clinical  experience  war- 
rants the  statement  that  the  membranous  angina  associated  with  the  fevers 
is  rarely  communicated  to  other  ])atieuts.  The  health  department  of  New 
York  does  not  keep  the  diphtheroid  cases  under  supervision.  Their  inves- 
tiiration  of  the  450  di})htheroid  cases  seems  to  justify  this  conclusion.  Park 
and  IJccbe  say  that  "  it  did  not  seem  that  the  secondary  cases  were  any  less 
liable  to  occur  where  the  ])rimary  case  was  isolated  than  when  it  was  not." 
Setpiela;  of  the  Diphtheroid  Angina.— Tho.  usual  mildness  of  the  disease 
is  in  part,  no  doubt,  due  to  the  less  frequent  systemic  invasion.  Some  of 
ihe  worst  forms  of  general  strei)tococcus  infection  are,  however,  seen  in  this 
disease.  There  are  no  peculiarities,  local  or  general,  which  can  be  in  any 
way  regarded  as  distinctive;  and  if  the  observation  of  Bourges  should  be 
corrobm-ated,  even  the  most  extensive  paralysis  may  follow  an  angina  caused 

by  it. 

Morbid  Anatomy. —A  majority  of  the  cases  die  of  the  faucial  or 
of  the  larvngeal  disease.  The  exudation  may  occur  in  the  mouth  and 
cover  the  "inner  surfaces  of  the  cheeks;  it  may  even  extend  beyond  the 
lips  on  to  the  skin.  This  was  met  once  in  30  autopsies  at  the  Montreal 
Oeneral  Hosiiital.  The  amount  of  exudation  varies  in  different  cases. 
I'snally  the  tons.is  and  the  pillars  of  the  fauces  are  swollen  and  covered 
with  tiie  false  membrane.    More  commonly,  in  the  fa;al  cases,  the  exuda- 


14-t 


Sl'KCIFIC   INFECTIOUS  DISEASES. 


tidii  is  vory  extensive,  involving  tlie  uvula,  the  soft  piiliite.  the  jmslerior 
nares,  and  "the  lateral  aii.l  posterior  walls  of  the  pharynx.  These  parts  aru 
covered  with  a  dense  psoudo-nieuihi'ane,  in  plaees  iirndy  adherent,  in  others 
beginning  to  separate.  Jn  extreme  eases  the  neerosis  is  advanced  and 
there  is  a  gangrenous  condition  of  the  parts.  The  membrane  is  of  a  dirty 
greenish  or  jzray  color,  and  the  tonsils  and  i)alate  may  be  in  a  state  of 
necrotic  sloughing.  The  erosion  may  be  deep  enough  in  the  tonsils  to 
o])en  the  carotid  artery,  or  a  false  a-etirism  may  1)e  produced  in  the  deep 
tissues  of  tile  neck.  tIic  nose  may  i  e  completely  blocked  by  the  i'alse  mem- 
brane, which  may  also  extend  into  the  conjunctiva-  and  through  the 
Eustachian  tubes  "into  the  middle  ear.  In  cases  of  laryngeal  diphtheria 
the  exudate  in  the  pharynx  may  be  extensive.  In  many  cases,  however,  it 
is  slight  upon  the  tonsils  and  fauces  and  abundant  n}K)n  the  epiglottis  and 
the  hirynx,  which  may  be  comjiletely  occluded  by  false  membrane.  In 
severe  cases  the  exudate  extends  into  the  trachea  and  to  the  bronchi  of 
thV  third  or  fourtii  dinu'nsion.  This  occurred  in  nearly  half  of  my  30 
Montreal  autojisies. 

In  all  these  situations  the  membrane  varies  very  much  in  consistence, 
depending  greatly  U])on  the  stage  at  which  death  has  taken  place.  If  death 
has  occurred  early,  it  is  tirm  and  closely  adherent;  if  late,  it  is  soft,  shreddy, 
and  readily  detached.  When  lirmly  adherent  it  is  torn  olT  with  ditliculty 
and  leaves  an  aliraded  mucosa.  In  the  most  extreme  eases,  in  which  there 
is  extensive  necrosis,  the  jnirts  look  gangrenous.  In  fatal  cases  the  lym- 
phatic glands  of  the  neck  arc  enlarged,  and  there  is  a  general  infiltration 
of  the  tissues  with  serum:  the  salivary  glands,  too,  may  be  swollen.  In 
rare  instances  the  memlirane  extends  to  the  gnllet  and  stomach. 

On  inspection  of  the  larynx  of  a  child  dead  of  mendiranons  cron]i,  the 
r'lma  is  seen  lilled  with  mucus  or  with  a  shreddy  material  which,  when 
washed  olf  carefully,  leaves  the  mucosa  covered  by  a  thin  grayish-yellow 
membrane,  which  may  be  uniform  or  in  ])atches.  It  covers  the  ary-e])i- 
glottic  folds  and  the  true  cords,  and  may  be  continued  into  the  ventricles 
or  even  into  the  trachea.  Above,  it  may  involve  the  e])iglottis.  It  varies 
nnich  in  consistency.  I  have  seen  fatal  cases  in  which  the  exudation  was 
not  actually  membranous,  but  rather  friable  and  granular.  It  may  form 
a  thick,  even  stratified  membrane,  which  fdls  the  entire  glottis.  The  ex- 
udation may  extend  down  the  trachea  and  into  the  bronchi,  and  may  pass 
beyond  the  epiglottis  to  the  fauces.  Usually  it  is  readily  stripped  off  fnun 
the  mucous  membrane  of  the  larynx  and  leaves  ex]iosed  the  swollen  and 
injected  mucosa.  On  examination  it  is  seen  that  the  fibrinous  material 
has  involved  chiefly  the  epithelial  lining  and  has  not  greatly  infiltrated  the 
subjacent  tissues. 

llistoldijical  Chniujrx. — We  owe  largely  to  tlie  labors  of  Wagner,  Wei- 
gert,  and  more  particularly  to  the  splendid  work  of  Oertel.  our  knowledge 
of  the  m'';:ite  chanjies  which  fnl\(>  iilace  in  di|)htheria.  The  following  is 
a  brief  abs.  ,ict  of  the  views  of  the  last-named  author; 

The  diiihtheritic  poison  induces  first  a  necrosis  or  death  of  cells  with 
which  it  comes  in  contact,  jiarticularly  the  superficial  c])ithelium  and  the 
leucocytes.    The  deeper  cells  of  the  mucosa  and  of  the  other  parts  reached 


DHMITIIKUIA. 


14;. 


\  the  postoricir 
riic'Si-'  parts  lire 
ercnt,  in  otlu'rs 

adviuu'od  am! 
lie  is  ol'  a  dirty 
e  in  a  state  of 

the  tonsils  to 
?ed  in  the  deeji 
the  i'alse  nieiu- 
d  throu<rli  the 
<,'eal  diphtlieria 
ses,  however,  it 
e  epijiloltis  and 
membrane.  In 
tlie  bronchi  ol' 
lialf  of  my  30 

in  consistenee, 
phioe.  If  death 
is  soft,  slireddy, 
'  with  ditlieiilty 
in  whieh  there 
eases  tlie  lyin- 
leral  infiltration 
l)e  swollen.  In 
inaeli. 

lions  croup,  the 
al  which,  when 
1  jirayish-yellow 
ers  the  ary-e]ii- 
o  the  ventricles 
lottis.  It  varies 
e  exudation  was 
'.  It  may  form 
[lottis.  The  ex- 
i,  and  may  pass 
tripped  otf  from 
the  swollen  and 
)rinous  material 
:y  infiltrated  the 

if  Wajrnor,  "NVei- 
.  our  knowled.ire 
Pile  following  is 

itli  of  cells  with 
thelinm  and  the 
ler  parts  reached 


l,y  the  ])oison  may  also  be  ail'ecled.     The  se(H)nd  change  is  hyaline  traiis- 
lormation  of  the'dead  cells,  or,  as   Wcigert  terms  it,  the  i)roduetion   ()f 
((.agulation-necrosis.     Tiie  bacilli  excite  inllamniation  with  the  migration 
ui  leucocytes,  which  arc  destroyed  by  the  poison      id  undergo  the  hyaline 
change.    *The  supcrlicial  epithelial  layers  undergo   .  similar  alteration,  and 
what  we  know  as  the  lal.-e  mcnilirane  represents  in  large  part  an  aggrega- 
tion of  dead  cells,  most  of  which  have  undergone  the  transformation  into 
hyaline   material,   and   have   become   much   di>torted   in   shapi>.      (icnuiiie 
iiijrinous  exudate  is,  iiowever,  associatiil  with  this  coagnlation-necro>is  of 
cells.    This  is  in  all  probaltility  a  ciinscr\ativc  process  l>y  which,  in  a  meas- 
ure, the  i)oison  is  loiali/.ed  and  prt'veiitcd  from  reaching  the  deeper  struc- 
tures.    The  laminated  condition  of  the  exudate  is  iirobably  produced  by 
the   inllainmatiim   of   dill'erent   layers.      The    formation   of   these   foci    of 
necrobiosis,  starting  from   the  ei)ithcliuin  and  proceeding  inward,  is,  ac- 
cording to  Oertel,  the  distinguishing  characteristic   of  diphtheria.     The 
action  of  the  poison  is  by  no  means  confined  to  the  superficial  mucosa  on 
whi.'h  the  bacilli  grow.    Although  they  do  not  themselves  penetrate  deeply, 
the  contiguous  bronchial  glands  show  extensive  foci  of  necrosis.     In  severe 
(as-,,  these  necrotic  areas  are  found  in  the  internal  organs,  in  the  solitary 
glands  of  the  intestines,  and  in  the  mesenteric  glands. 

The  blood-vessels  may  themselves  be  much  altered  and  the  capillaries 
may  show  oxtensive  hyaline  degeneration.  Every  one  of  the  liistoh)gical 
changes  described  liy  Oerlel  in  human  diiditlu'ria  may  be  i)arallele(l  in  tiie 
experimental  disease  induced  liy  the  Klebs-LoefUer  bacillus.  Welch  and 
Flexner  have  shown  that  similar  foci  of  necrosis  with  nuclear  fragnienta- 
tion  in  lymphatic  glands,  the  liver,  sidcen,  intestinal  mucosa,  and  other 
parts,  occur  in  the  experimental  diphtheria  of  guinea-pigs,  and  they  have 
demonstrated  that  these  necroses  are  due  to  the  so-called  tox-albumin  of 
the  diphtheria  bacillus.  The  local  evudate  is  caused  by  the  Itacilli  them- 
selves and  cannot  be  produced  by  the  tox-albumin  alone. 

The  changes  in  the  other  onjaiis  are  variable.  When  death  li.is  '>c- 
curred  from  asphvxia  there  is  general  congestion  of  the  viscera. 

C'ai)illary  broiichitis,  areas  of  collapse,  and  patches  of  broncho-pneu- 
monia are  almost  constantly  found  in  fatal  cases.  The  l)roncho-piieumonia 
comi)licating  diphtheria  o'ften  contains  the  Kle1)s-Loelller  bacillus,  l)Ut 
usually  in  combination  with  the  streptococcus  jiyogenes  or  the  diplococcus 
pneumonia'.  These  latter  organisms,  particularly  the  streptococcus,  are 
the  most  frequent  cause  of  the  pulmonary  complications  of  diphtheria. 
In  verv  malignant  cases  the  blood  may  be  fluid.  Fibrinous  coagula  may 
be  f(unid  in  the  heart,  but  the  wich'spread  idea  that  they  may  cause  sud- 
den death  is  erroneous.  :Myocardial  changes  are  not  infrequent,  and  in 
certain  cases  sudden  deatli  is  due  to  heart-failure  in  conseiiucnce  of  degen- 
eration of  the  muscle-fibres.  Endocarditis  is  extremely  rare.  It  was  not 
present  in  one  of  my  thirty  autopsies.  The  serous  membranes  often  show 
ecchymoses.  The  kidneys  present  parenchymatous  changes,  such  as  are 
associated  with  acute  febrile  affectitms.  There  may,  however,  be  acute 
nephritis.  The  spleen  and  liver  show  the  usual  febrile  changes.  The 
spleen  is  not  iilways  enlarged.    General  streptococcus  septicaemia  or  lesi<iiis 


14G 


SPECIFIC   INFECTIOUS   DISEASES. 


of  intornal  orp;ans  diip  to  localizations  of  the  stroptoonroiis  pynponoi?  aro 
(oiiininn  and  most  (lan<f'.n'oiis  complications  of  dipiitlicria.  'IMic  Klobs- 
Loclllcr  liaciliiis  jnay  lie  found  at  autopsy  in  the  blood  and  internal  organs, 
but  nsnally  only  in  small  nundicr. 

Symptoms. — 'I'iic  period  (d'  incubation  is  "  from  two  to  seven  days, 
oftcnest  two." 

Tbc  initial  symptoms  are  tliose  of  an  ordinary  fe])rile  attack — sli<j;bt 
cbilliness.  fever,  and  acliin-^  ])ains  in  tlie  back  and  lindis.  In  mild  cases 
tliese  symptoms  are  tritlin<,s  and  tlu;  cliild  may  not  feel  ill  enough  to  go 
to  bed.  I'sually  the  temperature  rises  within  the  first  twenty-four  hours 
to  10!;'. 5°  or  10;}°;  in  severe  cases  to  101".  In  young  children  there  may 
])e  convulsions  at  the  outset. 

Pharyngeal  Diphtheria.— In  a  typical  case  tliero  is  at  first  redness  of 
the  fauces,  and  the  child  complains  of  slight  ditliculty  in  swallowing. 
The  membrane  first  a])pears  upon  the  tonsils,  and  it  may  be  a  little  ditli- 
eult  to  distinguish  a  i)atchy  diphtheritic  pellicle  from  the  exudate  of  the 
tonsillar  cry])ts.  'J'he  i>liaryngeal  mucous  membrane  is  reddened,  and  the 
tonsils  tliemselves  are  swollen.  I'.y  the  third  day  the  membrane  lias  covered 
the  tonsils,  the  ])illars  of  the  fauces,  and  oerhaps  the  uvula,  which  is  thick- 
ened and  a'dematous,  and  may  fdl  compleiely  the  space  between  the  swollen 
tonsils.  The  membrane  may  extend  to  the  posterior  wall  of  the  pharynx. 
At  first  grayish-white  in  color,  it  changes  to  a  dirty  gray,  often  to  a  yellow- 
white.  It  is  firmly  adherent,  and  when  removed  leaves  a  bleeding,  slightly 
eroded  surface,  which  is  soon  covered  l)y  fresh  exudate.  Tlie  glands  in 
the  neck  are  swollen,  and  nuiy  be  tender.  The  general  condition  of  a 
l)aticnt  in  a  case  of  moderate  severity  is  usually  good;  the  temperature  not 
very  high,  in  the  absence  of  com])lications  ranging  from  lO'^"  to  103". 
The  pulse  range  is  from  100  to  V20.  Tiie  local  condition  of  the  throat 
is  not  of  great  severity,  aiul  the  constitutional  de])ression  is  slight.  The 
symptoms  gradually  abate,  the  swelling  of  the  neck  diminishes,  the  nu'in- 
branes  separate,  and  from  the  seventh  to  the  tenth  day  the  throat  becomes 
clear  and  convalescence  sets  in. 

Clinically  atypical  forms  are  extremely  common,  and  I  follow  hero 
Koplik's  division: 

(«)  There  may  be  no  local  manifestation  of  membrane,  but  a  simple 
catarrhal  angina  associated  sometimes  with  a  croupy  cough.  The  detec- 
tion in  these  cases  of  the  Klebs-Loef!ler  bacillus  can  alone  determine  the 
diagnosis.  Such  cases  are  of  great  numient,  inasmuch  as  they  may  com- 
municate the  severer  disease  to  other  children. 

(/))  There  are  cases  in  which  the  tonsils  are  covered  l>y  a  ])ultaceous 
exudate,  not  a  consistent  membrane. 

(r)  Cases  presenting  a  punctate  form  of  membrane,  isolated,  and  usually 
on  the  surface  of  the  tonsils. 

((/)  Ca«cs  which  begin  and  often  run  their  entire  coui'se  with  tlie  local 
picture  of  a  typical  lacunar  amygdalitis.  They  may  be  mild,  and  the  local 
exudavo  niav  not  extend,  but  in  other  cases  there  aro  ra|)id  development 
of  membrane,  a)\d  extension  of  the  disease  to  the  pharynx  and  the  nose, 
with  severe  septic  and  constitutional  symptoms. 


J 


DIPIITHKRIA. 


14- 


pynppnoi?  aro 


itornal  org.iiii^, 


to  sovon  days. 

attack — sli<j;lit 

In  mild  cases 

onmigli  to  j^o 

ii^y-i'our  lion  IS 

ron  tlu'vo  may 

irst  redness  of 
in  s\vall()\vin;f. 
0  a  little  dilli- 
exndate  of  the 
lened,  and  the 
ne  has  covered 
ivhicli  is  thick- 
>en  the  swollen 
f  the  pharynx, 
en  to  a  ycllow- 
HMling,  slij^ditly 
The  gLinds  in 
condition  of  a 
.'inperature  not 

10-r   to   103°. 

of  the  throat 
is  slight.  The 
;lies,  the  mem- 
throat  becomes 

I  follow  here 

,  but  a  simple 

li.     The  detee- 

determine  the 

they  nuiy  com- 

y  a  pultaceous 

ed,  and  usually 

with  the  local 
!,  and  the  local 
id  development 
;  and  the  nose, 


T 

K  (i)  I  iiilcr  the  term  ''latent  (!i|iiitlicria  '  Ileubncr  has  described  cases, 

■  usually  secondary,  occurring  chielly  in  hospital  practice,  in  young  persons 

■  ihe  suliject  of  wasting  atl'ectioiis,  such  as  riclscts  and  tulterculosis.     There 
H  are    fever,    naso-pharyngeal    catarrii.    aiul    gastro-intestinal    <listurbances. 

■  l)i|)htheria  may  not  be  suspeeted  until  severe  laryngeal  cnni|)|icatioiis  de- 

■  velop,  or  the  condition  may  not  be  determined  until  autopsy. 

■  Systemic  Infection. — The  conslitutional  disturbance  in  mild  diphtheria 
is  very  slight.  'J'here  are  instances,  too,  of  extensive  loeal  disease  without 
grave  systemic  symptoms.  As  a  rule,  the  gcnt'nil  features  of  a  case  bear 
a  detinite  relation  to  the  severity  of  tiu'  loeal  disease.  There  are  rare  in- 
stances in  which  from  the  outset  the  ciuistitutional  jirostration  is  extreme, 
the  pulse  freipicnt  and  small,  the  fever  high,  and  the  nervous  pheiionu'ua 
are  pronounced;  the  patient  may  sink  in  two  or  three  days  overwhelmed  I)y 
the  intensity  of  the  toxaemia,  'ilicre  are  cases  of  this  sort  in  which  the 
exudate  in  the  throat  nuiy  l)e  slight,  but  usually  the  nasal  synqitoins  are 
pronounced.  The  temperature  may  be  very  slightly  raised  or  even  sub- 
normal. ]\fore  commonly  the  severe  systt'inic  symptoms  ap|)ear  at  a  later 
(late  when  the  jiliaryngeal  lesion  is  at  its  height.  They  are  constantly  pres- 
ent in  extensive  disease,  and  when  there  is  a  sloughing,  betiil  condition. 
The  lymphatic  glands  become  greatly  enlarged;  the  pallor  is  extreiiu-;  the 
face  lias  an  a.^hcn-gray  hue;  the  pulse  is  rapid  and  feeble,  and  the  tem])era- 
tiire  sinks  below  normal.  In  the  most  a^-'n'avated  forms  there  are  "an 
grenous  ])roccsses  in  the  throat,  ami  in  rare  instances,  when  life  is  pro- 
longed, extensive  sloughing  of  the  tissues  of  the  neck. 

Kscherieh  accounts  for  the  disere])ancy  sometimes  observed  between 
the  severity  of  the  constitutinnal  distui'liaiiee  and  the  intensity  of  the  local 
proc{>ss,  l)y  assuming  varying  degrees  of  susce])tibility  to  the  diphtheria 
bacillus  on  the  one  hand,  and  to  its  poison  on  tlie  other  hand.  With  high 
local  susceiitibilitv  of  a  i>art  to  the  action  of  the  bacillus,  with  little  ireii- 
eral  suscei)til)ility  to  the  toxine,  there  is  extensive  local  exudate  with  mild 
constitutional  symptoms,  or  vice  versa,  severe  systemic  disturbance  with 
limited  local  inflammation. 

A  leucocytosis  is  jn'csent  in  di|ihtheria.  ]\forse  docs  not  think  it  of  anv 
])rognostic  value,  since  it  is  present  and  may  be  pronounced  in  mild  cases. 

Nasal  Diphtheria. — In  cases  of  jiharyngeal  diphtheria  the  Klebs-Loef- 
fler  bacillus  is  found  on  the  mucous  membrane  of  the  nose  and  in  the  secre- 
tions, even  when  no  membrane  is  lU'csent,  but  it  may  apparently  produce 
two  ail'ections  similar  enough  locally  but  widely  diU'ering  in  their  general 
features. 

In  membranous  or  fibrinous  rhinitis,  a  very  remarkable  affection  seen 
usually  in  children,  the  nares  are  occU])ied  by  thick  membranes,  but  there 
is  an  entire  absence  of  any  constitutional  disturbance.  The  condition 
has  l)een  studied  very  carefully  by  Park,  Abbott,  CJerber  and  Podack,  and 
others.  Pavenel  has  collected  TT  cases  (Medical  Xews,  IS!),"),  I),  jn  U  of 
which  a  bacteriological  examination  was  made,  in  33  the  Klebs-Loefller  ba- 
cillus being  present.  All  the  cases  ran  a  benign  course,  and  in  all  but  a 
few  the  niemljrane  was  limited  to  the  nose,  and  the  constitutional  symp- 
toms were  either  absent  or  very  slight.    Remarkable  and  puzzling  features 


us 


SrEClFlC   INFKC'TIOrS   DISKASKS. 


I..: 


'II 


iip; 


art'  that  tlio  (lincaHc  nms  a  liciii^ii  ('(nuvi',  and  that  iiilVttinn  of  otlu'T  fhil- 
(Ireii  in  the  family  is  cxtronioly  larc. 

On  the  (ithrr  hand,  nasal  diiihthi  ria  is  a|it  to  i«n'scnt  a  most  malignant 
type  of  the  disease.  Tlie  infeetioii  may  he  primary  in  tiie  nose,  and  in  a 
case  recently  in  my  wards  there  was  otitis  media,  and  the  KleljS-Loelller 
hacillns  was  separated  from  the  discharjie  licfore  the  condition  ol'  nasal 
diphtlieriii  was  suspectcfl.  W  hile  some  cases  are  of  mild  character,  others 
are  very  intense,  and  the  constitntioiial  >ymplonis  most  profound.  Ti'.e 
glandidar  intlammation  is  usually  very  inteUM'.  owing,  as  Jacolii  points  out, 
to  the  great  richness  of  tiie  na.-al  mucosa  in  lymphatics.  From  the  nose 
the  inllanimation  may  extt'ud  through  the  tear-ducts  to  the  conjuctiva- 
and  into  the  antra. 

Laryngeal  Diphtheria. — Mnuhnniinn^  Crcuji. — With  a  very  large  pro- 
jiortion  of  all  the  cases  of  nu'iiihranons  laryngitis  the  Klelis-LoeilU'r  hacil- 
lus  is  associated;  in  a  much  smaller  numher  other  organisms,  particularly 
the  streptoeoeeu.a,  arc  found.  Mendjranons  croup,  then,  may  be  said  to  he 
oitlier  genuine  diphtheria  or  diphtheroid  in  character.  Of  '-'Sf!  cases  in 
which  the  disease  was  confined  to  the  larynx  or  lironchi,  in  "Jvll  the  Klehs- 
Loelller  haeilli  were  found.  In  o?  they  were  not  present,  but  IT  of  these 
cultures  were  unsatisfactory  (I'ark  and  Beehe).  The  streiitococcus  cases 
are  more  likely  to  he  secondary  to  other  acute  diseases. 

S!/>iijit(iins. — Naturally,  the  clinical  symptoms  are  almost  identical  in 
the  n()n-s|iecilic  and  specific  forms  of  niendn'anous  laryngitis. 

The  aU'ection  hegins  like  an  acuti'  laryngitis  with  slight  hoarseness  and 
rough  cough,  to  which  the  term  croupy  ha^:  been  applied.  After  these 
symptoms  have  lasted  for  a  day  or  two  with  varying  intensity,  the  child 
suddetdy  becomes  worse,  usually  at  night,  and  there  are  signs  of  impeded 
respiration.  At  first  the  dilliculty  in  bre;itliing  is  paroxysnuU,  due  prob- 
ably to  nuire  or  less  spasm  of  the  muscles  of  the  glottis.  Soon  the  dyspnoea 
becomes  continuous,  inspiration  and  ex]iiration  become  ditlicult,  ])articu- 
larly  the  latter,  and  with  the  inspiratory  movements  the  epigastrium  and 
lower  intercostal  spaces  are  retracted.  The  voice  is  husky  and  may  be  re- 
duced to  a  whisper.  The  color  gradually  changes  and  the  imperfect  ai'ra- 
tion  of  the  blood  is  shown  in  the  lividity  of  the  lips  and  finger-tips.  Rest- 
lessness conies  on  and  the  child  tosses  from  side  to  side,  vainly  trying  to 
get  breath.  Occasionally,  in  a  severer  paroxysm,  portions  of  membrane  are 
coughed  out.  The  fever  in  membranous  laryngitis  is  rarely  very  high  and 
the  condition  of  the  child  is  usually  very  good  at  the  time  of  the  onset. 
The  pulse  is  always  increased  in  frequency  and  if  cyanosis  be  present  is 
small.  In  favorable  cases  the  dyspmea  is  not  very  urgent,  the  color  of  the 
face  remains  good,  and  after  one  or  two  paroxysms  the  child  goes  to  sleep 
and  wakes  in  the  nKU'ning.  perhaps  without  fever  and  feeling  comfortable. 
The  attack  may  recur  the  following  night  with  greater  severity.  In  nn- 
favorable  eases  the  dyspmea  bt'comes  more  and  more  urgent,  the  cyanosis 
deepens,  the  child,  after  a  period  of  intense  restlessness,  sinks  into  a  semi- 
comatose state,  and  death  finally  occurs  from  ])oisoning  of  the  nerve  cen- 
tres by  carbon  dioxide.  In  other  cases  the  onset  is  less  sudden  and  is  pre- 
ceded by  a  longer  period  of  indisposition.    As  a  rule,  there  are  pharyngeal 


''ii^ 


I    of  (itlu'T   fllil- 

iiost  iiiiili<,'naiit 
iiosi',  and  in  a 

Kk'l)^-L(.ctllLT 

lilidii  of  iKif^al 
laractcr,  oIIuts 
rofound.  Tlu' 
■dlii  |i()int»  om. 
From  tlio  noso 
the  fonjuctiva' 

rrv  larjre  pro- 
-LooIIKt  liacil- 
iis,  partii'iilaiiy 
V  be  said  to  1)0 
f  '^Xi'>  cases  ill 
•^•i'J  the  Klehs- 
)iit  ir  of  these 
ittocoeeiis  oases 

st  identical  in 

lioarseness  and 
I.  After  these 
isity,  the  cliild 
rns  of  impeded 
inal,  due  prolj- 
in  the  dyspnrea 
[Tieidt,  ]nu'tieu- 
[)i<;astriiim  and 
ind  may  be  re- 
imperfect  aera- 
t;er-tips.  Rest- 
ainly  trying  to 
memhranc  are 
very  liigli  and 
e  of  the  onset. 
s  be  present  is 
lie  color  of  the 
d  goes  to  sleep 
ig  comfortable, 
icrity.  In  un- 
it, the  cyanosis 
ks  into  a  semi- 
the  nerve  ccn- 
len  and  is  pre- 
are  pharyngeal 


DIPIITIIEIUA. 


Ill) 


>vniptoms.  Tlic  constitutional  distnrbaiice  miiy  be  more  severe,  the  fever 
l.ijdier,  and  tiiere  may  lie  swelling  of  the  glands  of  the  neck.  Inspection 
(if  the  fiiiiccs  may  show  the  presence  of  false  niemliranc>  on  the  [Mliars  or 
on  the  tonsils.  r>act''riological  examination  can  alone  iletermine  whetlur 
these  are  due  to  the  Klebs-l.i'cnicr  hacilliis  or  to  the  >trepti>(n((iis.  Faggi; 
held  that  non-contagious  nu'iubranous  croup  may  spread  ujiward  from  the 
larynx  just  as  diiihtlieritic  iniiammation  is  in  the  haliit  of  spreading  (hiwii- 
ward  from  the  fauces.  Ware,  of  lioston,  whose  essay  on  croup  is  perhaps 
the  most  solid  contribution  to  tiie  subject  made  in  tliis  country,  reported 
the  presence  of  exudate  in  the  fauces  in  M  out  of  7')  ca>es  of  ci'oup.  Tliese 
observations  were  made  jirior  to  ISiO,  during  periods  in  which  diphtheria 
was  not  epidemic  to  any  extent  in  iiosion.  In  protracted  cases  ])ulmoiiary 
synipt(uus  may  devclo]),  whi(  h  are  sonu'times  due  to  the  diiliculty  in  expt'l- 
hng  the  muco-pus  from  the  tiilics;  in  others,  the  false  membrane  extends 
into  the  trachea  and  even  into  the  bronchial  tulies.  During  the  ])aroxysm 
the  vcsicnlar  murnmr  is  scarcely  audible,  but  tlie  laiyugeal  stridor  may  In' 
loudly  Commuiiicated  ahuig  the  lironchial  tubes. 

Diphtheria  of  Other  Parts. — Primary  di[ihthcria  (ucurs  occasionally 
in  the  conjuiirlira.  Jt  follows  in  some  instances  tiie  ail'ectiini  nf  the  nasal 
iiuicous  memlirane.  Some  of  the  cases  are  severe  and  serious,  liut  it  has 
been  shown  by  C.  Friinkel  and  others  that  tiie  dijilitheria  liacilli  may  be 
])resent  in  a  conjunctivitis  catarrhal  in  character,  or  associated  witli  only 
slight  croupous  dejiosits. 

Diphtlieria  of  the  cvtcnial  oudiliirij  niralufi  is  seen  in  rare  instances  in 
which  there  are  diphtheritic  otitis  media  and  extension  thnnigh  the  tym- 
panic membrane. 

Di})litlieria  of  the  slin  is  most  frequently  seen  in  (he  severer  forms  of 
jiharyngeal  diphtheria,  in  which  tlie  membrane  extends  to  the  mouth  and 
lips,  and  invades  the  adjacent  jiortions  of  the  skin  of  the  face.  Tiie  skin 
about  tlie  anus  and  genitals  may  also  be  attacked,  rseudo-meinbranous 
iniiammation  is  not  uncommon  on  ulcerated  surfaces  and  wounds.  In 
very  many  of  these  cases  it  is  a  streptococcus  infection,  luit  in  a  majority, 
periia]>s,  in  wliicli  the  ])atient  is  sulfering  with  diphtheria,  the  Klebs-Loef- 
ller  bacillus  will  lie  found  in  the  fibrinous  exudate.  As  jiroposed  by  Welch, 
the  term  "wound  di])htlicria ''  should  be  limited  to  infection  of  a  wound 
by  the  Klebs-Loetller  bacillus.  This  "may  manifest  itself  as  a  simple 
inflammation,  or  iniiammation  with  sujierficial  necrosis,  or  iniiammation 
witli  more  or  less  adherent  pseudo-membrane.  The  conditions  as  regards 
varying  intensity  and  character  of  the  infection,  association  with  other 
bacteria,  particularly  strejitococci,  and  the  necessity  of  a  bacteriological 
examination  to  establish  the  diagnosis,  are  in  no  way  different  in  the  diph- 
theria of  wounds  from  those  in  diiihtheria  of  mucous  membranes.  Wound 
di])litheria  may  occur  without  demonstrable  connection  with  cases  of  diph- 
theria and  without  affection  of  the  throat  in  the  individual  attacked,  but 
such  occurrences  are  rare  "  (Welch).  Paralysis  may  follow  wound  diph- 
theria. Pseudo-membranous  inflammations  of  wounds  are  caused  more  fre- 
quently by  other  micro-organisms,  jiarticularly  the  streptococcus  jiyogenes, 
than  bv  the  Klebs-Loefller  bacillus.    The  fibrinous  memlirane  so  common 


■■^^ 


I 


150 


SPECinC   INFECTIOUS  PISEASFA 


) 


ifl   ' 


ill  tho  ncl^'lilmrliood  of  tlio  tniclu'otoniy  wound  in  diplitlicriiv  is  niroly 
iiss(Kiiit('(l  with  tin;  KlcLs-Loi'lllcr  ii:icilliis.  Diplithi'ria  «>l'  tlic  gi'uilal!-  is 
o(i'iisii)nullv  seen. 

Compiications  and  Sequelae. —Ol'  local  (•(inii)li(ations,  lia^nmr- 
vliaj,^o  Ironi  tiio  iiusc  or  tiiroal  may  occur  in  tho  sovc/c  iii<'cnitivc  cases. 
Si<in  rasiu's  arc  not  ini'mincnt,  ]mrticnlarly  tho  ditl'iisc  crytlicnia.  Occa- 
sionally there  is  urticaria  and  in  tho  sovoro  ciisos  imrimra.  TIk'  |inliiionary 
complications  are  extremely  imjiortant.  Fatrl  cases  almost  invariaMy  show 
capillary  hronehitis  with  Im.neiio-pneiimonia  and  lar>,u'  patches  of  collapse. 
In  very  bad  cases,  with  extensive  slon<;hinf,',  tho  septic  j.articl'S  may  roach 
the  bronchi  and  excite  <;angrcnous  processes  which  may  lead  to  severe  and 

fatal  iKi'niorrha;.^'. 

]Jenal  cimiplications  are  common.  Anniniliiiirid  is  present  m  all  severe 
oases.  It  may  cause  with  the  usual  tests  only  a  slight  turl)i(lity  of  the  urine, 
the  ordinary  i'ohrile  albuminuria.  In  others  there  is  a  large  amount  of 
albumin,  curdy  in  character.  It  is  only  when  the  albumin  is  in  consider- 
alde  (piantity'and  associated  with  ei.ithelial  or  blood  casts  that  tho  con- 
dition indicates  parenchymatous  uophritis  and  is  alarming.  Tiie  neiiliritis 
mav  appear  (piito  early ^iii  the  disease.  It  >ets  in  occasionally  with  com- 
])loto  suppression  of  the  urine.  In  comiiarison  with  scarlet  fever  tho  renal 
ehanges  lead  less  freciuently  to  gem>ral  dr()i)sy.  Mention  has  already  beeii 
made  of  tho  fro(iuency  and  gravity  of  septicrt'inia  aud  local  infection  of 
internal  jiarts  due  to  invasion  of  tho  streptococcus  pyogenes,  which  is  nearly 
a  constant  attendant  of  tbo  Klel)S-Loell!or  bacillus  in  tho  human  body. 

Of  the  se(|ucla'  of  diphtheria,  ],)triil!/sis  is  by  far  the  most  important. 
This  can  l)o  exiierimentally  jjroduced  in  animals,  as  already  noted,  by  the 
inoculation  of  the  toxic  nialerial  jn'oduced  by  the  bacilli.  The  i)aralysis 
oeeurs  in  a  variable  jiroportion  of  the  cases,  ranging  from  10  to  15  and 
oven  to  '•.'()  ]ier  cenr.  It  is  strictly  a  seiim  1  of  the  disease,  coming  on  usu- 
ally in  the  second  or  third  week  of  convalescence.  Occasionally  it  occurs 
as  "early  as  tho  seventh  or  eighth  day  of  the  disease.  It  may  follow  very 
mild  cases;  indeed,  the  local  lesion  may  be  so  trifling  that  the  onset  of 
the  paralysis  alone  calls  attention  to  tho  true  nature  of  the  trouble.  It  is 
proiiortionatolv  less  freciuont  in  children  than  in  adults. 

The  disease  is  a  toxic  neuritis,  duo  to  the  absorption  of  the  poison, 
and,  like  other  forms  of  multiple  neuritis,  has  an  extremely  complex  symp- 
tomatology, according  to  tho  nerves  whicli  are  affected.  The  paralysis  may 
be  local  or  general. 

Of  the  local  jiaralysos  tho  most  common  is  that  which  alfocts  tho  jtal- 
ate.  This  gives  a  nasal  character  to  tho  voice,  and,  owing  to  a  return  of 
li(piids  through  tho  nose,  causes  a  dilllculty  in  swallowing.  These  may  be 
the  only  symptoms.  Tho  ]ialato  is  seen  to  be  relaxed  aud  motionless,  and 
the  sensation  in  it  is  also  nnu'h  impaired.  The  atroction  may  extend  to 
the  ecmstrictors  of  the  idmrynx,  aud  deglutition  become  embarrassed. 
Within  two  or  three  weeks  or  even  a  shorter  time  the  paralysis  disappears. 
In  many  cases  the  affection  of  tlio  ])alafo  is  only  part  of  a  general  neuritis. 
Of  other  local  forms  perhaiis  tho  most  common  are  paralysis  of  the  eye- 
muscles,  intrinsic  and  extrinsic.    There  may  be  strabismus,  ptosis,  and  loss 


Dll'TITHKRIA. 


151 


[■via  i.s  rari'ly 
lio  goiiilal!?  i« 

idiis.  lui'iiior- 
•cralivo  casi's. 
lu'iiia.  Ocra- 
lic  |iiilin(UKU\v 
vai'ial'ly  hIiow 
c's  of  coUaiiSL'. 
I'S  may  roacli 
to  ^-fvoro  and 

t  ill  all  seven' 
\-  of  tiio  iirino, 
jfo  amount  of 
IS  in  consider- 
that  the  eon- 
The  iiei)liritis 
lly  with  coni- 
ever  the  renal 
■;  already  been 
il  infection  of 
iliieh  is  nearly 
uinan  body, 
ost  important, 
noted,  by  the 
The  i)aralysis 
10  to  1.5  and 
omin<i  on  iisu- 
nally  it  oeeurs 
ay  follow  very 
t  the  onset  of 
troui)le.     It  is 

of  the  poison, 
complex  symp- 
.'  paralysis  may 

lifects  tlie  pal- 
to  a  return  of 
These  may  bo 
iiotionless.  and 
may  extend  to 
0  embarrassed. 
ysis  disappears. 
oTieral  neuritis. 
•sis  of  tlic  eye- 
ptosis,  and  loss 


of  jH)\ver  of  accommodation.  I''acia]  painl\sis  may  (levdop,  and  in  dUe 
case,  two  ami  a  iialf  yciirs  later,  it  .-lill  persi-ted  with  coiilracturi'S.  'I'hr 
neuritis  may  lie  conlined  to  tlo'  nei'vcs  of  one  iindi,  thouf,'!!  more  commonly 
llie  icf:s  or  the  arms  arc  alVecIcd  t(ij,'ethi'r.  \'cry(irii'U  with  the  palatal  jiaraly- 
sis  is  associated  a  weakness  of  the  U"^s  withunt  d(  linite  palsy  but  with  In.-s 
iif  the  knee-jerk. 

Heart  svinjitoms  are  not  uncommnn.  'i'hcre  may  be  i^reat  retardalinn. 
even  1(1  tbirtv  beats  in  the  minute,  bradycardia  ;md  tachycardia  may 
alternate  in  the  siinie  patient,  llcai't-l'ailure  and  faliil  syncope  ni:iy  occur 
at  the  hci;,dit  of  the  disease  or  during  c<invalcsccnce.  if  ihey  occur  during 
the  fever,  the  child.  ]icrhaps  after  an  exaggeration  of  symplmus.  presents  an 
unusual  [lallm-.  The  pulse  becomes  weak  and  rapid,  liut  uiay  fall  to  lifly, 
fortv,  or  even  lower.  The  extremities  arc  cold,  the  tcmin'rature  sinks,  and 
death  takes  ]ilacc.  with  all  the  features  of  coll;i|isc,  within  a  few  hours. 
More  frc<iucntly  the  fatal  collajise  comes  dui'ing  convalescence,  even  as 
late  as  the  si.xtli  or  seventh  week  after  appannt  recovery.  'I'lie  attack 
may  set  in  abruptly,  ])erhaps  following  a  sudden  exertion.  More  com- 
nu)nly  there  have  been  symptoms  jioinling  to  disturbed  cardiac  rhythm, 
or  even  fainting-spclls.  In  some  instances  vomiting  has  ]ireccdcd  tin; 
serious  cardiac  attack.  There  may  be  no  jihysical  signs  other  than  slight 
increase  in  the  cardiac  dulness  and  a  galloii-rhythm  indiiatiug  dilatation. 
These  syiu])toms  were  formerly  ascribed  to  cardiac  throiubosis  or  to  endo- 
carditis. Possibly  in  some  of  the  cases  the  rcsidt  is  diu',  as  pointed  out 
by  Mosler  and  Leyden,  to  an  infectious  myocarditis,  but  in  a  majority  of 
the  cases  tlie  sym])toms  ure  probably  due  to  a  neuritis  of  the  cardiac  nerves. 

The  multii>le  form  of  diphtheritic  neuritis  is  not  uncommon,  it  may 
begin  with  the  ])alatal  alfcction,  or  with  loss  of  power  of  accommodation 
and  loss  of  the  tendon  reflexes.  'I'his  last  is  an  important  sign,  which,  as 
liernhardt,  lUizzard,  and  U.  L.  MacDonncll  have  shown,  may  occur  early, 
but  is  not  necessarily  followe<l  by  other  symptoms  of  neuritis.  There  is 
jiaraplcgia,  which  may  be  comjilcto  or  involve  oidy  the  extensors  of  the 
feet.  The  jiaralysis  may  extend  and  involve  the  arms  and  face  ami  render 
the  patient  entirely  lielidcss.  The  muscles  of  respiration  may  be  spared. 
The  chief  dan"-er  in  tlie.<e  severer  forms  comes  from  the  involvement  of 
the  heart  and  of  the  nuiscles  of  res|)iration;  but  the  outlook  is  in  many 
cases  not  so  bad  as  the  ])atient's  condition  would  indicate.  Of  \[]  cases 
collected  by  Cadet  do  (iassiconrt  (!  died.  The  sphincters  may  be  involved, 
tlioiiffh  they  are  often  spared. 

Diagnosis.— The  presence  of  the  Klcbs-T.oefller  bacillus  is  regarded 
by  bacteri<ilogists  as  the  sole  criterion  of  true  di|ilitheria,  and  as  this  organ- 
ism may  be  associated  with  all  grades  of  throat  affections,  from  a  simple 
catarrh"  to  a  sloughing,  gangr(>nous  jirnccss,  it  is  evident  that  in  many 
instances  there  will  1)e  a  striking  discrepancy  between  the  clinical  and  the 
bacteriological  diagnosis.  One  inestimable  value  of  the  recent  studies  has 
1)een  the  determination  of  the  diphtheritic  character  of  many  of  the  milder 
forms  of  tonsillitis  and  pharyngitis. 

Tb.e  bacteriological  diagnosis  is  simple.  The  plan  adopted  by  the 
Xcw  York  Health  Department  is  a  model  which   may  be  followed  with 


^■^ 


ili:| 


I  I 


152 


SPKCIFIC  IXFtX'TlOL'S  IHSEASKS. 


ailviiiit!i;:i'  ill  ntlicr  ••itics.  Oiillits  for  iiiakiii;.'  ciilliins,  cdiisistiii;,'  of  a 
l)(ix  idiitaiiiiii;:  a  tulic  nf  lilood-.^cnim  and  •!  >t(  rili/id  .-wali  in  a  tf.«t-tiilir. 
arc  (lititrilMitcil  to  alxxit  Inrty  stations  at  loiivcniciit  puinis  in  tlic  city. 
A  list  of  tln-si'  idacfs  is  imlilislicil,  and  a  |iliy>i(ian  can  olitain  tlu'  ontlit 
Sivv  of  cdst.  Tlif  dirccliinis  arc  as  i'ldlous:  "  'i'iic  [uiticnl  slnndd  Ih'  jiiaccd 
in  a  i,'(»<)d  lij^lit.  and.  if  a  child.  |»r()|)crly  liild.  In  cases  wlicrc  it  is  |M)ssii)lc 
to  ;;cl  a  L'licid  \  ii  v.  nf  tlic  tiiniat.  (lc|ircss  tlic  tonj^iic  and  rnh  tlic  cottdii 
?ual)  j.'cnllv  Imt  freely  .iiiainst  any  visil)le  cxndatc  In  other  easi's,  incUid- 
inj,'  lliose  in  whieii  tiie  exndatu  is  fonlliied  to  the  hirynx.  avoiding  the 
tongnc,  pass  the  >ual.  iar  !)a(  k  and  rnt)  it  freely  against  the  nmcuus  nieni- 
In-anc  of  the  iiharynx  and  tonsils.  Withont  laying  the  swah  down,  with- 
diaw  the  cotton  plug  from  the  cnltnre-tnhe.  insert  the  swal).  and  rnh  that 
portion  of  it  wiiich  lias  touched  the  I'xndate  gently  hut  thoroughly  all  over 
the  surface  of  the  Idood-seruni.  Do  not  push  the  swah  into  the  Idood- 
sernni,  nor  hreak  the  >urface  in  any  way.  Then  ri  phu'c  the  swaii  in  its  own 
tnlx'.  iihnr  l>"th  tulxs.  put  them  in  the  ho\.  ami  return  the  culture  oullit 
at  once  to  the  station  from  which  it  was  ohtaiued."  The  culture-tnhes 
which  have  heen  inoculated  are  kept  in  an  incuhalor  at  'M^  ('.  for  twelve 
hours  and  are  then  ready  for  examination.  Sonu'  prefer  a  nu'tluid  hy  which 
the  material  from  the  throat  collected  on  a  sterile  swah,  or.  as  recoin- 
inemled  tiv  von  l'',smarch.  on  small  pieces  of  sterili/eil  s|ioiige,  is  sent  to 
the  lal>oratory  where  the  cultures  and  microseoi)ieal  examination  arc  made 
by  a  hactci'iologi-t. 

An  imiuciliate  diagnosis  without  the  use  of  cultures  is  (d'teii  possible 
by  making  a  smear  preparation  of  the  exudate  from  the  throat.  The  Klebs- 
Loeiller  bacilli  may  he  present  in  snilieient  iiundiers,  and  may  ))e  (piite 
characteristic  to  an  expert.  In  this  connection  may  be  given  the  following 
statenunit  by  Park,  who  has  hail  such  an  exceptional  experience:  "  The  ex- 
amination by  a  competent  bacteriologist  of  the  bacterial  growth  in  a  blood- 
sernm  tnlie  which  has  been  pro|)erly  inoeidated  and  kept  for  fourteen  lionrs 
at  till'  body  temperature  can  be  thoroughly  relied  upon  in  eases  where  there 
is  visible  nicndirane  in  the  throat,  if  the  culture  is  made  during  the  jjcriod 
in  which  the  membrane  is  forming,  and  no  anti.<e])tic,  especially  no  mer- 
curial solution,  has  lately  been  a]iplied.  In  cases  in  which  the  disease  is 
confined  to  the  larynx  or  bronchi,  surprisingly  aecnrato  results  can  be 
(ilitained  froui  cultures,  but  in  a  certain  proportion  of  cases  no  diphtheria 
bacilli  will  be  found  in  the  first  culture,  and  yet  will  be  abundantly  [iresent 
in  later  cultures.  We  believe,  therefore,  that  absolute  reliance  for  a  diag- 
nosis cannot  be  placeil  upon  a  single  cidture  from  the  ]>iiarynx  in  purely 
laryngeal  cases." 

]Vhrrr  a  Jiiictrridlniiiral  iwaminnlion  rniinof  he  niailr.  Ihr  prarfltiaiirr  must 
regard  os  suspirlaiifi  all  farnifi  nf  throat  affcrthins  in  cliUdrcn,  and  rarrj/  out 
nicasitri'i^  of  !>i(ilaltou  and  disinfection.  Tn  this  way  alone  can  serious  errors 
bo  avoided.  Tt  is  not.  of  course,  in  the  severer  forms  of  membranous  an- 
gina that  mistake  is  likely  to  occur,  but  in  the  various  lighter  forms,  many 
of  which  are  in  reality  due  to  the  Klebs-Loefller  bacillus. 

A  large  ]U'oiiortion  of  the  cases  of  di])btlieroid  inilammatiou  of  the 
throat  are  due  to  the  streptococcus  pyogenes.     They  are  usually  milder, 


^'^J 


DIIMITllKUIA. 


i:.:! 


msistiii;,'  of  a 

III    il    tf.-t-tlllir. 

s  ill  till'  fitv. 
iiiii  till'  (limit 
iiild  lie  (iliici'il 
(■  it  is  [Hissililr 
lib  tlie  cottdii 
rasi'S,  iiiclinl- 
iivdiding  llu' 

lIllll'OllS    lIK'lll- 

Ij  iIdwii.  witli- 

,  ntul  rill)  lliiit 

iiijilily  all  over 

ito  till'  Iduod- 

\\;\\)  in  its  own 

iiiltiirc  (iiillit 

ciiltiiri'-tiilics 

('.  for  twi'lvr 

tliod  \>\  wiiicli 

or,  as   rccoin- 

1^^',  is  sent   to 

ition  arc  made 

often  possilile 
t.    Till'  Klilis- 

luay  hv  (jiiite 
1  the  following 
lice:  "  Tile  e\- 
\\h  in  a  blood- 
foiirtoen  hours 
;es  where  there 
'iiig  the  jieriod 
rially  no  mer- 

the  disease  is 
results  can   he 

no  diphtheria 
idantly  present 
ICC  for  a  diag- 
rynx  in  purely 

aditiiiiirr  must 
and  rarri/  out 
1  serious  errors 
enihranous  an- 
'r  forms,  many 

mat  ion  of  the 
.isually  milder, 


iiiid  the  lialiility  to  general  infection  is  h"  intense;  still,  in  .m  arlct  fcv.'r 
iiiid  otlitr  specitie  fevers  xmie  of  the  iiio^t  \iiiilciit  cases  of  throat  disease 

uilirh    \sv   see.    with    intc|i>e    >y-teniic    infcctiuli.   lire    cMU-i'd    hy    this    lllirro- 

urganisiii.  'I'Iicm'  .■.treptucdcciis  ca,-es  aie  prolialdy  iiiiich  les>  niiiMcroiis 
than  the  ligiires  which  1  have  given  would  indiciilc.  'I'hc  niort  careful 
(  \aiiiiiiaIioiis  ill  the  diphtheria  pavilions  of  liii.-|iilals  particularly  in  1mi- 
nipe.  ha\e  >liowii  that  in  the  large  majority  of  cases  admitted  the  Klchs- 
Loelller  hacilliis  is  present.  I  have  alnatly  referred,  under  the  section  on 
.-carlet  fc\cr.  to  ihc  (|lle>li()li  of  the  diagllo,-i>  lictwccli  scarlet  fever  with 
>e\ere  aiiLiiiia  and  diphtheria. 

Prognosis.- -in  lio>pital  pi'actice  the  disease  is  very  fatal,  the  per- 
centage of  death-  ranging  froni  thirty  to  lifty.  This  is  due  in  great  part 
to  the  admission  only  of  the  severi'r  form.-,  in  country  places  the  disease 
iiiav  display  an  ap|ialliiig  virulence,  in  cases  df  ordinary  si'vcrity  the  out- 
look is  usually  gooil.  itcath  re,-ult-  from  invohemeiit  id'  the  laryn.v,  septic 
infection,  sudden  hcart-failnrc,  diphtheritic  paralysis,  occasionally  from 
iira'inia.  and  sometimes  from  hroncho-pneiimonia  developing  during  con- 
valescence. 

Prophylaxis. — Isolation  of  the  sick,  disinfection  of  the  clothing 
and  of  cvciytliing  that  has  come  in  contact  with  the  patient,  careful 
scrutiny  of  the  milder  eases  id'  throat  disorder,  and  more  stringent  surveil- 
lance in  the  |icriod  of  cniivalcscence  are  the  e-sciilial  mea-uics  to  prevent 
the  s]H'cad  of  the  disea.-e.  Suspected  cases  in  families  or  schools  should  'le 
al  once  isolated  or  removed  to  a  hospital  for  infections  disorders.  When  a 
death  has  occurred  from  diphtheria,  the  liody  should  he  wrapjied  in  a  sliv'ct 
which  has  heeii  soaked  in  a  corro-ive-sulilimatc  solution  (1  to  ;{,()(»()),  and 
placed  in  a  closely  sealed  cojlin.     'I'he  funeral  should  always  he  private. 

In  eases  of  well-marked  di|ihtlieria  these  precautions  are  iisiially  car- 
ried out,  hut  the  (hief  danger  is  from  the  milder  eases,  particularly  the 
amhulatory  form,  in  which  the  di.-ease  has  jierhaps  not  liceii  suspected. 
lUit  from  sucli  patients  mingling  with  snseeptihle  children  the  disease  is 
often  conveyed.  The  healthy  children  in  a  family  in  which  diphtheria 
exists  may  carry  ihc  disease  to  their  school-fellows.  A  striking  illustration 
of  the  way  in  which  diphtheria  is  spread  is  given  hy  I'ark  and  I5eehe:  "  The 
child  of  a  man  who  kept  a  candy  store  developed  di|)htlieria;  there  win'c 
four  other  children  in  the  family,  and  these  were  in  no  way  isolated  from 
the  jnitient.  yet  none  of  them  develoi>ed  di])htheria:  but  children  who 
boughi  candy  at  the  store,  and  other  children  coming  in  contact  with  these 
in  school,  developed  diphtheria.  The  secondary  eases  ceased  to  develop  so 
soon  as  the  candy  store  had  been  closed." 

A  very  imjiortant  matter  in  the  jirojiliylaxis  relates  to  the  period  of 
convalescence.  Tt  has  been  shown  by  numerous  observations  that,  after  all 
the  membraiu'  has  cleared  away,  virulent  bacilli  may  persist  in  the  throat 
from  periods  ranging  from  six  weeks  to  six  months,  or  even  longer.  There 
is  evidence  to  show  that  the  disease  may  be  cnmmunicated  by  such  patients, 
so  that  isolation  should  be  continued  in  any  given  case  until  the  bacteri- 
ological examinatiim  shows  that  the  throat  is  free. 

It  cannot  be  too  strongly  emphasized  that  the  important  elements  in 


-     - 


m'f 


U 


15  J: 


SPECIFIC  INFECTIOUS  DISEASES. 


ilJ 

■!      i      '!'l 

/I 
M 


ihu  projiliyliixis  of  (liplitlicria  arc  llic  ri-:i(l  si-niliny  of  tho  tnililcr  types  of 
ihroiil  allVctioii,  and  tlir  tlioroii^li  i.-olatioii  and  (lisiiiffctioii  of  the  indi- 
vidual jiaticnts. 

Careful  atU'Utif.n  sliould  \'V  'j:\\r\\  to  the  throats  and  mouths  (d'  ehil- 
(Ircn,  particularly  to  the  tci'lh  and  tonsils,  as  Caiile  has  ur^t'd.  Swollen 
and  enlar'.n'd  tonsils  sliould  l)e  removed.  li\  persons  exposed,  the  anti- 
i^eplie  incuith  washes,  sueli  as  corrosive  suhliniate  (1  to  lO.OdO),  chlorine 
water  (1  to  I.lilO).  or  swalihinj,''  the  throat  with  a  diluti'd  l.oelller's  s<ilu- 
tion,  should  lie  ein]iloyed. 

Treatment. — 'i'hV  iniiuulant  points  are  hy--ienie  mcasui'es  to  pre- 
vent tlu'  sjiread  of  the  niahuly,  local  ir»'atnient  of  the  tlnoat  to  destroy 
the  bacilli,  medication,  general  or  siiecilic,  to  counteract  the  etVects  of  tlu 
toxines,  and,  lastly,  to  meet  tiie  complicatioiis  and  secpiehe. 

{ii)  Hygienic  Measures. — The  ])atient  should  he  in  a  room  from  which 
the  carpets,  curtains,  and  superOuons  furniture  have  l)een  removed.  The 
tem[)erature  should  be  ai)ont  G8°,  and  lliorou<rh  ventilation  sliould  be 
secured.  Tlie  air  may  be  kept  moist  by  a  kettle  or  a  steam-atomizer.  If 
possible,  only  the  nurse,  tli:'  cliihrs  mother,  and  the  doctor  should  come 
in  contact  witii  the  patient.  During  the  visit  the  ])hysician  should  wear 
a  linen  overall,  and  on  leaving  the  room  he  should  thoroughly  wash  bis 
hands  and  face  in  a  corrosive-siihlimate  solution.  The  strictest  ([uarantine 
should  be  employed  against  other  mi'inbers  in  the  house. 

{/))  Local  Treatment. — In  mild  cases  the  throat  syiii|)tonis  are  aloi;e 
jiromineiit.  A'igorniis  local  treatment  from  the  outset  should  be  carried 
out,  taking  esjiecial  care  in  all  instances  to  avoid  mechanical  injury  to 
the  tissues.  A  very  large  numlier  of  solutions  have  been  recommended. 
They  are  best  employed  with  a  swab  of  coHon-wool  or  a  soft  sponge,  or 
irrigation  with  hot  i  iitiseptic  solnlicms  may  lie  used.  The  direct  applica- 
tion with  a  swab  of  cotton-wool  or  sjumge  is,  as  a  rule,  eHVetive.  In  many 
young  children  it  is  really  a  most  trying  procedure  to  carry  out  the  treat- 
ment, and  sometimes  one  is  compelled  to  desist.  The  nurse  should  hold 
the  child  on  her  knees,  well  wrapped  in  a  shawl,  with  its  head  resting  on 
her  shoulder.  The  nose  is  then  held,  and  so  soon  as  the  child  opens  its 
mouth  a  cork  ■^hoiild  be  placed  between  the  molar  teOth.  'Hie  local  appli- 
cation can  then  be  made,  or  thorough  irrigation  carried  out.  Jn  infants 
the  disinfecting  fluids  are  sometimes  lietter  applied  through  the  nostrils. 
The  following  solutions  may  be  employed: 

Loeliler's  solution:  ]\rcnthol,  10  grammes  dissolved  in  toluol  to  30  cc. 
Liq.   Ferri  sesquichlorati,  -1  cc;  alcohol  al  sol.,  (10  cc. 

Corrosive  sublimate,  1  to  1,000,  either  alone  or  with  tartaric  acid,  5 
grammes  to  the  litre. 

Carbolic  acid,  )!  ]ier  cent  in  .'lO  per  cent  alcohol  solution,  is  much  em- 
ployed; some  jtrefer  to  touch  the  small  spots  of  exudate  with  jiure  carbolic 
acid. 

Aiuither  solution  is:  The  tincture  of  the  ])ercIiloride  of  iron,  a  drachm 
nnd  a  half,  in  glycerine,  one  ounce,  water,  one  ounce,  with  from  1.")  to  20 
minims  of  carbolic  acid.  Chlorine  water,  boric  acid,  peroxide  of  hydrogen, 
iodoform,  lactic  acid,  tryjisin,  and  papain  are  also  recom;  ended. 


^'t. 


DlPIITIlEIilA. 


155 


iiiiMcr  types  cf 
idii  ol'  till'  indi- 

lllOlltllS    ol'    C'llil- 

iirgi'd.  Swolk'U 
posed,  tlio  aiili- 
(l.()(Kl),  chlorine 
1    Loelller's  solii- 

leiisiu'es  to  pre- 
lii'oiit  to  destroy 
he  etVeets  of  the- 

Doiu  from  whieli 
I  removed.  The 
iitiuii  sliould  be 
iim-atomizer.  II' 
tor  should  coine 
•inn  slioidd  wear 
oiiirlily  wasli  his 
ietest  (jiiarantiiie 

])toiiis  are  aloi;e 
hould  lie  carried 
anii-al  injury  to 
n  recoiiiinended. 
1  soft  sponge,  or 
e  direct  applica- 
ective.  In  many 
ry  out  tlie  treat- 
urse  should  hold 

liead  resting  on 
L'  child  opens  its 

Tlu;  k»cal  appli- 
(Uit.  In  infants 
ugli  the  nostrils, 

toluol  to  3G  cc. 

.  tartaric  acid,  5 

on,  is  much  eni- 
ith  pure  carbolic 

if  iron,  a  drachm 
h  from  L")  to  20 
cide  of  hydrogen, 
■ended. 


Loelller's  solution,  which  has  been  given  a  very  thorongh  trial,  is  per- 
iiiips  the  most  satisfactory. 

Nasal  diiihtheria  recjuires  prompt  and  thorough  disinfection  (if  the 
imssages.  Jacohi  ri'commcnds  chloride  of  sodium,  saturated  boric  acid, 
or  1  Jiart  oi'  bichloride  of  nu'reury,  oo  of  chloride  of  sodium,  and  1,UU0 
of  waU'r.  or  the  1-pcr-cent  solution  of  carbolic  acid.  J.(H'lller"s  solution 
iniiy  be  diluted  and  applied  with  a  syringe  or  a  spray.  To  be  ell'ectual 
the  injection  must  be  ^iroperly  given.  The  nurse  should  be  instructed  to 
pMss  the  nozzle  of  the  syringe  horizontally,  not  vertically;  otherwise  the 
lluid  will  return  through  the  same  nostril. 

When  the  larynx  beconu-s  involved,  a  steam  tent  may  be  arranged 
upon  the  lu'd,  so  that  the  child  may  lireathe  an  atnu>s|ihere  saturati;(l 
with  moisture.  If  the  dyspniea  beciunes  urgent,  an  emetic  of  sulphate  of 
zinc  or  iiiccacuauha  may  be  given.  When  the  signs  of  obstruction  are 
marked  there  should  be  no  diday  in  the  performance  of  intubation  or 
tracheotomy. 

Hot  apjilications  to  the  neck  are  usually  very  grateful,  particularly  to 
vonng  children,  though  in  the  case  of  older  children  ami  adults  the  ice 
poultices  are  to  be  preferred. 

{(■)  General  Measures.— The  food  should  be  liquid — milk,  beef  juices, 
barley  water,  albunu'n  water,  and  soups.  The  child  should  be  encouraged 
to  drink  water  freely.  When  the  pharyngeal  involvement  is  very  great 
and  swallowing  painful,  nutritive  enemata  should  be  used.  In  cases  with 
severe  constitntioiuil  sym|)toms  stiuudants  should  be  given  early. 

:Medicines  given  internally  are  of  very  little  avail  in  the  disease.  There 
is  still  a  widespread  belief  in  "the  jirofession  that  forms  of  mercury  are  henc- 
licial.  The  tincture  of  the  ]ierchloride  of  iron  is  also  very  warmly  recom- 
Miended.  We  are  still,  however,  without  drugs  which  can  directly  coun- 
teract the  tox-alhnmins  of  this  disease,  and  we  must  rely  on  general 
measures  of  feeding  and  stimulants  to  sui)i)ort  the  strength. 

The  convalescence  of  the  disease  is  not  without  its  dangers,  and  patients 
should  be  very  carefully  watched,  i)articidarly  if  there  are  signs  of  heart 
weakness. 

The  diiditheritic  paralysis  requires  rest  •)  bed,  and  in  those  cases  in 
which  the  heart  rhythm  is  distm-lied  the  avoidance  of  sudden  exertion. 
In  the  chronic  foims  with  wasting,  massage,  electricity,  and  strychnine 
are  invaluable  aids.  If  swallowing  becomes  very  dillicnlt,  the  patient  must 
be  fed  with  the  stomach-tube,  which  is  very  nuieh  ])referable  to  feeding 

/)(■/•  reel  inn. 

{(l)  Antitoxine  Treatment.— As  above  mentioned,  aninuds  may  be  ren- 
dered innnune  against  dii)htheria.  and  the  blood  of  an  animal  so  treated 
when  introduced  into  another  animal  ])rotects  it  from  infection  with  the 
bacilli  of  the  disease.  The  observations  of  Hehriug,  Koux.  and  others 
have  shown  that  the  nse  of  the  blood-serum  of  an.mals  rendered  arti- 
ficially immune  against  diphtlieria  has  an  important  healing  influence 
upon'dii)htheria  spontaneously  acquired  in  man.  In  ynvparing  the  blood- 
serum  it  is  very  desirable,  of  conrse,  to  have  a  uniform  standard  of  strength. 
One  tenth  of  one  cubic  centir.ietre  of  what  Beliring  calls  his  normal  scrum 
10 


rri^ 


m\ 


1   :'fl 

i 

i 

'4 


156 


SPECIFIC  INFECTIOUS  DISEASES. 


will  counteract  ten  times  the  niininuini  of  (liphtheria  poison  fatal  for  a 
guinea-pig  weigliing  300  grammes.  One  cubic  centimetre  of  this  normal 
serum  he  calls  an  antitoxine  unit.  Holt  gives  the  following  directions  for 
the  use  of  the  antitoxine:  "  'Phe  general  experience  of  tin-  ])rofession  thus 
far  is,  that  for  children  over  two  years  old  the  initial  dose  should  be  from 
1,500  to  '-^,000  units  in  all  severe  cases,  iiu-hiding  those  of  laryngeal  steno- 
sis; this  dose  to  he  repeated  in  from  eighteen  to  tucnty-four  hours  if  no 
improvement  is  seen,  and  again  in  twenty-four  hours  if  the  course  of  the 
disease  is  unfavorable.  The  tliird  dose  is  rarely  necessary.  Ex-eptional 
cases  of  great  severity,  csi)ecially  when  seen  late,  should  receive  somewliat 
larger  doses  than  those  mentioned — i.e.,  3,000  units,  ^lild  cases  should 
receive  1,000  units  for  the  first  injection,  a  second  being  rarely  required. 
For  children  under  two  years  old,  the  initial  dose  in  a  severe  case  or  one 
of  laryngeal  stenosis  should  be  1,000  units,  to  be  repeated  as  above  indi- 
cated; in  a  mild  case,  COO  units.  The  most  concentrated  serum  is  to  be 
l)referrcd,  and  only  that  obtained  from  a  reliable  source  should  be  used." 

A  large  nund)er  of  ])rei)arations  are  now  on  the  market,  and  some 
caution  has  to  be  exercised  by  the  practitioner  as  to  the  serum  which  ho 
employs. 

In"  favorable  cases  the  effects  of  the  serum  are  seen  in  a  marked  amel- 
ioration of  both  tlie  local  and  general  symptoms.  Witliin  twenty-four 
hours  the  swelling  of  the  fauces  subsides  and  tlie  membrane  begins  to  dis- 
api)ear.  At  the  same  time  tlie  temperature  falls,  the  pulse  becomes  slower, 
and  the  general  condition  of  the  patient  improves  in  every  way.  In  cases 
of  moderate  severity,  when  tlie  injections  are  emjiloyed  early,  the  improve- 
ment in  both  the  throat  and  constitutional  symi)tonis  is  certainly  very 
striking.  The  earlier  the  cases  come  under  treatment  the  l)etter  are  the 
results.  There  are  cases,  however,  of  great  severity  in  which  the  anti- 
toxine has  been  employed  early  and  yet  has  not  saved  life. 

Among  the  untoward  effects  of  the  treatment  may  be  the  develojiment 
of  a  local  abscess,  which,  however,  is  rare,  diffuse  erythema  and  urticaria. 
Joint  i)ains,  and  albuminuria.  None  of  these  are  serious,  and  the  evidence 
is  not  conclusive  that  the  incidence  of  albuminuria  is  greater  in  the  cases 
treated  with  antitoxine. 

During  the  ])ast  three  years  evidence  has  been  accumulating  from  all 
l)arts  of  the  world  as  to  the  l)eneficial  eifects  of  the  antitoxine  treatment 
in  di]ihtheria,  but  figures  need  no  longer  be  (pioted  in  illustration.  The 
following  statement  from  Holt's  work  ex])resses  the  opinion  of  those  best 
able  to  judge  of  the  matter:  "  Tlu^  serum  is  much  less  ellicacious  in  the 
cases  of  so-called  mixed  infection  or  sejitic  diphtheria,  and  is  valueless  in 
the  meml)ranous  indammations  which  are  due  to  stre|)(oco(ci.  In  a  child 
the  sennu  sliould  be  injected  u]ion  a  clinical  diagnosis  of  diphtheria  witli- 
out  waiting  for  the  bacterial  examiniition.  In  a  mild  case  in  an  older  child 
this  ])erhaps  n\ay  bo  waited  for,  but  not  in  a  severe  one,  and  particularly 
not  in  a  laryngeal  ease.  Tlie  most  concentrated  ])re]iaration  of  antitoxine 
which  can  bo  o1)tained  should  be  employed.  In  cases  injected  during  the 
first  two  days  the  mortality  is  less  than  5  ])"r  cent.  The  evidence  is  con- 
clusive that  in  laryngeal  diphtheria  the  serum  in  sulheient  doses  largely 


J 


tmm 


ERYSIPELAS. 


i; 


on  fiitiil  for  a 
)1'  this  normal 
(lircclions  for 
)r(jf('ssion  thus 
houhl  be  from 
iryngcal  steno- 
iir  lioiirs  if  no 
'  course  of  the 
.  Ex-  optional 
eive  soniewlint 

I  cases  should 
aroly  required, 
■re  case  or  one 
as  above  indi- 
-cruni  is  to  be 
idd  be  used." 
ket,  and  some 
Tum  which  he 

marked  aniel- 
in  twenty-four 
'  be^nns  to  dis- 
)econK's  slower, 
way.  Tn  cases 
:,  tlie  improve- 
certainly  very 
better  are  the 
hich  the  anti- 

le  develoimient 

and  urticaria, 

id  the  evidence 

er  in  the  cases 

latinji  from  all 
xine  treatment 
istration.     The 

II  of  those  best 
icacious  in  the 

is  valueless  in 
ci.  In  a  child 
iphtheria  with- 
I  an  older  child 
nd  particularly 
n  of  antitoxine 
itod  during  the 
videuce  is  con- 
it  doses  largely 


prevents  the  extension  of  meudnane  into  the  lracli(>a  and  lironclii,  and 
thus  prevents  hroncho-pneumonia.  While  much  still  remains  to  lie  learned 
regarding   immunization,   present   kiu)\\ ledge  justilies   the  statement   that 

or  a  period — ap[)roximatcly  a  luonth — the  protection  coni'crri'd  is  ])rac- 
tically  complete.  Immunizing  doses  should  therefore  be  given  to  every 
child  in  an  iniVcted  household  or  iiistitutiou." 

The  ({ucstioji  of  immunizing  those  exposed  to  the  disease  is  a  very 
|iractical  one.  Jt  has  been  carried  out  on  a  large  scale  in  some  iustitu- 
tidus  with  satisfactory  results.  An  injection  of  the  Xo.  1  liehring  is  given, 
and  ir  tliouglit  ])roper  repeated  in  a  ivw  days.     The  immunity  appears  to 

le  transient,  only  persisting  for  a  few  weeks. 


XVII.    ERYSIPELAS. 

Definition. — An  acute,  contagious  disease,  characterized  by  a  special 
inflammation  of  the  skin  caused  by  the  streptococcus  erysipelatos  (strepto- 
coccus pathogencs  longus). 

Etiology. — Krysi])elas  is  a  widespread  alTection,  endemic  in  most  com- 
munities, and  at  certain  seasons  epidemic.  AVe  are  as  yet  ignorant  of  the 
atnios])heric  or  telluric  influences  which  favor  the  dilfusion  of  the  poison. 

It  is  ])articularly  prevalent  in  the  sjiring  of  the  year.  Of  *^,01'^  cases 
collected  by  Anders,  1,*^14  occurred  during  the  first  five  months  of  the 
year.  April  had  the  largest  number  of  cases.  The  aifection  prevails  ex- 
tensively in  old,  ill-ventilated  l)ospitals  and  institutions  in  which  the  sani- 
tary conditions  are  defective.  With  the  improved  sanitaticm  of  late  years 
the  number  of  cases  has  materially  diminished.  It  has  been  observed, 
however,  to  Ijreak  out  in  new  institutions  i-  !er  the  most  favorable  hygienic 
circumstances.  Erysi])elas  is  both  contagious  and  inoculal>le;  but,  except 
under  special  conditions,  the  poison  is  not  very  virulent  and  does  not 
seem  to  act  at  any  great  distance.  It  can  be  conveyed  by  a  third  jierson. 
The  poison  certainly  attaches  itself  to  the  furniture,  bedding,  and  walls 
of  rooms  in  which  patients  have  been  confined. 

The  disjiosition  to  the  disease  is  widespread,  but  the  susceptibility  is 
specially  marked  in  the  case  of  individuals  with  wounds  or  abrasions  of 
any  sort.  ]?ecently  delivered  women  and  persons  M-ho  have  been  the  sub- 
jects of  surgical  operations  are  particularly  prone  to  it.  A  woimd,  how- 
ever, is  not  necessary,  and  in  the  so-called  idiopathic  form,  although  it  may 
be  didicult  to  say  that  there  was  not  a  slight  abrasion  al)out  the  nose  or 
lips,  in  very  many  cases  there  certainly  is  no  obcervable  external  lesion. 

Chronic  alcolndism,  debility,  and  T'right's  disease  are  predisposing 
agents.  Certain  iiersons  si  ow  a  special  suscei)lil)ility  to  erysipelas,  and 
it  may  recur  in  them  repeatedly.  There  are  instances,  too,  of  a  family 
jiredisposition. 

The  specific  agent  of  the  disease  is  a  streptococcus  growing  in  long 
chains,  which  is  included  under  the  group  name  Slirptorocrus  pi/ogenes, 
with  which  the  SlrrplDcnrriif^  rrjislprhilns  a))pears  to  be  identical.  The  fever 
and  constitutional  i^ymptonis  are  due  in  great  part  to  the  toxins;  the  more 


•  j 


l.i 


1 


25g  SPECIFIC  INFECTIOUS   DISEASES. 

serious  viscera!  oc.mplications  arc  the  result  of  secondary  inetastalie  in- 

'' ywm»/n7«.-SuHceptiblc  animals  can  be  rendered  inunune  to  virulent 
strei.toeo.ei  l.v  repealed  non-letiud  injections  oi  cultures.  :^larniorek  lias 
attempted  lo  (.repare  a  curative  serum  by  injecting  animals  (donkey,  horse, 
.h.ep  will,  .■ultures  intensilied  by  being  grown  on  human  seruu-b.-ud  on. 
Such  a  serum  is  said  to  have  both  innnnnizing  and  curative  properties. 
The  tests  tbus  iar  ma.ie  are  not  imrticularly  jiromising. 

Morbid  Anatomy. -Kry«il'tdas  is  a  simple  inllammatior.  In  Us 
uncomplicated  forms  there  is  seen,  post  mortem,  little  else  than  m  lamma- 
torv  cedema.  Investigations  have  shown  that  the  cocci  are  lound  chielly 
in  the  lvmph-s,.aces  and  must  abundantly  in  the  z.me  of  sprea.l.ng  mllam- 
mation"  in  tlie  uninvolved  tissue  beyond  the  inllamed  margin  they  are 
to  be  found  in  the  Ivmpb-vessels,  and  it  is  here,  according  to  Met.^chni- 
koif  and  otbers,  that  an  active  warfare  goes  on  between  the  leucocytes 
and  the  cocci  (phagocytosis).  In  more  extensive  and  v.ruent  forms 
of  the  disease  there  is  usually  supi-uration.  It  is  stated  tau  the  mllam- 
,„,tiou  mav  pass  inward  from  the  seal,,  through  the  skull  to  the  meninges. 
'lh\<  1  have  never  seen,  but  in  one  case  1  traced  the  extension  Irom  the 
lace  along  tlie  fifth  nerve  to  the  meninges,  where  an  acute  meningitis  and 
thrombosis  of  the  lateral  sinus  were  excited. 

The  visceral  complications  of  erysipelas  are  numerous  and  imi.ortant. 
The  majoritv  of  them  are  of  a  septic  nature.  Infarcts  occur  in  the  lungs. 
spleen,  and  'kidneys,  and  there  may  be  the  general  evidences  oi  pya'uuc 

infection.  ,         ^.,.  -.         . 

Some  of  the  worst  cases  of  malignant  endocarditis  are  seeondai}  to 
erysipelas;  thus,  of  2:1  cases,  3  occurred  in  connection  with  this  disease. 
SiMitic  pericarditis  and  ideuritis  also  occur.  -,   .       , 

As  just  mentioned,  the  disease  may  in  rare  cases  extend  and  involve 
the  menin"-es.     I'neumonia  is  not  a  very  common  complication. 

Acute  nephritis  is  also  met   with;  it  is  often  ingrafted  upon  an   old 

clinuiic  trouble.  •  i,     .  •     i   , 

Symptoms.— Tlie  following  descrii.tion  applies  specially  to  erysipelas 
of  tiie  face  and  bead,  t!ie  form  of  the  disease  which  the  physician  is  most 
commonlY  called  upon  (o  treat. 

The  iiinihalioii  is  variable,  probably  from  tliree  to  seven  days. 
The  stage  of  iiirnsinit  is  often  marked  by  a  rigor,  and  followed  by  a 
rai)id  rise  in  the  temperature  and  other  characteristics  of  an  acute  fever. 
AVhen  there  is  a  b-cal  abrasion,  the  spot  is  slightly  reddened;  but  if  the 
disease  is  idioi.athic,  there  is  seen  within  a  few  hours  slight  redness  over 
the  brid-'c  of  the  nose  and  on  the  cheeks.  The  swelling  and  t(Mision  of  the 
skin  increase  and  within  twenty-four  hours  the  external  symptoms  are  well 
marked  The  skin  is  smooth,  tense,  and  a^deir  'ons.  It  looks  red,  feels 
hot  and  the  superficial  lavers  of  the  e])idermis  may  be  lifted  as  small  blebs. 
The  patient  oomi.lains  of  an  unjileasant  feeling  of  tension  in  the  skm; 
the  swelli'^ig  rapidlv  increases;  and  during  the  second  day  the  eyes  are 
ii«uallv  closed.  The  first-affected  jiaris  graduallv  become  pale  and  less 
swollen  as  the  disease  extends  at  the  periidiery.    ^Vhen  it  reaches  the  fore- 


ERYSIPELAS. 


ir.tt 


luolastalio  iii- 

uio  to  virulont 
^liinnorfk  luus 
(donkey,  horsi', 
scriiin-lioiiillon. 
live  pi'opurtios. 

iiatiiii'.  In  its 
llum  iiilUunma- 
e  ioiuul  chiefly 
)iva(lin<r  iiillaiii- 
iiavgin  tlioy  are 
i<r  to  ]\letf;chni- 
tlie  leucocytes 
vinilcnt  forms 
.hat  the  inflam- 
<)  the  meninges. 
L'nsion  from  the 
■  meningitis  and 

and  inijiortant. 
ur  in  tlie  lungs, 
uices  of  i)ya!mic 

iro  secondary  to 
'ith  this  disease. 

end  and  involve 

:'ation. 

ed  upon  an   old 

ally  to  erysipelas 
diysician  is  most 

,-en  days, 
ul  I'oliowed  hy  a 
f  an  acute  fever, 
lened;  hut  if  tlie 
ight  redness  over 
ml  tensitni  of  tlie 
^•mptoms  are  well 
t  looks  red,  feels 
ed  as  small  Ijlehs. 
iiori  in  the  skin; 
day  the  eyes  arc 
me  ]iale  and  less 
reaches  the  fore- 


Load  it  imvrrcsses  as  an  advancing  ridge,  perfectly  ^vell  detl.UMl  and  raised: 
d  .  nem  on  palpation,  hardened  extensions  can  1k>  .■elt  Leneath     he  sk.n 

,.i,h  is  not  vet  rcldened.     Even  in  a  case  of  n.oderate  scverUv    ti  e  1 
.....vnouslv' swollen,  the  eyes  are  closed,  the  hps  greatly  u-deuialou^,  U  e 
;;ars  tinckencd,  ti.e  scalp  is  swollen,  and  the   patients   leatures  are  qu.te 
„„,,cogni/.ai.le.     The  formatio.i  of  l>lehs  is  common  on  the  ey''!""^'  '  •'  - 

nd   hi^eiiead.     The   cervical   lyutph-glands  are  swollen,   hut   at'e   um  al 
M  a<ke<l  in  the  u-dema  of  the  neck.     The  tenq.erature  keeps  high  without 
;     vk  d  renussions  for  f<    r  or  live  days  and  the.t  defervescence  takes  place 
r  iisis.     Leucocvtosis  is  present.     Kirl<hri.le  has  noted  the  presence  u 
one  case  of  leuein  -utd  tyrosin  ur  the  urine.     The  getteral  <..mi,  mn  o    the 
patient  varies  nn.c^h  with   his   previous  state  o    health.       n  old  and    1  - 

•  itated   persons,  particdarly  itt  tltose  addi..te.l  to  alcohol,  the  con.t,    .- 

i^  nal  depressiotUnun  the  outset  ,nay  he  very  great.     Dehrium  .s  present, 
ll.e  ton.ie  hecomes  dry.  the  p.dse  feehlc.  and  there  ,s  marked  tendency  U> 
d.ath  from  toxaemia.     In   the  maj..rity  of  .ases,  however,  ^^'^    LZ 
t.nsive  lesions,  the  constitutional  distnrhattce,  cousu lenng  the  he  ght  o 
the  fever  ranee,  is  slight.    Tlie  mucous  mend.ratu.  ol  the  month  an-l  th.oa 

„av  he  swollen  and  reddened.    The  erysipelatous  intlamntatum  n.ay  extend 

„>  'the  larvux.  hut  the  severe  oMlema  of  this  part  oe..as>onal!y  me    w,  h  t. 

,„„n„„>dy   due  to  the  e.xtetision   of  the   intlamnuttion   Irom  without   in- 

''''There  are  cases  in  which  the  inllammation  extends  from  the  fa.r  to  jhe 
neck,  and  over  the  chest,  and  may  gradually  migrate  or  wander  over  the 
-rreater  part  of  the  hody  (/•:.  minrans). 

The  clo<e  relation  hetween  the  erysipelas  coccus  and  the  pus  organism, 
is  shown  hy  the  tre.p.ency  with  whicii  suppuration  occurs  m  hteial  ery- 
cinelas  Small  cutaneous  ahscesses  are  common  al.out  the  c  leek.  ami 
fiche^d  and  neck,  and  heneath  the  scalp  large  collectmns<>i  pus  may 
mimulate.  Suppuration  seems  to  ocur  more  fre.iuently  ,n  some  ep  - 
dc™tlmn  in  itiiers.  and  at  the  riiiladelphia  lIos,utal  one  y.ar  n..arly 
nil  the  cases  in  the  ervsipelas  wards  presented  local  ahscesses. 

Complications. -Met.ingitis  is  rare.  The  cases  in  which  death 
.K.curs  witli  marked  hrain  symptoms  do  not  usually  show  post  mo. tern, 
meningeal  alfection.     The  delirium  and  coma  are  due  to  the  fever,  or  to 

^"™umonia  is  an  occasional  complication,  ricerative  endocarditis  and 
septicauuia  ar.  more  comnum.  Allniminuria  is  almost  constant  particu- 
larlv  in  persons  over  fiftv.  True  mM-hritis  is  oecasumally  seen.  Da  (  osta 
has" called  attention  to  curious  irregular  returns  of  the  fever  whicli  oc.ur 
durin-  convnlescence  without  any  aggravation  of  the  local  condition.  Ma- 
laria may  coexist  with  erysipelas.     L.  F.  T'.arker  has  reported  such  a  case 

occurrin'"''  in  mv  wards.  .11 

The'lia-nosis  rar.'lv  presents  any  difficulty.  The  mode  of  onset,  he 
rii.id  ri-e  in  fever,  and  the  characters  of  the  local  disease  are  (luite  dis- 
tinctive Acute  necrosis  of  hone  may  sometimes  he  re-arded  as  orysipe  as, 
a  mistake  which  I  once  saw  made  in  connection  with  the  lowei  end  ot  the 
femur. 


IGO 


SPECIFIC  INFECTIOUS  DISEASES. 


Prognosis.— 11 1'iiltliy  adultri  rarely  dio.  The  {general  luortality  in 
hospitals  is  al.oiit  7  per  cent,  in  private  practice  about  1  per  cent  (Anders). 
Jn  the  new-born,  when  the  disease  attacks  the  navel,  it  is  aUnost  always 
fatal,  in  drunkards  and  in  the  aged  erysipelas  is  a  serious  aU'ection,  and 
deatii  may  residt  either  from  the  intensity  of  tlie  fever  or,  more  commonly, 
Ironi  toxa'niia,  'i'lu'  wanderinji  or  andndatory  erysipelas,  winch  has  a  more 
jjrotracted  course,  may  cause  death  from  exhaustion.  •     ■     i     • 

Treatment.— isolation  should  be  strictly  carried  out,  particularly  in 
hospitals.  A  practitioner  in  attendance  upon  a  case  of  erysipelas  should 
not  attend  cases  of  conlinemeiit. 

The  disease  is  self-limited  and  a  large  majority  of  the  cases  get  well 
without  anv  internal  medication.  1  can  speak  delinitely  on  this  point, 
having,  at  "the  riiiladel|)hia  Hospital,  treated  many  cases  m  this  way 
The  diet  should  be  nutritious  and  light.  Stimulants  are  not  required 
excei)t  in  the  ..Id  and  feeble.  For  the  restlessness,  delirium,  and  insomnia, 
chloral  or  the  bromides  may  be  given;  or,  if  these  fail,  opium.  ^Vhen  the 
fever  is  high  the  patient  may  be  bathed  or  sponged,  or,  in  j.rivate  practice, 
if  there  is  an  objection  to  this,  antipyrin  or  antifebri-i  may  be  given. 

Of  internal  remedies  believed  to  inlhience  the  disease,  the  tincture  of 
the  perchloride  of  iron  has  been  highly  recommended.  At  the  :\Iontreal 
General  Hospital  this  was  the  routine  treatment,  and  doses  of  half  a  drachm 
to  a  drachm  were  given  every  throe  or  four  hours.  I  am  by  no  means 
convinced  that  it  has  any  special  action;  nor,  so  far  as  I  know,  has  any 
medicine,    given    iiiternally.    a    definite    contnd    over    the    course    of    the 

disease. 

Of  local  treatment,  the  injection  of  antiseptic  solutions  at  the  margin 
of  the  spreading  areas  has  been  much  ])ractised.  Two-^.er-cent  solutions 
of  carbolic  acid,  the  corrosive  sublimate  and  the  biniodide  of  mercury  have 
been  much  used.  The  injection  should  be  made  not  into  hut  just  a  little 
beyond  the  border  of  the  inllamed  patch.  F.  V.  Henry  has  treated  a  large 
number  of  cases  at  the  rhiladel])hia  Ilosj.ital  with  the  last-mentioned  drug, 
and  this  mode  of  practice  is  certainly  most  rational. 

Of  local  ai)i)lications,  iclithyol  is  at  jiresent  much  used.  The  inflamed 
region  may  he  covered  with  salicylate  of  starch.  Perhaps  as  good  an  ap- 
j.Hcation  as  any  is  cold  water,  which  was  highly  recommended  by  Hip- 
pocrates. 

XVIU.   SEPTIOEMIA  AND  PYiflEMIA. 

Tn  tliese  days  of  asejisis  i)liysicians  sec  many  more  cases  of  septicemia 
and  ])yaMuia  than  do  the  surgeons.  For  one  case  in  the  post-mortem  room 
"wi;h  the  anatomical  diagnosis  of  soplicwmia  which  comes  from  the  surgical 
or  gyiiivcologieal  departments  of  the  Johns  TTo])kins  Hospital,  at  least 
fifteen  or  twenty  come  from  my  medical  wards.     Certain  terms  must  first 

be  defined. 

An  itifcrfinn  is  the  morhid  process  induced  hy  the  invasion  and  growth 
in  the  bod^'  of  pathogenic  micro-organisms.  An  infection  may  be  local, 
as  in  a  boi'.  <t  general,  as  in  some  cases  of  anthrax. 


■^'tjv 


SEPTICEMIA  AND  PYAEMIA. 


Itil 


mortality  in 
foiit  (Aiidi'is). 
almost  always 
alVi'c-tion,  ami 
Div  commoiily, 
icli  has  a  more 

particularly  in 
.-siiK'las  should 

casos  got  well 
on  this  point, 
:  in  this  way. 
,'   not  required 

and  insomnia, 
im.  When  the 
rivate  practice, 
he  given, 
the  tincture  of 
t  the  :\Iontroal 
:'  hall'  a  drachm 
1  hy  no  means 
know,  has  any 

course    of   the 

at  the  margin 
•-cent  solutions 
f  mercury  have 
nit  jnst  a  little 

treated  a  large 
iientioned  drug. 

The  inflamed 
as  good  an  ayj- 
onded  by  Ilip- 


s  of  septicaemia 
5t-mortem  room 
■om  the  surgical 
ispital,  at  least 
terms  must  first 

qnn  and  growtli 
n  may  be  local, 


An  inlnxiralion  is  the  m..rlml  c..n.lition  caused  by  the  absorption  of 
toxines,  in  large  part  .h>rived  fnm.  pathogenic  organisms.  llie  term 
s«»r(m((/  is  tiie  e(iuiv-'  nt  of  septic  intoxicatinii. 

\  hard-and-fast  ..ne  cannot  hv  drawn  liclweeii  an  mtection  and  an 
inf.xication,  but  agents  of  infection  alone  are  <apable  .d  reproduction, 
wiiereas  those  of  intoxication  are  diemical  poisons,  some  oi  which  are  |.ro- 
,lMce.l  bv  the  agency  of  bacteria,  or  l,y  vegetable  and  animal  cells.  Jnlee- 
tiou-^  diseases  wliich  are  communicated  directly  fnnn  one  person  to  another 
are  terme.l  c.mtagious,  and  the  infecting  agvnt  is  soniHimes  spoken  of  as 
•1  conta-inm.  -  Whether  or  not  an  infectious  disease  is  contagious  m  tlie 
i.rdinarv  .<ense  d.'i-ends  upon  the  nature  of  the  infectious  agent,  and  cspe- 
(iallv  upon  the  manner  of  its  elimination  from  and  reception  by  the  body. 
Most  but  not  all  contagious  diseases  are  infectious.  Scabies  is  a  contagious 
disease,  but  it  is  not  infectious  "  (Welch). 

Tiiere  are  three  chief  clinical  types  of  infection. 

1.   LOCAL   INFECTIONS  WITH   TIIH   DEVELOPMENT  OF  TOXINES. 

This  i<  the  comnum  mode  of  invasion  of  many  of  the  diseases  which 
we  have  already  considere.l.     Tetanus,  diphtheria,  erysipelas,  and   pneu- 
HH.nia  are  disea"ses  which  have  sites  of  local  infection  in  which  the  patho- 
ovnic  oroanisms  develop;  but  the  constituti.mal  elVects  are  cause.    l)y  the 
abs.nM.tion  .d'  the  pois<.nons  products.     The  diphtheria  toxme  pr...l  ices  all 
the  -eiieial  svmi.toms.  the  tetanus  toxine  every  feature,  of  the  disease  with- 
out Uie  presence  ..f  their  respective  bacilli.     Certain  of  the  symptoms  fol- 
lowing the  absorption  of  the  toxines  arc  general  to  all;  others  are  special 
and  peculiar,  according  to  the  organism  which  produces  them      A  chill, 
fever    general  malaise,  ].rostration,  rapid  pulse,  restlessness,  and  headache 
are  the  inost  fre.iuent.     With  Imt  few  exceptions  the  iebrilo  disturbances 
the  most  comm.)n   feature.     The  most  serious  olTects  are  seen  upon  the 
nervous  system  and  upon  the  heart,  and  the  gravity  of  the  symptoms  on 
the  part  of  these  organs  is  to  some  extent  a  measure  of  the  intensity  ot 
the  intoxication.    The  organisms  of  certain  local  infections  produce  poisons 
which  have  special  actions;  thus  the  diphtheria  toxine,  besides  having  the 
elTects  already  referred  to,  is  especially  prone  to  attack  the  ncrvoiu^  sys  em 
and  to  cause'p^'i'iplif™!  neuritis.    The  tetanus  toxine  has  a  specilic  action 
on  the  motor  neurones. 

2.  s::ptic.emia. 

Formerly,  and  in  a  surgical  sense,  tlie  term  "septicaemia"'  was  used  to 
designate  the  invasion  of  the  bh.od  and  tissues  of  the  body  by  he  organ- 
isms of  suppuration,  but  in  the  medical  sense  the  term  may  be  applied 
to  anv  c.ndition  in  which,  with  or  without  a  ]ov,]  site  of  mfcvt.on,  there 
is  microbic  invi.sion  of  the  blood  and  tissues.  1-ut  in  which  there  are  no 
foci  of  suppuratio...  Owing  to  the  great  develo]mient  of  bacteria  in  the 
hlood.  and  in  order  to  separate  it  sharply  from  local  infectious  processes 
with  toxic  invasion  of  the  body,  it  is  proposed  to  call  this  condition  bac- 
teramiia;  toxccmia  denotes  the  latter  state. 


102  ■  SPECIFIC   INFECTIOUS   DISEASES, 

('^i')  Progressive  Septicaemia  from  Local  Infection.— The  common  strcji- 
tooo«'(iis  and  stjipliylococciis  iiilVction  is  ns  a  rule  lirst  local,  and  the  tox- 
incs  aloiio  pass  into  the  blood.  In  other  instanivs  the  cocci  a])i)ear  in  the 
Llood  and  thronjjhoiit  the  tissues,  cansinj^  a  septica'inia  which  intensifies 
f^really  the  severity  of  the  case.  Other  infections  in  wliicli  the  hacterial 
invasion,  local  at  lirst,  may  hecomc  f^eneral  are  pneuinoni;;,  typhoid  fever, 
anthrax,  gonorrluea,  and  puerperal  l\'ver. 

The  clinical  features  of  this  form  arc  well  seen  in  tlio  cases  of  puer- 
peral se|)tica'niia  or  in  dissection  wounds,  in  which  the  course  of  tlie  infec- 
tion may  he  traced  alon;,^  the  lynn)hatics.  The  symi»toms  usually  set  in 
within  twenty-four  hours,  and  larcly  later  than  the  tliird  or  fourth  day. 
'^I'here  is  a  chill  or  chilliness,  with  moderate  fever  at  lirst,  which  <,n'adually 
rises  and  is  marked  hy  daily  remissions  ami  even  intermissions.  Tiie  pulse 
is  small  and  com|)ressil)le,  and  may  reach  I'-iO  or  higher,  ({astro-intestinal 
disturhaiues  are  common,  the  tongue  is  red  at  the  marjiin,  and  the  dorsum 
i.s  dry  and  dark.  There  may  !i>'  early  delirium  or  marked  mental  i)rostra- 
tion  and  apathy.  As  the  disea-  [irogrcsses  there  nuiy  be  pallor  of  the  face 
or  a  yellowish  tint.     Cajiillary  liaMuorrhages  are  not  nnconnnon. 

1'lu'  outlook  is  serious  in  streptococcus  cases.  Death  may  occur  within 
twenty-four  hours,  and  in  fatal  cases  life  is  rarely  ]iroloiitfed  for  more  than 
seven  or  ei<:jlit  days.  On  post-mortem  examimition  there  may  l)e  no  pross 
focal  lesions  in  the  viscera,  and  the  seat  of  infection  uuiy  present  only  sliglit 
chaiifjes.  The  s])ken  is  enlarged  and  soft,  the  l)lood  may  be  extremely 
dark  in  color,  and  lia'morrhages  are  couimon.  particularly  on  the  serous 
sin-faces.     Neither  thrombi  nor  emboli  ar  ■  found. 

^lany  instances  of  septica'mia  are  conil)ined  infections;  thus  in  diph- 
theria streptococcus  se])tica'mia  is  a  common,  and  the  most  serious,  event. 
The  local  dii- 'ase  ami  tlu-  sym])toms  ]ir(idueed  by  absorption  of  the  tox- 
ines  dominate  the  clinical  ])icture:  but  the  features  are  usually  much 
aggravated  by  the  systemic  invasion.  A  similar  infection  may  devt>lo])  in 
ty|)h()id  fever  ami  in  tuberculosis,  and  may  ol)scHre  the  ty])ical  ])icturo, 
leading  to  serious  errors  in  diagnosis.  The  septicaemia  is  not  always  duo 
to  the  stre])tococcus. 

{b)  General  Septicajmia  without  Recognizable  Local  Infection.— ^V//;)- 

togciiclir  Scpticwniia!^. — This  is  a  group  of  v^-ry  great  interest  to  the  physi- 
cian, the  full  importance  of  which  we  are  only  now  beginning  to  recognize. 
The  subjects  when  attacked  may  be  in  jicrfect  health;  more  commonly 
they  are  already  weakened  liy  acute  (H-  chronic  illness.  The  ])athogenic 
organisms  are  varied.  The  stre])tococcus  i)yogenes  is  the  most  common; 
the  forms  of  staphylococcus  nn  re  rare.  Other  occasional  causal  agentf.  are 
the  micrococcus  lanccolatus  (])neumococcus).  tbe  liacillus  ])roteus,  and  tbe 
bacillus  pyocyaneus.  Between  'May  1,  IS!)?,  and  June  1,  ISOT).  there  were 
sent  to  tbe  post-mortem  room  from  my  wards  21  cases  of  general  infection, 
of  which  1;!  were  due  to  tbe  strcjitococcus  pyogenes.  2  to  tbe  staiibylococcus 
pyogenes,  and  H  to  tbe  jmeumococcus.  Tn  IP  of  tbese  cases  tbe  patients 
were  already  tbe  subjects  of  some  other  mabidy,  which  was  aggravated,  or 
in  most  instances  terminat(>d,  by  tbe  general  sc])ticaMnia.  The  sym])toms 
vary  somowbat  witb  tbe  character  of  tbe  micro-organisms.     In  tbe  strep- 


-Tlio  romnmn  strop- 
t  local,  aiul  the  tox- 

ooeci  a]>jH'ar  in  tlio 
lia  wliii'li  intonsilii's 

wliicl)  the  hactorial 
loiii;;,  typhoid  I'cvor, 

1  tlio  casos  of  ])U('r- 
coiirso  f)l'  the  iiitVc- 
)toiHs  usually  set  in 
hircl  or  fourth  day. 
rst,  wliifh  fjfradually 
nissions.  Tiic  pulse 
■r.  (iaslro-iMtc'stiual 
^iu,  and  the  dorsum 
•ked  mental  prostra- 
be  pallor  of  the  face 
iK'ommon. 
ii  may  oeeur  within 
)u<red  for  more  than 
}rc  may  l)e  no  <:ross 
y  ])resent  oidy  slijiJit 
I  may  be  extremely 
ilarly  on  tlie  serous 

ions;  thus  in  diph- 
most  serious,  event, 
sorption  of  the  tox- 
are  usually  mueh 
ion  may  devt>lo])  in 
the  ty])ieal  ])ietnro, 
a  is  not  always  duo 

al  Infection.— ^V//;)- 

iterest  to  the  physi- 
innin^  to  recognize, 
th;  more  commonly 
s.     The   pathogenic 

tlie  most  common; 
lal  causal  agents,  are 
us  ])roteus,  and  the 
1,  ISOT),  there  were 
")f  general  infection, 
"»  the  staphylococcus 
e  cases  the  patients 

was  aggravated,  or 
lia.  The  symptoms 
sms.     In  the  strep- 


SEPTK'.KMI.V   AND    rV.KMlA. 


103 


t,.ff)rcus  cases  there  may  be  chills  with  high,  irregular  fever,  ami  a  mure 
,  iiiiraeteristie  scjilir  AixW  than  in  the  pneumoeoeciis  infection. 

.Must  of  these  ea.«es  come  correctly  under  the  term  '•  eryptogenetic  s(-pti- 
,;iinia  ■'  as  employed  by  Leube,  inasnnu'h  as  tiie  local  focus  of  infection  is 
iint  evident  during  life!  and  may  not  bo  found  after  death.  Although  most 
.,1'  these  cases  are  terminal  infections,  yet  it  is  well  to  i>ear  in  mind  that 
ihcre  are  instances  of  this  type  (d'  alfection  counng  ■  •  in  apparently 
licidthy  persons.  The  fever  may  be  extremely  irregular,  clianicteristic- 
;illv  septic,  and  peisist  for  many  weeks.  Foci  (d'  suppuration  may  not  de- 
\/iop.  and  may  not  he  found  even  at  autojisy.  1  have  mi:  several  occa- 
Mons  met  with  cases  of  an  intermittent  jiyrcxia  persisting  for  weeks,  in 
which  it  seemed  impossible  to  give  any  explanation  of  the  phenomemi,  and 
Mime  which  ultimately  recovered,  and  in  which  tuberculosis  and  malaria 
,(.iild  be  almost  positively  excluded.  These  cases  re(piiiv  to  be  carefully 
studied  bacleriologically.  '  Dreschfeld  has  descrilied  them  as  idiojiathic  in- 
termittent fever  of  ])yannic  character.  Local  sympt(Hns  may  be  alisent, 
though  in  three  of  his  cases  there  was  enlargement  of  the  liver,  and  in  two 
ihe  condition  was  a  dilfuse  sui>purative  hei>atitis.  The  jiyocyanic  disease, 
or  cyano-i)ya'mia,  is  an  extremely  interesting  form  of  infection  with  the 
baeiilus  pyocyaneus,  of  which  a  large  nund)er  of  cases  have  Iieen  reported 
ol'  late  Years.  "^  (See  Wollstein's  paper,  Archives  of  Tediatrics,  October,  18117. 
and  r.arker,  Jour.  Am.  :Med.  Assoc,  ISO;.) 


lu'  jiai 


3.  shptk'0-1'Y.t:mia. 

hoiicnic  micro-organisms  which   invade   the  blood   and   tissues 


may  settle  in  certain  foci  and  there  cause  suppuration.  When  midtiple 
abscesses  are  thus  produced  in  connection  with  a  general  infection,  the 
condition  is  kiuiwn  as  pya'mia  or,  perhaps  better,  septico-pya>iuia.  There  are 
no  speciiic  organisms  oi'  sup]nn'ation,  and  the  condition  of  i)ya'mia  may  be 
jiroduced  by  organisms  other  than  the  streittocoeci  and  staphylococci, 
though  these  are  the  most  common.  Other  forms  which  may  invade  the 
system  and  cause  foci  of  sui)i)uration  are  the  micrococcus  laneeolatus,  the 
gonococcus,  the  bacillus  coli  communis,  the  bacillus  typhi  abdoniinalis,  the 
bacillus  pndeus,  the  bacillus  ])yocyaneus.  the  bacillus  inlluenza\  and  very 
probably  the  bacillus  a'rogenes  capsulatus.  Tn  a  large  ]M'o]iortion  of  all 
cases  of  ])ya^mia  there  is  a  focus  of  infection,  either  a  sup])urating  external 
wound,  an  osteo-myelitis,  a  gonorrluva,  an  otitis  media,  an  empya'ma,  or  an 
area  of  suppuration  in  a  lymph-gland  or  about  the  ajipendix.  In  a  large 
majority  of  all  those  eases  the  common  pus  cocci  are  present. 

In  a  suppurating  wound,  for  example,  the  pus  organisms  induce  hyaline 
necrosis  in  the  smaller  vessels  with  the  production  of  thrombi  and  ])urulont 
phlebitis.  The  entrance  of  pus  organisms  in  small  nund)ers  into  the 
Idood  does  not  necessarily  ju-oduco  pyaemia.  Cmnmoidy  the  transmission 
to  various  parts  from  the  local  focus  takes  ]i]ac(  by  the  fragments  of 
thrombi  which  pass  as  emboli  to  dilTeront  parts,  where,  if  the  conditions  are 
favorable,  the  ^uis  organisms  excite  suppuration.  A  thrombus  which  is 
not  sepvic  or  eontamimited.  when  dislodged  and  impacted  in  a  distant 
vessel,  iiroduces  at  most  only  a  simple  infarction;  but,  coming  from  an 


164  SPECinc  INFECTIOUS  DISEASES. 

infected  source  aiitl  coiitiiiiiiii;:  pus  iiiicrolx's,  an  ii)(le|ieii(leiit  cenlro  of 
iiirectioii  is  cstal)iislic(l  wiierever  tlie  I'liilidliis  may  UiAiSv.  'I'liese  iiuli- 
liciideiit  siiiipiiratise  centres  in  pva'Miia.  known  as  eiiilnilic  or  nirldslalii 
iihsccsscs,  liavo  tlie  I'Dllowinj,'  <listril)Ution: 

((/)  In  external  wounds,  in  osteo-invelitis,  and  in  acute  plili'^nu)n  ni 
the  skin,  the  einl)oiic  particli's  very  irciiuently  excite  suppuration  in  tiie 
hin<rs,  producinj;  tiie  well-known  wed;,^e-slui|)ed  pyaiiiic  inl'arcts;  liut  in 
some  cases  tiie  int'i'ctcd  |)articles  pass  tlirougii  the  lungs,  am!  there  are  I'oci 
of  inllammation  in  the  iieart  and  kid  leys. 

(I))  Sujipurative  I'oci  in  the  territory  of  the  portal  ..ystoni,  particularly 
in  tlie  intestines,  produce  metastatic  aliscesses  in  the  liver  with  or  without 
suppurative  pylepli  hi  litis. 

Endocarditis  is  an  event  whicli  is  very  lialde  to  occur  in  all  forms  of 
seiitic'a'uiia,  and  niodilies  materially  the  character  of  the  clinical  features. 
Streptococci  and  staphylococci  are  the  most  common  or<,'anisms  present 
in  the  vefretations,  but  the  pneumococci,  gonoeocci,  tubercle  bacilli,  ty- 
jihoid  bacilli,  anthrax  biicilli,  and  other  forms  have  been  isolated.  The 
vcfictations  which  develop  at  the  site  of  the  valve  U'sion  become  cov- 
ered with  thrombi,  ]iarticles  of  which  may  be  dislodged  and  carried  as 
emboli  to  dilVerent  parts  of  the  body,  causing  multiiile  aliscesses  or  in- 
farcts. 

Symptoms  of  Septico-pysemia. — Tn  a  case  of  wound  infection, 
])rior  to  the  onset  of  the  characteristic  symptoms,  there  may  be  signs  of  local 
trouble,  and  in  the  case  of  a  discharging  wound  the  pus  may  change  in  char- 
acter. The  onset  of  the  disease  is  marked  by  a  severe  rigor,  during  which 
the  temperature  rises  to  103°  or  Id-t"  ami  is  followed  by  a  jirofuse  sweat. 
These  chills  are  re]ieated  at  intervals,  either  daily  or  every  other  day.  In 
the  intervals  there  may  be  slight  pyrexia.  The  constitutional  disturbance 
is  marked  and  there  are  loss  of  appetite,  nausea,  and  vomiting,  and,  as 
the  disease  jirogresses,  rajiid  emaciation.  Transient  erythema  is  not  un- 
common. Local  symptoms  iisually  develop.  If  the  lungs  ln'come  involved 
there  are  dysjuuva  and  cough.  The  ])hysical  signs  may  be  slight.  Involve- 
ment of  the  jileura  and  pericardium  is  common.  The  tint  of  the  skin  is 
changed;  at  first  iiale  and  white,  it  subse(pu'ntly  bccouu's  bile-tinged.  The 
spleen  is  enlarged,  and  there  may  be  intense  pain  in  the  side,  pointing  to 
perisplenitis  from  embolism.  I'sually  in  the  rapid  cases  a  typhoid  state 
develo]is,  and  the  patient  dies  comatose. 

In  the  chronic  cases  the  disease  may  be  prolonged  for  months;  the 
chills  recur  at  long  intervals,  the  temiierature  is  irregular,  and  the  condi- 
tion of  the  patient  varies  from  nvrnth  to  month.  The  course  is  usually 
slow  and  progressively  downward. 

Diagnosis.— Pyaemia  is  a  disease  frequently  overlooked  and  often  mis- 
taken for  other  affections. 

Cases  following  a  wound,  an  oiieration,  or  jmrturition  are  readily  recog- 
nized.    On  the  other  hand,  the  following  conditions  may  be  overlooked: 

Ostpn-myrlilift. — ITcre  the  lesion  may  be  limited,  the  constitutional 
symptoms  severe,  and  the  course  of  the  disease  very  rapid.  The  cause  of 
tiie  trouble  may  be  discovered  only  post  mortem. 


(lc|)cii(l('iit  ci'iilro  o| 
l(i(l;:('.  'I'licsf  imlc- 
•iiiliiilic   or   iiirldshilii 

ac'iiti'  |ilil('i:iiinii  ui 
'  siiipiHiriitiou  in  the 
mic  iiirarcts;  Imt  in 
cs,  iiiii!  tliorc  arc  loci 

.•ystc'iii,  particularly 
ivcr  with  or  wiilioiit 

cciir  ill  all  forms  of 

the  clinical  feature.-. 

II   orj,'aiiisiiis   proscut 

tul)crclc  ))acilli,  ty- 

liccii   isolated.     The 

lesion    lieconie   cov- 

ilfjred   aiul   carried   as 

i[)le  aiiscesses  or  in- 

of  wound  infection, 
iiuiy  he  sii;ns  of  local 
may  chanjre  in  char- 
ripir,  during  which 
by  a  jirofusc  sweat, 
every  other  day.  In 
itutional  disturbance 
x\  voniitinp,  and,  as 
erytbema  is  not  nn- 
ngs  l)ecome  involved 
,-  be  slight.  Involve- 
e  tint  of  the  skin  is 
lies  bile-tinged.  The 
the  side,  ])ointing  to 
■ascs  a  typhoid  state 

:ed  for  months;  the 
:ular,  and  the  condi- 
'he  course  is  usually 

ookcd  and  often  mis- 

on  are  readily  recog- 
nay  be  overlooked: 
!,    the    constitutional 
rapid.     The  cause  of 


skpti(m:mia  and  py.emia. 


105 


So,   too,   acute   septico-pya'uua    nuy    i'ollow    ,Miorrhnv    or   a    r'-^'static 

'""tCcs  are  s.mietinu>s  conf<.undcd  with  hirh-i'l  f'rn;  particularly  the 
„„„,,  ,l,ronic  instances,  in  wind,  there  arc  diarrh.ca.  great  prostration, 
,,,,|i,ium.  ati.l  irr..g.dar  fever.  The  >plccn,  too,  n,ay  he  cnlargvd.  1  he 
marked  lciicocvt..sis  is  an  important  ditVcrcntial  point. 

In  <ome  of  the  instamrs  of  iihrnilin'  ni,l<>n,nhhs  the  diagnosis  is  vcr\ 
,,il,i,nlt.  parlic.darlv  in  what  is  known  as  the  typhoid,  in  contradistinction 
to  the  septic,  type  of  this  disease.  In  onilr  milhini  Inhnrnlnsis  the  symi.- 
,o,ns  occasionally  roeiiihlc  those  of  septicaMiiia,  more  commonly  tlio>e  ol 

iviilioid   fever.  ,   ,    «  i        ,. 

■  The  nosl-frhrllr  mlhril i,lrs,  such  as  occur  alter  scarlet  fever  an-l  gon- 
,„.,lHea,  are  reallv  instances  of  mild  septic  infection.  The  joints  may 
.ometi.nes  suppurate  a.id  pyamiia  .levelop.  So,  abo.  ,n  Inhmnlns,.  u 
Ihv  kiduviix  and  aikuhnis  purlills  rc.-urring  rigors  and  sw.ats  diw  to  septu 
infection  are  common.  In  this  latitude  septic  and  pyaMuic  processes 
„re  too  often  confounded  with  mahirlu.  in  ...rly  tuberculosis,  or  even 
when  signs  of  excavation  are  present  in  the  Inng..  and  in  cas.v.  "l^'M'l'>>ra- 
tion  in  various  parts,  particularly  empyema  and  ab>cess  ol  tlie  livei.  t  u 
.lia-mosis  of  malaria  is  made.  Tlu'  pra.'titioncr  may  take  it  as  a  sale  nil.' 
;o  which  he  will  lind  very  few  exceptions.  Ihal  an   udrrwdind  tnrr  irlnri, 

n'.s'iV/.s'  (niiiiiiic  is  mil  iiidhinn. 

Otlu.r  conditions  as.-ociatcd  with  chills  which  may  be  mista.kcu  lor  pya- 
„,.^  ,„.^.  ,„.„,.,„„,,  „„„„i,,  ,.,.rtain  cases  of  llodgkinV  diseas...  the  he,.,tic 
intermittent  fever  asso..iatcd  with  the  lodgnient  of  gall-stones  at  the  oniice 
of  the  cmmott  duct,  rare  cases  of  essential  fever  in  n.'rvous  women,  ami 
the  intermittent  fever  sometimes  se.-n  it.  rapi.llv  deveh.pmg  <ance.. 

Treatment.-Thc  treatment  of  sei.tica.mia  and  pya-niia  is  laigelv  a 
surgical  i.roblem.  The  cases  which  come  nnder  the  notice  ol  the  ,.bysi- 
cia^  ttsnally  have  visceral  abscesses  or  ulcerative  endocarditis,  cond,  o  s 
wbich  are  irremediable.  We  have  no  remedy  which  controls  !>;  '  '■ 
Quinine  and  the  new  autipvretics  may  be  tncd,  btit  they  a,r  ol  '         " 

i  e.  Quinine  is  probably  bett..-  than  antipyrin  and  a.ttilehrm,  whu  .  In. 
t,„  t.niperaturo  for  a  time,  btit  when  a  ..arcfi  ^->;'--->y  Z^^; ; -;'  ' 
hour  ch  ,rt  is  taken,  it  is  often  found  that  the  depression  under  the  mllu- 
ence  of  the  drug  is  made  np  at  some  other  period  of  the  day;  a  morning 
niav  be  substituted   for  an  afternoon  fever. 

•tIh,  brilliant  and  remarkable  results  vvhicb  bdlow  complete  evacuation 
of  the  jms  with  thorough  drainage  give  the  indication  bu'  the  only  success- 
ful treatment  of  this  condition.  .       . 

I'nfortunatelv,  in  too  ntany  cases  wliicb  the  physuMan  is  called  upon 
to  treat,  the  region  of  suppuration  is  not  accessible,  and  w<.  havx'  to  be 
content  with  the  employme.it  of  gccal  measures  for  the  support  of  the 
patient's  strength. 

TETIMINAL  INFKCTIONS. 

It  mav  seem  paradoxical,  but  there  is  truth  in  the  statement  that  per- 
sons rareiv  die  of  the  disease  with  which  they  suller.     Seconda.-y  infec- 


lar,  SPKCIFIC  INFKC'TIOUS  DISEASES. 

tiuiis,  (tr.  as  \v(>  iiri'  npt  to  ciill  tlicm  in  lins|iitiil  work,  tcniiiiml  iiifcctioii  . 
carry  oil'  many  of  tlic  iiiciiralilc  cases  in  the  uanls.     I'Ic.mkt  *  lias  aiialy/i.| 
'.'.').")  cases  of  cliroiiie  renal  aini  cardiac  disease  in  which  complete  liacterin 
l<i;,ncal  examinations  wei'e  made  at  antojisy.     ivxclndin;;  tnliercuions  iiilVi 
tion,  '.'1.'!  i;ave  positive  and   I".'  iiepitive  resnits. 

'I'lie  ini'eciions  may  lie  local  or  jreiieral.  The  former  are  extrenicK 
common,  and  are  found  in  a  hir;,'e  |iro|iortion  of  all  cases  of  liri;^lit"s  disea>c. 
aiterio-sclcro.-is.  Iiearl-(li>case,  cirrhosis  id'  the  livei'.  and  other  chronic  (li>- 
orders.  All'ections  td'  the  serous  mcndiranes  (acute  pleurisy,  acute  |)eri- 
carditis,  lU'  peritonitis),  meninj:itis,  and  eiidocai'ditis  are  the  most  fre(|iienl 
lesions.  It  is  perhaps  safe  to  say  that  the  majority  cd'  cases  <if  ailvancc(l 
arteiio-sclerosis  and  of  Hrij^dit's  disease  suci  innh  to  these  intercurrent  infec- 
tions, '{"he  inl'i'ctive  a;.'ents  are  very  varied.  The  streptococcus  pyo^'ene> 
is  perha]is  the  most  common,  hut  the  pneumococcns,  staiiiiylococcus  anreus. 
the  Imcillus  proteus,  the  i^onococcns,  the  jras  hacilins.  aiid  tlie  hacillus  pyo- 
cyaneus  are  also  met  with. 

I'articniar  mention  may  he  here  niade  of  the  ferndnal  form  of  acute 
miliary  (ui)ercnlosis.  it  is  snrprisiiiir  in  how  many  instances  of  arterio- 
sclerosis, of  chronic  heart-disease,  of  Hrijiiit's  disease,  and  more  particu- 
larly (d'  ciri'hosis  of  the  liver,  the  fatal  event  is  deternnned  hy  an  aiMitc 
tuhercujosis  of  the  peritonaumi  or  |)leura. 

'i'lie  <,reiieral  terminal  infections  are  somewhat  less  common.  Of  S.")  case* 
(d'  chronic  nMial  disease  in  which  Flexner  found  ndcro-or;:anisms  at  au- 
to]isy,  ;i.s  exhiliited  ;:eneral  infei  lions;  of  IS  cases  of  chronic  cardiac  <liseaso. 
in  11  the  distriiintion  (d'  hacteria  was  jreneral.  The  hlond-scrum  of  persons 
sull'erini.'  from  adviince(]  chronic  disease  was  found  by  him  to  he  less  de- 
structive to  the  sta|ihylocoecns  aureus  than  normal  luunau  senun.  Other 
diseases  in  which  jicneral  ternnnal  infection  may  occur  are  llod<,d<in's  dis- 
ease, leukaMnia,  and  chronic  tulierculosis. 

And.  lastly,  jiroliahly  (d'  tlie  same  nature  is  the  termiiuil  entero-colitis 
po  frecjuontly  met  with  in  chronic  disorders. 


XIX.    RHEUMATIC    FEVER. 

Definition. — An  acute,  non-contafiious  fever,  depeiulent  U])on  an  un- 
known infective  af,'ent.  and  characterized  hy  multiple  arthritis  and  a  marked 
tendency  to  inilamniation  of  the  tihrous  tissues. 

"Etiology.— Dislriliiilidii  and  I'lrraJciire. — It  i)revails  in  temperate  and 
humid  climates.  Church  has  collected  interesting  statistics  on  this  ])oint. 
Oddly  (Mioujrh,  the  two  countries  with  the  hijrhest  admission  in  tlie  army  per 
thousand  <d'  streujzth — F,,<;y]tt,  7.0'.',  and  Canada,  (l.-^fl — have  climates  the 
nu)st  diverse,  'i'lie  returns,  however,  from  Canada  for  the  six  years  from 
ISSn  to  ISO'i  are  i>erhai)s  mo-e  correct,  2.83  ])er  thou.«and  of  stren<,ih.  The 
death-rate  for  the  five  years  1S81-S")  in  Great  Britain  was  !)7  per  million. 
In  the  Tnited  States  there  are  no  satisfactory  statistics;  the  disease  is  not 


■  Jour.  Exp.  Med.,  i,  1896. 


IMAGE  EVALUATION 
TEST  TARCfET  (MT-3) 


s»- 


1.0    !f  »=  11^ 


!  I.I 


1.25 


■^  lU    112.2 

Site  ■— 


I 


1.4 


JO 


2.0 


1.8 


:.6 


7 


L 


Photographic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  873-4503 


# 


•1>^ 


\ 


iV 


\\ 


■  -r^'^s^.,,-^     -.,.  -Vi.t" 


.-;»V.,,v...  -.^vi':?...;  v:-,^-;?.-  .i-A'-...   -^^•'/fvl^w^>■ii*v- ^•jfiiEty*!^^>iM«»v:'"'T'*t?TlX*^^^ 


^<b 


.V 


6^ 


^ 


# 


•«* 


'*" 


€^ 


T*^-.'    .;.T«iMt».«-*;,iW. 


:,!{*"■ 


L<y 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


vV 


RHEUMATIC  FEVER. 


167 


dealt  with  in  tlio  last  Census  Report  as  a  eause  of  death.  So  far  as  my 
])ersonal  ohservation  goes,  it  certainly  seemed  to  he  more  prevalent  in  Mon- 
treal than  in  riiiladelpiiia  or  Baltimore.  The  -reiieral  iiiii)ression  is  tliat 
the  disease  prevails  more  in  tlie  IJritish  isles  than  elsewhere;  l)iit,  as  L'luirch 
remarks,  the  returns  are  very  iini)erl'eet  (this  hf)lds  good  everywliere),  and 
prol)al)ly  the  death-rate  from  rhenmatie  fever  itself  is  very  nnieh  lower 
than  the  figures  would  indicate,  as  very  many  dill'erent  diseases  are  groujied 
under  this  heading.  In  Norway,  where  cases  of  rheumatic  fever  are 
notified,  there  were  for  the  four  years  1888-!)2  1;5,(m-1  cases,  with  2r)i) 
deaths. 

Season. — In  London  the  cases  reach  the  maximum  in  the  months  of 
Septendjer  and  Octoher.  In  the  ^Montreal  Cieneral  Jlospital  HeU's  statis- 
tics of  450  cases  show  that  the  largest  numher  was  adnutled  in  Fehruary, 
.March,  and  Aiirjl.  Newsholnie  has  brought  forward  statistics  to  show  that 
the  disease  ])revails  most  in  the  dry  years  or  a  succession  of  such,  and  is 
specially  ])revalent  when  the  subsoil  water  is  ahnornially  low  and  the  tem- 
perature of  the  earth  high. 

Age.— Young  adults  are  most  frecpiently  affected,  hut  the  disease  is  hy 
no  means  uncommon  in  children  hetween  the  ages  of  ten  and  fifteen  years. 
Sucklings  are  rarely  attacked,  and  i)rohal)ly  many  of  the  cases  which  have 
been  descrihed  belong  to  a  totally  dill'erent  atl'ection,  the  arthritis  of  in- 
fants. In  exeeiitional  cases,  however,  true  rheumatism  does  occur.  The 
following  age  table  is  hased  ui)on  A'yii  cases  admitted  to  the  ^lontreal  Gen- 
eral Hospital:  Under  fifteen  years,  4.38  per  cent;  from  fifteen  to  twenty- 
live  years,  48.08  per  cent;  from  twenty-five  to  thirty-five  years,  25.87  per 
cent";  from  thirty-five  to  forty-five  years,  13.0  per  cent;  above  forty-five 
years,  7.4  per  cent.  Of  the  055  cases  analyzed  by  Whipham  for  the  Col- 
lective Investigation  Committee  of  the  British  :Medical  Association,  only 
;i-v'  cases  occurred  under  the  tenth  year  and  80  per  cent  hetween  the  twen- 
tieth and  fortieth  year.  These  figures  scarcely  give  the  ratio  of  cases  in 
children. 

Sex.— If  all  ages  are  taken,  males  are  aiTccted  oftener  than  females, 
In  the  Collectivf!  Investigati(m  Kei)ort  there  were  375  males  and  27S) 
females.  Up  to  the  age  of  twenty,  however,  fenudes  predominate.  Be- 
tween the  ages  of  ten  and  fifteen  girls  are  more  prone  to  the  disease. 

Hp.rediti/.—U  is  a  deeply  grounded  helief  with  tiie  jiublic  and  the  pro- 
fession that  rheumatism  is  a  family  disease,  hut  Church  thinks  tiie  evidence 
is  still  imperfect.  Its  not  rare  occurrence  in  several  members  of  the  same 
family  is  used  hy  those  who  helieve  in  the  infectious  origin  as  an  argument 
in  favor  of  its  being  a  house  disease. 

The  occupations  wh'wh  necessitate  ex]iosure  to  cold  and  great  changes 
of  temperature  predispose  strongly  to  rheumatic  fever.  The  disease  is  met 
with  oftenest  in  drivers,  servants,  bakers,  sailors,  and  laborers. 

ChiU, — Exposure  to  cold,  a  wetting,  or  a  sudden  change  of  temperature 
are  among  the  most  important  factors  in  determining  the  onset  of  an 
attack. 

ImmnnUy  is  not  afforded  by  an  attack;  on  the  contrary,  as  in  rheuma- 
tism, one  attack  predisposes  the  subject  to  the  disease. 


/ 


''•■''..'^•■'.•"-',i'a.l>-  'M^ii*"-- 


jgg  SPECIFIC  INFECTIOUS  DISEASES. 

Rheumatic  Fever  as  an  Acute  Infectious  Disease.-(«)  l^l^^^T^^.^';^^^ 
-KluHMnatie  IVvor,  a.  N.NV.holnio  l.as  .hown,  occurs  in  -^P^^  ""-,;;" ^ 
ro.n.lar  iKTio.licitv,  recurring  at  interval,  of  three,  four  or  mx  y^^^^^t 
v^-yin.'  uuu-h  iu' intensity.  A  severe  epi.ienm^  is  apt  to  l,e  ioilmsoa  In 
:;?;:^tlu.ee  um  outbreaks.  ''  The  curves  of  the  "-'J'^lJ^/^ll^lf  ^  •  ;.  " 
annroxiu.ate  very  cU.sely  to  those  of  pyivmia,  puerperal  lever,  and  erjsip 

rdi:^-^hK.h  are  certainly  associaU.!  .ith  ^l-^'^^----;;;';;;;:;^,, 
(('iu.reh).     The  constancy  also  of  the  seasonal  variations  i.  an  a.l.lit.onal 

""'ir;V;;«!:;:/  M.,...-l'hysieians  have  ion,  been  impressed  vnth  the 
strik  n<      1    Wi  y  .>f  the  symptoms  of  rheumatic  fever  to  those  of  sep  ic 
1/eco^.n  the  character  of  the  fever,  the  mode  of  inyolvement  of    lo 
nt    the  tendency  to  relapse,  the  sweats,  the  anaMuia,  the  leucocj-^^osis,  and 
iJ^v  \l'     the  frni  liahilit'y  to  endocarditis  and  involvement  oi  the  serou 
i^d.;anes,   acute   rheumatic   fever   resenildes   P^-"-.  ;-J.  ;;  "^^it    a 
may    indeed,  he  taken  as  the  very  type  ol  an  acute  infection.     But    a> 
Si  n  Ma  kenzie  remarks,  acute  rheumatism  ^''""l^^'^'  .'^^"^J    jd    f 
.i  Sy    r mn  the  point  of  view  of  the  rheumatic  polyarthritis  of  the  ad  1, 

i7as  a  whole  in  its  manifestations  at  dilVerent  periods  ol  lite;  yet  eve 
f  om   Ids     andpoint  the  multiform  manifestations  of  the  rheumatic  poison 
•  "hil'ihood  and  youii,  adults  may  very  reasonahly  be  referred  to  the  elfect 
of  the  toxines  of  inicro-or<ranisms.  ,.       i       i  j..i„ 

Special  E.Uknre.-^The  bacteriology  of  acute  rhenma  ism  has  la  ej 
attr u  ted   a   great   deal   of   attention.      Mantle,   Salili,   Leydeii     C  hvostek, 
S  n'       A^udnie,  and  others  have  contributed  important  studic^.     A  ro- 
vi^v  of    heir  wo  k.  however,  justifies  the  conclusion  that  no  positive  proof 
ns  a"  y      been  olfered  of  the  constant  association  of  any  special  micro- 
o  lamisin  with  the  disease.     Singer  in  an  extensive  monograph  at  eni,>t. 
to'iiow  that  in  rheumatic  fever  the  organisms,  consisting  chieily  ot  sta- 
ll     end  streptococci,  are  discharged  in  numbers  m  the  unne.Spe- 
cU    tress  has  been  laid  upon  the  tonsils  as  the  point  of  entrance  of    ho 
h^  ction.    It  has  long  been  known  that  tonsillitis  is  a  very  frequent  initial 
.ym^^^^^^      in  the  disc^se-SS  out  of  GO  eases  in  Singer's  series.     Indeed 
son    have  gone  so  far  as  to  say  that  there  is  always  a  primary  infeetive 
tZble  in  the  lacuna^  of  the  tonsils,  to  which  the  rheumatic  fever  is  second- 
ary arising  from  the  absori>tion  of  microbes  or  their  products. 

Other  views  as  to  the  nature  of  rheumatism  arc  the  melahohc  or  chemical. 
tint  it  depends  upon  a  morbid  material  produced  within  the  system  m 
c  V  Vrocesses^f  assimilation.  It  has  been  suggested  that  this  mate- 
rial <  act  c  acid  (I'rout)  or  certain  combinations  with  laetie  acid  (Latham) 
lur  knowledge  of  the  chemical  relations  of  the  various  products  produced 
he  egressive  nutritive  changes  is  too  limited  to  warrant  much  reliance 
Ion  thc<e  views.  l?ichardson  claims  to  have  produced  rheumatism  by  in- 
iectiuL'  lactic  acid  and  bv  its  internal  administration. 

A>nws  Theorti  of  Acnte  7?/icm»«7fs,».-Tliis  was  specially  advocated 
hv  Z  late  Dr.  J.  K.  Mitchell,  of  Philadelphia.  According  to  tins  view, 
e  th  the  nerve  centres  are  primarily  affected  by  cold  and  the  local  lesions 
arc  rcallv  trophic  in  character,  or  the  primary  nervous  disturbance  leads 


RHEUMATIC  FEVER. 


169 


Evidence. 
1  without 
L'ursi,  and 
lowod  liy 
itics  .  .  . 
I  oryi'iiw- 
lanisiiis  " 
idditional 

with  tho 
of  septic 
nt  of  tho 
tosis,  and, 
ho  serous 
)scly,  and 
But,  as 
dorcd  not 
the  adult, 
;  yet  even 
itic  poison 
I  the  eifect 

has  lately 
Chvosiek, 
OS.     A  ro- 
itivo  ])roof 
•ial  micro- 
ii  attem])ts 
Mly  of  sta- 
rine.    Spe- 
mce  of  tho 
Lient  initial 
j.     Indeed, 
•y  infective 
r  is  second- 

or  chemical: 
!  system  in 
;  this  mate- 
1  (Latham), 
ts  produced 
iich  reliance 
itism  by  in- 

y  advocated 
o  this  view, 
local  lesions 
rbancc  leads 


to  errors  in  metabolism  and  tho  accumulation  of  lactic  acid  in  the  system. 
The  advocates  of  this  view  regard  as  analogous  tlic  artlwopathios  of  myelitis, 
locomotor  ataxia,  and  chorea. 

Morbid  Anatomy. — Tiiere  are  no  changes  el'aracteristic  of  the  dis- 
ciise.  Tlie  aU'eeted  joints  show  hy[iera'mia  and  swelling  of  tho  synovial 
iiiciiibranes  and  of  tiio  ligamentous  tissues.  There  may  be  slight  erosion 
of  the  cartilage.  Tlie  lUiid  in  tlie  joint  is  turl)i(],  alljuminoiis  in  character, 
iiiul  contains  leucocytes  and  a  few  lil)rin  Hakes.  I'us  is  very  rare  in  uiuom- 
l>liiatcd  cases.  IJIieumatism  rarely  proves  fatal,  cxeept  when  there  are 
hcrious  complications  sueh  as  pericarditis,  endocarditis,  myocarditis,  pleu- 
risy, 0.  jmeumonia.  The  conditions  found  show  nothing  peculiar,  nothing 
til  distinguish  them  from  other  forms  of  inllamnuition.  In  death  from 
hyperpyrexia  no  special  cluinges  occur.  The  blood  usually  contains  an 
I'Nccssive  amount  of  iil)rin.  In  tho  secondary  rheumatic  inllammations, 
iis  ])lcurisy  and  pericarditis,  various  pus  organisms  have  been  found,  pos- 
sihly  the  result  of  a  mixed  infection. 

Symptoms. — As  a  rule,  the  disease  sets  in  abruptly,  but  it  may  1)0 
jirccedcd  by  irregidar  pains  in  tho  joints,  slight  malaise,  sore  throat,  and 
|i:irticularl\  by  tonsillitis.  A  definite  rigor  is  unconnnon;  more  often 
ihcre  is  slight  chilliness.  The  fever  rises  (juickly,  and  with  it  one  or  more 
(if  the  joints  Ijocome  ]minful.  Within  twenty-four  hours  from  tho  onset, 
the  disease  is  fully  developed.  The  tem])erature  range  is  from  102°  to 
lol'.  The  ])ulsc  is  freijuent,  soft,  and  usually  above  lUO.  The  tongue  is 
moist,  and  rapidly  becomes  covered  with  a  white  fur.  There  are  the  ordi- 
nnry  symptoms  associated  with  an  acute  fever,  such  as  loss  of  api)otite, 
thirst,  constipation,  and  a  scanty,  highly  acid,  highly  colored  urine.  In  a 
iiiMJoi-ity  ( *■  the  cases  there  are  profuse,  very  acid  sweats,  of  a  peculiar  sour 
nilor.  Sudaminal  and  miliary  vesicles  are  abundant,  the  latter  usually  sur- 
t'oiiiidcd  by  a  minute  ring  of  hypera'mia.  The  mind  is  clear,  except  in 
the  cases  with  hyperpyrexia.  Tho  alfected  joints  are  ])ainful  to  move, 
soon  become  swollen  and  hot,  and  ])resent  a  reddish  flush.  Tho  knees, 
iiiikles,  elbows,  and  wrists  are  tho  joints  usually  attacked,  not  together, 
but  successively.  For  example,  if  tho  knee  is  first  affected,  the  redness 
may  disap])ear  from  it  as  the  wrists  become  painful  and  hot.  The  disease 
is  seldom  limited  to  a  single  articulation.  The  amoinit  of  swelling  is  vari- 
able. Extensive  effusion  into  a  joint  is  rare,  and  mtu-h  of  the  enlargement 
i.-:  due  to  the  infiltration  of  the  periarticular  tissues  with  seruTu.  Tlie 
swelling  may  be  limited  to  tho  joint  proper,  but  in  the  wrists  and  ankles 
it  sometimes  involves  tho  sheaths  of  the  tendons  and  produces  great  n\- 
birgement  of  the  hands  and  foot.  Corresponding  joints  arc  often  affeciod. 
In  attacks  of  great  severity  every  one  of  tho  larger  joints  may  be  involved. 
The  vertebral,  sterno-clavicular,  and  phalangeal  articulations  are  less  often 
iiiljamed  in  acute  than  in  gonorrha^al  rheumatism.  Perhaps  no  disease  is 
more  ])ainful  than  acute  ])olyarthritis.  The  inability  to  change  tho  posture 
without  agonizing  pain,  the  drenching  sweats,  the  prostration  and  utter 
lif'lplessness,  combine  to  make  it  one  of  the  most  distressing  of  febrile 
iiiVections.  A  special  feature  of  tho  disease  is  the  tendency  of  tho  inflamma- 
tion to  subside  in  one  joint  while  developing  with  great  intensity  in  another. 


\ 


170 


SPECIFIC  INFECTIOUS  DISEASES. 


The  tomporaturc  range  in  an  ordinary  attack  is  between  102°  and  104°. 
It  is  i)eculiarly  irregular,  with  marked  remissions  and  exaeerl)ations,  de- 
l)onding  very  much  upon  tiie  intensity  and  extent  of  the  artieuhir  inthim- 
mation.  Dei'erveseeiiee  is  usually  gradual.  Tlie  profuse  sweats  materially 
influenee  the  temperature  curve.  If  a  two-hourly  chart  is  made  and  oh- 
servations  u|)on  the  sweats  are  noted,  the  remissions  will  usually  he  found 
coincident  with  the  sweats.  The  perspiration  is  sour-sn'"lling  'ind  acid  at  ^ 
first;  but,  wlien  jjcrsistent,  becomes  neutral  or  even  alkaline. 

The  blood  is  profoundly  -ind  rapidly  altered  in'  acute  riieumatism. 
There  is,  indeed,  no  acute  .ebrile  disease  in  which  the  anajmia  develops 
with  greater  rapidity.    Tliere  is  a  well-marked  leucocytosis. 

With  tlie  high  fever  a  murmur  may  often  be  heard  at  the  apex  region. 
Khdoeardilis  is  also  a  common  cause  of  an  apex  bruit.  The  lieart  should 
be  carefully  examined  at  the  lirst  visit  and  subsequently  each  day. 

The  urine  is,  as  a  rule,  reduced  in  amount,  of  high  density  and  high 
color.  Jt  is  very  acid,  and,  on  cooling,  deposits  urates.  The  chlorides 
may  be  greatly  diminished  or  even  absent.  Febrile  albuminuria  is  not 
uncommon. 

The  saliva  may  become  acid  in  reaction  and  is  said  to  contain  an  excess 
of  sulphocyanides. 

Subacute  Rheumatism.— This  represents  a  milder  form  of  the  dis- 
ease, in  which  all  the  symptoms  are  less  pronounced.  The  fever  rarely  rises 
above  101°;  fewer  joints  are  involved;  and  the  artliritis  is  less  intense. 
The  cases  may  drag  on  for  weeks  or  months,  and  the  disease  may  finally 
become  chronic.  It  should  not  be  forgotten  that  in  children  this  mild. or 
subacute  form  may  be  associated  with  endocarditis  or  pericarditis. 

Com.plications. — These  are  important  and  serious. 

(1)  Hyperpjrrexia. — The  temi>erature  may  rise  rai)idly  a  few  days  after 
the  onset,  and  be  associated  with  delirium;  'out  not  necessarily,  for  the 
temperature  may  rise  to  108°  or,  as  in  one  of  Da  Costa's  cases,  110°,  with 
out  cerebral  symi)toms.  Hyperpyrexia  is  most  common  in  lirst  attacks, 
57  of  107  cases  (Church).  It  is  most  apt  to  occur  during  the  .-ecoud  week. 
The  delirium  tnay  jirecede  or  follow  the  onset  of  the  liyperpyrexia.  As  a 
rule,  with  the  high  fever,  the  pulse  is  feeble  and  frequent,  the  prostration 
is  extreme,  and  finally  stupor  supervenes. 

(2)  Cardiac  AfTections. — (o)  Endocarditis,  the  most  freipient  and  serious 
complication,  occurs  in  a  considerable  percentage  of  all  cases.  Of  8S9  oases, 
49-1  had  signs  of  old  or  recent  endocarditis  (Church).  The  liability  to 
endocarditis  diminishes  as  age  advances.  It  increases  directly  with  the 
number  of  attacks.  Of  IIG  cases  in  the  first  attack,  58.1  })er  cent  had  endo- 
carditis, (53  per  cent  in  the  second  attack,  and  71  per  cent  in  the  third 
attack  (Stephen  lilackenzie).  The  mitral  segments  are  most  frequently  in- 
volved and  the  affection  is  usually  of  the  sim])le,  verrucose  variety.  Ulcer- 
ative endocarditis  in  the  course  of  acute  rheumatism  is  very  rare.  Of  209 
cases  of  this  disease  which  I  analyzed,  in  only  24  did  the  symptoms  of  a 
severe  endocarditis  arise  during  the  progress  of  acute  or  subacute  rheuma- 
tism. This  complication,  in  itself,  is  rarely  dangerous.  It  produces  few 
symptoms  ai-d  is  usually  overlooked.    Unhai)})ily,  though  the  valve  at  the 


A 


itaai 


.02"  and  104°. 
erliations,  (k'- 
.iciilar  inHam- 
'ats  materially 
made  and  oli- 
lally  1)0  found 
\il  nnd  acid  at 

!  rlioiiniatism. 
Eiuia  develops 

e  ai)ox  region. 
.'  heart  should 
h  day. 

isity  and  high 
The  chlorides 
iiinuria  is  not 

itain  an  excess 

)rm  of  the  dis- 
ver  rarely  rises 
s  less  intense, 
se  may  finally 
n  this  mild. or 
jarditis. 

few  days  after 
sarily,  for  the 
ses,  110°,  with 
1  first  attacks, 
e  occoud  week, 
pyrexia.  As  a 
the  prostration 

jnt  and  serious 
Of  8S9  cases, 
he  liahility  to 
ectly  with  the 
cent  had  cndo- 
t  in  the  third 
frequently  in- 
ariety.    Ulcer- 
rare.     Of  -209 
symptoms  of  a 
)acute  rheuma- 
t  produces  few 
le  valve  at  the 


RIIEUiMATlC  FEVER, 


171 


linio  may  not  he  seriously  damaged,  the  inflammation  starts  changes  wiru.li 
lead  to  sclerosis  and  retraction  of  tiie  segments,  and  so  to  clironic  valvular 
(li.-caso. 

(b)  Pericai'dilis  may  occur  independently  of  or  together  with  endo- 
carditis. It  may  be  simple  ili)riiious,  scro-librinous,  or  in  children  puru- 
lent. Clinically  we'meet  it  more  frecpir^tly  in  connection  with  rheunia- 
ii.-ni  tiian  all  other  all'ections  cond)iiUHl.  The  jjhysical  signs  are  very  char- 
acteristic. The  condition  will  be  fully  described  uiuler  its  api)ropriate  sec- 
tion. A  peculiar  form  of  delirium  may  develop  during  the  [irogress  of 
iheuniatic  pericarditis. 

((■)  Myocardilis  is  most  frequent  in  connection  with  endo-pericardiid 
(lianges.  As  Sturges  insisted,  the  term  cardilin  is  api)licable  to  many  cases. 
'I'lic  anatonncal  condition  is  a  granular  or  fatty  degeneration  of  the  heari- 
niusile,  which  leads  to  weakening  of  the  walls  and  to  dilatation.  It  is  not, 
I  lliink,  nearly  so  common  as  the-othcr  cardiac  affections.  S.  West  has  v- 
[lortcd  instances  of  acute  dilatation  of  the  heart  in  rheunuitic  fever,  ui  one 
(if  which  marked  fatty  changes  were  found  in  the  heart-fibres. 

(3)  Pulmonary  Affections. — Pneumonia  and  i)leurisy  occurred  in  9.!'4 
per  cent  of  3,433  cases  (Stephen  Mackenzie).  They  frequently  accompany 
the  cases  of  endo-pericarditis.  According  to  Howard's  analysis  of  a  large 
inunber  of  cases,  there  were  pulmonary  com[)lications  in  only  10.5  oer 
cent  of  cases  of  rheunuitic  endocarditis;  in  58  ])er  cent  of  cases  of  j'cri- 
carditis;  and  in  71  per  cent  of  cases  of  endo-pericarditis.  Congestion  of 
the  lung  is  occasionally  found,  and  in  several  cases  has  proV'?d  rnpidly 
fatal. 

(4)  Cerebral  Complications. — These  are  due,  in  part,  to  the  hyper- 
pyrexia and  in  j)art  to  the  sjjecial  action  upon  the  brain  of  the  tv>xic  agent 
(if  the  disease.  They  may  be  grouped  as  follows:  («)  Delirium.  This  is 
u.-^ually  associated  with  the  hyiK-rpyrexia,  but  may  be  independent  of  it. 
It  may  be  active  and  noisy  in  character;  more  rarely  a  low  muttering 
delirium,  passing  into  stupor  and  coma.  Special  mention  must  be  made 
uf  the  delirium  which  occurs  in  connection  with  rheumatic  ])ericarditis. 
Delirium,  too,  may  be  excited  by  the  salicylate  of  soda,  either  shortly  after 
its  administration,  or  more  commonly  a  week  or  ten  days  later.  (/;)  Coma, 
wliicli  is  more  serious,  may  develop  without  preliminary  delirium  or  con- 
vulsions, and  may  prove  rapidly  fatal.  Certain  of  these  cases  are  associ- 
ated with  hyperpyrexia;  but  Sonthey  lias  reported  the  case  of  a  girl  who, 
without  previous  delirium  or  high  fever,  became  comatose,  and  died  in  liss 
than  an  hour.  A  certain  number  of  such  cases,  as  those  reported  by  Da 
Costa,  have  been  associated  with  marked  renal  changes  and  were  evidently 
luivmic.  The  coma  may  develop  during  the  attack,  or  after  convalescence 
has  set  in.  (r)  Convuhions  are  less  common,  though  they  may  ])rccedc 
the  coma.  Of  127  observations  cited  by  Besnier,  there  were  37  of  delirium, 
v)idy  7  of  convulsions,  17  of  coma  and  convulsions,  54  of  delirium,  conui, 
luid  convulsions,  and  3  of  other  varieties  (Howard),  {d)  Chorea.  The 
relations  of  this  disease  and  rheumatism  will  be  subsequently  discussed. 
It  is  sufficient  here  to  say  that  in  only  88  out  of  554  cases  which  I  liave 
iuialyzed  from  the  Infirmary  for  Diseases  of  the  Nervous  System,  Phila- 

11 


A 


SPECIFIC  INFECTIOUS  DISEASES. 


.,  c.trcmoly  common.    A  .«    .n,l,ar,      .    n   >  ^  «  ^ -c  ^^^._^_^^.__^ 

form  eruptions  arc  occasionally  7  '   .'^    it       'lo>*tt"l  "'-'l"^^'  *''« 

s„b  utanoons  nodnlos  attached  to  tLo  ''■"'1';""  ""J,,  f  ;'';,. ^o    late,  since 

II.  Bulletin,  liiJo).     inty  \<uj^  ,.„.;ef,     Thev  also  occur 

and  are  most  numerous  on  the  fingers,  hands,  and  ''^''^l'-  J^'^.L     Thev 

-r;:^^'3tii:&^^^^^   ......eo.  ^.« 

oeenr  al«.  in  inigramc  gont  an.l  artl.nt,.  Idorman       1  „        ^„„  ■,,„„, 

nnule  np  ot  ronn.l  an.l  s,,,mlle-sl.aiwl  cell.    '  ""^If  "^Vtative  en,locar.litis 

nodnles,  there  oeenr  n,  'I'™:™'™"  »     ,.  "  t^  "^^  "  nodositfe  cn- 
ron,arta*le.mallh,d,»whK,ha      henol^^^^^^^^^^^^ 

tani-es  epheraeres       In  "  '*°  "'/' '.    „.    ,  »„   „,„,,  „.,,„..  in  a.hlition  to 
arthritis)   «;*'-;,:'    j:,,„;\;r;:ri:inffl.™        areas  ot  soreness 

","«,nis;.ely  tender  and  paintnl  '^'-^^^^^^^^ti,,  „  Anstin 

The  r,,-r.«  »V"''^nnu ^^^^s     "     d  ti   n  f  probable'that  medi- 

Flint  first  showed,  a  silMinutod  '''''''• '^"'.      „{  „„„,.     Onll  and 

tt;,;"":d,olLr':L:dSra":riro"  ;^  et«  ;:;«.:.  speda,  treatment, 

"tittrrn%rrr.veri..dnem„stfr,^^^^^ 

nerringham  has  reported  «™» -;;;":;■;;"„/'  J'^'^rnt'  In  a  few 
fatty  degeneration  and  «•''»  "f/""™' °^,  "^J  „,/„t  the  Montreal  Gen- 
rare  eases  it  result.  ?7;«-J^  JJ'^  J,  My  «/  "'Men  death  was  dne  to 
oral  Ilospita  .n  »h,eh  we  'l;™f  J  J"^;™'^  j  ,,,  „i,,„ko.  There  was 
rnller's  alkaline  n.a.,nentwWad^h^^^^^^^^^       P^.Y^^.       ^^^^^^^^  ^, 

tts^t^eliLstirwressive  doses  of  the  salicylate  of  soda. 


L 


RnEUMATIC  FEVER. 


173 


pt  to  develop 
troiuely  rare, 
that  in  ulcer- 
'  rluiUiuiitisin, 

en  mertioncd 
).  Scarlalini- 
lout  urticaria, 
I  whothor  the 
sis  rhcuinatiea 

form  of  small 
Hi  bc(;n  known 
I  of  late,  since 
jmmon  in  this 
b\itcher.  J.  H. 
:o  a  large  pea, 
'hey  also  occur 
icapuhi;.    They 
ring  the  fever, 
together  of  an 
ty  and  usually 
liidren  than  in 
a  positive  indi- 
'  in  association 
aneous  nodules 
igically  they  are 
these  firm,  hard 
ive  endocarditis 

"  nodosites  cu- 
arditis  (without 
',  in  addition  to 
ireas  of  soreness 
1,  })nt  pale  pink, 
liod. 

It  is,  as  Austin 
hable  that  medi- 
tiiri^c.  Gull  and 
pecial  treatment, 

y  to  myocarditis, 
"th  day  there  was 
•dium.  In  a  few 
le  Montreal  Gen- 
leath  was  due  to 
stake.  There  was 
ing  symptoms  of 
ate  of  soda. 


i 


Diagnosis. — Practically,  the  recognition  of  acute  rheumatism  is  very 
easy;  but  tliere  are  several  all'ections  which,  in  yome  jjarticulars,  closely 
resemble  it. 

(1)  Multiple  Secondary  Arthritis.— I'luler  lliis  term  may  be  embraced 
tlie  various  forms  of  arthritis  wliicli  come  on  or  follow  in  the  course  of  the 
infective  diseases,  sudi  as  gonorrluea,  scarh't  fever,  dysentery,  and  cerebro- 
.^pinal  meningitis.  Of  these  the  gonorrhu-ul  form  will  receive  special  con- 
sideration and  is  the  type  of  tiie  entire  group. 

(i)  Septic  Arthritis,  which  devclojjs  in  the  course  of  pyivmia  from  any 
cause,  and  particularly  in  puerperal  fever.  No  hard  and  fast  line  can  be 
drawn  between  these  and  the  cases  in  the  first  grouj);  but  the  inilamniation 
rapidly  passes  (m  to  su])puration  and  there  is  more  or  less  destruction  of 
the  joints.  The  conditions  under  which  the  arthritis  develo])s  give  a  clew 
at  once  to  the  nature  of  the  case.  Under  this  section  may  also  be  men- 
tioned: 

(a)  Acute  necrosis  or  acute  ostco-mi/clilis,  occurring  in  the  lower  end 
of  the  femur,  or  in  the  tibia,  and  wliicli  may  be  mistaken  for  acute  rheu- 
matism. Sometimes,  too,  it  is  multiple.  The  greater  intensity  of  the  local 
symptoms,  tlie  involvement  of  the  epiphyses  rather  than  the  joints,  and 
the  more  serious  constitutional  disturbances  are  ])oints  to  be  considered. 
The  condition  is  unfortunately  often  mistaken  for  acute  arthritis,  and,  as 
the  treatment  is  essentially  surgical,  the  error  is  one  which  may  cost  the  life 
of  the  patient. 

{b)  The  acute  arthritis  of  infants  must  be  distinguished  from  rheuma- 
tism. It  is  a  disease  which  is  usually  confined  to  one  joint  (the  hip  or 
knee),  the  effusion  in  which  rapidly  becomes  purulent.  The  alfection  is 
most  common  in  sucklings  and  is  undoul)tedly  pya'mic  in  character.  It 
may  also  develop  in  the  gonorrlural  oidithalmia  or  vaginitis  of  the  new- 
born, as  pointed  out  by  Clement  Lucas. 

(3)  Gout. — While  the  localization  in  a  single,  usually  a  small,  joint,  the 
age,  tlie  history,  and  the  mode  of  onset  are  features  which  enable  us  to  recog- 
nize acute  gout,  there  are  in  this  country  many  cases  of  acute  arthritis, 
called  rheumatic  fever,  which  are  in  reality  gout.  The  involvement  of  sev- 
eral of  the  larger  joints  is  not  so  infrequent  in  gout,  and  unless  tophi  are 
present,  or  unless  a  very  accurate  analysis  of  the  urine  is  made,  the  diagnosis 
may  be  difficult. 

Treatment.— The  bed  should  have  a  smooth,  soft,  yet  elastic  mattress. 
The  patient  should  wear  a  flannel  night-gown,  which  may  be  opened  all  the 
way  down  ihe  front  and  slit  along  the  outer  margin  of  the  sleeves.  Three 
or  four  of  those  should  be  made,  so  as  to  facilitate  the  freciuent  changes 
required  after  the  sweats.  He  may  wear  also  a  light  flannel  cape  about  the 
shoulders.  IFe  should  sleep  in  l)lankets,  not  in  sheets,  so  as  to  reduce  the 
liability  to  catch  cold  and  obviate  the  unpleasant  clamminess  consequent 
upon  heavy  sweating  Chambers  insisted  that  the  liability  to  endocarditis 
and  pericarditis  was  much  reduced  when  the  patients  v.-qt(}  in  blankets. 

Milk  is  the  most  suitable  diet.  It  may  be  diluted  with  alkaline  min- 
eral waters.  Lemonade  and  oatmeal  or  barley  water  should  be  freely  given. 
The  thirst  is  usually  great  and  may  be  fully  satisfied.    There  is  no  objoc- 


-imsi 


?'wt4»^jffiilddtli&^^!i^ES££a^<aaSiU^Q%^;>^.^^^ 


#" 


If 


SPECIFIC  INFECTIOUS  DISEASES. 


Z  to  ^.o..  ana  ..ps .  u.  ^^  .^t  ^;;;^-- ;-.!S;;S 

,,e  given  at  slu.rt  and  .tated  "'teru  b.     A        "  ^^^^.^^  ^ 

fuller  diet  amy  bo  allowed,  'j^;'. -^  ,^^t.     r  a„ee.  ^  It  often  sufllcos  to 
The  local  treatn.ent  is  ol  \1  ^'f  ^f!  ,;       .j,,  i«  ^evero,  hot  eloths  n.ay 
,.ap  the  a.reete.1  jo.nts  m  eot  on^  ^    .      \  .j^l^.^.tc  of  .oda,  0  draehn.; 
be  applied,  :.aturated  with  1-ullei  s  i«  "< "  'Pineture  ^f  aconite 

uidlmnn,  1  oz.;  glyec^ine^  oz  ;  «  ^  ^^^^^  ^^^  "  chlorofonu  linin.ent 
or  ehloral  may  he  ^^^^^^^y't!'' "^^f^"^  i,  of  great  serviee  in  uUay- 
is  also  a  good  applieation.  ^^^'"'^'l^^^^'^M,  the  joints  enclosed  m 
,ng.  the  pain.  I  have  seen  m  a  -rn  n  ho^  ^.^^,  J^^^^  ^^^^  ,^^,^,,g,, 
phister  of  l^u-is  .pparentl        th  guat  rd  1^  ^^^,^^^^  ^^^.^_     ^^^^^^^^^ 

lith  moderate  iirmness,  ^\»   ,;l\  "^^^^  ^  j^t.    Cold  compresses  are  mneh 
rarely  well  borne  in  an  acntc-ly  "!«;  "J    "^        ^,,,,,,,  ,„a  below  the  joint 

,"cd  in  (iermany.  The  ^PPl'^''^^;!^"  "Vh  eh  was  ed  so  mnch  a  few  years 
^ften  relieves  the  pain,  'ri^-u^od  .  nch^-  -^^^.^^^  ^^  ^^^^  ,..^^^,,,,^ 
ago,  is  not  to  be  compared  vith  the  li^ni     u 

thermo-cantery.  ,  ^|     duration  or  conrse  of  the 

Medicines  have  l.tt  c  or  "f.f^^^jX'ions,  practically  takes  its  own 
disease,  which,  like  other  f  "-''""^^  '^^''iXh  wire  regarded  so  long  as 
Ze  t;  disappear.  Salicyl  -^l-^f^/;  ^  J  paiin  11.  P.  ^o.^nVs 
specific,  are  now  known  \«/f  .f'f^^^^^.t  .iluence  the  dnration  of_  the 
olahorate  analysis  shows  that  ^"^y/^"  ^;;;,^,.,  „f  cardiac  complications, 
disease.     Nor  do  they  prevent  the  «^^""  ^^  ^^^,,  f.^qnent  than  m 

thile  nnder  their  nse  relapses  «-     --;:    ^'^j, ,  severe  ^in  the  salicyl 
any  other  method  of  treatment^  „^"/rldi  appoint  ns  in  their  action, 
componnds  give  P^'-'^^^^/^^'tnTn  dois  fo    eight  or  ten  doses,  may  be 
Sodium  salicylate,  m  ^^"^7"^  '^  ^.  ^^f  ^^  hm^ty-grain  doses  may  be  used 
given.     The  bicarbonate  of.po  a^^'™^  ^'^  '^^ers;  others  the  salicylic  acid 
tvith  it.     Many  prefer  salicm  (.^[•/^\)^;"^  :^^^';,    j^  years  used  the  oil  of 
(.r.  20)  or  salol.     I  have  for  the  P'^^*  ^^^  "'         J,„„a  it  quite  as  effi- 
Ivintergreen.  recommended  ^Y  I-mnicu^^^  ^^^    .^hours  in\nilk.     The 
cacious.     Twenty  minims  may  be  g'^^"  ^^^      ^^  ^^^^.^t  of  the  disease, 
salicyl  compounds  are  best  given  m  fn  1  dose    ^^he^^^  .^  ^^^^^^^^  ^^ 

ri;:;t^msCe  S^"  ^a^^ltogether,  as  relapses  are  certainly 

-is:rirts.ui.ti..^ 

The  potassium  bicarbonate  ^'^  ^^^^^-'Y'lZ^ZrUler,  who  so  warmly 
or  four  hours  until  the  --.-/J^;^^^^^,!' habit  of  ordering  a  drachm 
supported  this  method  of  treatment,  ^^««^[  ^^^^^_^^^^  ^^  ^^^^^^j 

and  a  half  of  the  soduvm  ^^^f  ";^^^,;;  J^'  ff,,vescent  at  the  time  of  ad- 
acetate  in  three  ounces  of  ^  at^yj"^'  -^  ^^  ^n  ounce  of  lemon-juice. 
niinistration  by  half  a  drachm  «*.  ^  "\Xisnally  by  the  end  of  twenty- 
This  is  given  every  three  -  j^J  f^^,^^^  is  then  reduced, 

four  hours  the  urine  is  ^^^^^^^  "^^^^^^J^y  the  degree  of  acidity  of  the 
and  the  amount  subsequently  ^'f^^'^^^  ^e  secretion  alkaline.  Opinion 
nrine,  only  enough  being  f^^^^'^^^lZZ  treatment,  cardiac  compliea- 
is  almost  unanimous  that,  unacr  inc  u 


CHOLERA  ASIATICA. 


175 


food  should 
stablii-Ued  a 

n  suflicos  to 

cloths  may 

G  dnl(•hln^^•, 
■0  of  aconite 
,rm  liniinont 
vice  iu  allay- 
i  enclosed  in 
.nd  bandaged 
Friction  is 
ses  are  much 
low  the  joint 
h  a  few  yf^iiTs 
tlie  raquolin 

conrse  of  the 
takes  its  own 
ed  so  long  as 
.  P.  Howard's 
iration  ot  the 
complications, 
liient  than  in 
)ain  the  salicyl 
1  their  action, 
doses,  may  he 
IS  may  he  used 
e  salicylic  acid 
ised  the  oil  of 
it  qnite  as  cffi- 
in  milk.     The 
:  of  the  disease, 
reqiieney,  or,  if 
2S  are  certainly 

J  he  iised  alone, 
iven  every  three 
,  who  so  warmly 
dering  a  drachm 
mi  of  potassium 
the  time  of  ad- 
j  of  Icmon-jnice. 
e  end  of  twenty- 
is  then  reduced, 
:)f  acidity  of  the 
Ikaline.     Opinion 
cardiac  complica- 


tions are  less  common.  'I'he  c(>nil)inati()n  of  tlie  salicylates  with  the  alkali 
is  i>robably  the  most  satisfactory,  fare  must  be  taken  to  watch  the  heart 
during  the  administration  of  tiiese  remedies,  since,  if  given  freely,  tliey  are 
very  depressing. 

To  aUay  the  i)ain  oi)iiiin  may  ])e  given  in  tlie  form  of  Dover's  pow  ler, 
or  morphia  ]iypo«lermicaliy.  Antipyrin,  antifebrin,  and  phenaeetin  are 
useful  sometimes  for  tlie  purjiose.  During  convak'scence  iron  is  indicated 
in  full  doses,  and  quinine  is  a  useful  tonic.  Of  the  conqilications,  hyper- 
pyrexia shouhl  be  treated  by  tlie  cold  bath  or  tlie  cold  pack.  The  treat- 
nient  of  endocarditis  and  ])ericarditis  and  the  pulmonary  complications 
will  be  considered  under  their  respective  sections. 

To  prevent  and  arrest  endocarditis  Calon  urges  the  use  of  a  series  of 
small  blisters  along  the  course  of  the  third,  fourth,  fifth,  and  sixlli  inter- 
costal nerves  of  the  left  side,  applied  one  at  a  time  and  repeated  at  ditfer- 
ent  points.  Potassium  or  sodium  iodide  is  given  in  addition  to  tlie  salicyl- 
ates.   The  patients  are  kept  in  bed  for  about  six  weeks. 


XX.    CHOLERA   ASIATICA. 

Definition. — A  snecific,  infectious  disease,  caused  by  the  comma  ha- 
eillus  of  Koch,  and  characterized  clinically  by  violent  purging  and  rapid 
collapse. 

Historical  Summary. — Cholera  has  been  endemic  in  India  from  a 
remote  period,  but  only  within  the  present  century  has  it  made  inroads  into 
Europe  and  America.  An  extensive  epidemic  occurred  in  lS3;i,  in  which 
year  it  was  brouglit  in  immigrant  ships  from  Great  Britain  to  Quebec.  It 
travelled  along  the  lines  of  trafRc  up  the  Great  Lakes,  and  finally  reached 
as  far  west  as  the  military  posts  of  the  upper  Mississippi.  In  the  same 
year  it  entered  the  United  States  by  way  of  New  York.  There  were  re- 
currences of  the  disease  in  1835-36.  In  1848  it  entered  the  country  througli 
Xew  Orleans,  and  spread  widely  up  the  Mississippi  Valley  and  across  the 
continent  to  California.  In  18-19  it  again  appeared.  In  1854  it  was  intro- 
duced by  immigrant  sliijis  into  Xew  York  and  prevailed  widely  through- 
out tha  eourtry.  In  18GG  and  in  18G7  there  were  less  serious  epidemics. 
In  1873  it  again  appeared  in  the  United  States,  hut  did  not  jircvail  widely. 
In  1884  there  was  an  outbreak  in  Europe,  and  again  in  1892  and  1893. 
Although  occasional  cases  have  been  brought  by  ship  to  the  quarantine 
stations  in  this  country,  the  disease  has  not  gained  a  foothold  here  since 
1873. 

Etiology.— In  1884  Koch  announced  the  discovery  of  the  specific 
organism  of  this  disease.  Subsequent  observations  have  confirmed  his 
statement  tliat  the  comma  bacillus,  as  it  is  termed,  occurs  constantly  in 
the  true  cholera,  and  in  no  other  disease.  It  has  the  form  of  a  slightly 
bent  rod,  which  is  thicker,  but  not  more  than  about  half  the  length  of  the 
tubercle  bacillus,  and  sometimes  occurs  in  corkscrew-like  or  S  forms.  It  is 
not  a  true  bacillus,  hut  really  a  spirochete.  The  organisms  grow  upon  a 
great  variety  of  media  and  display  distinctive  and  characteristic  appear- 


\i.^^7^^'i 


T 


'I 


;k 


SI'KCIFIO  ISPECTIOrs  DISF.ASKa 

,1„.    Kn,.l,  f..un,l  .1.0,,,  i„  .!,.■  s..U.r4«.V.  ...  I,..V,a,  ,,,,.1  tl.oy  »•'- ;«:"';;;f. 
„„„  .I.e.  WlK.  water  ,lnri„s  .1,.;  I1«,..I-'K  'f''  ':"';;,/;,.  ,i,V,,,,'-  ■,■,„ 

::'ii;r '::^  z:')CfZi r"-u;r  "n.;;"™; 

:;:?;  :..:^;;^^:ri2  'i^r;:i.;;:; ;;:;  ::;..";;;;,a":r:„.,,,„..^..£ 

i„„,H„„i wall, I..,. ... ti..>» «■,.,, a •""'■. ;;'"';,  " v;,„,,,„,,„„i 

in  ♦],.'  (1.M)tli>'  (if  till'  L'iiiK  s  ami  in  tlic  still  iU'v\ni  ii>mu..  i 

tre  nllod  with  thin,  watery  contents,  containing  cou.ina  baolh  m  ahno.t 
''"V^r Tonne -K.A.   in   his   studies   of   cholera   failed   to   find   tl.o 

Dead  cultures  are  toxic;  and  the  symptoms  produced  by  the  "*''         '""  ^. 

I "Hnto  the  blood,  peritoneal  cavity,  or  -|-tanoous  t i...e.     No  ab- 
soriition  takes  place  from  the  intestine  unless  the  epithelial  lajcr  lias 

'"■■  taH.f/v-T.i/nrus  found  that  the  blood-serum  of  human  beings  who 
h-ul  Z   '    d  fr     1  cholera  contained  an  antidotal  substance  which  won  d 
^  ^        ih^  Lai  result  of  intraperitoneal  inj^.tions  ^^^^^^^^^^^^ 
rnin,..,  .,i.r«     }\    PfcifTer  sliowcd.  Contrary  to  La/arus,  that  this  suDstanct 
wrno    if'th    n  t   re  of  an  antitoxine,  but  was  actively  bactericKliil,  and 
:3  r  pid  d";ntegration  of  the  introduced  baciUh     Ti- J>1'><;?--- 
d-    nimal    rendered  immune  to  the  bacillus  contains  this  body.  ,,1- 1><  " 
„        e  depends  the  success  of  the  "  Pfeiffer  seruni  reaction       or    he 
Intif  a   In  of  the  true  cholera  vibrio  and  its  dilTerentiat.on  from  all  other 
ftnwi^r  resemble  it.     ITaffkinc  has  carried  out  immunizing  injec  n.ns 
t  lol    a  cultures  in  India  on  a  large  scale  with  very  promising  r'^^i'- 

Modes  Of  Mection.-As  in  other  diseases,  individual  peculiarities  conn 
for  mucd  Id  <Sg  epidemics  virulent  cholera  bacilli  have  been  isolated 
frLn  tb^'mal  stools'of  healthy  men.     Cholera  cultures  have  also  been 

swallowed  with  impunity.  .  ,  Mhovs  in 

The  disease  is  not  highly  contagions;  physicians,  nurses^  and  others  m 

close  contact  with  patiexits  are  not  often  affected.     On  the  other  hand, 


I. 


CHOLERA  ASIATICA. 


177 


ore  isolated 
i)iirinf:  o])i- 

iter  cvacuii- 
Thfy  very 
rinous  num- 
)  inviido  tlicj 
y  avo  I'diukI 
ixi)t'riinental 
er  OS.     But 
1  if  Ivi'pt  in 
with  opium, 
lie  intestiiK':^ 
Hi  in  almost 

to  find  tlio 
itional  jjymp- 
lios  from  tlic 
ie>=e  prol)al)ly 
K.  rfeitVer 
li  the  proteid 
be  separated, 
itroduetion  of 
le  algid  ?tage 
[1  death  often 

often  ecpially 
iinals  if  intro- 
snes.  No  ab- 
iayer  has  been 

an  beings  who 
?  whieh  would 
lera  vibrios  in 
this  substance 
cterioidal,  and 
ic  blood-serum 
3dy.    Tpon  its 
'tion"  for  the 
1  from  all  other 
izing  injecti<ms 
sing  results, 
uliarities  count 
,-0  been  isolated 
have  also  been 

5,  and  others  in 
:he  other  hand, 


washerwomen  and  those  who  are  brought  into  very  close  contail  with  liic 
linen  of  the  ch.ilira  patients,  or  with  tiieir  stools,  are  particularly  prone  to 
catch  the  disease.  Tiwre  have  been  several  instances  of  so-called  "  lahora- 
torv  cholera,"  in  whieh  students,  having  been  aceidentally  infected  while 
working  with  the  cultures,  have  deveh.i.cd  the  disease,  ami  al  least  one 
death  has  resulted  from  this  cause.* 

Vegetal)les  which  liave  heen  waslu'd  in  the  infected  water,  particularly 
lettuct^s  ■md  cresses,  may  conv(  v  the  disease.  Milk  may  also  be  contanu- 
i.atcd.  'I'lie  bacilli  live  on  fresli  bread,  butter,  and  meat,  for  from 
six  to  eight  davs.  In  regions  in  which  the  disease  prevails  the  jiossihil- 
ity  of  the  inl'ec'tion  of  food  hy  ilies  should  l)e  borne  in  min.l.  since  it  has 
been  sliown  that  the  bacilli  may  live  for  at  least  three  days  in  tiieir  intes- 
tines. 

Infection  through  the  air  is  not  to  be  much  dreaded,  since  the  germs 

when  dried  die  rapidly. 

The  disease  is  projuigated  cliiedy  by  contaminated  water  used  lor  drink- 
ing, cooking,  and  washing.  The  virulence  of  an  ei)idemic  in  any  regicm 
isTn  direct  proportion  to  the  imperfection  of  its  water-supply.  In  India 
the  demonstration  of  the  connection  between  drinking-water  and  cholera 
infection  is  complete.  The  Haml)urg  epidemic  is  a  most  remarkable  illus- 
tration. The  unfiltercd  water  of  the  Kibe  was  the  chief  supply,  although 
taken  from  the  river  in  such  a  situation  that  it  was  of  necessity  directly 
contaminated  by  sewage.  It  is  not  known  accurately  from  what  source  the 
contagion  came,  whether  from  Russia  or  from  France,  but  in  August,  1893, 
there  was  a  sudden  explosive  ejiidemic,  and  within  three  months  nearly 
18,000  persons  were  attacked,  with  a  mortality  of  -12.3  jier  cent.  The  neigh- 
boring city  of  Altoiia,  wliicli  also  took  its  water  from  the  F.loe,  but  whicli 
had  a  thoroughly  well-eiiuipped  modern  iiltration  system,  had  in  the  same 

period  only  oKi  cases.  _  ,.    ,     ■ 

Two  main  types  of  ei)ideniics  of  cholera  are  recognized:  the  iirst,  in 
whicli  many  individuals  are  attacked  simultaneously,  as  in  the  Hamburg 
outbreak,  and  in  which  no  direct  connection  can  be  traced  between  the 
individual  cases.  In  this  tvi)e  there  is  widespread  contamination  of  the 
drinkiiK'-water.  In  the  other  the  cases  occur  in  groups,  so-called  cholera 
nests;  individuals  are  not  attacked  simultaneously  but  successively.  A 
direct  L  nnection  between  tlie  cases  may  be  very  dillicult  to  trace.  Again, 
both  the«e  types  may  be  combined,  and  in  an  epidemic  which  has  started 
in  a  widespread  infection  through  water,  there  may  be  other  outbreaks, 
which  are  exam])les  of  the  second  or  chain-like  type. 

I'ettenkofer,  on  the  other  hand,  denies  the  truth  of  tliis  drinking- 
water  theory,  and  maintains  that  the  conditions  of  the  soil  are  of  the  great- 
est importance;  particularly  a  certain  porosity,  combined  with  moisture 
and  contamination  with  organic  matter,  such  as  sewage.  He  holds  that 
germs  develop  in  the  subsoil  moisture  during  the  warm  months,  and  that 
thev  rise  into  the  atmosphere  as  a  miasm. 

The  disease  always  follows  the  lines  of  human  travel.    In  India  it  has. 


Reincke,  Deut.  mcd.  Wochcnschr.,  1894. 


;:-»Wy^*i^ivA' 


178 


SPECIFIC  INFECTIOUS  DISEASES. 


in  many  notable  case,  l)eon  vvi<lely  spread  by  pilgrims  It  is  earned  also 
bv  caravans  and  in  ships.  It  is  not  conveyed  throngh  the  atmosphere 
^  PUia^  situated  at  the  sea-level  are  more  prone  to  tlie  di.ease  than  inland 
towns  In  liigh  altitudes  the  disease  does  not  prevail  so  extensively.  A 
h  ten  perat'^ure  favors  the  development  of  cholera,  but  in  Kurope  and 
America  Ihe  epidemics  have  been  chiefly  in  the  late  summer  and  in  the 

""*  The'disoase  affects  persons  of  all  ages.    It  is  particularly  prone  to  attack 

the  intei  p^^te  and  those  debilitated  by  writ  of  food  and  by  bad  surround- 

vs     Depressing  emotions,  such  as  fear,  undoubtedly  have  a  marked  influ- 

"m.e.-    It  is  doubtful  whether  an  attack  furnishes  immunity  against  a 

'''Morbid  Anatomy. -There  are  no  characteristic  anatomical  changes 
in  cSbv^a  post-mortem  diagnosis  of  the  nature  of  the  disease  could 
be  made  by  any  competent  bacteriologist,  as  the  micro-organisms  are  spe- 
/;"  and  extinctive.     The  body  has  the  appearances  associated  with  pro- 
lourd  collapse.    There  is  often  marked  post-mortem  elevation  of  tempera- 
nre     The  rigor  movtis  sets  in  early  and  may  produce  displacement  of  the 
limbs     The  lower  jaw  has  been  seen  to  move  and  the  eyes  to  ro  ate     \  ari- 
o"    movements  of  the  arms  and  legs  have  also  been  noted.    The  b  ood  i 
thick  and  dark,  and  there  is  a  remarkable  diminution  in  the  amount  of  its 
water  and  salts.    The  peritonanim  is  sticky,  and  the  cods  of  intestines  are 
c.on.Tosted  and  look  thin  and  shrunken.     There  is  nothing  special  m    he 
appearance  of  the  stomach.    The  small  intestine  usua  ly  contains  a  turb.d 
se  urn,  similar  in  appearance  to  that  which  was  passed  m    he  s  ools.    Ihc 
nuicos;  is,  as  a  rule,  swollen,  and  in  very  acute  cases  sligli  ly  hypera^mi  ; 
later  the  congestion,  which  is  not  uniform,  is  more  marked,  especially 
alxnit  the  Pever's  patches.    Post  mortem  the  eiiithelial  lining  is  sometimes 
denuded,  but  this  is  probably  not  a  change  which  takes  place  freely  during 
life     In  the  stools,  however,  large  numbers  of  columnar  epithelial  ce  Is  have 
been  described  by  many  observers.    The  Ixicilli  are  found  ax  the  contents  of 
the  intestineand'in  the  mucous  membrane.  The  spleen  is  usuallysmal  .  Ihe 
liver  and  kidneys  show  cloudy  swelling,  and  the  latter  extensive  coagulation- 
necrosis  and  destruction  of  the  epithelial  cells.     The  heart  is  flabby;  the 
right  chambers  are  distended  with  blood  and  the  left  chambers  are  usually 
eiiintv     The  lungs  are  collapsed,  and  congested  at  the  bases. 

The  above  appearances  are  those  met  with  in  cases  which  prove  rapidly 
fatal  When  the  patient  surdves  and  death  occurs  during  reaction  there 
n.n'y'lie  more  definite  inflammatory  appearances  in  the  intestines  leading 
to'extensive  necrosis  and  fibrinous  exudation,  and  more  pronounced  changes 

in  the  kidneys  and  liver.  ,  .     ^,       -i    •      • 

In  the  acute  cases  the  rice-water  discharges  contain  the  vibrios  in  ])rac- 
ticallv  pnre  cultures;  at  a  somewhat  later  stage  other  bacteria  make  their 
appearance,  while  in  the  stage  of  cholera-typhoid  the  comma  bacilli  are 

demonstrated  with  difficulty.  ^  •     i       n  i    1 1„ 

Symptoms. -A  period  of  incubation  of  uncertain  length,  probably 
not  more  than  from  two  to  five  days,  precedes  the  development  of  the 
symptoms. 


CHOLERA  ASIATICA. 


179 


irricd  also 
sphere, 
lan  inland 
slvely.  A 
urope  and 
ind  in  the 

e  to  attack 
surround- 

rked  intla- 
against  a 

ia.\  changes 
scase  could 
ns  are  spe- 
[  with  pro- 
)f  tempera- 
iient  of  the 
tate.    Vari- 
he  blood  is 
lonnt  of  its 
testincs  are 
3eial  in  the 
ns  a  turbid 
;tools.    The 
hyperffmic; 
I,  especially 
s  sometimes 
pcely  during 
al  cells  have 
contents  of 
ysmall.  The 
coagulation- 
flabby;  the 
;  are  usually 

irove  rapidly 
iction,  there 
:ines  leading 
need  changes 

)rios  in  ])rac- 
a,  make  their 
la  bacilli  are 

;th,  probably 
iment  of  the 


Three  stages  may  be  recognized  in  the  attack:  the  preliminary  diar- 
rhoea, the  collapse  stage,  and  the  period  of  reaction. 

(a)  The  preliminary  diarrhaa  may  set  in  abruptly  without  any  previous 
indications.  :More  commonly  there  are,  for  one  or  two  (hiys,  colicky  pains 
in  tiie  abdomen,  with  looseness  of  the  bowels,  periuips  vomiting,  with  hoad- 
aciie  and  depression  of  spirits.    Tliere  may  be  no  fever. 

{h)  Collapse  Stage.— The  diarrluca  increases,  or,  without  any  of  tiie 
preliminary  symptoms,  sets  in  with  the  greatest  intensity,  and  profuse 
liipiid  evacuations  succeed  each  other  rapidly.  There  are  in  some  instances 
griping  pains  and  tenesmus.  More  commonly  there  is  a  sense  of  exhaustion 
and  collapse.  The  thirst  becomes  extreme,  the  tongue  is  white;  cramps  of 
great  severity  occur  in  tlie  legs  and  feet.  Within  a  few  hours  vonuting 
sets  in  and  becomes  incessant.  Tlie  patient  rapidly  sinks  into  a  condition 
of  collapse,  the  features  are  shrunken,  the  skin  has  an  ashy  gray  hue,  the 
eyeballs  sink  in  the  sockets,  the  nose  is  pinched,  tlie  cheeks  are  hollow, 
tlie  voice  becomes  husky,  the  extremities  are  cyanosed,  and  the  skin  is  shriv- 
elled, wrinkled,  and  covered  witlia  clammy  perspiration.  The  temperature 
sinks.  In  the  axilla  or  in  the  mouth  it  may  be  from  live  to  ten  degrees 
below  normal,  but  in  the  rectum  and  in  the  internal  parts  it  may  be  103" 
or  10-i°.  The  pulso  becomes  extremely  feeble  and  flickering,  and  the  patient 
gradually  jiasses  into  a  condition  of  coma,  though  consciousness  is  often 
retained  until  near  the  end. 

The  fa?ces  are  at  first  yellowish  in  color,  from  the  bile  pigment,  but 
soon  they  bccon'c  grayisli  M-hite  and  look  like  turliid  whey  or  rice-water; 
whence  tlie  term  "  rice-water  stools."  There  are  found  in  them  numerous 
small  flakes  of  mucus  and  granular  matter,  and  at  times  blood.  The  re- 
action is  usually  alkaline.  The  fluid  contains  all)umin  and  the  chief  min- 
eral ingredient  is  chloride  of  sodium.  :Microscopically,  mucus  and  ei)ithelial 
cells  and  innnmcrable  bacteria  are  seen,  the  majority  of  the  latter  being 

the  comma  bacilli. 

The  condition  of  the  patient  is  largely  the  result  of  the  concentration 
of  the  blood  consequent  upon  the  loss  of  serum  in  the  stools.  There  is 
almost  complete  arrest  of  secretion,  particularly  of  the  saliva  and  the  urine. 
On  the  other  hand,  the  sweat-glands  increase  in  activity,  and  in  nursing 
women  it  has  been  stated  that  the  lacteal  flow  is  unafl"ected.  Tliis  stage 
sometimes  lasts  not  more  than  two  or  three  hours,  but  more  commonly  from 
twelve  to  twenty-four.  There  are  instances  in  which  the  patient  dies 
before  purging  begins — the  so-called  cholera  sicca. 

(c)  Reaction  Sta(Jc.—^^'hcn  the  patient  survives  the  collapse,  the  cyano- 
sis gradually  disappears,  the  warmth  returns  to  the  skin,  which  may  have 
for  a  time  a  mottled  color  or  present  a  definite  erythematous  rash.  The 
heart's  action  becomes  stronger,  the  urine  increases  in  quantity,  the  irrita- 
bility of  the  stomach  disappears,  the  stools  are  at  longer  intervals,  and  there 
is  no  abdominal  pain.  In  the  reaction  the  temperature  may  not  rise  above 
normal.  Xot  infrequently  this  favorable  condition  is  interrupted  by  a  recur- 
rence of  severe  diarrhtra  and  the  patient  is  carried  ofp  in  a  relapse.  Other 
cases  pass  into  the  condition  of  what  has  been  called  cholera-fi/phoid,  a 
state  in  which  the  patient  is  delirious,  the  pulse  rapid  and  feeble,  and  the 


180 


SPECIFIC  INFECTIOUS  DISEASES. 


niesc  symptoms  have  been 


tongue  dry.    Death  finally  occurs  with  coma. 

attributed  to  ura'uiia.  ,     „    „         ,        e  f,.      Tl.nrp 

During  epidemics  attacks  arc  found  of  all  grades  of  seventy,  riicre 
are  cases  of  diarrhu-a  witli  griping  pains,  liquid,  copious  stools,  vomi  ing, 
and  cramps,  with  slight  collapse.  To  these  the  term  choknne  has  hcen 
aT)T)lied  They  resemble  the  milder  cases  of  cholera  mw/ras.  At  the  oppo- 
s  te  end  of  the  series  there  are  the  instances  of  cholera  sicca,  m  which 
death  may  occur  in  a  few  hours  after  the  onset,  without  diarrh.ea.  There 
are  also  cases  in  which  the  patients  are  overwhelmed  with  the  poison  and 
die  comatose,  without  the  preliminary  stage  of  collapse. 

eomplications  and  Sequel©. -The  typhoid  condi  ion  has  al- 
ready beim  referred  to.  The  consecutive  nei.hritis  rarely  induces  dropsy. 
DipMheritic  colitis  has  been  described.  There  is  a  special  endency  to 
diphtheritic  inHammation  of  the  mucous  membranes  particularly  of  he 
throat  and  genitals.  Tneumonia  and  pleurisy  may  develop,  ^^^ /^f^ruc- 
tive  r.bscess(t  mav  occur  in  dilferent  parts.  Suppurative  parotitis  is  not 
very  uncommon,  'in  rare  instances  local  gangrene  may  develop  A  troiibe- 
8ome  symptom  of  convalescence  is  cramps  in  the  muscles  of  the  arms  and 

^'^  Diagnosis. -The  only  affection  with  which  Asiatic  cholera  could  be 
confounded  is  the  cholera  nostras,  the  severe  eholeraie  diarrluea  ^dMeh 
occurs  during  the  summer  months  in  temperate  climates      Ihe  chnKai 
picture  of  the  two  affections  is  identical.    The  extreme  collapse,  vomiting, 
and  rice-water  stools,  the  cramps,  the  cyanosed  appearance   arc  all  seen  in 
the  worst  forms  of  cholera  nostras.    In  enfeebled  persons  death  may  occur 
within  twelve  hours.    It  is  of  course  extremely  important  to  be  ab  e  to  diag- 
nose between  the  two  affections.    This  can  only  be  done  by  one  thoroughly 
versed  in  bacteriological  methods,  and  conversant  with  the  diversified  flora 
of  the  intestines.     The  comma  bacillus  is  present  in  the  dejections  ot  a 
great  majority  of  the  cases  and  can  be  seen  on  cover-glass  preparations. 
Though  the  eye  of  the  expert  may  he  able  to  differentiate  between  the 
bacillus  of  irno  cholera  and  that  which  occurs  in  cholera  nostras,  cultures 
should  be  made,  from  which  alone  positive  results  can  be  obtained. 

Attacks  very  similar  to  Asiatic  cholera  are  produced  m  poisoning  by 
arsenic,  corrosive  sublimate,  and  certain  fungi;  but  a  difficulty  m  diagnosis 

could  scarcely  arise.  . 

The  prognosis  is  always  uncertain,  as  the  mortality  ranges  m  different 
epidemics  from  30  to  80  per  cent.  Intemperance,  debility,  and  old  age 
are  unfavorable  conditions.  The  more  rapidly  the  collapse  sets  in,  the 
greater  is  the  danger,  and  as  Andral  truly  says  of  the  malignant  form.  It 
begins  where  other  diseases  end-in  death."  Cases  with  marked  cyanosis 
and  verv  low  temperature  rarely  recover.  ,  •    w 

Prophylaxis.— Preventive  measures  are  all-important,  and  isolation 
of  the  sick  and  thorough  disinfection  have  effectually  prevented  the  dis- 
ease entering  England  or  the  Ignited  States  since  1873.  On  several  occa- 
sions since  that  date  cholera  has  been  brought  to  various  ports  m  America, 
but  has  been  checked  at  quarantine.  During  epidemics  the  greatest  care 
should  be  exercised  in  the  disinfection  of  the  stools  and  linen  of  the  pa- 


CHOLERA  ASIATICA. 


181 


I 


have  been 

ty.  There 
,  vomiting, 
e  has  heen 
t  the  oppo- 
;,  in  which 
tt-a.  There 
poison  and 

on  has  al- 
ices  dropsy. 
:endency  to 
>arly  of  the 
nd  destruc- 
stitis  is  not 
A  trouble- 
le  arms  and 

>ra  coukl  be 
rlicea  which 
The  cUnical 
se,  vomiting, 
e  all  seen  in 
h  may  occur 
able  to  diag- 
e  thoroughly 
ersified  flora 
jections  of  a 
preparations, 
between  the 
tras,  cultures 
ained. 

poisoning  by 
'  in  diagnosis 

s  in  different 

and  old  age 

sets  in,  the 

int  form,  "  It 

rked  cyanosis 

and  isolation 
!nted  the  dis- 

several  occa- 
;s  in  America, 

greatest  care 
en  of  the  pa- 


tients. When  an  cindemic  prevails,  persons  should  bo  warned  not  to  drink 
water  unless  i)reviously  boiled.  Errors  in  diet  should  he  avoided.  As  tlie 
disease  is  not  more  co  itagious  than  typhoid  fever,  the  chance  of  a  person 
passing  safely  througli  an  epidemic  depends  very  much  upon  how  far  he 
is  able  to  carry  out  tlioroughly  prophylactic  measures.  Digestive  disturb- 
ances are  to  be  treated  promptly,  and  particularly  the  diarrhtca,  which  so 
often  is  a  preliminary  symptom.  For  this,  opium  and  acetate  of  lead  and 
large  doses  of  bismuth  should  be  given. 

Medicinal  Treatment.— During  the  initial  stage,  when  the  diar- 
rhoea is  not  excessive  but  the  abdominal  ])ain  is  marked,  opium  is  the  most 
efTicient  remedy,  and  it  should  be  given  hyiwdermically  as  mor])hia.  It  is 
advisable  to  give  at  once  a  full  dose,  which  nuiy  be  repeated  on  the  return 
of  the  pain.  It  is  best  not  to  attempt  to  give  remedies  by  the  mouth,  as 
they  disturb  the  stomach.  Ice  should  be  given,  and  brandy  or  hot  coffee. 
In  the  collapse  stage,  writers  speak  strongly  against  the  use  of  oi)ium.  Un- 
doubtedly it  must  be  given  with  caution,  but,  judging  from  its  effects  in 
cholera  nostras,  I  should  say  that  colla])se  per  se  was  not  a  contra-indica- 
tion.  The  patient  may  be  allowed  to  drink  freely.  For  the  vomiting,  which 
is  very  dillicult  +o  check,  cocaine  may  be  tried,  and  lavage  with  h  vater. 
Creasote,  hydrocyanic  acid,  and  creolin  have  been  found  useless.  Rumpf 
advises  calomel  (gr.  -J)  every  two  hours. 

External  applications  of  heat  should  be  made  and  a  hot  bath  may  be 
tried.  Warm  applications  to  the  abdomen  are  very  grateful.  Hypodermic 
injections  of  ether  will  be  found  serviceable. 

Irrigation  of  the  bowel— enteroclysis— with  \varm  water  and  soap,  or 
tannic  acid  (2  per  cent),  should  be  used.  With  a  long,  soft-rubber  tube, 
as  much  as  3  or  4  litres  may  be  slowly  injected.  Not  only  is  the  colon 
cleansed,  but  the  small  bowel  may  also  be  reached,  as  shown  by  the  fact 
that  the  tannic-acid  solutions  have  been  vomited. 

Owing  to  the  profuse  serous  discharges  the  blood  becomes  concentrated, 
and  absorption  takes  place  rapidly  from  the  lymph-spaces.  To  meet  this, 
intravenous  injections  were  introduced  by  Latta,  of  Leith,  in  the  ei)idemic 
of  1832.  Uy  preceptor,  Bovell,  flrst  practised  the  intravenous  injections 
of  milk  in  Toronto,  in  the  epidemic  of  1854.  A  litre  of  salt  solutioji  at  107° 
may  be  injected,  and  repeated  in  a  few  hours  if  no  reaction  follows.  Less 
risky  and  equally  efficacious  is  the  subcutaneous  injection  of  a  saline  solu- 
tion. For  this,  conmion  salt  should  be  used  in  the  i)roi)ortion  of  about  four 
grammes  to  the  liter.  With  rubber  tubing,  a  cannula  from  an  aspirator,  or 
even  with  a  hypodermic  needle,  the  warm  solution  may  be  allowed  to  run 
by  pressure  beneath  the  skin.  It  is  rapidly  absorbed,  and  the  process  may 
be  continued  until  the  pulse  shows  some  sign  of  improvement.  This  is 
really  a  valuable  method,  thoroughly  physiological,  and  should  be  tried 
in  all  severe  cases. 

In  the  stage  of  reaction  special  pains  should  be  taken  to  regulate  the 
diet  and  to  guard  against  recurrences  of  the  severe  diarrhoea. 


;®s;?aajei««siiu*jswifc«iss^ii^^  ' 


'.cii:*m.  ■ 


1S2 


1 


SPECIFIC  INFECTIOUS  DISEASES. 
XXI.   YELLOW    FEVER. 


itso'il  rltio^hip'witl,  tl,e  J..ca.e  cannot  bo  ,M  to  have  t  ■...  .Jofuntol, 

"""Sigy-The  disease  provail,  ondonucally  in  the  Wost  Imlio,  ami 
in  c^rl^Sons  of  tl,«  Spanlh  Main.  Fron,  .l>»c  repons  ■*  oc.as.ona  > 
extends  and,  undor  suitaljlc  oonditiom,  prevails  epidemioa  ly  "'  "'«^°«'^^^ 
en  State.  Now  and  then  it  is  brought  to  the  "6«  «»P""^  »  *»  Atta 
eoast  Fonnerly  it  oeourred  extensively  in  the  1-' "''™  .*"•;"'■  ,f"  '"^ 
latter  oart  o(  the  last  century  and  the  beginning  o£  tins,  frightful  epi- 
™  L'  trevrncd  h,  rhibulelplfia  and  other  ^'°f -"VvStel  Ca^™"" 

September  and  October.    Tbe  population  of  tbc  ^.^^Y  at  the  t.mt  ^  as  on^ 
40  000     Enidcnnc«  occnrrcd  in  the  United  States  in  1 . 9  < ,  1  -  J8,  1>JJ,  an^^ 
:S2,ith:  disease  prevailed  slightly  in  Boston  and  ^^^^ 
Baltimore     In  1803  and  1805  it  again  appeared;  then  lor  ■i.anj  years  tht 
oii^biri  s  were  slight  and  localized.    In  1853  the  diseu-e  raged  thronghont 
he  Southern  States.    In  Xew  Orleans  alone  there  -s  a  ••.rtaWy  o    neai 
8  000     In  18G7  and  1873  there  were  moderately  severe  ci     '■mics     In  lb  » 
TLt  extensive  epidemic  occurred,  chiefly  i-  Lo7aiia    f k^^^^^^^^ 
Mississippi.     The  total  mortality  was  nearly  1G,000.     There  haxe  since 
Jtn  local  outbreaks,  the  last  in  1897,  in  which  in  ^^- O^'  J^^  Xp-Il 
tember  8th  to  December  11th  there  were,  according  to  the  ^Ia""«/i«^P^^^^^^^ 
Cor  s,  1,902  cases,  with  288  deaths.    In  Europe  it  has  occasionally  gained 
;Toot hold,  but  th^re  have  been  no  widespread  CF<^«--^f  ^.f .^^^^^ 
Spanish  ports.    The  disease  exists  on  the  west  coast  of  Africa     It  is  some 
S  ca  Tied  to  ports  in  Gieat  Britain  and  France,  but  it  has  never  ex- 
"Sed  into  thosJ  countries.     The  history  of  the  disease  and  its  genera 
sjmptomatology  are  exhaustively  treated  of  in  the  classical  works  of  Rene 
T  1  'Rncbo  and  Bercnarer-Feraud.  .       ,  .  , 

Sa   re  o'pni^es  three  areas  of  infection:  (1)  The  focal  zone  in  which 
the  d^  ase  is  ne^er  absent,  including  Havana,  Vera  Cruz,  Rio,  and  other 
S  .anish-American  ports.    (2)  The  perifocal  zone  or  regions  of  periodic  epi- 
d  rtincluding  tie  ports^  of  the  tropical  Atlantic  in  A-r-  -  .Afr^ 
(3)  The  zone  of  accidental  epidemics,  between  the  parallels  of  io    nortli 

''''Z':^^t  invariably  due  to  the  i^o^-tion  of  the  j^ison 
either  by  patients  affected  with  the  disease  or  through  m  ected  art  cles^ 
1 1  uie  t  oiably  the  poison  may  be  conveyed  by  fomites  The  channels  of 
infS  on  ar  believed  to  be  the  digestive  canal  and  the  lungs.  Ind,^nd.lals 
0   a  1  ages  and  races  are  attacked.    The  negro  is  much  less  susceptible  than 


-.-».  V'A^-r^'^ 


^im 


YELLOW  FE\T^R. 


183 


!,  character- 
mria,  and  a 
causing'  the 
marelli,  but 
r'l)  dollnitely 

,  Indies  and 
occasionally 
1  the  South- 
the  Atlantic 
tcs.     In  the 
rightful  epi- 
?he  epidemic 
V  Carey,  was 
States.    The 
,  September, 
le  months  of 
ime  was  only 
)8,  1799,  and 
■xtensively  in 
my  years  the 
d  throughout 
lity  of  nearly 
lies.    In  1878 
Alabama,  and 
•e  have  since 
ms  from  Sep- 
irine  Hospital 
ionally  gained 
except  in  the 
I.    It  is  some- 
has  never  ex- 
id  its  general 
vorks  of  Rene 

zone  in  which 
lio,  and  other 
if  periodic  epi- 
ca  and  Africa, 
i  of  -45°  north 

of  the  poison 
fected  articles, 
he  channels  of 
s.  Individuals 
asceptible  than 


the  white,  but  he  does  not  enjoy  an  immunity.  Residents  in  soiitlu-rn 
countries,  in  which  the  disease  is  prevalent,  are  not  so  susceptible  as 
strangers  and  tenqxyrary  residents.  Males  are  more  frecpiently  alfected  and 
the  ntortality  is  greater  among  them,  owing  i)n)l)al)ly  to  greater  exposure. 

Very  young  ehildren  usually  eseai)e;  hut  in  the  epidemics  of  large 
cities  the  number  under  live  attacked  is  large,  since  they  constitute  a  con- 
siderable proportion  of  the  population  uni)rotected  by  previous  attack. 
Guiteras  .states  that  the  "foci  of  endemieity  of  yellow  fever  are  essentially 
maintained  by  the  creole  infant  poi)ulation,  which  is  subject  to  the  disease 
in  a  very  mild  form."  Immunity  is  acquired  by  ])assing  through  an  attack 
or  by  prolonged  residence  in  a  locality  in  which  the  disease  is  endemic.  The 
statement  so  often  made  that  the  Creoles  are  exempt  from  yellow  fever  has 
been  abundantly  disproved.  They  certainly  are  not  so  susceptible,  but  in 
severe  epidemics  they  die  in  numbers.  The  evidence  in  favor  of  inherited 
immunity  is  not  conclusive. 

Cuiidilions  favorinij  the  Development  of  Epidemics.— \v:\\o\\  fever  is  a 
disease  of  the  sea-coast,  and  rarely  prevails  in  regions  with  an  elevation 
above  1  000  feet.  Its  ravages  are  most  serious  in  cities,  particularly  when 
the  sanitary  conditions  are  unfavorable.  It  is  always  most  severe  in  the 
badlv  drained,  unhealthy  portions  of  a  city,  where  the  population  is  crowded 
to<rether  in  ill-ventilated,  badly  drained  houses.  The  disease  prevails  dur- 
ing the  hot  season.  Humidity,  heat,  darkness,  and  want  of  air  seem  to  be 
the  proper  coefficients  for  the  preservation  of  the  poison  (Sanarelli).  In 
Havana  the  death-rate  is  greatest  during  the  months  of  June,  July,  and 
•VucTimt  The  epidemics  in  the  Tnited  States  have  always  been  in  the  sum- 
mer and   autumn   months,   disappearing   rapidly   with   the   onset   of   cold 

weather.  ,,.  a.  .i      t      i        en 

Bacteriology  of  YeUow  Fever.— Sanarelli,*  the  director  of  the 
Institute  of  Experimental  :Medicine  at  ^lontevideo,  has  described  an  organ- 
ism which  he  calls  the  hacUlus  icteroides,  with  the  following  characters: 
It  is  a  slender  rod  from  2  to  4  mikrons  in  length,  a  facultative  amerobe, 
ciliated  and  motile.  It  dec-dorizes  by  Gram's  method,  grows  well  on  ordi- 
nary media,  does  not  coagnlato  milk,  ferments  saccharine  fluids,  and  is 
pathogenic  to  lower  animals.  In  man,  dogs,  and  monkeys  it  is  stated  to 
produce  a  clinical  picture  similar  to  that  of  the  natural  disease,  fhe 
bacillus  is  found  only  in  the  blood  and  tissues,  never  in  the  stomach  or 
bowels.  It  occurs  in  'very  small  numbers,  but  produces  a  toxme  "f  *:-^traor- 
dinary  intensity.    It  has  only  been  found  in  rather  more  tlian  halt  of  the 


*  The  work  of  Sanarelli  has  been  marred  by  a  seriesof  unjustifiable  experiments  upon 
men.  which  should  receive  the  nn.iunlifle.l  condemnation  of  the  profession.  I"  ""«  ««"^« 
every  dose  of  medicine  given  is  an  experiment,  since  who  can  tell  the  nature  of  the  reac- 
tion ?  But  the  limitation  of  deliberate  experimentation  on  human  beings  should  be  clearly 
defined.  Voluntarily,  if  with  full  knowledge,  a  fellow-crcature  may  submit^  to  certain 
tests  and  trials,  iust  as  a  physician  may  experiment  on  himself.  rugs,  the  value  or 
which  has  been  carefully  tested  on  a.imals  (it  found  harmless),  may  be  tried  on  patients, 
since  in  this  way  alone  can  progress  be  made.  But  deliberate  experiments  ^"^h-^  Sana- 
relli carried  out  with  cultures  of  known  and  tested  virulence,  and  which  were  followed  by 
serious,  nearly  fatal  illness,  are  simply  criminal. 


■.;>»«M»  •■fc',  i^»t«l<»nt^'  * 


;'.*;JKJ8W53!KaSSS3»i^' 


;®a4iS'-:o'aaRSKseKas»Mi«i»3s«'^^^ 


' 


1S4 


SPECIFIC  INFECTIOUS  DISEASES. 


! 


Hi 
III 


II 


cases.  This,  Sanardli  claiius,  is  owing  to  tho  almost  constant  intervention 
of  secondary  infections,  in  wliicli  strei)tococci,  staphylococci,  or  the  colon 
l)acilii  overspread  the  hody,  hel'ore  the  death  of  the  ])atient,  with  such  a 
(|iiaiitity  of  toxic  products  that  they  kill  or  attenuate  the  bacillus  icteroi<lcs. 
This  is  a  very  weak  point  in  his  statement.  The  bacillus  possesses  a  remark- 
able resistance  to  drying  and  to  tlie  action  of  sea-water.  The  presence  of 
moulds  favors  its  vitality  and  growth.  Tiie  aniaril  poison,  as  Saiuirel  calls 
the  product  of  the  bacillus  icteroides,  is  said  to  ])ossess  three  special  i)rop- 
erties — emetic,  liaMuorriuigic.  an<l  steatogcnic.  'i'he  injection  of  the  fdtered 
cultures  into  man  produced  *'  tiie  fever,  congestions,  ha'morrhages,  vomit- 
ing,, steatosis  of  the  liver,  cephalalgia,  nei)hritis,  anuria,  urivmia,  icterus, 
delirium,  and  coll;ipse  "'!  The  results  of  inoculation  into  dogs  are  ecpially 
reniarkable.  J5oth  the  bacilli  by  themselves  and  tiic  to.\incs  produce  fever, 
diarrluea,  vomiting,  and  an  early  ha'matemesis.  The  most  characteristic 
changes  are  in  the  liver,  which  ])resi'nts  large  jiatches  of  yellow  color,  nuule 
up  of  hepatic  cells,  which  have  undergone  complete  fatly  degeneration. 
The  kidneys  show  an  acute  iiarenchymatous  nephritis. 

An  interesting  j)oint,  one  which  favors  the  specificity  of  the  bacillus 
icteroides,  and  supplements  in  an  important  way  Sanarclli's  work,  is  the 
existence  of  an  agglutinative  reaction  in  the  blood  of  yellow  fever  j)atients. 
The  Archinards  of  New  Orleans  and  Woodson  of  the  United  States  army 
state  that  in  50  cases  of  yellow  fever  studied  during  the  recent  epidemic  the 
agglutination  with  cessation  of  motion  was  obtained  in  over  70  ])er  cent. 
The  work  was  done  with  cultures  of  the  bacillus  icteroides  of  Sanarelli 
obtained  from  the  Pasteur  Institute,  and  with  cultures  made  from  the  local 
cases.  Should  this  fact  be  confirmed  in  subse(iuent  epidemics,  it  will  solve 
the  all-imjiortant  question  of  the  early  diagnosis  of  the  disease.  Blood 
taken  as  early  as  the  second  day  gave  a  i>roni])t  and  characteristic  reaction. 
Surgeon-(ieneral  Sternberg,  whose  researches  on  yellow  fever  have  been  so 
important,  described  an  organism  wliich  he  called  tho  bacillus  X,  and  wliich 
he  claims  to  l)e  the  same  as  Sanarelli's  bacillus.  It  has  much  the  same 
characters,  but  prcsi.'iits  minor  jK'culiaritics.  The  question  of  the  identity 
of  the  two  has  not  yet  been  settled. 

Morbid  Anatomy. — The  skin  is  more  or  less  jaundiced.  Cutane- 
ous ha-morrhages  may  be  present.  Xo  specific  or  distinctive  internal  lesions 
have  been  found.  The  blood-serum  contains  ha'nu)globin,  owing  to  de- 
struction of  tl)c  red  cells,  just  as  in  pernicious  malaria.  The  heart  some- 
times, not  invariably,  shows  fatty  change;  the  stomach  presents  more  or 
less  liyperaMuia  of  tho  mucosa  with  catarrhal  swelling.  It  contains  the 
material  which,  ejected  during  life,  is  known  as  the  hhirJi-  vDmit.  The  essen- 
tial ingredient  in  this  is  transformed  blood-jugment.  In  the  two  specimens 
which  I  have  had  an  op])ortunity  of  examining  it  differed  in  no  resi)ect 
from  the  material  found  in  other  alTections  associated  with  ha^matemesis. 
There  is  no  proof  that  this  black  material  depends  upon  the  growth  of  a 
micro-organism.  The  liver  is  usually  of  a  ])ale  yellow  or  brownish-yellow 
color,  and  the  cells  are  in  various  stages  of  fatty  deseneration.  From  the 
date  of  Louis'  observations  at  Gibraltar  in  1828,  the  appearances  of  this 
organ  have  been  very  carefully  studied,  and  some  liave  thought  the  changes 


ff^^^LJ-  ■  iVt  — WAJ>— «*H'Wl'i''^^*"*t!<f 


yp:llow  fever. 


185 


ntorvention 
r  tlu'  colon 
nth  Hiuh  a 
■;  ic'toroides. 
s  a  roinark- 
pri'soiice  of 
narol  calls 
R'cial  prop- 
thc  liltorod 
i<Ios,  vomit- 
lia,  icterus, 
arc  cciiially 
)(Uico  fever, 
uiractcristic 
color,  made 
L'generation. 

the  bacillus 
York,  is  the 
i-er  patients. 
States  army 
'pidcnuc  the 
ro  per  cent, 
of  Sanarelli 
DUi  the  local 
it  will  solve 
'aso.  Ijlood 
itic  reaction, 
lave  been  so 
[,  and  which 
ch  the  sauie 
the  identity 

h\.  Cutane- 
ernal  lesions 
iwing  to  de- 
heart  some- 
■nts  more  or 
contains  the 
T''e  essen- 
vo  specimens 
n  no  respect 
lannatemcsis. 
growth  of  a 
iwnish-yellow 
1.  From  the 
anccs  of  this 
t  the  changes 


in  it  to  be  characteristic.  Councilman  has  de'scribed  remarkable  apjiear- 
ances  in  the  liver-cells  which  he  believes  are  distinctive  and  peculiar.  Fatty 
degeneration  and  regions  of  necrosis  are  present  in  all  cases.  The  kidiu'vs 
ofren  show  traces  of  dilfuse  nephritis.  The  epithelium  of  the  convoluted 
tubules  is  swollen  and  very  granular;  there  may  also  ))e  necrotic  changes. 
In  l)oth  liver  and  kidneys  i)acteria  of  various  sorts  have  been  described. 

Symptoms. — The  incubation  is  usually  three  or  four  days,  but  it 
may  l>e  less  than  twenty-four  hours  or  prolonged  to  seven  days.  Tlie  onset 
is  sudden,  as  a  rule,  without  premonitory  symptoms,  and  in  the  early  hours 
of  the  morning.  Chilly  feelings  are  common,  and  are  usually  associated  with 
headaclu'  and  very  severe  pains  in  the  back  aiul  limbs.  Tlie  fever  rises 
rapidly  and  the  skin  feels  very  hot  and  dry.  The  tongue  is  furred,  but 
moist;  the  throat  sore.  Nausea  and  vomiting  are  jjresent,  and  become  more 
intense  on  the  secoiul  or  third  day.  The  Ixuvels  are  usually  constipated. 
The  following,  in  detail,  are  the  more  important  characteristics; 

Pacies. — Even  as  early  as  the  first  morning  the  patient  may  i)resent  a 
very  characteristic  facies,  according  to  Oiiitcras,  one  of  the  three  distin- 
guishing features  of  the  disease.  The  following  descrijjtion  is  taken  from 
him;  The  face  is  decidedly  flushed,  more  so  than  in  any  other  acute  infec- 
tious disrase  at  such  an  early  period.  The  eyes  are  injected,  the  color  is 
a  bright  red,  and  there  may  be  a  slight  tumefaction  of  tiie  eyelids  and  of 
the  lips.  Even  at  this  early  date  there  is  to  be  noticed  in  connection  with 
the  injection  of  the  superlicial  capillaries  of  the  face  and  conjunctiva?  an 
element  of  icterus,  and  '"  the  early  manifestation  of  jaundice  is  undoubtedly 
the  most  characteristic  feature  of  the  facies  of  yellow  fever."  It  has  to  be 
looked  for  very  carefully. 

llie  Fever.— On  the  morning  of  the  first  day  the  temperature  may  vary 
between  100°  and  10()°,  usually  between  102°  and  103°.  During  the  even- 
ing of  the  first  day  and  the  morning  of  the  second  day  the  temperature 
keeps  about  the  same.  Tliere  is  a  slight  diurnal  variation  on  the  second 
and  third  day.  In  very  mild  eases  the  fever  may  fall  on  the  evening  of  the 
second  or  on" the  morning  of  the  third  day,  or  in  abortive  cases  or  in  unde- 
veloped cases  in  children  even  at  the  end  of  twenty-four  hours.  In  cases 
that  are  to  terminate  favorably  the  defervescence  takes  ])lace  by  lysis  during 
a  iieriod  of  two  or  three  days.  The  remission  or  stage  of  calm,  as  it  has  been 
called,  is  succeeded  by  a  febrile  reaction  or  secondary  fever,  which  lasts  one, 
two,  or  three  days,  and  in  favorable  cases  falls  by  a  short  lysis.  On  the 
other  hand,  in  fatal  cases  the  temperature  rises  rapidly,  becomes  higher 
than  in  the  initial  fever,  and  death  follows  shortly. 

The  Pulse.— On  the  first  day  the  pulse  is  rarely  more  than  100  or  110. 
On  the  second  or  third  day,  while  the  fever  still  keeps  up,  the  pulse  begins 
to  fall,  and  mav  have  become  slower  Ijy  as  much  as  20  lieats  while  the  tem- 
perature has  risen  1.5°  or  2°.  On  the  evening  of  the  third  day  there  may  be 
a  temperature  range  of  103°  and  a  pulse  of  only  T"),  or  "a  temperature 
between  103°  and  104°  with  a  pulse  running  from  70  to  80."  This  impor- 
tant diagnostic  feature  wa^  first  described  by  Faget,  of  Xew  Orleans.  Dur- 
ing the  defervescence  the  pulse  may  become  still  slower,  down  to  50,  48,  or 
45°  or  even  as  low  as  30.    A  slow' pulse  with  the  defervescence  is  not  the 


■~-«C'*ses5iif'' 


Si5^'?^;>rJry'ii-;WgS^^  l-*;*MS«'S;?-'.>-r:.-«.»»">t;„5ir>- 


[I 

t 


^gg  SPECIFIC  INFECTIOUS  DISEASES. 

Kpocial  circulatory  feature  'of  the  disease,  but  the  slowing  of  the  puhe  with 
a  death/  or  even  risiiuj  temperature.  ,  .   ,     ,         .    •  ♦;„ 

Allnminuria.-'m.,  regarded  by  tiuiteras  as  the  third  characteristc 
svinptom  of  tlie  disea.^e,  occurs  as  early  as  the  evening  of  the  third  day.  tie 
Bays  very  truly  that  it  is  very  rare  so  early  in  other  fevers  except  those  of  an 
unusually  severe  tvpe.  "  Even  in  the  mild  cases  that  do  not  go  to  oed- 
cases  of  'talking  yellow  fever  -on  the  second,  third,  or  four.h  day  of 
the  disease  albuminuria  will  show  itself/'  It  may  be  (,uite  transient.  In 
the  severer  cases  th.e  amount  of  albumin  is  large,  and  there  may  be  numer- 
ous tube-casts  and  all  the  signs  of  an  intense  acute  nei.hritis;  or  complete 
suupression  of  the  urine  may  supervene,  and  death  may  occur  in  urivmic 
convulsions  or  coma  within  twenty-four  or  thirty-six  hours.  Guiteras  in- 
sists that  the  evening  urine  should  be  specially  examined.  He  states  that 
the  presence  of  albumin  on  the  first  day  and  its  persistence  on  the  second 
indicate  a  severe  case.  With  the  secondary  rise  in  temperature  the  jaundice 
becomes  more  intense. 

Gasiric  Feature.'^.-"  Btoek  romi7.'— Irritability  of  the  stomach  is 
present  from  the  very  outset,  and  the  vomited  matter  consists  of  tlic  con- 
tents of  the  stomach,  ond  subsequently  of  mucus  and  a  grayish  tluui  In 
the  second  stage  of  the  disease  the  >omiting  becomes  more  pronounced  and 
in  the  severe  cases  is  characterized  by  the  presence  of  blood.  It  may  be 
coiuous  and  forcible,  producing  much  pain  in  tlie  abdomen  and  along  the 
gullet  There  is  nothing  specific  in  the  "black  vomit"  of  yellow  fever. 
It  consists  of  altered  blood.  "  Black  vomit  "  is  not  necessarily  a  fatal  symp- 
tom thoutrh  it  occurs  only  in  the  severer  forms  of  the  disease.  Other  ha>m- 
orrhagic  features  may  be  "present— petechia;  on  the  skin  and  bleeding  from 
the  gums  or  from  other  mucous  membranes.  The  bowels  are  usually  con- 
stipated, the  stools  not  clay-colored,  as  in  Jaundice  from  obstruction.  They 
are  sometimes  tarry  from  the  presence  of  altered  blood. 

Mental  Features. — In  very  severe  cases  the  onset  may  be  with  active 
delirium.  "  As  a  rule,  in  a  majority  of  cases,  even  when  there  is  black 
vomit,  there  is  a  i)eculiar  alertness;  the  patient  watches  everything  going 
on  about  him  with  a  peculiar  intensity  and  liveliness.  This  may  be  due 
in  part  to  the  terror  the  disease  inspires "  (Guiteras).  The  first  signs  of 
mental  cloudiness  may  be  due  to  the  urtiemic  coma. 

Relapses  occasionally  occur.  Among  the  varieties  of  the  disease  it  is 
important  to  recognize  "the  mild  cases.  These  are  characterized  by  slight 
fever,  continuing  for  one  or  two  days,  and  succeeded  by  a  rapid  convales- 
cence. Such  cases  would  not  be  recognized  as  yellow  fever  in  the  absence 
of  a  prevailing  epidemic.  Cases  of  greater  severity  have  high  fever  and 
the  features  of  the  disease  are  well  marked — vomiting,  prostration,  and 
haMuorrhages.  And  lastly,  there  are  malignant  cases  in  which  the  patient 
is  overwhelmed  by  the  intensity  of  the  fever,  and  death  takes  place  in  two 
or  three  days.* 


•  For  a  full  discnssion  of  the  morbid  anatomy  and  symptomatolofry  of  the  disease  the 
student  is  referred  to  the  works  of  Joseph  Jones,  of  New  Orleans,  and  to  his  papers  in  the 
Journal  of  the  American  Medical  Association,  1895, 1. 


•niTUM.^>«  'JMHT^ '  Vi « 


YELLOW  FEVER. 


18^ 


e  pulse  with 

liaracteristic 
rcl  ilay.  He 
thoso  of  an 
go  to  bed — 
unh  (lay  of 
ansicnt.  In 
y  bo  mnnor- 
or  complete 
r  in  iirivmic 
Guiteras  in- 
e  states  that 
11  the  second 
the  jaundice 

stomach  is 
}  of  the  con- 
!:ih  fluid.  In 
■nonnced  and 
It  may  bo 
nd  along  the 
yoUow  fever, 
a  fatal  synip- 

Other  ha>m- 
)leeding  from 
'  itsiially  eon- 
iction.    They 

e  with  active 
here  is  black 
pything  going 
5  may  be  duo 
first  signs  of 

J  disease  it  is 
ized  by  slight 
apid  convales- 
n  the  absence 
igh  fever  and 
ostration,  and 
ch  the  patient 
s  place  in  two 


of  the  disease  the 
his  papers  in  the 


In  severe  cases  convale.sconce  may  bo  coni|)licatod  by  the  occurrence  of 
parotitis,  abscesses  in  various  jiarts  of  tlio  body,  and  diarrha'a.  An  attack 
confers  an  im;minity  which  j)orsists,  as  a  rule,  through  life. 

Diagnosis. — (a)  From  Dviujiie. — Tiie  dilliculty  in  the  dilforential 
diagnosis  of  tiioso  two  diseases  lies  in  their  fretiuent  coexistence,  as  during 
ihe  epidemic  of  IS!)?  in  jiarts  of  tiio  Southern  States.  For  example,  wlietiier 
yi'llow  fever  existed  last  year  in  Galveston  is  still  unsettled,  some  observers 
( laiming  tliat  dengue  aloue  ]>revailed,  otiiers,  iiicliuling  (iuiteras  and  West, 
allirming  tliat  tiiero  were  a  certain  numljor  of  cases  of  true  yellow  fever.  On 
tlie  one  hand,  if  the  suspicious  cases  were  dengue,  we  must  acknowledge  that 
Itreak-bone  fever  nuiy  be  a  much  more  serious  disease  than  writers  state, 
and  that  certain  of  the  symi)toms,  particularly  the  hiomorrhages,  occur  in  a 
larger  i)roportien  of  cases  tlum  has  been  heretofore  acknowledged.  Of  the 
other  sym])tonis,  too,  one  writer  states  that  jaundice  of  mild  grade  was  the 
rule  from  first  to  last.  Albumin  was  not  infrccjuently  present  in  the  urine, 
and  the  lack  of  correlation  between  the  pulse  and  the  temperature  was  so 
frequent  as  to  bo  almost  the  rule.  There  was  no  case  of  black  vomit. 
Dengue,  as  I  have  stated  in  the  article  on  that  disease,  i)revailod  to  a  remark- 
alile  extent  in  the  city  of  (Jalveston.  On  the  other  hand,  if  the  cases  ex- 
amined by  Ciuiteras  and  declared  by  him  to  Ijo  yellow  fever  were  truly 
cxami)les  of  tliat  disease,  there  is  the  anomalous — indeed,  unicjue — fact  of 
an  outbreak  of  yellow  fever  in  a  city  which  had  not  had  the  disease  in  epi- 
demic form  since  18G7,  and  in  which  it  did  not  assume  epidemic  propor- 
tions and  did  not  increase  the  death-rate,  which  for  the  months  of  August, 
.September,  and  October  of  181)7  was  lower  than  for  the  corresponding 
three  months  in  18!)G  and  18D5.  After  a  review  of  the  local  literature  on 
the  question,  I  confess  myself  to  be  (juite  unable  to  decide  ujjon  the  points 
at  issue.  I  have  dwelt  U])on  this  matter  in  order  that  practitioners  may 
realize  how  diiricult  the  diagnosis  may  be  under  certain  circumstances.  It 
is  quite  useless  to  emplr.^.size  in  parallel  columns  the  differential  points 
between  the  two  diseases.  Doubtless  in  a  majority  of  all  tht  :ases  the  three 
diagnostic  points  upon  which  Guiteras  lays  stress — the  facies,  the  albu- 
minuria, and  the  slowing  of  the  pulse  with  maintenance  or  elevation  of 
the  fever — are  sufTiciont  for  the  diagnosis.  He  states,  too,  that  jaundice, 
which  does  sometimes  occur  in  dengue,  rarely  appears  as  early  as  the  second 
or  third  day  of  the  disease,  and  on  this  much  stress  should  be  laid.  Iltt'm- 
orrhages  are  much  less  common  in  dengue,  but  that  they  do  occur  has  been 
recognized  by  authorities  ever  since  the  time  of  Rush.  It  is  most  sincerely 
to  be  hoped  that  the  work  of  the  Archinards  and  Woodson  on  the  serum 
diagnosis  may  prove  final,  in  wliich  case  we  shall  have  a  positive  diagnostic 
criterion,  such  as  we  now  have  for  malarial  fever. 

(b)  From  Malarial  Fever. — In  the  early  stages  of  an  epidemic  cases  are 
very  apt  to  be  mistaken  for  forms  of  malarial  fever.  In  the  Southern  States 
the  outbreaks  have  usually  been  in  the  late  summer  months,  the  very  season 
in  which  the  a?stivo-autumnal  irregular  malarial  fever  prevails.  Among 
the  points  to  be  specially  noted  are  the  absence  of  early  jaundice  in  ma- 
larial fever.  Even  in  the  most  intense  types  of  infection  the  color  of  the 
iikin  is  rarely  changed  within  four  or  five  days.     To  the  experienced  eye 


-.«ll8a5ffi3»^8»E«ai<«-^*8«SlWBiSF^-^^ 


SPKCIFIC  INPFX'TIOUS  DISEASES. 


188 

the  fucios  would  b.  uf  consi.kTal.lf  lu'lp.    AH.u.nin  is  nuvly  im-sont  in  the 
uri.u"  so  rally  us  the  scc-ond  day  iu  a  malarial  inlVclion.    Ot  .or  ..npor  ant 
points  are  the  marked  swelling  of  the  s,.le..n  in  malaria,  while  ...  ye  low 
fever  it  is  not  often  enlarged.     lIa>morrl.ages.  a.ul  particularly  the  l.huk 
vomit    a.e  very  rare  in  the  acute  forms  of  a'stivo-antumnal  malarial  luicc- 
tion    'in  the  so-ealled  l.am.orrhagie  malarial  i'ever  the  patient  has  usually 
had"p.evious  attaeks  of  n.alaria.     Ihemaluria  is  a  pron.ine..t  leature   while 
in  yellow  fever  it  is  l.y  no  means  fre.iuent.     Two  special  points  of  more 
importance,  j.erhai.s,  than  any  of  these  general  sy,npto...at.e   i;eat...-es  are 
(1)  the  examination  of  the  hlood  for  malarial  parasites.     Ihe  iorms  to  bo 
looked  for  are  the  small,  ring-shai.ed  organisn.s  of  the  a>8tivo-autumnal 
infections.     As  a  rule,  their  presence  is  readily  deter....ned  hy  any  one 
f„„ii;av  with  their  general  cha.-aeters.    They  are,  l.owevcT,  ol  al    Iorms  the 
n...st  dilllc.lt  to  recog..i/e,  a..d,  while  they  may  he  very  ah..ndant,  there  are 
eases  in  which  the  organisms  are  extremely  s.'anty  in  the  peripheral  cir- 
culation.    Under  such  eireumstances  in  a  case  of  doubt  it  m.ght  be  jus  i- 
flable  to  ta,)  the  spleen.     (•.')   If  Sanarelli's  researches  are  confirine.l    the 
agglutination  test  will  he  a  very  important  aid  in  the  diagnosis  ..f  .loubtiul 

''"'prognosiB.-In  its  graver  forms,  yellow  fever  is  one  of  the  most 
fatal  of  epidemic  diseases.  The  mortality  has  ranged,  in  various  epidemics, 
from  15  to  85  per  cent.  In  heavy  drinkers  and  those  who  liave  been  ex- 
posed to  hardships  the  death-rate  is  much  liigher  than  among  the  better 
classes.  In  the  epidemic  of  1878,  in  New  Orleans,  while  the  mortali  y  m 
hospitals  was  over  50  per  cent  of  the  white  and  21  per  cent  of  the  colored 
patients,  in  private  practice  it  was  not  more  than  10  per  ^l^'^t  among  the 
white  patients.  The  death-rate  was  very  low  in  the  epidemic  of  1897 
Favorable  symptoms  arc  a  low  grade  of  fever,  slight  jaundice,  absence  ot 
ha'morrhages,  and  -.  free  secretion  of  urine.  If  the  temperatu.-e  rise  above 
103°  or  104°  during  the  first  two  days,  the  outlook  is  serious.  151ack  vomit 
is  not  an  invariably  fatal  symptom.  Cases  with  suppression  of  urine,  de- 
lirium, coma,  and  convulsions  rarely  recover. 

Propliylaxis.--The  measures  to  be  taken  are — 
(n)  "  Exclusion  of  the  exotic  germ  of  the  disease  by  the  sanitary  super- 
vision, at  the  port  of  departure,  of  shi])s  sailing  from  infected  ports,  and 
thorough  disinfection  at  the  port  of  arrival,  when  there  is  evidence  or  rea- 
sonable snsi.icion  that  they  are  infected;  (h)  isolation  of  the  sick  on  ship- 
board, at  (piarantine  stations,  and,  so  far  as  practicable,  in  recently  infected 
places-  {(■)  disinfection  of  excreta,  and  of  the  clothing  and  bedding  used 
by  the  sick,  and  of  localities  into  which  cases  have  been  introduced,  or 
which  have  become  infected  in  any  way;  (d)  depopulation  of  infected  places 
— i  e  the  removal  of  all  supcei)tible  i)ersons  whose  presence  is  not  neces- 
sary for  the  care  of  the  sick  "  (Sternberg).  During  an  epidemic,  individuals 
who  must  remain  in  the  locality  should  avoid  the  regions  m  which  the  dis- 
ease prevails  most;  they  should  live  temperately,  avoiding  all  excesses,  and 
should  be  careful  not  to  get  overheated,  either  in  the  sun  or  by  exercise. 

Treatment.— Careful  nursing  and  a  symptomatic  plan  of  treatment 
probably  give  the  best  results.     Bleeding  has  long  since  been  abandoned. 


,^^-^^.■^c^^fi0'lMg^l»saf^'i*ei'■*^''f^■^^llMlr^wrr'•'^^^'.■-. 


BUBONIC  I'LAOUE. 


189 


f\ 


jscnt  in  the 
r  iinpiirtatit 
t-  ill  yi'llnw 
y  tlio  hliuk 
liirial  iiit'ec- 
lias  usually 
atr.ri',  whilo 
iits  of  more 
ri'aturcs  arc 
I'uriiis  to  bo 
^'o-autumnal 
])y  any  one 
ill  forms  the 
nt,  there  are 
riplieral  cir- 
,'lit  1)0  justi- 
iiiiriiu'il,  the 
,  of  doubtful 

of  the  most 
IS  ei)idoinies, 
avo  boon  cx- 
ig  the  butter 

mortality  in 
f  iho  colored 
t  anion?  the 
nic  of  1897. 
p,  absonoe  of 
ire  rise  above 

IMack  vomit 
of  urine,  de- 


mitary  super- 
•d  ports,  and 
denee  or  rea- 
siek  on  sliip- 
?ntly  infected 
bedding  used 
titroduced,  or 
iifected  places 

is  not  neces- 
ic,  individuals 
vhich  the  dis- 

excesses,  and 
y  exercise. 

of  treatment 
!n  abandoned. 


How  much  imtionts  will  stand  in  this  disease  is  illustrated  by  Hush's  prac- 
tice, wiiioh  was  of  the  most  heroic  eharactor.  lie  says:  "From  a  newly 
arrived  Knglishman  I  took  111  ounces,  at  twelve  bleedings,  in  six  days; 
four  wore  in  twenty-four  hours.  I  gave  within  the  course  of  the  same  six 
days  nearly  1")(»  grains  of  calomel,  with  the  usual  [iroiwrtions  of  ^alaj)  and 
gamboge."  ♦  With  the  courage  of  his  convictions  this  modern  Sangrado 
himself  submitted  to  two  bleedings  in  one  day,  and  had  his  infant  of  six 
weeks  old  bled  twice!  Neither  einctics  nor  purgatives  are  now  employed. 
Of  s|)ccial  remedies  (piinine  is  warmly  recommended,  and,  when  luvnior- 
rliage  sets  in,  the  perchloride  of  iron.  Digitalis,  aconite,  and  jaborandi 
have  been  employed.  Sternberg  advises  the  following  mixture:  Hicar- 
lionate  of  soda,  l")!)  grains;  bieiiloride  of  mercury,  |  grain;  pure  water, 
1  (piart.  Three  tablespoonfuls  every  hour.  This  is  given  on  the  view  that 
the  siiecide  agent  is  in  the  intestine,  and  that  its  growth  may  imssibly  be 
restrained  by  tiiis  antacid  and  antiseptic  mixture.  The  fever  is  best  treated 
by  hydrothera])y.  There  arc  several  reports  of  the  good  clTects  of  cold 
baths,  sponging,  and  the  apjilication  of  ice-cold  water  to  the  head  and  the 
extremities  in  this  disease.  Vomiting  is  a  very  dillic  ult  symptom  to  control. 
Mor))bia  hypodermically  and  ice  in  small  (piantities  are  probably  the  best 
remedies.  Medicines  given  by  the  mouth  for  this  purpose  are  said  to  be 
rarely  elhcacious. 

We  have  no  drug  which  can  be  depended  upon  to  check  the  hn-m- 
orrhages.  Ergot  and  acetate  of  lead  and  opium  are  recommended.  The 
uramiic  symptoms  arc  best  treated  by  the  hot  bath.  Stimulants  should  be 
given  freely  during  the  second  stage,  when  the  heart's  action  becomes 
feeble  and  there  is  a  tendency  to  collapse.  The  i)atient  should  l)e  carefully 
fed;  but  when  the  vomiting  is  incessant  it  is  best  not  to  irritate  the  stom- 
ach, but  to  give  nutritive  encmata  nntil  the  gastric  irritation  is  allayed. 

Serum  Treatment  in  Yellnw  Fever. — SanarcUi's  most  recent  comnuinica- 
tion,  I^farch  8,  1808,  gives  an  acconnt  of  the  use  of  the  blood-serum  from 
two  horses,  one  of  wliicli  had  been  nnder  treatment  for  eighteen  months, 
the  other  for  twelve.  Altogether  of  the  22  cases  treated  with  the  serum  5 
died,  a  mortality  of  22.7  per  cent,  lie  has  been  testing  the  i)rophylactic 
power  of  this  anliamarilic  serum,  but  so  far  on  too  small  a  scale  to  judge  of 
its  efficacy. 

XXII.    BUBONIC    PLAGUE. 

Definition.— A  specific,  infectious  disease  of  extraordinary  virulence 
and  very  ra])id  course,  characterized  by  inllammation  of  the  lymphatic 
glands  (buboes),  carbuncles,  and  often  luvmorrhages. 

History  and  Geographical  Distribution.— The  disease  was 
probably  not  known  to  the  classical  Greek  writers.  The  earliest  positive 
account  dates  from  the  second  century  of  our  era.  The  plague  of  Athens 
and  the  pestilence  of  the  reign  of  Marcus  Aurelius  were  apparently  not  this 
disease  (Payne).     From  the  great  plague  in  the  days  of  Justinian  (sixth 


•  Manuscript  letter  to  Redman  Coxe. 


-jSJ5«S«^^?*«SS^feVipi;eS7v^"  ;-.;>ai>-W;.i%i^^'';'?s?:i»^' ■'  :;.*J'6* 


190 


SPECIFIC   INFKCTIOUS  DISEASES, 


('.'ntiiry)  to  tlic  iiiiilillc  of  the  Hcvciiloonth  century  ('|>i(li'nii('s  nf  varyiiij; 
severity  oeturicd  in  iMimpe.  Aiiionc;  the  most  disasti'dus  Wiif*  tlie  laiUDUrt 
"  bhiek  (h'lith  "  of  tiie  loiirteeHtli  eeiitiiry.  wliieii  (ivernm  lluropo  ami  ile- 
striiyed  a  fourth  of  the  |io|>uhitiou.  In  tiie  seventeenth  eentury  it  raj,'ed 
viruk'Utiy,  and  tlurinji  the  >,n'eat  (jhigue  of  l.onchm,  in  l(iii">,  aiioul  *,U,tl0U 
l)eo|)k'  died.  During  the  present  eentury  the  pla^'ue  in  Kurojie  has  been 
eonlined  almost  exilusively  to  Turkey  and  soutiurn  Uiissia.  The  hist  out- 
break was  a  small  e|tidenuc  in  lM;.S-'7t».  Tliere  are  now  live  indepeiulent 
eiulemie  centres  of  the  disease— (I)  the  province  of  Tripoli,  {'i)  eouthwest- 
cru  Arabia,  (M)  a  large  section  of  Asia,  comprising  Mesopotamia,  Persia, 
and  Kurdestan.  (I)  the  districts  of  Kumaon  and  Uurwhal  in  northwestern 
Indiir,  and  ('>)  smithwestern  China  (I'ayiu'). 

Kenewed  interest  has  recently  been  aroused  in  the  disease  by  the  ejii- 
demic  at  Hong-kong  in  18!)f,  from  which  in  the  space  of  three  nu)nths 
l',r)0(l  peoiile  died.  Far  more  serious  has  been  the  outbreak  in  India  in  the 
])rosidency  of  IJondiay.  It  l)egan  in  the  city  of  i5ond)ay  in  September, 
18!t(!,  during  three  months  developed  gradmilly,  nuiintained  a  great  in- 
tensity for  three  m<intlis,  and  then  slowly  declined.  In  the  nine  months 
nt  least  20,M)0  people  died.  After  a  period  of  (luiescence  in  the  city  of 
r.ombay  it  again  broke  out  with  great  virulence  during  the  early  part  of 
the  i)resent  year  (ISilS).  At  the  time  of  writing  it  has  spread  widely 
throughout  the  presidency,  and  is  in  many  respects  the  most  ominous  of 
recent  ejiidemies. 

Etiology, — The  sjiecific  organism  of  the  disease  is  a  bacillus  discov- 
ered by  Kitasato  and  carefully  studied  by  Yersin  and  others.  It  resembles 
somewhat  tlu^  lincillus  of  chicken  cholera,  and  grows  in  a  jx'rfectly  char- 
acteristic manner.  The  bacillus  pestis  occurs  in  the  blood  and  in  the 
organs  of  the  body,  and  has  also  been  found  in  the  dust  and  in  the  soil  of 
houses  in  which  the  ])atients  have  lived.  Flies  and  fleas  die  from  the  dis- 
ease, and  may  convey  the  infection.  Rats,  mice,  and  dogs  are  readily  in- 
fected, and  diseased  animals  will  convey  the  plague  to  bealthy  ones. 

The  disease  prevails  most  freijuently  in  hot  seasons,  though  an  out- 
break may  occur  during  the  coldest  weather  of  winter.  Persons  of  all  ages 
are  attacked.  It  spreads  chiefly  among  the  poorer  classes,  in  the  slums  of 
the  great  cities,  and,  in  fact,  wherever  the  hygienic  conditions  are  most 
faulty.  There  is  much  in  favor  of  the  view  that  the  plague  is  a  soil  disease, 
the  virus  of  wliieh,  like  that  of  anthrax  and  tetanus,  resides  permanently 
in  the  soil  of  the  aflfected  di-stricts  (see  Payne  in  Allbutt's  System).  Tlie 
method  of  s])read  was  well  recognized  by  De  Foe:  "  Xo  one  in  this  whole 
nation  ever  received  the  sickness  or  infection  but  wlio  received  it  in  the 
ordinary  way  of  infection  from  somebody,  or  the  clothes,  or  touch,  or 
stench  of  somebody  that  was  infected  before." 

'While  liie  virus  of  the  plague  may  he  communicated  from  one  person 
to  another  tbrough  the  air,  the  disease  has  not  the  extreme  contagiousness 
of  small-pox  or  of  scarlet  fever.  It  attaches  itself  particularly  to  houscn 
and  to  the  clothing  and  bedding.  In  the  Bombay  epidemic  few  attendants 
upon  the  sick — nurses  and  physicians — have  been  attacked,  and  a  writer 
states  that  among  the  hundreds  of  British  troops  daily  employed  on  cordon 


--f  i^»isa^==«;?4««e<'«=»«='*"rBMh«'*W' ■''P=^''r'"r  vit.^^^ 


nURONIC  PLAGUK. 


lit  I 


.f  varying 
In."  I'aiUDiiri 
ic  uml  dc- 
y  it  ra^;c'il 
lilt  10,(100 

•  lias  Ik'C'H 
c  last  out- 
(U'I)oiulL'nt 
Houtluvcst- 
lia,  Persia, 
rtliwestern 

)y  tho  epi- 
i'o  months 
idia  in  the 
•loptcmhcr, 
1  {ireat  in- 
110  months 
tho  city  of 
rly  i)art  of 
oail  widely 
)miiu)us  of 

his  diseov- 
t  rcsemliles 
ectly  t'liar- 
ind  in  the 

the  soil  of 
)m  tlie  dis- 

readily  in- 

incs. 

ih  an  out- 

of  all  ages 
le  slums  of 
s  are  most 
'oil  disease, 
ornianently 
toni).     Tlie 

this  whole 
d  it  in  the 

•  touch,  or 

one  person 
tagiousness 
/  to  houses 
attendants 
id  a  writer 
I  on  cordon 


dntv  and  searcli  parties  and  in  llie  disiiifrction  of  houses  not  a  single  case 
oeeiirred. 

Clinical  Forms.  —  Most  writers  recognize  three  varieties — prslis 
niilrniiis,  or  the  Iniminant  variety,  prsllH  major,  and  /<r,s7t,«f  minor.  \n  tho 
/(c.s/i'.v  nulinms  death  may  oeeiir  within  twenty-four  iioiirs.  It  is  an  intense 
septica'una,  with  or  witinnit  the  develo|)ment  of  lia'iiiorrliages,  ami  rarely 
witii  glandular  enlargements.  The  jiislis  major  is  the  common  severe 
Itiihonie  form — maliiinanl  ailcnilis,  as  Cautlie  terms  it.  'I'lie  jwslix  miimr 
is  usually  met  witii  hefore  the  outlirealv  of  the  severe  epidemic,  and  is  char- 
acteri/ed  hy  glandular  swellings  hut  very  slight  fever  and  constitutional 
distiirhances,  and  is  rarely  I'alal. 

A  very  interesting  form  has  heen  recognized  during  the  Uomliay  epi- 
demic; namely,  the  primary  plague  ])i..  ,  iionia,  which  hegins  with  a  chill, 
]iain  in  tin;  side,  and  cou^h,  with  rusty  expectoration.  Tliere  are  rarely 
s\veHinj:s  of  the  lymjih  glands.  The  l5onihay  I'lagiie  Committeo  give  the 
I'ollowiu''  interesting  classification: 


1.  Willi    cnliirp'd    frliiiiils    (trravity   ncconliii^    to 
syinptoms  and  severity  of  uttuck). 


2.  Without  cnlurged  glnnds  (almost  always  fatal). 


I'ciiKiriil. 
Ingiiiiinl. 
Axillary. 
Cervii'iil. 
Tonsillar. 

.Si'i)ticn?inip. 
I'lit'unioiiic. 
Jlescntcric,  ontcric,  or 

giistro-iiitostiual. 
Nciitiritic. 
.  Cerebral. 


Symptoms. — Tlie  following  is  a  brief  summary  of  tho  symptoms  of 
the  ordinary  hiihonic  form: 

The  stage  of  incubation  is  rarely  more  than  three  or  four  days. 

The  stage  of  invasion  is  characterized  hy  headache,  backache,  stiffness 
in  the  limbs,  a  feeling  of  anxiety  and  restlessness,  and  great  depression  of 
spirits.  The  breathing  is  hurried,  and  haMiiorrhages,  particularly  from  tho 
nose  or  from  the  lungs,  may  occur.  After  these  syiui)toms  have  ))ersisted 
for  from  twelve  to  thirty-six  hours,  the  temperature  rises  and  tlie  ]iulse 
becomes  ra])id.  The  fever  may  reach  104°  or  oven  10G°;  the  tongue  be- 
comes brown,  collapse  synqitonis  are  apt  to  su])ervene,  and  in  very  severe 
infections  the  patient  may  die  at  this  stage.  In  at  least  two  thirds  of  all 
cases,  however,  a  fourth  ])eriod  is  reached,  characterized  by  the  development 
of  glandular  swellings  or  buboes.  The  inguinal  glands  are  most  often  af- 
fected, then  in  order  the  axillary,  the  cervical,  and  the  popliteal.  The  first 
sign  of  the  swelling  appears  usually  from  the  third  to  the  fifth  day.  Reso- 
lution may  occur,  or  suppuration,  or  in  rare  cases  gangrene.  Carbuncles 
also  may  develop  in  different  parts  of  the  skin,  particularly  on  the  legs, 
buttocks,  or  back.  Suppuration  is  a  favorable  feature.  Do  Foe  recognized 
this  in  his  graphic  account  of  the  London  plague,  stating  that  "if  these 
swellings  could  be  brought  to  a  head  or  to  break  and  run,  or,  as  the  sur- 
geons call  it,  to  digest,  the  patient  generally  recovered." 


rf''fr*;7r"f:vp<v-'  M'ro*.--:;,:.-^— •  ■ 


•a*swhe;^w>3Sf3g§ieK>:!aSt.;^:'  sSss^MSr 


'-'■.rv'tViSt^?'"." 


.%r^^i-  -twj5?5\^',-\"^-' 


192 


SPECIFIC  INFECTIOUS  DISEASES. 


I 


At  thi .  stage  petecliia.  very  commonly  show  themselves,  and  may  be  very 
extensive.     TlLe  have  been  called  the  "plague  spots,"  or  the  "   oken  so 
ihe  Xea«e  "  and  gave  to  it  in  the  middle  ages  the  name  of  the  Black 
DeaiJ     Hanno^rhages  from  the  mucous  membranes  may  also  occur;  m 
some  epidemics  hiemoptysis  has  been  especially  frequent. 

Convalescence  nuiy  proceed  rapidly,  or  may  be  much  prolonged  by  the 

"^"r^ZS^^i  the  disease  is  the  highest  of  any  known  infection, 
reachit  f  o  n  70  to  90  per  cent  of  all  attacked.  In  the  Ilong-kong  llos- 
pUd  during  the  recent  epidemic  it  is  stated  that  the  mortality  was  9o  per 

''"  PrOT)hylaxis.-The  following  brief  extract  is  taken  from  Kitasato's 

report    "The  disease  prevails  especially  under  faulty  hygienic  conditions; 

t  is  therefore  urged  that  general  hygienic  measures  be  carried  out.    Propc 

re  ei  acles  for  sewage  should  be  provided;  a  pure  water-supply  afforded, 

Z:^':ta  streams  ^re  to  be  cleansed;  all  V^^^^^^^^f^'^l^'Z:^ 
lated-  the  furniture  of  the  sick-room  washed  with  a  2-per-ccnt  caibolic 
ol^i'o  n  milk  of  lime;  old  clothes  and  bedding  are  to  be  steamed  a 
Too'  C  for  at  least  an  h^ur,  or  exposed  for  a  few  hours  to  sunhght  If 
jr^ib  e'  al  hifected  articles  should  be  burned.  The  evacuations  of  the 
s  ok  are'  to  be  mixed  with  milk  of  lime,  and  those  who  die  of  the  disease 
a^to  be  buried  at  a  depth  of  three  metres,  or  preferably  cremated.  Afer 
r  covery  the  patient  is  to  be  kept  in  isolation  at  least  one  month.  All  con- 
tict  wifh  tlie  sick  is  to  be  avoided,  and  great  care  is  to  be  exercis  d  v^.th 
JSerence  to  food  and  drink."  For  the  disinfection  of  buildings,  Haffkine 
«ufr<^ests  sulphuric  acid  of  the  strength  of  1  to  200. 

Treatment.-In  a  disease  the  mortality  of  which  may  reach  as  ugh 
as  80  01  'jTp^  cent  the  question  of  treatment  resolves  itself  into  making 
?he  patient  as  comfortable  as  possible,  and  following  out  certain  general 
n-inSes  such  as  guide  us  in  the  care  of  fever  patients.  Cantlie  recom- 
nds  purgation  and  stimulation  from  the  outset,  and  the  use  of  morphia 
for  le  pafn  The  local  treatment  of  the  buboes  is  impr^tant,  and  good 
results  a niiarently  follow  the  injection  of  the  bichloride  of  merctuT. 

it    live  inoculation  has  been  introduced  by  Ilaffkme.     Sterilized 
bouillon  cultures  of  the  plague  bacillus  are  used.    Injections  with  mcrcas- 
r  X  i^  ^  of  these  soluble  toxines  are  practised,  which  are  followed  by 
Ud  re  ctionary  symptoms.     Some  thousands  of  persons  have  been  inocu- 
a  od    y  h  m  in  Indi  .    IlafTkine  claims  for  the  method  very  positive  suc- 
Itnd  quotes  the  following  in  support  of  his  contention:  "  I.rst,  as  re- 
n^rd.  animals  being  rendered  immune.     Twenty  rats  from  a  s  up  ne^^ly 
?■  ied  from  Europe  were  seized;  of  these,  10  were  inoculated      Subse- 
iCn   y  tie  20  rats\vere  ke])t  together  in  a  cage,  into  which  a  rat  sii  fenng 
fS  pi  gue  was  introduced.     Of  the  uninoculated,  9  were  seized  wit 
i     ue  ind  died,  whereas  of  those  rendered  immune  only  1  contracted  the 
ieC     Secondly,  at  Fran,  a  village  possessing  1^00  mhab.tants    when 
ague  broke  out"  429  persons  were  inoculated  by  the  serum  m  question. 
Of  t^se   only  7  were  attacked  by  plague,  and  al    recovered   wluls    of  the 
uninoe  i;ted'2G  were  seized  and  24  died.    Thirdly,  m  the  town  of  Lower 


:J  .*.'.:—.„"■" '^•F'.i"'*'*  ■ 


»nftf-:i.'fr>   J-"'. 


-  -f^^  #*.4«,"i,n''iCTW'-«*»*««l»i''"»**'-^  ■ 


DYSENTERY. 


193 


lay  be  very 

'  tokens  oi' 

the  Black 

occur;  in 

ged  by  the 

.  infection, 
-kong  lloij- 
was  95  per 

1  Kitasato's 
conditions; 
ut.    Proper 
J  afforded; 
disease  iso- 
!nt  carbolic 
steamed  at 
inlight.     If 
ions  of  the 
the  disease 
itod.    xVfter 
h.    xN.ll  con- 
ercised  with 
gs,  Haffkine 

!ach  as  high 
into  making 
tain  general 
ntlie  recom- 
!  of  morphia 
\i,  and  good 
ercury. 
I.  Sterilized 
with  increas- 
;  followed  by 
!  been  inocu- 

positive  suc- 
'  First,  as  re- 
a  ship  newly 
ited.  Subse- 
.  rat  suffering 
:  seized  with 
ontractcd  the 
hitants,  when 
1  in  question. 

whilst  of  the 
nvn  of  Lower 


D,minn  2  197  persons  were  inoculated,  0,033  remaining  unprotected.     Of 
dina  ter  M.sAlied,  whereas  only  3(5  of  the  persons  inoculated  succumbe. 
\  ^  to.     FouAhly,  at  Lanowli,  a  village  with  .(.O  -  |a  "  |>"  s   so,n 
wo  hours"  distance  fn.nt  B.nubay,  323  persons  were  ■•UM.da  nd  3 

^vere  content  to  reuuun  unprotected.  Anu)ng  he  io""^^'-  1  e^  ^^^  ^^ 
c.i<es  and  7  deaths;  aniong  the  latter-that  is,  the  un.nocu  ate  1-.8  poi- 
sons c'racted  the'  disease,  of  whom  58  died.  Fifthly,  at  K.rkee  ou  ol 
Xa  M^O  inhabitants  OU  availed  then.selves  of  the  t-tuient  w  ub 
H59  i^mam^d  unprotected.  Of  the  latter,  J^^  -<  I'^f '^j' ^^^•!!^; !  ^i; 
whereas  of  the  inoculated  32  cases  occurred,  with  1 .  deaths  onlj      (b.  it.sh 

^^' A  ™i  IhSli^ms  been  introduced  by  Yersin,  the  immunizing  serum 
beinVobt  led  filin  the  horse.  In  Canton  good  results  appj^ir  o  have 
fulTowcHl  the  use  of  the  serum,  but  the  recent  rei.ort«  irom  Bombay  are 
not  so  favorable. 

XXIII.    DYSENTERY. 

Deflnition.-rnder  this  clinical  term  are  described  several  different 
fornisot  intestinal  ffux,  characterized  by  frequent  stools,  and  m  the  acute 
:tag"by  tormina  and  tenesmus.  Anatomically  there  is  inllammation  and 
usuallv  ulceration  of  the  large  bowel.  .-,-,■  ^t 

Etiology.-Dysentery  is  one  of  the  four  great  epidemic  diseases  of 
the  worW  T;  the  tropics  it  destroys  more  lives  than  cholera,  and  it  has 
been  more  fatal  to  armies  than  powder  and  shot.  „...,,.iv  nocir 

While  especially  severe  in  the  tropics,  sporadic  cases  constantly  occii 
in  more  temUte' climates,  and  under  favoring  -;-"'f  ;--  ^^C 
are  found  even  in  the  more  northern  countries,  such  as  C  a  uida  and  Noi 
t4y  I  has  become  less  frequent  of  late  years,  owing  to  improved  sam- 
arv  conditions.  The  statistics  of  the  Montreal  Genera  Hospital,  or  he 
tw^ntv  yea  s  ending  May  1,  1889,  show  a  remarkable  decrease  m  the  dis- 
ese  In  the  decade  ending  May,  1879,  150  cases  were  adm.  ted;  whereas 
in  the  last  ten  years  there  have  been  only  31  admissions.  There  has  been 
fi  similar  decrease  at  the  Pennsylvania  Ilosiutal. 

Tn  the  Soithern  cities  of  this  country  dysentery  is  more  prevalent;  even 

when  nof  q'lemic,  sporadic  cases  are  common.     In  Baltimore  it  prevails 

pvprv  summer  and  has  on  several  occasions  been  epidemic. 

■  EiXc'ot  dysentery  have  occurred  in  the  United  S  ates  lor  mcvre 

thin  a  m  turv,  and  Woodward  has  collected  the  data  which  show    he 

,.  i,     rPM-s      Perhaps  the  most  serious  was  that  which   prevailed 

various  out  .re.d^s^     p  i  f,,  the  war  of  secession  the  disease  existed  to  an 

Z.ng  extent    nbo^hLmies.    According  to  Woodward's  report,*  there 

were   n  tl  e  F  loral  service  in  all  259,071  cases  of  acute  and  ^^^'^^^ 

of  chron  c  dysentery.    Probably  a  considerable  proportion  of  the  182,o86 

cases  of  duonic  dianWjhoul^^ 

',       r^       •    1  Tr;»fnpv  of  the  War  of  the  Rebellion,  Medical,  vol.  ii ;  the  most 

and  ability  of  the  author. 


■mmg*^:ixiim-«iseatiem's 


■ffltuefflraair-' 


:F/»r5;^-' 


PiUH^:-" 


194 


SPECIFIC  INFECTIOUS  DISEASES. 


\mi 


nial  census  reports  since  1850  show  a  progressive  decrease  i;i  the  total  num- 
ber of  (leatlis  from  this  disease.  It  ].revails  most  extensively  in  tlie  summer 
and  autumn.  Sudden  changes  of  temperature  appear  more  harmlul  than 
variations  in  moisture.  Tiie  ellluvia  from  decomposing  animal  matter  have 
been  thought  by  some  to  predispose  to  or  even  to  cause  the  disease.  That 
dvsenteric  airections  are  more  frequent  in  malarial  localities  has  long  been 
known,  and  is  ])roha))ly  connected  with  external  conditions  favoring  their 
development.  With  reference  to  the  inlluence  of  drinking-water,  Wood- 
ward is  d(.ul)tless  correct  in  stating  that  the  elfects  of  dissolved  mineral 
matters  have  been  greatly  exaggerated.  On  the  other  hand,  from  the  days 
of  the  old  (ireek  physicians,  it  has  been  held  tlmt  the  impurities  in  the 
stagnant  water  of  marshy  districts  and  i.onds  may  give  rise  to  diarrluca 
and  dysentery.  Here,  however,  it  is  not  probable  that  the  vegetable  impuri- 
ties are  directly  causative,  but  that  the  organic  matter  renders  the  wattT 
a  more  favoral.le  medium  for  the  development  of  the  organisms  which 

cause  the  disease.  . 

Dyspeptic  conditions,  particularly  those  caused  by  the  ingestion  of  liad 
food  and  unrii)e  fruit,  seem  to  ])redispose  to  the  disease.  (Jreat  stress  has 
been  laid  by  German  authorities  on  the  importance  of  constipation  as  a 

causal  factor.  ,  •,        mi 

Dysentery  occurs  at  all  ages.  There  is  no  race  immunity.  Ihe  con- 
tagiousness of  the  disease  is  doubtful.  The  experience  of  the  civil  war  is 
dcddedly  against  it,  but  the  possibility,  as  with  typhoid  fever,  must  be 
acknowledged. 

Clinical  Forms.— («)  Acute  Catarrhal  Dysentery— Ihis  may  occur 
sporadically  or  endemically,  and  is  the  variety  most  frequently  found  in 
temjierate  climates. 

Morbid  jhintomi/.—Thv  lesions  are  confined  to  the  large  bowel;  some- 
times the  ileum  also  is  involved.  Tiie  mucous  membrane  is  injected, 
swollen,  and  often  covered  with  tenacious  blood-stained  mucus.  The  most 
striking  feature  is  the  enlargement  of  the  solitary  follicles,  which  stand 
out  prominently  from  the  mucous  membrane.  In  very  acute  forms,  as  in 
children,  the  picture  is  that  of  an  acute  follicular  colitis.  In  more  pro- 
tracted cases  the  follicles  su])i)urate  or  are  capjied  with  an  area  of  necrotic 
tissue.  In  other  instances  the  sloughs  have  separated  and  the  entire  colon 
presents  numerous  ulcers,  most  of  which  have  develo])ed  from  the  follicles, 
while  others  have  resulted  from  necrosis  and  sloughing  of  the  intervening 

tissue 

Symptom/^. — There  may  be  preliminary  dyspepsia  or  slight  pains  in  the 
abdomen.  Chills  arc  rare.  Diarrhoea  is  the  most  constant  initial  symp- 
tom, and  at  first  is  not  ])ainful.  Usually  within  thirty-six  hours  the  char- 
acteristic features  of  the  disease  develop— abdominal  pain  of  a  colicky, 
•T-riiiing  character  and  frequent  stools,  which  are  passed  with  straining  and 
tenesinus;  the  eoiistitutional  disturbance  is  variable,  and  in  mild  cases 
may  be  slight.  Tlie  temperature  is  not  high;  at  the  outset  the  range  may 
be  102°  or'^103°.  The  tongue  is  furred  and  moist,  and  as  the  disease  ])ro- 
gresses  becomes  red  and  glazed.  Xausea  and  vomiting  may  be  present, 
but  as  a  rule  the  patient  retains  nourishment.    The  constant  desire  to  go 


ij.i..    I     .,-■  ~^^,^^  •mwVK'.'MteiA^ 


■^—^■'vefr-  •■ii»*)"T 


DYSENTERY. 


195 


total  num- 
lie  sunimor 
riiiful  than 
natter  have 
case.  That 
s  long  boon 
oring  their 
iter,  Wood- 
ed mineral 
)ni  the  days 
ities  in  the 
to  diavrluea 
ible  impnri- 
s  the  water 
lisms  which 

^tion  of  had 
it  stress  has 
ipation  as  a 

.  The  con- 
civil  war  is 
er,  must  he 

3  may  occur 
;ly  found  in 

)owel;  f'ome- 
is  injected, 
1.  The  most 
which  stand 
forms,  as  in 
n  more  pro- 
a  of  necrotic 
entire  colon 
tlie  follicles, 
'  intervening 

pains  in  the 
initial  symp- 
iirs  the  char- 
:>f  a  colicky, 
straining  and 
11  mild  cases 
le  range  may 
?  disease  pro- 
y  he  present, 
;  desire  to  go 


to  stool  and  the  straining  or  teni'sinus  are  tlie  most  distressing  symptoms. 
The  abdomen  may  lie  Hat  and  hard.  The  thirst  is  often  excc-^sive.  Tiie 
stools  in  this  variety  of  dysentery  have  the  following  characters:  During 
llie  first  twenty-four  or  forty-eiglit  hours  they  consist  of  more  or  less  clear 
mucus  and  lilood  mi.xed  witii  small  iWcal  scybala.  After  this  they  become 
|iiirely  gelatinous  and  l)loody,  and  are  small  and  frequent,  from  fifteen  to 
two  hundred  in  twenty-four  hours,  according  to  the  severity  of  the  case. 
Al>out  tlie  end  of  the  lirst  week  the  mucus  l)ecomes  opacpie,  llie  ])roi)ortion 
of  blood  diminishes,  and  grayish  or  brownish  shreddy  material  a])pears  in 
tiie  stools,  which  become  gradually  reduced  in  frequency.  At  this  time 
they  may  be  wholly  composed  of  a  greenish  pultaceous  material  with  mucus. 
As  the  disease  siil)si(les,  fa'cal  matter  again  a])pears  in  the  stools,  increasing 
in  amount  until  they  become  normal.  Microscoj)ieal  examination  of  the 
glairy  l)loody  stools  shows  red  blood-corpuscles,  few  or  many  leucocytes, 
and  constantly  large,  swollen,  roun<l  or  oval  epithelioid  cells,  containing 
fat-drops  and  vacuoles.  These  are  not  infreciuently  mistaken  for  anuvbie. 
Occasionally  the  ceiroinnnas  iiilcsfiiKili.f  is  seen  in  large  numl)ers.  'J'he  ba- 
cillus i)yocyaneus  has  been  foun  F.  ('.  Curtis  in  a  recent  epidenuc  at 
Ilartwick,  X.  Y.  Not  only  was  resent  in  the  stools  in  large  numbers, 
but  it  was  isolated  from  the  drinking-water  in  almost  jnire  culture. 

Course  of  ihe  Disrase. — The  milder  cases  run  a  course,  as  Flint  has 
shown,  of  about  eight  days;  severer  ones  rarely  terminate  within  four 
weeks.  The  all'ection  occasionally  becomes  chronic.  Peritonitis  and  liver 
ab.<cess  are  extremely  rare.  Of  abscesses  of  the  liver  among  the  first  1,000 
aiito])sies  at  the  Johns  Hopkins  Hospital,  nor  more  than  two  or  three  were 
associated  with  dysentery  other  than  amtebic. 

{b)  Tropical  Dysentery— Amoebic  Dysentery. — This  form  of  intestinal 
flux  is  characterized  by  irregular  diarrlKca  ami  the  constant  i)resenee  in  the 
stools  of  the  amwha  coli  (Ijiisch),  amwha  (Ji/seiilrricr  (Councilman  and  La- 
fleiir).  It  is  this  variety  which  ])revails  extensively  in  the  tropical  and  sub- 
tropical regions,  and  which  jiroves  so  fatal  in  epidemic  form.  The  aiiKclia 
is  a  unicellular,  proto])lasmic,  motile  organism,  from  15  to  30  /j.  in  diameter, 
consisting  of  a  clear  outer  zone,  ectosarc,  and  a  granular  inner  zone,  endo- 
sarc,  containing  a  nucleus  and  one  or  more  vacuoles.  It  was  first  described 
by  Lambl  in  1859,  and  subsequently  by  Liisch,  who  considered  it  the  cause 
of  the  disease.  In  the  endemic  dysentery  of  F'gyjit,  Kartulis,  in  1SS3, 
found  these  amceba^  constantly  in  the  stools,  in  the  intestines,  and  in  the 
liver  abscesses.  lie  was  afterward  enabled  to  cultivate  them  in  straw  in- 
fusion, and  re])roduced  the  disease  ex])erimentally  in  cats.  In  1800  I 
reported  a  ca.-e  of  dysentery  with  abscess  of  the  liver,  originating  in 
Panama,  in  which  the  amcrba^  were  found  in  the  stools  and  in  the  pus  from 
the  abscess;  and  Councilman  and  Lafleur  *  have  described  the  clinical 
features  and  anatomical  lesions  .'n  a  series  of  ca.«es  of  this  form  of  dysen- 
tery in  my  wards.  Dock  has  demonstrated  their  presence  in  a  number  of 
cases  in  Oalveston.  and  IMusser  has  found  them  in  riiiladelphia.  A  careful 
study  has  been  made  recently  of  35  cases  by  II.  F.  Harris.     Anuebii?  are 

*  Jolins  Hopkins  [lospital  Reports,  vol.  ii. 


f 


wwiiiKi^in '■ni^  iTii^tfi 


»WiMMIHiflaBIMI«MBStoe«WB»«8^^ 


i^'-^,..-'-:^.^ 


190 


SPECIFIC  INFECTIOUS  DISEASES. 


occasionally  foun.l  in  the  .tool,  of  healthy  men  Qu.ncke  a  -1  Roo  rccog^ 
nizc  three  forn..  of  parasitic  anueba.,  two  ot  wh.ch  are  patho,n  u  1  he 
disease  is  very  connnon  in  tropical  and  subtrop.ca  coun  ries.  It  .,  ho\  - 
ever  found  n  ore  or  less  widely  distributed  throughout  Europe  and  ^o  t 
America.  The  sources  of  infection  are  not  known,  but  :t  seems  probable 
fbnt  one  of  them  is  drinkini;-water. 

.UW.^^lm'/'>'"V.-The  k  ms  are  found  in  the  large  intestine,  some- 
times in  the  lower  portion  of  the  ileum.  Abscess  of  the  liver  is  a  common 
seonence     I'erforation  into  the  right  lung  is  not  infrequent 

^ 7,  i/,,.V-The  lesions  consist  of  ulceration,  produced  by  preceding 
inf.Uration,  general  or  local,  of  the  snbnuicosa,  due  to  an  axleniatons  con- 
1^1  d  tf  iiiultiplication  of  the  fixed  cells  of  the  tissue.  In  the  earliest 
't  g  t  i^le  local  infiltrations  appear  as  hcmisphei-ical  elevations  above  he 
.eneral  level  of  the  mucosa.  The  mucous  membrane  over  these  soon  he- 
comes  necrotic  and  is  cast  off,  exposing  the  infiltrated  submucous  tissue  as 
a  ^ayish-yellow  gelatinous  mass,  which  at  first  forms  the  fioor  of  the  ulcer, 
but  is  subsequently  cast  off  as  a  slough.  i  ^    ^vlth   infiltrated 

The  individual  ulcers  are  round,  oval,  or  irregular,  Mith  indurate  , 
undermined  edges.     The  visible  aperture  is  often  small  compared  to  the 
bs    "f  t'sue  beneath  it,  the  ulcers  undermining  the  mucosa,  coalescing 
and  forming  sinuous  tracts  bridged  over  by  apparently  normal  muco 
membrane.  ^Vccording  to.  the  stage  at  which  the  lesions  are  observed     he 
floor  of  the  ulcer  maf  be  formed  by  the  submucous,  the  muscu  ar,  or  the 
erous  coat  of  the  intestine.    The  ulceration  may  affect  the  whole  or  some 
portion  only  of  the  large  intestine,  particularly  the  caecum,  «-  l^^Pati 
and  «i>nnoid  flexures,  and  the  rectum.     In  severe  cases  the  whole  of  the 
^esUne  is  much  thickened  and  riddled  with  ulcers,  with  only  here  and 
there  islands  of  intact  mucous  membrane.  ^-      ^-      ^ 

The  disease  advances  by  progressive  infiltration  of  the  connective-  issue 
lavers  of  the  intestine,  which  produces  necrosis  of  the  overlying  structures. 
Thus  in  severe  cases  there  may  be  in  different  parts  of  the  bowel  slough- 
incr  'e'n  masse  of  the  mucosa  or  of  the  muscularis,  and  the  same  process  is 
observed,  but  not  so  conspicuously,  in  the  less  severe  forms. 

In  some  cases  a  secondary  diphtheritic  inflammation  complicates  the 

"''^ilealiiigtkes  place  by  the  gradual  formation  of  fibrous  tissue  in  the 

floor  and  at  the  edges  of  the  ulcers,  which  may  ultimately  result  in  partial 

and  irregular  strictures  of  the  bowel.  i     ^      f 

Microscopical  examination  slio.s  a  notable  absence  of  the  products  of 

purulent  inflammation.  In  the  infiltrated  ^^'f'^Vo^'^'^'^'^jT;;'^^ 
are  seldom  found,  and  never  constitute  purulent  collections.  On  the  other 
hard  there  \?.  proliferation  of  the  fixed  connective-tissue  cells.  Amo^b* 
aiVfmmd  more  or  less  abundantly  in  the  tissues  at  the  base  of  and  around 
the  ulcers,  in  the  lymphatic  spaces,  and  occasionally  in  the  blood-vessels. 

The  lesions  in  the  Urer  are  of  two  kinds:  firstly,  local  necroses  of  the 
parenchvma,  scattered  throughout  the  organ  and  possibly  di^  to  the  achon 
of  chemical  products  of  the  anurba^;  and,  secondly,  abscesses  ^jiese  may 
be  «ingle  or  multiple.     When  single  they  are  generally  in  the  right  lobe, 


'*-4«K  *3Lii=l;:  »rri?:  •e''^»v*^ 


itmM^otHM  i\t.54«caBe9«"<tnafr*"*»»  *4v»-nsrtM*iw*»i*i*«"'«i»c*HBW?:r 


DYSENTERY. 


197 


Roos  recog- 

Conie.     The 

It  ^fi,  liov- 

aml  Xortli 

ns  probable 

stine,  some- 
s  a  common 

y  preceding 
matous  con- 
i  the  earliest 
IS  above  the 
ese  soon  be- 
ous  tissue  as 
of  the  ulcer, 

1  infiltrated, 
pared  to  the 
I,  coalescing, 
-mal  mucous 
abserved,  the 
eular,  or  the 
hole  or  some 
,  the  hepatic 
whole  of  the 
nly  here  and 

nective-tissue 
iig  structures, 
bowel  slough- 
,me  process  is 

mplicates  the 

tissue  in  the 
suit  in  partial 

le  products  of 
ear  leucocytes 
On  the  other 
ells.  Amoeba; 
of  and  around 
.lod-vessels. 
lecroses  of  the 
e  to  the  action 
s.  These  may 
the  right  lobe, 


cither  toward  the  convex  surface  near  its  diaplivagmalic  attachment,  or  on 
llie  concave  surface   in   proximity  to  the  bowel.     :Multii.le   al)scosses  are 
<mall  and  generally  superlicial.    In  an  early  stage  the  abscesses  are  grayish- 
vellow,  with  sharply  delhied  contours,  and  contain  a  spongy  necrotic  ma- 
terial, with  more  or  less  fluid  in  its  interstices.     Tlie  larger  abscesses  have 
ragged  necrotic  walls,  and  contain  a  more  or  less  viscid,  greenish-yellow 
..rTeddish-yellow  purulent  material  mixed  with  l)lood  and  slireds  of  liver- 
ti-^siie.     Tlie  older  al)scesses  have  filjroiis  walls  of  a  dense,  almost  carti- 
la-nnous  toughness.     A  section  of  the  abscess  wall  shows  an  inner  necrotic 
zone,  a  middle  zone  in  which  there  is  great  proliferation  of  the  connective- 
tissue  cells  and  compression  and  atrophy  of  the  liver-cells,  and  an  outer 
zone  of  intense  hvpinemia.    There  is  the  same  absence  of  i.urulent  niilam- 
mation  as  in  the^ntestine,  except  in  those  cases  in  which  a  secondary  in- 
fection with  pyogenic  organisms  has  taken  place.     The  material  from  the 
ab.^cess  cavity  "shows  chielly  fatty  and  granular  detritus,  few  cellular  ele- 
ments, and  amceba!  in  variable  numbers,  which  are  also  found  in  the  abscess 
walls,  chiefly  in  the  inner  necrotic  zone.    :Mallory  has  devised  a  dilferential 
stain,  by  which  they  can  be  distinguished  in  tissues.     Cultures  are  usually 
sterile.     Lesions  in  "the  lungs  are  seen  when  an  abscess  of  the  liver— as  so 
frequently  hai)pens— points  toward  the  diaphragm   and   extends  by  con- 
tinuity through  it  into  the  lower  lobe  of  the  right  lung.     An  exhaustive 
study  of  the  anurbic  al)scess  of  the  liver  lias  recently  been  niiule  hy  \V.  T. 
Howard,  Jr.,  and  C.  F.  Hoover,  of  Cleveland  (American  Journal  of  the 
Medical  Sciences,  1897,  ii). 

St/mpto Dili. —The  onset  may  be  sudden,  as  in  catarrhal  dysentery,  or 
gradual,  beginning  as  a  trifling"  and  perhaps  transient  diariinea.  In  severe 
gangrenous  cases  the  abruiit  onset  is  more  common.  The  subsecpient  course 
is  a  very  irregular  diarrluea,  marked  by  exacerbations  and  intermissions, 
and  progressive  loss  of  strength  and  flesh.  There  is  moderate  fever  as  a 
rule,  but  many  cases  are  afel)rile  throughout  the  greater  part  of  their  course. 
Abdominal  pain  and  tenesmus,  usually  present  at  the  onset,  especially  in 
severe  cases,  may  be  entirely  absent,  and  vomiting  and  nausea  are  only 
occasionally  observed.  The  stools  vary  very  much  in  number  and  ajipear- 
ance  in  di"fferent  cases  and  at  different  periods  in  the  same  cases.  They 
may  be  very  frequent,  bloody,  and  mucoid  at  the  outset,  as  in  catarrhal 
dysentery;  but  their  main  characteristic,  when  the  disease  is  \\ell  estab- 
lished, is  fluidity.  From  six  to  twelve  yellowish-gray  li(iuid  stools,  con- 
taining mucus  and  occasionally  blood  in  varying  proportions,  are  jiassed 
daily  for  weeks.  Actively  moving  amtelnv  are  found  in  these  stools,  more 
abundantly  during  exacerbations  of  the  diarrhaui,  and  disapi)ear  gradually 
as  the  stools  become  formed. 

Abscess  of  the  liver,  and  especially  of  the  liver  and  lung,  is  a  fre(pient 
and  formidable  complication.    In  India  it  occurs  once  in  every  four  or  five 

CflSCS 

The  duration  of  the  disease  in  uncomplicated  cases  varies  from  six  to 
twelve  weeks.  Eecovery  is  tedious,  owing  to  amvmia  and  muscular  weak- 
ness, often  delayed  by  relapses,  and  there  is  in  all  cases  a  constant  tend- 
ency to  chronicity.    The  mortality  is  much  higher  than  in  catarrhal  dysen- 


><HM«IWB'S^i^'^iiCA9'^'^'^^W»?!B^9EBa^^ 


193  SPECIFIC  INFECTIOUS  DISEASES. 

tery.     A  fatal  issue  is  due  eitlior  to  the  iuitial  gravity  of  the  intestinal 
lesions,  to  exhaustion  in  i)rolonge(l  eases,  or  to  involvement  of  the  Hver. 

{(■)  Diphtheritic   Dysen^  T.— A    form    of    eolitis   or    entero-eolitis    in 
wliieli  ureas  of  necrosis  o(  the  mucous  mcmhranes,  which  on  sejja- 

ration  leave  ulcers.     This  s:  (a)   As  a  primary  disease  conunjr  on 

acutely  and  sometimes  provin.i  .ital.  In  its  milder  grades  the  tojjs  of  the 
folds  of  the  eolon  are  capped  with  a  thin,  yellow  exudate.  In  seve-er  forms 
the  eolon  is  enormously  enlarged,  the  walls  are  thickened,  stiff,  and  infil- 
trated, and  the  mucosa,  from  the  ileo-ca>cal  valve  to  the  rectum,  is  repre- 
sented hy  a  tough,  yellowish  material,  in  whicli  on  section  no  trace  of  the 
glandular  elements  can  he  seen.  The  condition  is  one  of  extensive  necrosis 
of  the  mucosa.  There  are  cases  in  which  this  necrosis  is  superficial,  in- 
volving only  the  ui)per  layers  of  the  mucous  memhrane;  hut  iii  the  most 
advanced  forms  it  nuiy  he',  as  in  the  description  hy  Rokitansky,  "  a  hlack, 
rotten,  friahle,  charred  mass."  The  areas  of  necrosis  nuty  he  more  local- 
ized, and  large  sloughs  are  formed  which  may  ])e  a  half  to  three  fourths 
of  an  inch  in  thickness  and  extend  to  the  serosa.  There  are  instances  in 
which  this  condition  is  confined  to  the  lower  portion  of  the  large  howel. 
A  sailor  from  the  I^Iediterranean  was  admitted  to  the  :\Iontreal  General 
Hospital  under  my  care  with  symptoms  resembling  tyjdioid  fever.  The 
autopsy  showed  enormous  sloughs  in  the  rectum  and  in  the  sigmoid  flexure, 
but  scarcely  any  disease  in  tlie  transverse  or  ascending  colon.  In  cases 
which  last  for  niany  weeks  the  sloughs  separate  and  nuiy  be  tlirown  off, 
sometimes  in  large  tubular  ])ieces. 

{h)  Smmdari/  Diphlhn-ltic  Diisentpn/.—TinH  occurs  as  a  terminal  event 
in  many  acute  and  chronic  diseases.  It  is  not  infrequent  in  chronic  heart 
alTcctions,  in  Bright's  disease,  and  in  cachectic  states  generally.  In  acute 
diseases  it  is,  as  pointed  out  by  Bristowe,  most  frctpiently  associated  with 
pneumonia.  Anatomically  there  may  be  only  a  thin,  superficial  infiltra- 
tion of  the  u]i])er  layer  of  the  mucosa  in  localixx'd  regions,  particularly  along 
the  ridges  and  folds  of  the  colon,  often  extending  into  the  ileum.  In  severer 
forms  the  entire  mucosa  may  be  involved  and  necrotic,  sometimes  having 
a  rough,  granular  ai)pearance.  In  the  secondary  colitis  of  pneumonia  the 
exudation  may  be  i)seudo-mendiranous  and  form  a  firm,  thin,  white  pellicle 
which  seems  to  lie  upon,  not  within,  the  mucous  membrane. 

Slim pfoms.— The  clinical  features  of  diphtheritic  dysentery  are  very 
varied.  In  the  acute  primary  cases  the  patient  from  the  outset  is  often 
extremely  ill,  with  high  fever,  great  prostration,  pain  in  the  abdomen,  and 
frequent  discb.firges.  Delirium  may  be  early  and  the  clinical  features  may 
closely  resemble  those  of  severe  tyi)hoid.  I  have,  on  more  than  one  occa- 
sion, known  this  mistake  to  be  made.  The  abdomen  is  distended  and  often 
tender.  The  discharges  are  frequent  and  diarrhcral  in  character,  and  tenes- 
mus may  not  be  a  striking  symptom.  Blood  and  mucus  may  be  found  early, 
but  are  not  such  constant  features  as  in  the  follicidar  disease.  This  primary 
form  is  very  fatal,  but  tlte  sloughs  may  se})arate  and  the  condition  become 
chronic.  In  the  secondary  form  there  may  have  been  no  symptoms  to 
attract  attention  to  the  large  bowel.  In  a  majority  of  the  cases  the  patient 
has  a  diarrhea — three,  four,  or  more  movements  in  the  day,  which  are  often 


-  s^^^ui*^^'*:***!:^!***?^*' 


.«j.«»»-4Ma*-t.M**i*-Aa«'  ■  «'-■  »«M«w«'  '^w*' 


(?«II»**»=<Wl»*■i'*''^*ft^~ 


DYSENTERY. 


19l» 


0  intestinal 
the  liver, 
•o-colitis    in 
t'h  on  sepa- 

cominjf  on 

tojjs  of  tlic- 
've'er  forin.s 
I,  and  infil- 
in,  i.s  rcpre- 
traco  of  tlie 
sive  necrosis 
|)erfieial,  in- 
iii  the  ninst 
y,  "  a  black, 

more  loeal- 
hree  fourths 
instances  in 
large  bowel, 
real  General 

fever.  The 
noitl  flexure, 
n.     In  cases 

tlirown  off, 

rniinal  event 
hronic  heart 
y.  In  acute 
ociated  with 
icial  infiltra- 
cularly  along 
I.  In  severer 
times  having 
eumonia  the 
vhite  pellicle 

cry  are  very 
itset  is  often 
bdomen,  and 
features  may 
an  one  occa- 
led  and  often 
.'r,  and  tenos- 
'  found  early. 
This  primary 
lition  become 
symptoms  to 
^s  the  patient 
lich  are  often 


profuse  and  weakening.    A  little  blood  and  mucus  may  be  j)assed  at  first, 
but  they  are  not  specially  characteristic  elements  in  the  stools. 

In  all  forms  of  dysentery  death  usually  results  from  asthenia.  The 
pulse  l)ecomes  weaker  and  more  rapid,  tiie  tongue  dry,  the  face  pinched, 
the  skin  cool  and  covered  with  sweat,  and  the  ]iatieiit  falls  into  a  drowsy, 
torpid  condition.  Consciousness  may  I)e  retained  until  the  last,  but  in 
t!ie  jirotractcd  cases  there  is  a  low  delirium  deepening  into  collapse. 

('/)  Chronic  Dysentery. — This  usually  succeeds  an  acute  attack,  though 
the  amcebie  form  may  be  sidjacute  from  the  outset  and  not  present  an  acute 
]ieriod.  Anatomical  changes  in  the  large  intestine  in  chronic  dysentery 
are  variable.  There  may  be  no  ulceration,  ami  the  entire  nuu'osa  presents 
a  rough,  irregular  jmckered  aiipearancc,  in  places  slate-gray  or  blackish  in 
color.  The  subinuco.^a  is  thickened  and  the  muscular  coats  are  hy|ier- 
trophied.  There  nmy  be  cystic  degeneration  of  the  glamUdar  elements,  as 
is  beautifully  figured  in  Woodward's  volume. 

I'lcers  are  usually  ])resent,  ofleu  extensive  and  decjdy  ])igmentcd,  in 
places  perhaps  healing.  The  sulmnicous  and  muscidar  coats  are  thick- 
ened and  the  calibre  of  the  bowel  may  be  reduced.  Stricture,  however,  is 
very  rare. 

The  sijmplovis  of  chronic  dysentery  are  l)y  no  nu'ans  definite,  and  it  is 
not  always  ])ossible  to  separate  the  cases  from  those  of  chronic  diarrluea. 
Many  of  the  characteristic  symptoms  of  the  acute  disease  are  aljsent.  Tenes- 
mus and  severe  grijiing  pains  rarely  occur  excejjt  in  acute  exacerbations. 
The  character  of  the  stools  varies  very  much.  IJlood  ami  necrotic  shreddy 
tissue  are  not  often  found.  ^lucus  is  ])a.ssed  in  variable  anu)unts.  On  a 
mixed  diet  the  faeces  are  thin,  often  frothy,  and  contain  particles  of  food. 
The  motions  vary  from  four  or  live  to  twelve  or  more  in  the  twenty-four 
hours.  There  are  cases  in  which  marked  constipation  alternates  with  at- 
tacks of  diarrluea,  and  scybala  may  be  passed  witli  much  mucus.  In  many 
cases  the  faeces  have  a  semi-fluid  consistency,  and  a  yellowish  or  brown  color 
depending  on  the  amount  of  bile.  Fragments  of  undigested  food  may  be 
found,  and  the  discharges  have  the  character  of  what  is  termed  a  lienteric 
diarrhcoa.  Indeed,  variations  in  the  bile  and  in  the  food  give  at  once  cor- 
responding differences  in  the  character  of  the  stools.  In  the  amoebic  form 
recurrences  are  comnu)n  in  which  blood  and  mucus  again  appear  in  the 
stools,  accompanied  perhaps  by  pus.  Flatulence  is  in  some  cases  distress- 
ing, and  there  is  always  more  or  less  tenderness  along  the  course  of  the 
colon.  The  ai)petite  is  capriciou.s,  the  digestion  disordered,  and  unless  the 
jiatient  is  on  a  strictly  regulated  diet  the  number  of  stools  is  greatly  in- 
creased. The  tongue  is  not  often  furred;  it  is  more  commonly  red,  glazed, 
and  beefy,  and  becomes  dry  and  cracked  toward  the  end  in  protracted 
cases.  There  is  always  anannia  and  the  emaciation  may  be  extreme;  with 
the  exception  of  gastric  cancer,  we  rarely  see  such  ghastly  faces  as  in 
patients  with  prolonged  dysentery.  The  com])lications  arc  those  already 
referred  to  in  the  acute  form.  The  greater  debility  renders  the  patient 
more  liable  to  the  intercurrent  affections,  such  as  pneumonia  and  tuber- 
culosis. Ulceration  of  the  cornea  was  frequently  noted  during  the  civil 
war. 


io«5EsmJa«ii>a»*'.-«»a«^! 


.•»BiWS*«»«=«i!*«<e»5SS»»«<«)i^^ 


^■V*--«..'?-W?l'  ,T- 


200 


SPECIFIC  INFECTIOUS  DISEASES. 


Complications  and  Sequelae.— A  local  peritonitis  may  arise  Ly 
extension,  or  a  diil'use  inilainnuition  may  follow  ])erforaiion.  which  is  usually 
fatal.  Wlicn  this  occurs  almut  the  Ciwal  region,  ]»erityi)lilitis  results;  when 
low  down  in  the  rectum,  periproctitis.  In  108  autopsies  collected  by  Wood- 
ward i)eri'oration  occurred  in  11.  J^y  far  the  most  serious  comidiention 
is  al)sccss  of  the  liver,  which  occurs  frequently  in  the  tropics  and  is  not 
very  uncommon  in  this  country.  It  was  not,  however,  a  frequent  com- 
plication in  dysentery  during  the  civil  war.  In  this  latitude  it  is  certainly 
not  \nicommon.  It  usually  comes  on  insidiously.  'Die  symptoms  will  he 
discussed  in  connection  with  hepatic  abscess. 

In  extensive  epidemics,  however.  Woodward  states  that  cases  of  ordinary 
dysentery  occur  associated  with  all  the  phenomena  of  malaria.  We  have 
had  a  niunber  of  instances  of  the  coexistence  of  the  two  diseases.  With 
reference  to  tyi)hoid  fever,  as  a  complication,  this  author  mentions  that  the 
combination  was  exceedingly  frequent  during  the  civil  war,  and  charac- 
teristic lesions  of  both  diseases  coexisted.    In  civil  practice  it  is  extremely 

rare. 

Sydenham  noted  that  dysentery  was  sometimes  associated  with  rheu- 
matic i>ains,  and  in  certain  epidemics  joint  swellings  have  been  especially 
prevalent.  They  are  probably  not  of  the  nature  of  true  rheumatism,  but 
rather  analogous  to  those  of  gonorrheal  arthritis.  In  severe,  protracted 
cases  there  may  l)e  ])leurisy,  pericarditis,  endocarditis,  and  occasionally  pyic- 
mic  manifestations,  amcmg  which  may  be  mentioned  pylephlebitis.  Chronic 
Bright's  disease  is  also  an  occasional  sequel.  In  protracted  cases  there  may 
be  an  ana-mic  tedcma.  An  interesting  sequel  of  dysentery  is  jiaralysis. 
Woodward  rei)orts  8  cases.  Weir  Mitchell  mentions  it  as  not  uncommon, 
occurring  chielly  in  the  form  of  paraplegia.  As  in  other  acute  fevers,  this 
is  due  ])robably  to  a  neuritis.  Intestinal  stricture  is  a  rare  sequence— so 
rare  that  no  case  was  reported  at  the  Surgeon-CJenerars  office  during  the 
war.  Among  the  sequehe  of  chronic  dysentery,  in  ])ersons  who  have  recov- 
ered a  certain  measure  of  health,  may  be  mentioned  persistent  dyspepsia 
and  irritability  of  the  bowels. 

Diagnosis.— The  recognition  of  the  acute  follicidar  form  is  easy;  the 
frecjuency  of  the  passages,  the  presence  of  blood  and  mucus,  and  the  tenes- 
mus forming  a  very  characteristic  picture.  Local  affections  of  the  rectum, 
particularly  syphilis  and  epithelioma,  may  produce  tenesmus  with  the 
passage  of  "mucoid  and  bloody  stools.  The  acute  diphtheritic  form,  coming 
on  with  great  intensity  and  with  severe  constitutional  disturbances,  is  not 
infrequently  mistaken  for  typhoid  fever,  to  which  indeed  in  many  cases 
the  resemblance  is  extremely  close.  The  higher  grade  of  fever,  the  more 
pronounced  intestinal  symptoms,  the  presence,  particularly  in  the  early 
stage,  of  a  small  amount  of  blood  in  the  stools,  the  absence  of  enlargement 
of  the  spleen,  the  rose  rash,  and  the  Widal  reaction  should  lead  to  a  correct 
diagnosis.  In  the  amn>bic  form  the  diagnosis  can  readily  be  made  by  ex- 
amination of  the  stools.  A  characteristic  feature  of  these  eases  is  their 
irregular,  chronic  course.  A  patient  may  be  about  and  in  fairly  good  con- 
dition, with  well-formed  stools  and  very  slight  intestinal  disturbance,  in 
whose  faeces  the  ama'bffi  may  still  be  discovered,  and  in  whom  the  disease 


■— r-j#RK  -satse3*;«eacssmi'wr': 


.m*S«^B»**«»W«f-M**'-**«'-'««**«»^^'^^^ 


DYSENTERY. 


201 


i 


lay  arise  by 
oil  is  u-<ually 
•osiilts;  when 
c'd  by  Wood- 
complication 
s  and  is  not 
cqncnt  coin- 
t  is  certainly 
tonis  will  bo 

s  of  ordinary 
a.  We  have 
icasos.  With 
ions  that  the 
and  cliarac- 
is  extremely 

1  with  rhcii- 
!cn  csj)eeially 
Limatism,  but 
•e,  protracted 
isionally  pyw- 
itis.  Chronic 
scs  there  may 
is  jiaralysis. 
t  uncommon, 
te  fevers,  this 
sequence — so 
30  during  the 
o  have  recov- 
ent  dyspepsia 

n  is  easy;  the 
ind  the  tenes- 
if  the  rectum, 
[lus  with  the 
form,  coming 
bancos,  is  not 
n  many  cases 
vcr,  the  more 
in  the  early 
f  enlargement 
id  to  a  correct 
}  made  by  ex- 
cases  is  their 
irly  good  con- 
isturbance,  in 
>m  the  disease 


is  at  nnv  time  likely  to  recur  with  intensity.  In  some  cases,  com].licated 
bv  abscess  of  the  liver  and  lung  discliarging  tlirougii  a  lironcluis,  tlie  diag- 
nosis mav  rest  on  the  detection  of  amo-lKi-  in  the  sputa,  when  they  cannot 
be  found"  in  the  stools  owing  to  the  latency  of  the  intestinal  disturbance. 
Lcucocytosis  is  rare  excei)t  when  complications  arise.  Instances  have  oc- 
curred in  niv  wards. 

Treatment.— Flint  has  shown  that  sporadic  dysentery  is,  in  its 
sligiiter  grades  at  least,  a  sell'-limited  di,>^ease,  which  runs  its  course  in  eight 
or^nine  days.  Heading  a  report  of  his  cases,  one  is  struck,  however,  with 
their  co!ni)arative  mildness. 

Tlie  enormous  surface  involved,  amounting  to  many  scpiare  feet,  the 
constant  im'scncc  of  irritating  particles  of  food,  and  tlie  impossibility  of 
getting  absolute  rest,  are  conditions  which  render  the  treatment  of  dysen- 
tery pwuliarly  difhcult.     ^rorcover,  in  the  severer  cases,  when  necrosis  of 
the  mucosa  has  occurred,  ulccrraion  necessarily  follows,  and  cannot  in  any 
way  be  obviated.    When  a  case  is  seen  early,  i.articularly  if  there  has  been 
constipation,  a  saline  purge  should  be  given.    The  free  watery  evacuations 
])roduced  by  a  dose  of  salts  cleanse  the  large  bowel  with  the  least  possible 
irritation,  and  if  necessary,  in  the  course  of  the  disease,  particularly  if 
scybala  are  present,  the  dose  may  be  repeated.     Purgatives  pre,  as  a  rule, 
objectionable,  and  the  profession  has  largely  given  up  their  use.    Of  medi- 
cines given  by  the  mouth  which  are  supposed  to  have  a  direct  elTect  upon 
the  disease,  ipecacuanha  still  maintains  its  reputati(m  in  the  tropics.     It 
did  not,  however,  i)rove  satisfactory  during  the  civil  war;  nor  can  I  say 
that  in  cases  of  sporadic  dysentery  I  have  ever  seen  the  marked  effect 
described  by  the  Anglo-Indian  surgeons.     The  visual  method  of  adminis- 
tration is  to  give  a  iireliminarv  dose  of  opium,  in  the  form  of  laudanum  or 
morphia,  and  half  an  hour  after  from  20  to  GO  grains  of  ipecacuanha.    If 
rejected  by  vomiting,  the  dose  is  repeated  in  a  few  hours. 

]\Iimite  doses  of  corrosive  sublimate,  one  hundredth  of  a  grain  every 
two  hours,  are  warmly  recommended  by  Einger.  Large  doses  of  bismuth, 
half  a  drachm  to  a  drachm  every  two  hours,  so  that  the  patient  may  take 
from  12  to  l'>  drachms  in  a  day,  have  in  many  cases  had  a  beneficial  effect. 
To  do  good  it  must  be  given  in  large  doses,  as  recommended  by  Monneret, 
who  gave  as  high  as  70  grammes  a  day.  It  certainly  is  more  useful  in  the 
chronic  than  the  acute  cases.  It  is  best  given  alone.  Opium  is  an  invalu- 
able remedy  for  the  relief  of  the  pain  and  to  quiet  the  peristalsis.  It  should 
be  given  as  morphia,  hypodermically,  according  to  the  needs  of  the  pa- 
tient. .    ,      i.      i.1 

The  treatment  of  dvscntery  l)y  topical  applications  is  by  far  the  most 
rational  plan.  A  serious  obstacle,  however,  in  the  acute  cases,  is  the  ex- 
treme irritability  of  the  rectum  and  the  tenei^mus  which  follows  any  at- 
tempt to  irrigate  the  colon.  A  preliminary  cocaine  suppository  or  the  injec- 
tion of  a  small  quantity  of  the  4-per-cent  solution  will  sometimes  relieve 
this,  and  then  with  a  long  tube  the  solution  can  be  allowed  to  flow  in  slowly. 
The  patient  should  be  in  the  dorsal  position  witli  a  pillow  under  the  hips^ 
so  as  to  get  the  etTect  of  gravitation.  Water  at  the  temperature  of  100° 
is  very  soothing,  but  the  irritability  of  the  bowel  is  such  that  large  quan- 


n9iiMtara(anx3!«ic«cK 


■mtiba£se,ri,^m»'^!Si&.*»y^SSfil^SSti^^>ff&>^^ 


rtCiit^-— -A-i- 


202 


SPECIFIC  INFECTIOUS  DISRASES. 


titles  can  rarely  be  retained  for  any  tiiiie.     When  the  acute  symptoms  sub- 
side, the  iiijirlions  are  better  borne,     \urioiis  a.-^trinj:ei;ts  may  be  used- 
alum,  aielate  of  lead,  sidphate  oi'  zinc  and  copper,  and  nitrate  of  silver. 
Of  these  remedies  the  nitrate  of  silver  is  the  best,  thon;;h,  1  think,  not  in 
very  acute  cases,     in  tlie  chronic  form  it  is  perhaps  the  most  satisfactory 
method  of  treatment  which  we  have.     It  is  useless  to  j,'ive  it  in  ;he  small 
injections  of  two  or  three  ounces  with  1  to  2  grains  of  the  salt  to  the  ounce, 
it  must  lie  a  larw  irrif,'ati!iK  injection,  which  will  reach  all  parts  of  the 
colon.     This  plan  was  introduced  l)y  Hare,  of  Kdinburjrh,  and  is  highly 
recommended  liy  Steplicn  .MacKeiizie  and  11.  V.  \Vood.    The  solution  must 
be  ii^iirly  strong,  '<;0  to  30  grains  to  the  pint,  and  if  possiiile  from  '.]  to  (i 
pints  of  fluid  must  l)e  injected.     To  begin  with  it  is  well  to  use  not  more 
than  a  draciim  to  the  :.''i)ints  or  2^  \nnU,  and  to  let  the  warm  lluid  run 
in  slowly  thro\igh  a  tube  passed  far  into  the  bowel.     It  is  at  times  intensely 
liainfid  and  is  rejected  at  once.     Argyria,  so  far  as  1  know,  has  never  fol- 
lowed the  prolonged  use  of  nitrate  of  silver  injections  in  chronic  dysentery. 
In  the  cases  of  ania'bic  dysentery  we  have  been  using  at  the  Johns  Hopkins 
Hospital  with  great  ^enetlt  warm  injections  of  quinine  in  strengtli  of  1  to 
5,000,  1  to  •-.',r)()0,  and  1  to  1,000.     The  aimebie  are  rapidly  destroyed  by 
the  drug.    These  large  injections  are  said  not  to  be  without  a  certain  degree 
of  danger.     I  have  never  seen  any  ill  eireeis,  even  witii   the  very  large 
amounts.     When  there  is  not  much  tenesmus,  a  small  injection  of  thin 
starch  with  half  a  drachm  to  a  drachm  of  laudanum  gives  great  relief,  but 
for  the  tormina  and  tenesmus,  the  two  most  distressing  symptoms,  a  hypo- 
dermic of  mor])hia  is  the  only  satisfactory  remedy.     Local  api)lications  to 
the  abdomen,  in  the  form  of  light  ])oultices  or  turpentine  stupes,  are  very 
grateful. 

The  diet  in  acute  cases  must  be  restricted  to  milk,  whey,  and  broths, 
and  during  convalescence  the  greatest  care  must  bo  taken  to  ])rovide  only 
the  nu)st  digestible  articles  of  food.  In  chronic  dysentery,  diet  is  perhaps 
the  most  important  element  in  the  treatment.  The  number  of  stools  can 
frequently  be  reduced  from  ton  or  twelve  in  the  day  to  two  or  three,  by 
})lacing  the  patient  in  bed  and  restricting  the  diet.  Many  cases  do  well 
on  milk  alone,  but  the  stools  should  be  carefully  watched  and  the  amount 
limited  to  that  which  can  bo  digested.  If  curds  appear,  or  if  nnich  oily 
matter  is  seen  on  microscopical  examination,  it  is  host  to  reduce  the 
amount  of  milk  and  to  su])plcmcnt  it  with  beef-juice  or,  better  still,  egg- 
albumen.  The  largo  doses  of  bismuth  seem  specially  suitable  in  the  chronic 
cases,  and  the  injections  of  nitrate  of  silver,  in  the  way  already  mentioned, 
should  always  be  given  a  trial. 


XXIV.   MALARIAL   FEVER. 

Definition. — An  infectious  disease  characterized  by:  (n)  paroxysms  of 
intermittent  fever  of  quotidian,  tertian,  or  quartan  typo;  (h)  a  continued 
fever  with  marked  remissions;  (c)  certain  pernicious,  ra])idly  fatal  forms; 
and  {d)  a  chronic  cachexia,  with  anaemia  and  an  enlarged  spleen. 


■jyit'-^tt-MW.-' 


-.T^jr-^.-ttBTWSiSrTss: 


I 


iptoms  sub" 
•  Ijo  U!<ecl — • 
f  of  silver, 
link,  not  in 
satisfiU'tory 
11  lilt"  i^niall 
)  t'lo  ounce. 
iiirls  of  the 
1(1  it-  highly 
lution  must 
from  15  to  (> 
so  not  more 
m  ihiid  run 
les  intensfly 
IS  never  fol- 
c  dysentery, 
ins  Hopkins 
ijrtli  of  1  io 
lestroyed  hy 
rtain  degree 
'  very  large 
ion  of  thin 
it  relief,  but 
uns,  a  hypo- 
plications  to 
les,  are  very 

and  broths, 
])rovido  only 
?t  is  perhaps 
jf  stools  can 
or  three,  by 
ases  do  well 

the  amount 
if  much  oily 

reduce  the 
er  still,  egg- 
1  tlie  chronic 
y  mentioned. 


paroxysms  of 
a  continued 
fatal  forms; 

en. 


MALAlU.VIi   FKVER. 


20» 


With  the  disease  are  invariably  nssociated  the  ha-matozoa  described  by 

Laveran.* 

Etiology.— (1)  Geographical  Distribution.— In  I'.uropo,  southern  Uu.s- 
8ia  and  curtain  jiarts  of  Italy  are  lunv  the  chief  seats  of  the  disease.  It 
is  not  widely  prevalent  in  (iermany,  France,  or  England,  und  the  foci  of 
ei)idemics  are  becoming  yearly  more  restricted. 

In  the  United  States  nuilaria  iuis  progressively  diminished  in  extent 
and  severity  during  the  past  fifty  years.  The  records  of  the  health  boards 
of  the  larger  cities  on  tlie  Atlantic  coast  which  give  a  high  mortality  from 
the  disease  are  ((uite  untrustworthy.  From  New  Kngland,  where  it  once 
prevailed  extensively,  it  has  gradually  disapjiearcd,  but  there  has  of  late 
years  been  a  slight  return  in  some  iilaces.  In  the  city  of  New  York  the 
milder  forms  of  the  disease  are  not  uncommon.  In  rhiladelpliia  and  along 
the  valleys  of  the  Delaware  and  Schuylkill  iJivers,  fornu'rly  hot-beds  of 
malaria,  the  disease  has  become  much  restricted.  In  Baltimore  a  few  cases 
develop  in  the  autmnn,  but  a  majority  of- the  patients  seeking  relief  are 
from  the  outlying  districts  and  one  or  two  of  the  inlets  of  Chesaiicake  Hay. 
Throughout  the  Southern  States  there  are  nuuiy  regions  in  which  malaria 
l)revails;  but  here,  too,  the  disease  has  diminished  in  jjrevalcnce  and  in- 
tensity. In  the  Northwestern  States  malaria  is  almost  unknown.  It  is  rare 
on  the  Pacific  coast.  In  the  region  of  the  (ireat  Lakes  malaria  prevails 
only  in  the  Lake  Erie  and  Lake  St.  Clair  regions.  The  St.  Lawrence 
districts  remain  free  from  the  disease. 

In  India  malaria  is  very  prevalent,  particularly  in  the  groat  river  basins. 
In  Burnui  and  Assam  severe  types  are  nu't  with,  and  recently  the  anomalous 
form  of  fever  known  as  the  Kdla-azar  of  Assam  has  been  shown  to  be  ma- 
larial (Rogers). 

In  Africa  the  malarial  fevers  form  the  great  obstacle  to  European  set- 
tlements on  the  coast  and  along  the  river  basins.  The  hlad--walcr  or  West 
African  fever  of  the  Gold  Coast  is  a  very  fatal  typo  of  malarial  ha!mo- 

globinuria. 

(2)  Telluric  Conditions.— The  importance  of  the  state  of  the  soil  in  the 
etiology  of  malaria  is  universally  recognized.  It  is  seen  particularly  in 
low,  marshy  regions  which  have  an  abundant  vegetal)le  growlli.  Kstu- 
arie's,  badly  drained,  low-lying  districts,  the  course  of  old  river-beds,  tracts 
of  land  which  are  rich  in  vegetable  matter,  and  jmrticularly  districts  su<  h 
as  the  Roman  Campagna,  which  have  been  allowed  to  fall  out  of  cultiva- 
tion, are  favorite  localities  for  the  dcveloj)ment  of  the  malarial  jioison. 
Those  conditions  are  most  frequently  found,  of  course,  in  tropical  and 
subtropical  regions,  but  nothing  can  be  truer  than  the  fact  that  rooking 
marshes  of  the  most  pestilent  appearance  may  bo  entirely  devoid  of  the 
poison,  and  the  disai)pearance  of  the  disease  from  a  locality  is  not  necos- 


♦  For  a  full  ponsidcration  o'  the  mnlnria  prolilein  as  it  has  presented  itself  to  ns  in 
Baltimore  diirintr  the  past  nine  years,  the  r?ader  is  referred  to  the  monoprraph  of  Thayer 
and  Ilewetson,  and  the  article  of  Barker  in  vol.  v  of  the  Johns  Hopkins  Hospital  Re- 
ports, to  the  exhaustive  article  by  Welch  and  Thayer  in  Loomis  and  Thompson's  System 
of  Medicine,  and  to  Thayer's  Lectures  on  the  Malarial  Fevers,  New  York,  1897. 
13 


,„■--- l>o^^"»■^!«  TT  J-OTTWSr 


r^ajirrTiT-TT-T-. 


\  , 


# 


204 


SPEriPlC  INFECTIOUS  DISEASES. 


Karily  nssocinlod  witli  any  iiiatcrial  improvement  in  the  condition  of  tin' 
ninrslics  or  of  tiie  soil.  Tliiis,  in  New  Kngland  and  in  parts  of  western 
Canada,  in  wliicli  malaria  formerly  was  very  ])revalent,  the  increased  sahi- 
l)rity  is  usually  attrihuted  to  the  clearing'  of  the  forests  and  the  hetter 
draina^T  of  the  jjround;  hut  these  improvements  alone  ean  seareoly  e.\- 
jdain  the  disap]»eaninee.  since  in  many  districts  there  are  marshy  traets 
and  low-lyinj;  lands  in  every  resjiect  like  those  in  which,  e-en  in  the  same 
hititude,  the  disease  still  prevails.  In  short,  it  is  impossihlo  to  ascertain 
from  the  mitiire  of  the  soil  and  climate  in  any  f,nven  i)lace  whether  it  is 
malarial  or  not.  In  the  al)sence  of  accurate  knowledj,^'  as  to  the  hahitat 
of  the  haMiiatozoa,  the  only  nu-ans  of  deciding  this  ))oint  is  l)y  notiein<j;  the 
effect  of  residence  in  such  a  place  on  the  Iiunuin  suhjcct,  preferahly  one  of 
the  Caucasian  race. 

(3)  Season. — In  the  tropics  there  are  minimal  and  maximal  pcriod^^, 
the  former  correspond inj;  to  the  summer  and  winter,  the  latter  to  the 
s])rinpr  and  autumn  months.  In  temperate  re<;ions,  like  the  central  Atlan- 
tic States,  there  are  oidy  a  few  cases  in  the  sprinjx,  usually  in  the  month  of 
May,  and  a  larf;e  iiumlier  of  cases  in  Septendjer  and  Octoher,  and  some- 
times in  \ovend)er. 

(4)  Meteorological  Conditions. — (a)  Ileal. — A  tolcrahly  hifrh  tempera- 
ture is  one  of  the  cs.sential  conditions  for  the  development  of  the  virus. 
It  is  more  jirevalent  after  ])rolonf;ed  hot  summers. 

(/()  ^[()ishnr. — In  the  tro])ics  the  nudarial  fevers  are  most  prevalent  in 
the  rainy  seasons.  In  the  temperate  climates  the  relation  between  the 
rainfall  and  malaria  is  not  so  clear,  and  cases  are  more  numerous  after  a 
dry  summer;  l)ut  if  either  heat  or  moisture  is  excessive,  the  development 
of  the  virus  is  checked  for  a  time. 

(r)  Winds. — Many  facts  are  on  record  which  seem  to  indicate  that  the 
poison  may  ho  carried  to  some  distance  hy  wiiuls.  Tlio  planting  of  trees 
has  been  held  to  interfere  with  the  transmission  by  ])revailing  winds. 
Possibly,  however,  the  quickly  growing  trees,  such  as  the  Eucalyptus  ghhu- 
hts,  have  acted  more  beneficially  by  drying  the  soil. 

(5)  Specific  Gravity.— 'i1uit  the  distrilmtion  of  the  poison  of  malaria 
is  inlluenced  by  gravity  has  long  been  conceded.  Persons  dwelling  in  the 
upper  stories,  or  in  buildings  elevated  some  distance  above  the  ground, 
are  exempt  in  a  marked  degree. 

The  Specific  Germ.— As  Ilirsch  correctly  remarks,  the  late  J.  K.  ]\Iitch- 
ell  "  was  the  first  to  approach  in  a  scientific  spirit  the  nature  of  infec- 
tive disease  and  particularly  in  malarial  fever."  ^Many  attempts  were 
made  to  discover  a  constant  and  characteristic  organism.  In  1880  Laveran, 
a  French  army  surgeon,  announced  the  discovery  of  a  parasite  in  the  blood 
of  patients  attacked  by  malarial  fever.  During  the  next  three  years  he 
juiblislied  nine  additional  communications,  but  for  a  time  these  observa- 
tions attracted  little  attention.  The  Italian  observers  Marcliiafava,  Celli, 
and  Golgi  corroborated  T.averau's  statements.  In  this  country  Laveran's 
work  was  confirmed  by  Councilman,  by  mj'self.  Walter  James,  Dock,  and 
many  othe^-  In  India,  Vandyke  Carter's  gocjd  work  on  the  subject  has 
been  followed  up  by  a  number  of  observers.    So  far  as  I  know,  not  a  single 


^rpr.%iKTnng^^. 


^^fSntiiT^-! 


MALARIAL  PEVKtt. 


205 


tion  of  till' 

of    WCStlTIl 

rcasod  suhi- 
tlio  better 
■icivrcoly  e.\- 
iirsliy  tracts 
in  the  Bamo 
to  asa-rtain 
hotluT  it  U 
the  habitat 
noticinj:;  tlio 
ralily  one  of 

inal  period^, 
lUtor  to  the 
ntral  Allan- 
lie  month  of 
',  and  sonie- 

ph  tempera- 
dI  the  virns. 

prevalent  in 
between  the 
erous  after  a 
development 

cate  that  the 
iting  of  trees 
iiiling  -winds. 
ill/ pi  us  (jlobii- 

n  of  malaria 

,'elling  in  the 

the  ground, 

J.  K.  Mitch- 
ure  of  infec- 
ttempts  were 
1880  Laveran, 
3  in  the  blood 
hree  years  he 
these  observa- 
iiiafiiva,  Celli, 
itry  Laveran's 
es,  Dock,  and 
le  subject  has 
V,  not  a  single 


observer,  who  has  had  the  necessary  training  and  the  material  at  hi3  com- 
mand, has  tailed  to  (iemoii.strate  the  existence  of  liiese  jiarasites. 

Tiie  bodies  which  have  Iteen  found  invariably  nssociated  with  all  forms 
of  malarial  fevers  belong  to  the  protozoa  and  to  a  group  of  organisms 
known  as  the  ha'iiwiijtozoa,  usually  placed  among  the  sporozoa.  I'arasites 
of  the  red  i)lood-corpuseles  have  been  met  with  ul)unduntly  in  the  blood 
of  iisii,  turtles,  and  many  si)ecies  of  i)irds  (sec  i)apers  by  W.  (i.  Maeallum 
anil  <»pie  in  .Journal  of  Experimental  .Medicine,  vol.  ii). 

The  parasites  are  true  liaMuocytozoa,  existing  and  ])nrsuing  their  cycle 
of  e.xistence  within  the  red  blood-corpuscles  of  the  infected  individual. 
Tiie  youngest  forms,  small,  hyaline,  anueboid  bodies,  enter  the  red  blood- 
eoriniscjcs  and  develoii,  accumnlating,  as  tiiey  increase  in  size,  line  gran- 
ules of  dark  ])igment,  which  is  formed  at  the  expense  of  tin;  Inemogloltin 
of  the  including  corpuscle.  When  the  organisms  have  reached  their  full 
development  and  destroyed  tiicir  iiosts.  tiie  pignu'ut  grannies  gather  into 
a  central  clump  or  block,  and  tlie  ])arasites  break  up  into  a  number  of  small 
round  or  ovoid  hyaline  bodies,  each  one  of  wlii<h  represents  a  fresh  young 
organism  ready  to  attack  a  new  corpuscle  and  begin  again  a  cycle  of 
existence. 

Several  varieties  of  the  parasite  have  been  separated,  each  of  which  is 
associated  with  a  characteristic  type  of  fever.  These  varieties  are:  (1) 
The  parasite  of  tertian  fever;  (2)  the  parasite  of  quartan  fever;  (3)  the 
jiarasite  associated  with  the  more  irregular  fevers  occurring  in  temperate 
climates,  in  the  later  summer  and  autumn — the  "  a'slivo-autnmnal  fever" 
of  the  Italians.  Ciolgi  first  jiointed  out  the  remarkable  fact  that  the  para- 
sites of  the  regularly  intermittent  fevers— tlu!  tertian  and  (piartan  ])arasites 
—exist  in  the  blood  in  great  groups,  all  the  members  of  which  are  approxi- 
mately at  the  same  stage  of  development.  Tims  an  entire  group  of  myriads 
of  parasites  undergoes  sporulati(m  within  a  ])eriod  of  several  hours.  The 
sponthiiioii  of  mich  a  group  of  pnrasilfs  is  olwaijs  folhnced  bi/  the  malarial 
paroxysm,  wliich  very  ])ossil)ly  depends  upon  some  toxic  sul)stance  which  is 
developed  at  the  time  of  sporulation.  The  tertian  parasite  reiptires  about 
forty-eight  hours  to  accomplish  its  cycle  of  development  and  undergo 
sporulafion.  Thus  with  infections  with  a  single  group  of  tertian  parasites, 
sporulation  occurs  every  other  day,  resulting,  as  might  be  expected,  in 
tertian  paroxysms.  ]\rore  often,  however,  infections  with  two  groups  of  ter- 
tian parasites  arc  seen — groups  reaching  maturity  on  alternate  days,  and 
causing  cpiotidian  paroxysms.  Very  rarely  infections  with  multiple  groups 
of  vhe  ])arasito  are  met  with. 

The  cycle  of  existence  of  the  quartan  parasite  lasts  about  seventy-two 
hours,  ami  if  but  one  group  of  organisms  be  present,  typical  quartan  fever 
results.  The  presence  of  two  groups — double  quartan  infection — is  asso- 
ciated with  paroxysms  on  two  successive  days,  followed  ])y  a  day  of  inter- 
mission; the  presence  of  three  groups  gives  rise  to  quotidian  paroxysms. 
Very  rarely  more  than  three  groups  may  be  present. 

The  parasite  of  the  autumnal  type  possesses  a  cycle  of  development  the 
exact  duration  of  which  is  still  a  subject  of  dispute;  it  is  probably  vari- 
able, lasting  from  twenty-four  hours  or  less  to  forty-eight  hours  or  even 


I 


nwf:i-^"^«.'ns;- 


" -3B!'VEC?;"^'.AjSS!«lW.~ 


1 1 


206 


SPECIFIC  INFECTIOUS  DISEASES. 


more,  tlie  variationf?  dt'pcnding  upon  contlitions  not  wholly  known.  AVhilc 
at  the  beginning  of  the  infection  the  arrangement  of  the  parasites  in  groups 
may  he  made  out,  this  regular  arrangement  often  disai)})ears,  and  organ- 
isms at  diil'erent  stages  of  development  may  he  found  at  the  same  time. 

Segmentation  nuiy  thus  occur  at  irregular  intervals,  sometimes  almost 
continuously.  The  resulting  fever  may  be  regidarly  intermittent,  but  is 
often  irregular  and  sometimes  continuous. 

The  pardsilc  of  icrUaii  fever  begins  its  cycle  of  development  as  a  small, 
hyaline,  auuehoid  body.  This  rai)idly  accumulates  fine  brown  pigment 
granules  which  are  thrown  into  active  motion;  the  including  corpuscle 
becomes  exi)anded  and  decolorized  as  the  parasite  grows.  The  full-grown 
tertian  organism  is  about  the  size  of  a  normal  red  corpuscle.  In  sporida- 
tion  the  segments  numljer  from  tifteen  to  twenty,  or  even  more. 

The  parosiie  of  ijuarlaii  fever  is  very  similar  in  its  appearance  to  the 
tertian  organism.  The  amccbcrid  movements  arc,  however,  slower,  and 
the  ])igment  granules  are  coarser,  darker,  and  in  less  active  motion.  The 
fully  developed  parasite  is  smaller,  while  the  corjjuscle  in  which  the  or- 
ganism develops,  instead  of  becoming  expanded  and  decolorized,  as  in  the 
tertian  infections,  rather  shrinks  about  the  parasite  and  assumes  a  deeper, 
greenish,  somewhat  brassy  color.  In  sporulation  the  segments  are  fewer, 
from  five  to  ten  in  numljer.  They  are  arranged  with  great  regularity 
about  the  central  pigment  cluni])  or  block,  forming  beautiful  "  rosettes."' 

The  parasite  of  the  a'ntivo-nuinmnal  fever  is  considerably  smaller  than 
the  other  varieties;  at  full  development  it  is  often  less  than  one  half 
the  size  of  a  red  blood-corpuscle.  The  pigment  is  much  scantier,  often 
consisting  of  a  few  minute  granules.  At  first  only  the  earlier  stages  of  de- 
velopment, small,  hyaline  bodies,  sometimes  with  one  or  two  ])igmcnt  gran- 
iiles,  are  to  be  found  in  the  peripheral  circulation;  the  later  stages  are  ordi- 
narily only  to  be  seen  in  the  l)lood  of  certain  internal  organs,  the  spleen 
and  bone  marrow  particularly.  The  corpuscles  containing  the  parasites 
become  not  infrequently  shrunken,  crenated,  and  brassy-colored.  After 
the  process  has  existed  for  about  a  week,  larger,  refractive,  crescentie, 
ovoid,  and  round  bodies,  with  central  clum])s  of  coarse  pigment  granules, 
begin  to  aj)])ear.  These  Ijodies  are  characteristic  of  jEstivo-autumnal  fever. 
Their  significance  is  a  matter  of  dispute. 

From  the  full-grown  tertian  and  quartan  parasites,  and  from  the  round 
bodies  -with  central  pigment  clumps  in  a'stivo-autumnal  infections,  long, 
actively  moving  llagclla  may  develop;  these  may  at  times  break  loose  and 
move  about  free  among  the  corpuscles.  The  observations  of  W.  G.  Mac- 
allum  suggest  that  flagellation  is  a  sexual  process,  the  flagella  representing 
the  male  elements.  Manson  thinks  that  the  flagella  represent  the  forms 
in  which  the  parasites  exist  outside  the  body.  Ross,  in  India,  observed 
the  flagellation  in  l)lood  taken  from  the  stomach  of  mosquitoes  which  had 
been  allowed  to  feed  upon  malarial  subjects,  ^lanson  suggests  that  the 
mosquito  is  the  intermediate  liost  in  the  life  history  of  the  parasite. 

The  general  symjjtoms  and  morbid  anatomy  of  malaria  are  in  hnr- 
mony  with  the  clianges  which  these  parasites  induce.  The  remarkable 
periodicity  of  the  manifestations  of  paludism  arc  well  explained  when  we 


.y.wjTii  ■i."i-'V,wn;nr5«:S,J«rjp>u41. 


/  ♦^r^VtsinlsS^  .!■».'■;-■«- ^ -; 


MALARIAL  FEVER. 


207 


wn.  'While 
>s  in  groups 
and  organ- 
lie  time, 
lines  ahnot^t 
tent,  but  id 

;  as  a  small, 
vn  pigment 
g  corpuscle 
;  full-grown 
In  sporula- 

•ancc  to  the 
slower,   and 
lotion.     The 
liich  the  or- 
kI,  as  in  the 
les  a  deeper, 
;s  are  fewer, 
it  regularity 
"  rosettes." 
smaller  than 
an  one  half 
antier,  often 
stages  of  de- 
igment  gran- 
igos  are  ordi- 
s,  the  spleen 
the  parasites 
ored.     After 
e,  crescent  ic, 
ent  granules, 
tumnal  fever. 

)m  the  round 
Gctions,  long, 
3ak  loose  and 
:  W.  G.  Mac- 
,  representing 
nt  the  forms 
idia,  observed 
les  which  had 
rests  that  the 
parasite. 
I  are  in  hnr- 
le  remarkable 
incd  when  we 


consider  the  relations  which  those  manifestations  bear  to  the  life  history 
of  the  parasite.  The  destruction  of  the  red  blood-corpuscles  by  the  organ- 
ism can  be  traced  in  all  stages.  Tlie  presence  of  pujmcnl  in  the  blood  and 
viscera  so  characteristic  of  malaria  results  from  tlie  transformation  of  the 
ha'inoglobin  by  tlie  parasites.  The  antcmia  is  a  direct  conseipience  of  th" 
widespread  destruction  of  the  corpuscles  themselves.  The  severe  cerebral 
symptoms  in  ]iernicious  cases,  as  well  as  the  occasional  cases  of  choleri- 
form  malaria,  have  Ijcen  shown  to  be  associated  with  the  special  localiza- 
tion of  the  parasites  in  capillaries  of  the  brain,  or  in  the  mucous  membrane 
of  the  gastro-intestinal  tract. 

There  are,  however,  many  gai)S  in  our  knowledge.  While  by  hypo- 
dermic or  intravenous  inoculation  malarial  infection  may  be  transferred 
from  one  individual  to  another,  the  same  type  always  appearing  in  the 
inocidated  individual,  yet  we  are  quite  ignorant  of  the  form  in  which  the 
parasite  exists  outside  of  the  human  body.  All  exi)eriinents  at  cultivation 
of  the  parasites  have  failed.  We  are  therefore  also  ignorant  as  to  the  man- 
ner of  infection.  The  evidence  appears  to  suggest  that  this  occurs  generally 
through  the  respiratory  tract,  though  proof  of  this  supposition  is  want- 
ing. That  infection  may  occur  hyi)odermically  is  proved  by  the  inocula- 
tion experiments.  Repeated  attempts  to  bring  al)out  infection  through 
the  gastro-intestinal  tract  have  all  failed. 

Meantime,  awaiting  further  knowledge,  advantage  may  be  taken  of  the 
constant  presence  of  the  parasite  in  malaria.  This  alone,  without  refer- 
ence to  the  true  nature  of  the  organism,  is  a  fact  of  the  highest  impor- 
tance. To  be  able,  everywhere  and  under  all  circumstances,  to  differenti- 
ate between  malaria  and  other  forms  of  fever  is  one  of  the  most  important 
advances  which  has  l)een  made  of  late  years  in  practical  medicine. 

Morbid  Anatomy.— The  changes  result  from  the  disintegration  of 
the  red  blood-cori)uscles,  accumulation  of  the  ])igment  thereby  formed,  and 
possibly  the  inlluence  of  toxic  materials  jiroduced  by  the  ]iarasite.  Cases 
of  simple  malarial  infection,  the  ague,  are  rarely  fatal,  and  our  knowledge 
of  the  morbid  anatomy  of  the  disease  is  drawn  from  the  pernicious  malaria 
or  the  chronic  cachexia.  Rupture  of  the  enlarged  spleen  may  occur  spon- 
taneously, but  more  commonly  from  trauma.  A  case  of  the  kind  was  ad- 
mitted under  my  colleague,  "llalsted,  in  June,  188i),  and  Dock  has  re- 
cently reported  two  cases. 

(i)  Pernicious  Malaria.— The  blood  is  hydra^mic  and  the  serum  may 
even  be  tinged  with  hamioglobin.  The  red  blood-corpuscles  present  the 
cndoglobnlar  forms  of  the  parasite  and  are  in  all  stages  of  destruction. 
The  %)lcen  is  enlarged,  often  only  moderately;  thus,  of  two  fatal  cases 
in  my  wards  the  spleens  measured  13X8  cm.  and  It  X  8  cm.  respect- 
ively. Tn  a  fresh  infection,  the  spleen  is  usually  very  soft,  and  the  pulp 
hike-colored  and  turbid.  Tn  cases  of  intense  reinfection  the  spleen  may 
be  enlarged  and  firm.  The  amoimt  of  pigment  in  the  spleen  elements 
is  greatly  increased.  The  pulp  contains  large  numbers  of  red  corpuscles 
enclosing  parasites.  Enormous  numbers  of  phagocytes,  large  and  small, 
are  to  he  seen,  some  of  the  larger  being  necrotic.  The  liver  is  swollen  and 
turbid.     In  very  acute  cases  there  is  not  necessarily  any  macroscopic  pig- 


•*T^-T«Si' 


208 


SPECIFIC  INFECTIOUS  DISEASES. 


mentation,  though  microscopically  the  capillaries  may  be  packed  with 
phagocytes,  which  may  almost  occlude  the  vessels.  Parasites  may  be  pres- 
ent in  considerable  numbers,  usually  within  the  red  corpuscles.  Areas  of 
dissemiiuited  necrosis  closely  similar  to  those  observed  in  typhoid  fever, 
diphtheria,  and  other  acute  infectious  diseases,  have  been  described  by 
Guarnieri,  Bignami,  and  Barker.  In  association  Avith  these  areas,  Barker 
describes  capillary  thrombosis.  Perivascular  (portal)  iniiltration  has  been 
found  in  a  very  acute  case  in  a  young  man  (Dock).  The  k-idiiei/s  show  only 
moderate  pigmentation,  with  nu)re  or  less  parenchymatous  degeneration. 
In  severe  cases  with  ha'nioglobinuria  there  nuiy  be  extensive  necrosis  of 
the -epithelium  of  the  convoluted  tubes  with  hamorrhagcs  into  the  glom- 
eruli and  interstitial  tissue.  The  hrain  usually  shows  interesting  changes. 
In  severe  cases  of  some  duration  the  tissue  is  stained,  sometimes  chocolate- 
colored.  In  mild  cases  the  discoloration  is  present,  but  less  marked.  The 
blood-vessels,  especially  the  arterioles  and  capillaries,  contain  large  num- 
bers of  parasites,  with  partial  or  total  destruction  of  red  blood-corpuscles, 
and  phagocytes.  Occlusions  of  arterioles  by  parasites  are  often  seen,  to- 
gether with  perivascular  infection  and  punctate  luTmorrhages.  In  some 
instances  changes  of  this  sort  occurring  in  special  areas  have  given  rise  to 
focal  symptoms. 

In  some  acute  pernicious  cases  with  choler-ic  symptoms,  the  capillaries 
of  the  gastro-intestinal  mucosa  may  be  packed  with  parasites. 

('2)  Malarial  Cachexia.— In  fatal  cases  of  chronic  pahidism  death  occurs 
usually  from  anaemia  or  the  htemorrhage  associated  with  it. 

The  ana-mia  is  profound,  particularly  if  the  patient  has  died  of  fever. 
The  spleen  is  greatly  enlarged,  and  may  weigh  from  seven  to  ten  pounds. 
If  the  disease  has  persisted  for  any  length  of  time,  it  is  firm  and  resists 
cutting.  The  capsule  is  thickened,  the  parenchyma  brownish  or  yellowish- 
brown,  with  areas  of  pigmentation,  or  in  very  protracted  cases  it  is  ex- 
tremely melanosed,  particularly  in  the  trabeculae  and  about  the  vessels. 

The  liver  may  be  greatly  enlarged;  but,  as  a  rule,  the  increase  in  size 
is  moderate  in  proportion  to  that  of  the  s])leen.  It  may  present  to  the 
naked  eye  a  grayish-brown  or  slate  color,  due  to  the  large  amount  of  pig- 
ment, in  the  portal  canals  and  beneath  the  capsule  the  connective  tissue 
is  impregnated  with  melanin.  Varying  with  the  duration  of  the  disease, 
the  shade  of  color  of  the  liver  ranges  from  a  light  gray  to  a  deep  slate- 
gray  tint.  The  texture  is  firm,  but  there  is  not  necessarily  any  great  in- 
crease in  the  connective  tissue.  Histologically,  the  pigment  is  seen  in  the 
Kupffer's  cells  and  the  pcrivascidar  tis^ic. 

The  kidneys  may  be  enlarged  a.'rt  jirescnt  a  grayish-red  color,  or  areas 
of  pigmentation  may  be  seen.  The  pigment  may  be  diffusely  scattered 
and  particidarly  marked  about  the  blood-vessels  and  the  :Malpighian  bodies. 
The  peritonaeum  is  usually  of  a  deep  slate-color.  The  mucous  membrane 
of  the  stomach  and  intestines  may  have  the  same  hue,  due  to  the  pigment 
in  and  aboiit  the  blood-vessels.  In  some  cases  this  is  confined  to  the  lymph 
nodules  of  Peyer's  patches,  causing  the  shaven-beard  appearance. 
(3)  The  Accidental  and  Late  Lesions  of  Malarial  Fever. 
(n)  The  Liver. — Paludal  hepatitis  i)lays  a  very  important  role  in  the 


"«ws>  v«!8»"R»^t3«BB»»mi*iaa«!«a»b«*r>!»«»wiwi»^^ 


-ta^m.amxXBmfni^vyV''^s^'  •«!.i^ 


MALARIAL  FEVER. 


209 


packed  with 
nay  bo  prcs- 
s.  Areas  of 
])hoid  fever, 
iescribed  by 
ireas,  Barker 
ion  has  been 
!/s  sliow  only 
k'generation. 
3  necrosis  of 
to  the  glom- 
:ing  changes. 
,es  cliocolate- 
larketl.  The 
I  hirge  niim- 
)d-coriniscles, 
ten  seen,  to- 
ss. In  some 
given  rise  to 

he  capillaries 

death  occurs 

lied  of  fever. 
)  ten  pounds. 
Ill  and  resists 
or  yellowish- 
ascs  it  is  ex- 
the  vessels, 
crease  in  size 
resent  to  the 
nount  of  pig- 
nective  tissue 
f  the  disease, 
a  deep  slate- 
any  great  in- 
is  seen  in  the 

'olor,  or  areas 
sely  scattered 
ighian  bodies. 
)us  membrane 
1  the  pigment 
to  the  lymph 
incc. 

at  role  in  the 


history  of  malaria,  as  dcscril)od  by  French  writers.  Kolsch  and  Kicncr 
devote  over  sixty  pages  to  a  description  of  the  various  forms,  parenchym- 
atous and  interstitial,  describing  under  the  latter  three  dill'erent  varieties. 
The  existence  of  a  cirrhosis  dependent  upon  the  irritation  of  large  quan- 
tities of  pigment  in  the  liver  is  untpu'stioned,  but  only  those  cases  in  which 
the  history  of  chronic  malaria  is  definite,  ami  in  which  the  melanosis  of 
both  liver  and  spleen  coexist,  sliould  be  regarded  as  of  paludal  origin. 

(b)  Pucumoiiia  is  believed  by  many  authors  to  be  common  in  malaria, 
and  even  to  depend  directly  ujwn  the  malarial  poison,  occurring  either  in 
the  acute  or  in  the  chronic  forms  of  the  disease.  T  have  no  iiersonal 
knowledge  of  such  a  special  jmcumonia.  It  certainly  does  not  occur  in  tlie 
intermittent  or  remittent  fevers  which  prevail  in  Philadelphia  and  Balti- 
more. The  two  diseases  may  be  concurrent.  Inflammation  of  the  lungs 
may  develop  during  a  simple  intermittent,  and  the  (piinine  may  check  the 
chills  without  iuniiencing  in  any  way  the  pneumonia. 

(c)  N ephril is. —Uodaratc  albuminuria  is  a  frecpient  occurrence,  having 
occurred  in  40.-1  per  cent  of  the  rases  in  my  wards.  It  is  much  more  fre- 
(pient  in  the  irstivo-autumnal  infections. 

Acute  nephritis  is  a  not  unusual  conqdication  of  the  disease.  Kare  in 
the  milder  forms,  it  is  relatively  freiiuent  in  ivstivo-autumnal  infections, 
having  occurred  in  over  4.5  per  cent  of  my  cases.  Chronic  nephritis  occa- 
sionalTy  follows  long-continued  or  frequently  repeated  infections. 

Clinical  Forms  of  Malarial  Fever— (l)  The  Regularly  Inter 
mittent  Fevers.— («)  Tertian  fever;  (b)  cpiartan  fever.  These  forms  ar( 
characterized  by  recurring  paroxysms  of  what  are  known  as  ague,  in  winch, 
as  a  rule,  chill,  fever,  and  sweat  follow  each  other  in  orderly  sequence.  The 
stage  of  incubation  is  not  definitely  known;  it  jirobably  varies  much  ac- 
cording to  the  amount  of  tlie  infectious  material  absorbed.  Experimentally 
the  period  of  incubation  varies  from  thirty-six  to  fifteen  days,  being  a 
trifle  longer  in  cpiartan  than  in  tertian  infections.  Attacks  have  been  re- 
ported within  a  very  short  time  after  the  apparent  exposure.  On  the 
other  hand,  the  ague  may  be,  as  is  said,  "  in  the  system,"  and  the  patient 
may  have  a  paroxysm  months  after  he  has  removed  from  a  malarial  region, 
though  I  doubt  it"  this  can  be  the  case  unless  he  has  had  the  disease  when 

living  there.  ... 

Description  of  the  raroa-ysm.—Thc  patient  generally  knows  lie  is  going 
to  have  a  chill  a  few  hours  before  its  advent  by  uniileasant  feelings  and 
uneasy  sensations,  sometimes  by  headache.  The  paro.xysm  is  divided  into 
three  stages— cold,  hot,  and  sweating. 

Cold  Stage.— Thii  onset  is  indicated  by  a  feeling  ot  lassitude  and  a 
desire  to  yawn  and  stretch,  by  headache,  unea.sy  sensations  in  the  epigas- 
trium, sometimes  by  nausea  and  vomiting.  Even  before  the  dull  begins 
the  thermometer  indicates  some  rise  in  temperature.  Gradually  the  pa- 
tient begins  to  shiver,  the  face  looks  cold,  and  in  the  fully  developed  rigor 
the  whole  body  shakes,  the  tect.i  chatt9r,  and  the  movements  may  often 
be  violent  enough  to  shake  the  bed.  Not  only  does  the  patient  look  cohl 
and  blue,  but  a  surface  thermometer  will  indicate  a  reduction  of  the  skin 
temperature.     On  the  other  hand,  the  axillary  or  rectal  temperature  may, 


tp.'sarirrss^'t'.' 'jw.  «v 


-rPWWTsawasacMiBSBWff^-'aacsi.L'i.'  -ijaiittx'K." 


*'»Tr',rrJ?^.'^'tS'.-^<y.*"?g''-^  ;,.>  ^.' 


210 


SPECIFIC  INFECTIOUS  DISEASES. 


1   i   i   ^    §  §   §   § 


s    s 


s;     s 


,,,^ij(ia,Baiawa»ss^^ 


a 


3a«K»*''>i 


n»Wiii««!«»»'aB>(«i«»-  ■*i»*»^»i»«i»»M««:eiW«4*p'-ssiw»!"^-^««'  ■■" 


2J2  SPECIFIC  INFECTIOUS  DISEASES. 

during  the  chill,  be  greatly  increased,  and,  as  shown  in  the  chart,  the  fovcr 

,„ay  nse  dunng  the  chill  to  105°  or  lUO^     Of  symptom,  a.soc,atcd^h 

1,0  dull,  nausc^v  and  vomiting  are  common.     There  n.ay  be  uiten.e  h  a  1- 

he.     The  pulse  is  c,uick,  sn.all,  and  hard.     The  ur>ne  .  ^n.v.a..a^n 

ciuantity.     The  chill  lasts  for  a  variable  tin.e,  from  ten  or  .  v,  .ve  mmute, 

''  'ti!::!  :L;t  ISa  m  by  transient  Hushes  of  heat;  g^du^^y  the 
coldness  of  the  surface  disappears  and  the  f^'^'^'^^^^'^J^ 
The  contrast  in  the  patienfs  appearance  is  striking:  the  face  i.  1  u.hcc , 
th  h  1  1^  iv  congested,  the  skill  is  reddened,  the  pulse  is  full  and  bound- 
y       hearfs  action  is  forcible,  and  the  patient  nuiy  complain  o    a  th  ob^ 

bing  headache.  There  may  be  active  <1^'I'';'-"-  ;\l!"^.'^'"\'\i';;:  ^  ^ 
ju,.rped  through  the  .ard  .indow  and  sustained  fata  ^^i-'^'J^]^'^ 
temperature  mav  not  increase  much  during  this  stage;  m  fact,  by  tic 
im  ion  of  the  chill  the  fever  may  have  reached  its  maximum,  lie 
din-aiion  of  the  hot  stage  varies  from  half  an  hour  to  three  or  four  houis. 
The  patient  is  intensely  thirsty  and  drinks  eagerly  of  <^«  f^;;^  ;;•  , 

Sircatiiui  SUuir.—Ucaih  of  perspiration  ai)pear  upon  the  face  and  gi.ul 
.ally"      0  tire'body  is  bathed  in  a  copious  sweat.     The  nncomloi-t.dde 
I'Z^r  associated  ^viill  the  fever  disappears,  the  headache  is  relieved,  and 
wit  In  an  hour  or  two  the  paroxysm  is  over  and  the  patient  usually  sink 
rntoT  refreshing  sleep.     The  sweating  varies  much.     It  may  be  drenching 
in  character  or  it  mav  be  slight.  <•  i.    *•  „ 

Chart  XI  is  a  facsimile  of  a  ward  temperature  chart  '- ^^^^  ^^ 
acn.e  The  duration  of  the  paroxysms  on  1-ebruary  Is  ,  3d,  and  .,th  ^^a. 
from  twelve  to  sixteen  hours.  Quinine  in  two-grain  doses  -^«  g-^"  «^ 
the  5th  and  was  sufficient  to  prevent  the  on-commg  paroxysm.  «"  he  .t  i 
though  the  temperature  rose  to  100.5°.  The  small  doses,  howe^er,  weie 
not  etfective,  and  on  the  0th  he  had  a  severe  chill. 

The  total  duration  of  the  paroxysm  averages  from  ten  to  t«ohc     on  s 
but  mav  be  shorter.    Variations  in  the  paroxysm  are 'common.     Thus  the 
i      "mav,  instead  of  a  chill,  experience  only  a  slight    eehng  of  coldness 
11     most  common  variation  is  the  occurrence  of  a  ho    stage  alone,  or  w 
vo  y  slight  sweating.     During  the  paroxysm  the  spleen  is  enlarged  and 
he  edge  can  usually  be  felt  below  the  costal  margin.      n  the  interval  or 
tern  ission  of  the  paroxysm  the  patient  feels  very  well    and,  unless  the 
di    Ise  is  unusifally  severe,  he  is  able  to  be  up.     Bronchitis  is  a  common 
s^rn'om.    ITerpes' usually  labial,  is  perhaps  as  frequently  seen  m  ague  as 

'^  T;;;r:M..  /......W,  1,.,,:,,.,,  F.....-As  has  been  stated  in  the 

description  of  the  parasites,  two  distinct  types  o    the  regularly  intermt- 
tonrflvers  have  been  separated.    These  are  (a)  tertian  fever  and  (h)  quartan 

^''7a)  Tcrlian  Frrrr.-This  tvpe  of  fever  depends  upon  the  presence  in 

the  bood  of  the  tertian  parasite,  an  organism  which,  as  stated  above    is 

,a  Iv  present  in  sharply  Vlefined  groups,  whose  cycle  of  development       ts 

miroximately  forty-eight  l.ours.   sporulation   occurring  every   third   day. 

rLf  "on'vvith  mie^^roup  of  tlic  tertian  parasite  the  paroxysms  occur 


&^SSiSm^^ 


.-i7?«sa-.ts; 


Aa»?^5^aS5«aBKaKSB3fcS«BM««^^ 


!*"«:i5es<«.T~ 


MALARIAL  FEVER. 


218 


rt,  the  fever 
jciated  with 
itense  heiid- 
hicreiii-ed  in 
ive  mimites 

;ratliuilly  the 
itensely  hot. 
■e  iw  Hushed, 

I  and  hound- 

II  of  a  throb- 
in  this  stage 
.  The  rectal 
fact,  by  the 
anium.  The 
r  four  honrs. 
iter. 

jce  and  grad- 

inconifortable 

relieved,  and 

nsually  sinks 

be  drenching 

?ase  of  tertian 
and  r)th  was 
was  given  on 
(IS  on  the  7th, 
liowevcr,  were 

twelve  honrs, 
on.  Thus  the 
\S  of  coldness, 
alone,  or  with 

enlarged  and 
:he  interval  or 
nd,  nnless  the 
3  is  a  common 
een  in  agnc  as 

"I  stated  in  the 
darly  intermit- 
ind  (h)  qnartan 

ho  presence  in 
stated  above,  is 
velopment  lasts 
^ery  third  day. 
aroxvsms  occur 


synohronouslv  witli  sporulation  at  reniarl<a1)ly  regular  intervals  of  about 
forty-eight  hours,  every  tiiird  day— hcueo  the  luiine  tn-linii.  Very  coin- 
inoniy,  however,  there  may  Ije  two  groups  of  parasites  wiiicii  reach  uiatunty 
,.n  alternate  days,  resulting  tluis  in  daily  (<iiwli,ll<in)  paroxysms— ./.-i/Wc 
Irrlian  infection.  Quotidian  fever,  depending  upon  double  tcrtum  mlec- 
lion,  is  the  most   fre(iuent  type  in  the  acute  intermittent   fevers  in  this 

latitude.  ,  .    .    ,•  -i 

(b)  Qnarlan  7<VcfC.— This  type  of  fever  depends  upon  infection  wuli 
the  quartan  parasite,  an  organism  which  occurs  in  wcU-delined  groups, 
whose  cycle  of  existence  lasts  about  seventy-two  hours.  In  in  lection  with 
one  group  of  parasites  tlie  jiaroxysm  oc<nirs  every  fourth  ilay;  hence  the 
term  quartan.  At  times,  however,  two  groups  of  the  parasites  nuiy  be 
present;  under  these  circumstances  paroxysms  occur  on  two  successive 
days,  with  a  day  of  intermission  f.dlowing.  In  infection  with  three  groups 
of  parasites  there  are  daily  paroxysms. 

Thus  a  qnotidian  intermittent  fever  may  be  due  to  lulection  witU 
either  the  tertian  or  (juartan  parasites. 

Course  of  the  Disease.— Mivr  a  few  paroxysms,  or  after  the  disease  has 
persisted  for  ten  days  or  two  weeks,  the  patient  may  get  well  without  any 
special  medication.  I  have  repeatedly  known  the  chills  to  stop  spontane- 
ously. Such  cases,  however,  are  very  liable  to  recurrence.  Persistence  oL 
the  fever  leads  to  ana-mia  and  hiumatogenous  jaundice,  owing  to  the  de- 
struction of  the  red  l^lood-disks  by  the  ].arasitcs.  Vltimately  the  condition 
mav  become  chronic,  and  will  be  described  under  malarial  cachexia,  ihe 
regularly  intermittent  fevers  yield  promptly  and  inunediately  to  treatment 

with  (luinine.  ,    _  _,  .. 

(2)  The  more  Irregular,  Remittent,  or  Continued  Fevers.  —  ^stivo 
autumnal  Fever.— This  tvpe  of  fever  occurs  in  temperate  climates,  chiefly 
in  the  later  snnnner  and  fall;  hence  the  term  given  to  it  by  Marchiafava 
and  Celli,  a'stiro-auinwnal  fever.  The  severer  forms  of  it  prevail  in  the 
Sonthern  States  and  in  troi)ical  countries,  where  it  is  known  chielly  as 
lilions  remittent  fever.  The  entire  gronp  of  cases  included  nnder  the  terms 
remittent  fever,  hitious  remittent,  and  ti/pho-matarial  fevers  requires  to  be 

studied  anew.  . 

Tliis  type  of  fever  is  associated  with  the  presence  in  the  blood  ot  the 
fpstivo-autnmnal  parasite,  an  organism  the  length  of  whose  cycle  of  de- 
velopment is  probaldy  subject  to  variations,  while  the  existence  of  multiple 
groups  of  the  parasite,  or  the  absence  of  arrangement  into  definite  groups, 

is  not  infrequent.  ^     j,        ■  it 

The  symptoms  are  therefore,  as  might  be  expected,  often  irregular.  In 
some  instances  there  mav  be  re-ular  intermittent  fever  occurring  at  uncer- 
tain intervals  of  from  twentv-four  to  forty-eiglit  hours,  or  even  moro^  In 
the  cases  with  longer  remissions  the  paroxysms  are  longer.  Some  of  the 
quotidian  intermittent  cases  may  closely  resemble  the  quotidian  fever  de- 
ponding  upon  double  tertian  or  triiile  quartan  infection,  (^ommonly,  how- 
over  the  paroxvsms  show  material  difFeronces;  their  length  averages  over 
twenty  hours,  instead  of  from  ten  or  twelve;  the  onset  occurs  often  with- 
out ciiills  and  even  without  chilly  sensations.     The  rise  in  temperature  is 


ssftS^i^amiiiiwa/r'-^SEaiiV 


—        ■«?«»7CiT-«fl 


■3^;=^K■J!5*IBKiS'f3*B*a*^■■STa«l••-  -i*--  -iVVv 


214 


SPKCIPIC  INFECTIOUS  DISEASES. 


if' 


frociucntly  gradual  and  slow,  instead  of  sudden,  while  tlie  fall  may  occur 
liy  lysis  iustciid  of  liy  crisis.  There  is  ii  marked  tendency  toward  antieii)a- 
tion  ill  tile  ])ai'o.\ysiiis,  while  I'lViiiieiitly,  from  the  anticiimtion  of  one  jiarox- 
ysiii  or  tlie  retardation  of  another,  more  or  less  continuous  fever  may 
result.  Soiiietiiiies  there  is  coiitimions  fever  without  sharii  paroxysms  In 
tliese  eases  of  continuous  and  remittent  fever  the  jiatient,  seen  fairly  early 
in  the  disease,  has  a  Hushed  I'aie  and  looks  ill.  Tlie  tongue  is  furred,  the 
pulse  is  full  and  bounding,  but  rarely  dicrotic.  The  temperature  may  range 
from  1(1'^°  to  1015°,  or  is  in  some  instances  higher.  The  general  appear- 
ance of  the  ])alieiit  is  strongly  suggestive  of  tyi)hoid  fever — a  suggestion 
still  furtiier  Itorue  out  by  the  existence  of  acute  sjilenic  enlargement  of 
moderate  grade.  As  in  intermittent  fever,  an  initial  bronchitis  may  be 
present.  The  eoiiise  of  these  cases  is  variable.  The  ever  may  be  con- 
tinuous, with  iciiiissi(»iis  more  or  less  marked;  definite  paroxysms  with  or 
without  (bills  may  occur,  in  which  the  temperature  rises  to  105°  or  10G°. 
Intestinal  ,«yiui)tonis  are  usually  absent.  A  sligiit  lia'inatogenous  jaundice 
may  develop  early.  Delirium  of  a  mild  type  may  occur.  The  cases  vary 
very  greatly  in  severity.  In  some  the  fever  subsides  at  the  end  of  the  week, 
and  the  ])ractitioiicr  is  in  doubt  whether  he  has  had  to  do  with  a  mild 
typhoid  or  a  simjile  febricula.  In  other  instances  the  fever  persists  for 
from  ten  days  to  two  weeks;  there  are  marked  remissions,  perhaps  chills, 
with  a  furred  tongue  and  low  delirium.  Jaundice  is  not  infixMjuent.  These 
are  the  eases  to  which  the  term  hilious  remUlent  and  ti/pho-malnrial  fevers 
are  applied.  In  other  instances  the  synij)toins  become  grave  and  assume 
the  character  cd'  the  pernicious  type.  It  is  in  this  form  of  malarial  fever  that 
so  much  confusion  still  exists.  The  similarity  of  the  cases  to  typhoid  fever 
is  most  striking,  more  particularly  the  apjiearance  of  the  fades,  and  the 
patient  hwls  very  ill.  The  cases  dev(dop,  too,  in  the  autumn,  at  the  very 
time  when  typhoid  fever  occurs.  The  fever  yields,  as  a  rule,  promptly 
to  (juinine,  tlxnigh  here  and  there  cases  are  met  with — rarely  indeed  in  my 
ex])erience — which  are  refractory.  It  is  Just  in  this  grouj)  that  the  observa- 
tions of  Laveran  will  be  found  of  the  greatest  value.  Several  of  the  charts 
in  Thayer  and  Hewetson's  rejiort  show  how  closely,  in  some  instances, 
the  disease  may  simulate  tyjihoid  fever. 

Tiie  (liafinusis  of  malarial  remittent  fever  may  be  definitely  made  by 
the  examination  of  the  blood.  The  small,  actively  motile,  hyaline  forms 
of  the  a'stivo-autumnal  ]>arasite  are  to  be  found,  while,  if  the  case  has 
lasted  over  a  wi'ek,  the  larger  erescentic  and  ovoid  bodies  are  usually  seen. 
In  many  cases  liero  we  are  at  fi-  '  unable  to  distinguish  between  typhoid 
and  continued  malarial  fever  ^\  out  a  blood  examination.  A  more  wide- 
spread use  of  this  means  of  diagnosis  will  enable  us  to  bring  some  order 
out  of  the  confusion  which  exists  in  the  cla;  ication  of  the  fevers  of  the 
South.  At  present  the  following  febrile  affections  are  recognized  by  vari- 
ous ]ibysicians  as  occurring  in  the  subtropical  regions  of  this  continent: 
(a)  Typhoid  fever;  (h)  typho-malarial  fever — a  typhoid  modified  by  ma- 
larial infection,  or  the  result  of  a  combined  infection;  (c)  the  malarial 
remittent  fever;  and  (rl)  continued  thermic  fever  (Guiteras).  In  these 
various  forms,  all  of  which  may  be  characterized  by  a  continued  j>yrexia 


t!y^vvnv-~-j^'i"?'Ji»';MW»)V'Mv-i^^Wi.>''iari*^4''-'  \!r-'<^'^-inw,'''^i!jA^-!4'^M'y^¥---'i-koi<:  .i^'  v^-n...'  Tr-.i-t^fr-iWA^.a*--  ^■^(gr- 


II 


MALAUIAL  FEVER. 


215 


1  may  occur 
ird  anticii)a- 
1'  one  j)arox- 
!  fever  may 
oxysnis  In 
fairly  early 
;  furred,  the 
e  may  range 
oral  ajipear- 
1  suggestion 
argement  of 
itis  may  be 
nay  be  con- 
sms  with  or 
05°  or  10G°. 
)us  jaundice 
0  cases  vary 
of  the  week, 
with  a  mild 
persists  for 
rhaps  chills, 
lent.  These 
Inrial  fevers 
and  assume 
al  fever  that 
yphoid  fever 
ies,  and  the 
at  the  very 
e,  prom])tly 
ndeed  in  my 
the  observa- 
)f  the  charts 
le  instances, 

'ly  made  by 
('aline  forms 
he  case  has 
isually  soon, 
cen  typhoid 
more  wide- 
some  order 
overs  of  the 
zed  by  vari- 
s  continent: 
fled  by  ma- 
ihe  malarial 
In  these 
ued  pyrexia 


with  remissions  or  with  chills  and  sweats  (for  we  must  romeuibor  that  chills 
1111(1  sweats  in  typhoid  fever  are  by  no  means  rare),  the  blood  examinatioa 
will  enalile  us  to  discover  those  which  depend  upon  the  malarial  poison. 
In  many  of  these  cases  of  continued  or  remittent  fever  earel'ul  inquiry 
will  show  that  at  the  lioginning  the  i)ationt  had  several  intermittent  parox- 
ysms. In  this  latitude  we  have  not  the  opportunity  of  seeing  many  of 
the  protracted  and  severe  cases,  but  I  am  inclined  to  think  tliat  future 
observations  will  show  that,  apiirt  from  tiie  thermic  fever,  there  are  only 
two  forms  of  these  continued  lev;'is  in  tlie  South— the  one  due  to  the 
liiphoid  and  the  other  to  the  malarial  infection.  The  typiioid  fever  of 
rhiladelphia  and  J^altiuiore  ])resonts  no  essential  dilVeronce  from  the  dis- 
ease as  it  occurs  in  Montreal,  a  city  practically  free  from  malaria.  Dock 
has  shown  conclusively  that  cases  diagnosed  in  Texas  as  continued  nuilarial 
fever  were  really  true  tyi)boid.  The  Widal  reaction  is  now  an  important 
aid  in  diagnosis. 

Pernicious  Malarial  Fever.— This  is  fortunately  rare  in  temperate  cli- 
mates, and  the  number  of  cases  wbieli  now  occur,  for  exaiui)le,  in  Pliila- 
delphia  and  JJaltimore,  is  very  much  loss  than  it  was  thirty  or  forty  years 
ago.  Among  the  eases  of  malaria  which  have  been  under  observation  during 
the  past  eight  years  there  were  only  seven  of  the  i)ernieious  form.  I'er- 
nieious  fever  is  always  associated  with  the  a!stivo-autumnal  parasite.  The 
following  are  the  most  important  types: 

(a)  The  comatose  form,  in  which  a  patient  is  struck  down  with  symp- 
toms of  the  most  intense  cerebral  disturbance,  either  acute  delirium  or, 
more  frequently,  a  rajiidly  dovoloiiing  cimia.  A  chill  may  or  may  not  pre- 
cede the  attack.  The  fever  is  usually  high,  and  the  skin  hot  and  dry. 
The  unconsciousness  may  ])ersist  for  from  twelve  to  twenty-four  hours,  or 
the  patient  may  sink  and  die.  After  regaining  consciousness  a  second 
attack  may  come  on  and  iirovc  fatal.  In  these  instances,  as  has  been  stated, 
the  special  localization  of  the  infection  is  in  the  brain,  where  actual  tiirombi 
of  parasites  with  marked  secondary  changes  in  the  surrounding  tissues  have 

been  found. 

(b)  Algid  Form.— In  this,  the  attack  sets  in  usually  with  gastric  symp- 
toms?; there  arc  vomiting,  intense  prostration,  and  feebleness  out  of  all 
proportion  to  the  local  disturbance.  The  jiatient  complains  of  feeling  cold, 
although  there  may  be  no  actual  chill.  The  tomi^oraturo  may  be  normal, 
or  even  subnormal;  consciousness  may  be  retained.  The  pulso  is  feeble 
and  small,  and  the  respirations  are  increased.  There  may  be  most  severe 
diarrhoea,  the  attack  assuming  a  cboleriform  nature.  The  urine  is  often 
diminished,  or  even  suppressed.  This  condition  may  persist  with  slight 
exacerbations  of  fever  for  several  days  and  the  patient  may  die  in  a  condi- 
tion of  profound  asthenia.  This  is  essentially  the  .same  as  described  as 
the  asthenic  or  adi/iiamic  form  of  the  disease.  In  the  cases  with  vf.miting 
and  diarrhoea,  :\Iarchiafava  has  shown  that  the  gastro-intestinal  mucosa  is 
often  the  seat  of  a  special  invasion  by  the  parasites,  actual  tJxombosis  of 
the  small  vessels  with  superficial  ulceration  and  necrosis  occurring.  Simi- 
lar lesions  were  found  by  Barker  in  the  gastro-intestinal  tract  of  a  case 
from  my  wards. 


'JeC:?^rii 


-,■:«?— 


21G 


HPIX'IFIC  INFECTIOUS   DISEASES. 


((■)  llamorrlKKjif  Fnniis. — In  nil  tiic  scvcro  types  of  malarial  infec- 
tion, espet'iully  if  persistent,  liieinorriiaf^o  may  ocuur  from  the  mucous 
inemhranes.  An  ini|>nrtant  form  is  tlie  malarial  hdmaliirin,  wiiicli  in  some 
instances  assumes  a  very  malifiuant  type.  J'aroxysms  of  af,'ue  may  pre- 
cede the  attack,  but  in  many  cases  called  nuilarial  luematuria  there  is  no 
febrile  paroxysm.  The  condition  is  usually  an  ha'moj,dol)iiiuria,  thoujjh 
blood-<'orpus(ie:-  are  present  also.  In  severe  cases  tiiere  is  bleeding  from 
the  mucous  membranes.  Jaundice  is  present,  but  to  a  variable  extent, 
and  is  hicmatojrenous,  due  to  the  destruction  of  the  red  blood-corpuscles. 
Malarial  luematuria  occurs  in  epidemic  form  in  many  regions  of  the  South- 
ern ytates,  and  in  some  seasons  proves  very  fatal. 

!Many  diU'erent  forms  of  pernicious  nudarial  fever — diaphoretic,  synco- 
pal, pneumonic,  pleuritic,  choleraic,  cardiac,  gastric,  and  gangrenous — all 
of  which  depend  upon  some  special  symptom,  have  been  described. 

Malarial  Cachexia. — The  syni]»tonis  of  chronic  malarial  jjoisoning  are 
very  varied.  It  may  follow  the  frecpient  recurrence  of  ordinary  inter- 
mittent fever,  a  common  setpience  in  this  country.  A  patient  has  chills 
for  several  weeks,  is  imi)roperly  or  imperfectly  treated,  and  on  exposure 
the  chills  recur.  This  may  be  repeated  for  several  months  until  the  pa- 
tient i)rcsents  the  two  striking  features  of  malarial  cachexia — namely, 
ancvmia  and  an  etilanjcd  spleen.  Cases  developing  without  chills  or  with- 
out fel)rile  ])aroxysms  are  almosi:  unknown  in  this  region.  They  nuiy 
occur,  however,  in  intensely  malarial  districts,  l)ut  in  such  cases  the  patients 
have  fever,  though  chills  nuiy  not  supervene.  The  most  pronounced  types 
of  malarial  cachexia  which  we  meet  with  here  are  in  sailors  from  tlie  West 
Indies  and  Central  America.  Tiiere  is  profound  aniemia;  the  blood  count 
may  be  as  low  as  one  million  ])er  cubic  millimetre;  the  skin  has  a  saffron- 
yellow  or  lemon  tint,  not  often  the  liglit  yellow  tint  of  ])ernicious  ancemia, 
but  a  darker,  dirtier  yellow.  The  spleen  is  greatly  enlarged,  firm,  and 
hard.  It  rarely  reaches  the  dimensions  of  the  large  leukiemic  organ,  but 
comes  next  to  it  in  size. 

Tlie  general  sym])tonis  are  those  of  ordinary  anannia — breathlessness 
on  exertion,  (edema  of  the  ankles,  hamiorrhages,  ])articularly  into  the  retina, 
as  noted  by  Stephen  ^lackenzie.  Occasionally  the  bleeding  is  severe,  and 
I  have  twice  known  fatal  haunatemesis  to  occur  in  association  with  the 
enlarged  spleen.  The  fever  is  variable.  The  temperature  may  be  low  for 
days,  not  going  above  99.5°.  In  other  instances  there  may  be  irregular 
fever,  and  the  tcmiierature  rises  gradually  to  102.5°  or  1U3°.  The  cases 
in  fact  present  a  ])ict\we  of  splenic  anannia. 

With  careful  treatment  the  outlook  is  good,  and  a  majority  of  cases 
recover.  The  sjdeen  is  gradually  reduced  in  size,  but  it  may  take  several 
montlis  or,  indeed,  in  some  instances,  several  years  before  the  ague-cake 
entirely  di-^ajiiiears. 

Among  the  rarer  pyni])toms  which  may  develop  as  a  result  of  malarial 
intoxication  may  be  mentioned  parajiJcijia,  cases  of  which  have  been  de- 
scribed by  Gibney,  Suckling,  and  others.  Some  of  the  cases  are  doubtful, 
and  have  been  attributed  to  malaria  simply  because  the  paralysis  was  inter- 
mittent.    It  is  a  condition  of  extreme  rarity.     Xo  case  is  mentioned  by 


avBajK-:i-;iCJUxe??;f"r»3«<e>WS>»ws«s:53l^^  — 


MALARIAL  FEVKU. 


217 


rial  infcc- 
le  mucous 
L'li  ill  some 
!  may  pre- 
tluTo  is  no 
•ia,  tliougii 
'ding  from 
l)lo  extent, 
-eorpusek's. 
the  South- 

etio,  synco- 
renous — all 
)ed. 

isoning  are 
nary  inter- 
t  has  chills 
)n  exposure 
iitil  the  pa- 
ia — namely, 
lis  or  with- 
They  may 
the  patients 
uncod  types 
m  the  West 
blood  count 
IS  a  sadron- 
ous  anaemia, 
1,  firm,  and 
;  organ,  but 

reathlessness 
0  the  retina, 
severe,  and 
on  with  the 
y  be  low  for 
be  irregular 
.     The  cases 

rity  of  cases 
take  several 
le  ague-cake 

t  of  malarial 
five  been  de- 
are  doubtful, 
sis  was  inter- 
iicntioned  by 


Kelseh  and  Ki.'ner.  Suckling's  case  had  iiad  several  attacks  of  malaria, 
tile  last  of  wiiich  preceded  by  about  two  wirks  tiu-  onset  of  the  nervous 
symptoms,  wliieii  were  headaciie.  giddiness,  loss  of  speech,  and  i)araplegia. 
the  attack  was  transient,  but  he  had  a  sul)se(iiu'nt  attack  wiiuii  also 
followed  an  ague-lit.  The  ])atient  was  an  old  soldier  who  luxl  had  syi)h- 
ilis,  a  jmint  which  somewhat  complicated  the  ease.  OrrhitU  lias  been 
described  as  developing  in  malaria  l)y  Cliarvot  in  Algiers  and  Fedeli  in 
Konie. 

Diagnosis.— The  l)lood.  as  one  might  expect,  shows  markeil  changes 
in  malarial  fever.  In  the  regularly  intermittent  fevrrs  tiiere  is  a  loss  in  red 
corpuscles  after  each  paroxysm,  which  may  be  considerable,  but  which  is 
rajtidly  compensated  liuring  the  intermissions.  In  jvstivo-autumnal  fever 
the  losses  are  oftener  greater  and  more  permanent.  In  any  case  of  malaria 
which  has  existed  for  any  length  of  time  there  is  always  considerable 
anivmia.  TJie  luenioglobin,  as  in  all  secondary  ana-inias,  is  diminished, 
usually  in  greater  i)roi)ortion  than  the  corpuscles.  The  leucocytes  are 
almost  invariably  diminished  in  mimber  in  malarial  fever.  The  reduc- 
tion is  greatest  just  after  the  paroxysms,  the  numl)er  increasing  slightly 
at  the  beginning  of  the  febrile  paroxysm.  The  deferential  count  shows  a 
relative  diminution  in  iiolynuclcar  leucocytes,  with  a  relative  increase  in 
the  large  mononuclear  forms,  exactly  the  same  condition  that  is  seen  in 
typhoid  fever.  Sometimes  in  fatal  post-malarial  anannia  the  blood  shows 
all  the  characteristics  of  true  ])ernicious  anaMuia;  in  other  instances  of 
fatal  anannia,  where  the  blood  during  life  has  shown  an  absence  of  leuco- 
cytosis,  or  of  nucleated  red  cor])uscles,  the  marrow  of  the  long  bones  has 
been  found  to  be  perfectly  yellow,  showing  no  evidi'iice  of  regenerative 

activity.  ,, 

The  diagnosis  of  the  various  forms  of  malaria  is  usually  easy,  llio 
continued  remittent  and  certain  of  the  pernicious  cases  olfer  diniculties, 
which,  however,  are  now  greatly  lessened  or  entirely  overcome  since  Lav- 
cran's' researches  have  given  us  a  positive  diagnostic  indication.  :Many 
forms  of  intermittent  pyrexia  are  mistaken  for  malarial  fever,  particu- 
larly the  initial  chills  of  tuberculosis  and  of  sejitic  infection.  In  tiiese  in- 
stances the  blood  shows  leucocytosis,  which  is  rare  in  malaria.  If  the  prac- 
titioner will  take  to  heart  the  lesson  that  an  intermittent  fever  which  resists 
quinine  is  not  malarial,  he  will  avoid  ;nany  errors  in  diagnosis.  In  the 
so-called  masked  intermittent  or  dumb  ague,  the  fel)rile  manifestations  are 
more  irregular  and  the  symptoms  less  pronounced;  but  occasionally  chills 
occur,  and  the  therapeutical  test  usually  removes  every  doubt  m  the  diag- 
nosis, n.     i.- 

The  malarial  poison  is  supposed  to  iuHuence  many  aflections  in  a  re- 
markable way,  giving  to  them  a  paroxysmal  character.  A  whole  series  of 
minor  ailments  and  oine  more  severe  ones,  such  as  neuralgia,  arc  attrib- 
uted to  certain  occult  effects  of  paludism.  The  more  closely  such  cases 
are  investigated  the  less  definite  appears  the  connection  with  malaria, 
rractitioners  in  districts  entirely  exempt  from  the  disease  have  to  deal  with 
ailments  which  present  the  same  odd  periodicity,  and  which  the  physicians 
of  the  Atlantic  coast  attribute  to  a  "  touch  of  malaria." 


.'.  ,Y.;jOWWAS--«fi.>i<>'a.JiK 


r.;?»*5-*- ■V"I?-"":W!!"' 


218 


SPECIP^IC  INFFX'TIors  DISEASES. 


Treatment. — W'v  tlo  not  know  as  yot  Imw  tin'  pdisoii  roaches  tho  sys- 
tem. Infection  seems  nHK>*t  liable  to  ocriir  at  iii;:lit.  In  regions  in  wliiili 
the  disease  [>rovails  extensively  the  tlrinkin^'-walcr  may  he  hoih-d,  thiinj,'h 
all  ex|)eriments  tend  to  show  that  tiie  vims  does  not  enter  throu<;li  the 
gastro-intestinal  traet.  Persons  jjoing  to  a  malarial  region  slioidd  take 
ahout  10  grains  of  ([niiiine  daily,  though  Sr/.ary  found  that  "i  grains  three 
times  a  day  was  a  sullieii'nt  protection  against  tiie  disease.  During  the 
jiaroxysm  the  patient  should,  in  the  cold  stage,  ho  wrapped  in  hlankets  and 
given  hot  driid<s.  The  reactionary  fever  is  rarely  dangerous  even  if  it 
reaches  a  high  grade.  The  body  nuiy,  however,  he  sponged.  In  quinine 
we  possess  a  sj)ecilic  remedy  against  malarial  infection.  Experiment  has 
ph(»wn  that  the  ])arasit('s  are  most  easily  destroyed  hy  (jninine  at  the  stage 
when  they  ai'e  free  in  the  circulation — that  is,  during  and  just  after  sporu- 
lation.  While  in  most  instances  the  parasites  of  the  regularly  intermittent 
fevers  may  l)e  destroyed,  even  in  the  intra-corpuscular  stage,  in  a'stivo-ati- 
timinal  fever  this  is  much  more  dithcult.  It  should,  then,  he  our  object, 
if  wo  wish  to  most  eifectiudly  eradicate  the  infection,  to  have  as  much 
quinine  in  circulation  at  the  time  of  the  paroxysm  and  shortly  before  as  is 
jiossible,  for  this  is  the  jieriod  at  which  sporuhition  occurs.  In  the  regu- 
larly intermittent  fevers  from  10  to  30  grains  in  divided  doses  througliout 
the  day  will  in  many  instances  prevent  any  fresh  ])aroxysm8.  If  the  patient 
comes  under  observation  shortly  before  an  expected  ])aroxysm,  the  admin- 
istration of  a  good  dose  of  quinine  just  before  its  onset  may  be  advisable 
to  obtain  a  maximum  effect  upon  that  group  of  parasites.  Tho  quinine 
will  not  prevent  the  ])aroxysm,  l)ut  will  destroy  the  greater  part  of  tho 
group  of  organisms  and  ])revent  its  further  recurrence.  It  is  safer  to  give 
at  least  20  to  30  grains  daily  for  the  first  three  days,  and  then  to  continue 
the  remedy  in  smaller  doses  for  the  next  two  or  three  weeks.  In  restivo- 
autnmnal  fever  larger  doses  may  be  necessary,  though  in  relatively  few  in- 
stances is  it  necessary  to  give  more  than  30  to  -10  grains  in  the  twenty-four 
liours. 

The  quinine  should  be  ordered  in  solution  or  in  capsules.  Tho  pills 
and  compressed  tablets  are  more  uncertain,  as  they  may  not  be  dissolved. 

A  question  of  interest  is  the  cfTicient  dose  of  quinine  necessary  to  cure 
the  disease.  I  have  a  number  of  charts  showing  that  grain  doses  three 
times  a  day  will  in  many  cases  pr  ^it  the  paroxysm,  but  not  always  with 
the  certainty  of  the  larger  dosr  nses  of  opstivo-autumnal  fever  with 

pernicious  symjitoms  it  is  r-  j  get  the  system  under  the  influence 

of  quinine  as  rapidly  as  in  these  instances  the  drug  should  be 

administered  hypodermi  j  the  hisulphate  in  30-grain  doses,  with  5 

grains  of  tartaric  acid,  every  two  or  three  hours.  The  muriate  of  quinine 
and  urea  is  also  a  good  form  in  which  to  administer  the  drug  hypoder- 
mically;  10,  15,  or  20  grain  doses  may  be  necessary.  In  the  most  severe 
instances  some  observers  advise  the  intravenous  administration  of  quinine, 
for  which  the  very  soluble  bimuriate  is  well  adapted.  Fifteen  grains  with 
a  grain  of  sodium  chloride  may  be  injected  in  ahout  2  drachms  of  distilled 
water.  For  extreme  restlessness  in  these  cases  opium  is  indicated,  and  car- 
diac stimulants,  such  as  alcohol  and  strychnine,  are  necessary.     If  in  the 


53xr:v\eS;rspaiPf5yjjp3:;E;*saie?swr*^-i^^ 


MALTA   FHVIMI. 


210 


Kc9  tlio  sys- 
is  in  wliiih 
led,  tlioiigli 
liniUfili  tlic 
;li<iiilil  tiiko 
,'rains  three 
During  tho 
ilaiikets  and 
>  oven  if   it 

In  quinine 
eriment  has 
at  tlie  stajic 
after  sporu- 
interniittent 
n  a'stivo-au- 
I  our  object, 
ve  as  much 

before  as  is 
[n  the  re}j;u- 
1  tlirou<j;hout 
f  tlic  patient 
,  the  admin- 
be  advisable 
The  quinine 

part  of  the 
safer  to  give 
I  to  continue 
In  ffistivo- 
ively  few  in- 
'  twenty-four 

3.     The  pills 
le  dissolved, 
ssary  to  cure 

1  doses  three 
;  always  with 
al  fever  with 
the  influence 
ng  should  be 
loses,  with  5 
te  of  quinine 
rug  hypoder- 

2  most  severe 
n  of  quinine, 
n  grains  with 
as  of  distilled 
ited,  and  car- 
y.     If  in  the 


onmntopo  form  the  internal  temperature  is  raised,  the  patient  should  Ik; 
|iut  in  a  bath  and  douseij  wilii  cdld  water.  i''(>r  malarial  amemia,  iron  und 
arsenic  are  indicated. 

An  interesting  (piestion  is  much  discussed,  whether  (piinine  does  not 
cause  or  at  any  rate  aggravate  tlie  lueniogloliiniiria.  We  Iwive  not  yet  seen 
a  case  in  wliich  this  eouditioii  lias  (ucurred  as  a  result  of  the  use  of  tho 
drug.  Jt  seems  localized  in  certain  seiitious;  aiul  Hastiancili  states  that  it 
is  not  seeu  in  the  Ii'duian  uiahirial  fevers.  He  recommends  that  in  any  case 
of  lucmoglohinuria  if  the  iijooii  siu)ws  parasites  ([uiiiiuc  should  be  admin- 
istered freely,  in  the  post-nuiiarial  forms  (piinine  aggravates  the  attack.  In 
an  active  uiJdurial  infection  the  patient  runs  less  risk  witti  the  quinine. 


XXV,    MALTA    FEVER. 

(Undulant  Feivr.) 

Definition.— An  endemic  fever,  charactorij^ed  by  an  irregular  course, 
unduiatory  J'yrexial  relapses,  profuse  sweats,  rheunmtic  pains,  arthritis, 
aiul  an  enlarged  spleen.  An  organism,  the  micrococcus  Melitensis,  is  pres- 
ent in  all  cases. 

The  greater  part  of  our  knowledge  of  this  remarkable  diseas-c  we  owe 
to  the  work  if  the  army  surgeons  stationed  at  (Gibraltar  and  Malta,  par- 
ticularly to  Marston,  to'lkuce,  and  recently  to  Hughes,  whose  important 
work  on  the  subject  1  have  used  freely  for  this  article. 

Distribution. ---The  disease  prevails  extensively  at  Malta,  and  is  also 
met  with  in  the  countries  bordering  on  the  Mediterranean;  hence  the  name 
Mediterranean  fever.  It  is  known  in  Gibraltar  as  Hock  fever,  and  in  Sicily 
aTul  Italy  it  is  known  as  Ncapolilan  fever.  It  i)robably  is  also  met  with 
in  India  and  China.  Hughes  suggests  that  some  of  the  indefinite  forms  of 
fever  in  America  conform  to  this  type,  but  the  evidence  before  us  at  pres- 
ent is  certainly  against  this  view. 

Etiology.— The  disease  is  not  contagious.  It  prevails  in  summer,  and 
in  infected  regions  is  endemic,  occasionally  assuming  epidemic  characters. 
Insanitary  conditions  favor  its  spread,  but  we  cannot  as  yet  say  whether  tho 
poison  isair-borne  or  water-borne.  Hughes  thinks  that  the  former  is  the 
more  probable  view,  Bruce  the  latter.     Young,  healthy  adults  are  chiclly 

attacked. 

'I'he  micrococcus  Melitensis,  discovered  by  Bruce,  has  not  yet  been  iso- 
lated from  the  blood,  but  occurs  in  large  numbers  in  the  spleen.  It  is  con- 
stantly present  in  fatal  cases.  Tho  morphological  and  cultural  characters 
have  been  accurately  studied  by  11.  K.  Durliam.  Inoculations  into  monkeys 
produce  a  disease  somewhat  similar  to  tliat  in  man,  and  the  micrococcus 
can  be  isolated  from  the  infected  animal. 

Symptoms.— There  is  no  specific  fever  wliicli  presents  the  same  re- 
markable grou])  of  ])henomena.  The  period  of  incubation  is  from  six  to 
ten  days.  "  riinically  the  fever  has  a  peculiarly  irregular  temperature  curve, 
consisting  of  intermittent  waves  or  undulations  of  pyrexia,  of  a  distinctly 
remittent  character.  These  pyrexial  waves  or  undulations  last,  as  a  rule, 
14 


S^-itif^'  ;iJr»rfi.  Aiv"'-*^* 


r^r«r3r«r?';»CpW5«l^"-Wr  J! " 


220 


SPECIFIC   INFECTIOUS  DISEASES. 


from  one  to  three  weeks,  with  an  apyrexial  interval,  or  period  of  temporary 
abatement  of  jo'rexial  intensity  between,  lasting'  for  two  or  more  days. 
In  rare  cases  tlie  remissions  may  become  so  marlvcd  as  to  give  an  ahnost 
intermittent  character  to  the  febrile  curve,  clearly  distinguishable,  how- 
ever, from  the  paroxysms  of  paludic  infection.    This  pyrexial  condition  is 
usually  much  prolonged,  having  an  uncertain  duration,  lasting  for  even 
six  months  or  more.     Unlike  i)aludisin,  its  cour.-e  is  not  markedly  ailected 
by  the  administration  of  quinine  or  arsenic.     Its  course  is  often  irregular 
and  even  erratic  in  nature.    This  pyrexia  is  usually  accompanied  by  obs  i- 
nate  constipation,  progressive  ana>mia,  and  debility.     It  is  often  compli- 
cated with  and  followed  by  neuralgic  symptoms  referred  to  the  penplieral 
or  central  nervous  system,  arthritic  ed'usious.  painful  inllammatory  condi- 
tions of  certain  fibrous  structures,  of  a  localized  nature,  or  swelling  ot  the 
testicles"  (Hughes).     This  author  recognizes  a  malignant  type,  m  whicti 
the  disease  may  prove  fatal  -    'lin  a  week  or  ten  days;  an  undulatory  type 
—the  common  variety-in  winch  the  fever  is  marked  by  intermittent  waves 
or  undulations  of  variable  length,  separated  by  periods  of  apyrexia  and  free- 
dom from  svmptoms.     In  this  really  lie  the  peculiar  features  of  the  dis- 
ease, and  the  unfortunate  victim  may  suffer  a  series  of  relapses  which  may 
oxtend  from  three  months,  the  average  time,  to  two  years.    Lastly,  there 
is  an  intermittent  type,  in  which  the  patient  may  simply  have  daily  pyrexia 
toward  evening,  without  any  special  complications,  and  may  do  well  and 
be  able  to  go  about  his  work,  and  yet  at  any  time  the  other  serious  features 
of  the  disease  may  develop. 

The  mortality  is  slight,  only  about  2  per  cent.  There  are  no  character- 
istic morbid  lesions.  The  seriousno'.s  of  the  disease  is  in  its  protracted 
course,  so  that  in  the  army  the  loss  of  time  is  a  very  grave  item.  Ma.ta 
fever  has  to  be  distinguished  carefully  from  typhoid  fever  ana  from  ma- 
laria. From  the  latter  it  can  be  now  readily  diiferentiated  by  the  examina- 
tion of  the  blood.  A  characteristic  serum  reaction  is  present.  From  Dur- 
ham's observations  on  animals  it  is  probable  that  the  organism  may  bo 
isolated  from  the  urine  even  after  apparent  recovery. 

Treatment.— General  measures  suitable  to  typhoid  fever  are  indi- 
cated. Fluid  food  should  be  given  during  the  febrile  period.  Hydro- 
therapy, either  the  bath  or  the  cold  pack,  should  be  used  every  third  hour 
when  the  temperature  is  above  103°  F.  Otherwise  the  treatment  is  symp- 
tomatic. Xo  drugs  appear  to  have  any  special  influence  on  the  fever.  A 
change  of  climate  seems  to  promote  convalescence. 


XXVI.   BERI  BERI. 

Definition.— An  endemic  and  epidemic  multiple  neuritis  of  unknown 
etiology,  occurring  in  troT)ical  and  sulitropical  countries,  characterized  by 
motor  and  sensory  paralysis  and  anasarca.  _      .     ni  • 

History.— The  disease  is  believed  to  be  of  great  antiquity  m  China, 
and  is  possildy  mentioned  in  the  oldest  known  medical  treatise.  In  the 
early  years  of  this  century  it  attracted  much  attention  among  the  Anglo- 


TT?sr 


-TtJnrcKErssaaf^" 


BERI-BEKI. 


221 


temporary 
lore  days, 
an  almost 
iljle,  how- 
)iuliliou  is 
;  for  even 
ly  alTectod 
1  irregular 
I  by  obsti- 
;n  compli- 
pcriphoral 
ory  condi- 
ing  of  the 
,  in  which 
latory  type 
tent  waves 
a  and  free- 
of  the  dis- 
which  may 
istly,  there 
lily  pyrexia 
0  well  and 
Ills  features 

»  character- 
protracted 
em.  Malta 
i  from  ma- 
le exainina- 
From  Dur- 
sm  may  bo 

r  are  indi- 
d.  Hydro- 
third  hour 
nt  is  symp- 
.0  fever.    A 


of  unknown 
acterized  by 

ty  in  China, 
isc.  In  the 
;  the  Anglo- 


Indian  surgeons,  and  we  may  date  tlie  modern  scientific  study  of  the  dis- 
ease from  iMakolmson's  monograph,  ])uljlished  in  ^Madras  in  1S35.  The 
opening  of  Japan  gave  an  opportunity  to  the  German  pliysieians  holding 
university  positions,  particularly  Uaelz,  Scheube,  and  nnuo  recently  Grimm, 
to  investigate  the  disease.  The  studies  of  the  native  Japane.se  pliysicians, 
particularly  Miura  and  Takagi,  and  of  the  Dutch  i)liysicians  in  the  East, 
have  contributed  much  to  our  knowledge.  An  added  interest  has  been 
given  to  the  subject  by  tlie  di.scovery  of  tlic  disease  auiong  the  Cape  Cod 
fishermen,  and  l)y  the  recurring  outbreaks  of  endemic  neuritis  at  the  Rich- 
mond Asylum  in  Dublin  and  at  the  State  Insane  Hospital  at  Tuscaloosa, 

Ala. 

Distribution. — ]}eri-beri,  Kakke,  or  endemic  neuritis  prevails  most 
extensively  in  tlie  Malay  Archipelago;  in  certain  of  the  Dutcli  colonies  tiie 
mortality  among  the  coolies  is  simply  friglitful.  It  is  widely  distributed 
through  parts  of  China  and  Japan.  In  India  it  has  become  less  common, 
but  is  still  prevalent  in  parts  of  Burma.  Localized  oiill»reaks  have  occurred 
in  xVustralia.  It  prevails  extensively  in  parts  of  South  America  and  in  the 
West  Indies,  and  from  the  ports  of  these  countries  cases  occasionally  reach 
the  United  States.  Birge,  of  Provincetown,  and  J.  J.  Putnam  encountered 
beri-beri  among  the  fisliermen  on  the  Xewfoundland  Banks.  Birge  writes 
(March  10,  181)8)  that  he  has  seen  47  cases  of  botlx  the  wet  and  the  dry 
form.  The  disease  is  not  entirely  confined  to  the  fishermen  on  the  Grand 
Banks,  but  develops  occasionally  among  tiiose  living  on  shore  or  making 
"shore  trips."  In  ISDS-'UO  a  remarkal)lc  outbreak  of  endemic  neuritis 
occurred  at  the  State  Insane  Hospital  at  Tuscaloosa,  Ala.,  which  has  been 
described  fully  by  E.  D.  Bondurant.*  Between  February,  lS95,and  October, 
189fi,  in  a  population  of  l,'i()0  there  were  Tl  cases  with  21  deaths.  None 
occurred  among  tlie  200  employees  of  the  hosi)ital.  The  negroes  were  rela- 
tively less  affected  than  the  whites.  The  chief  symptoms  were  "  muscular 
weakness,  tenderness,  pain,  parivsthesia%  loss  of  deep  reflexes,  followed  by 
atrophy  of  muscles  and  the  electrical  reaction  of  degeneration,  accom- 
panied by  rise  of  temperature,  gastro-intestinal  disturljance,  general  ana- 
sarca, and  tachycardia."  At  the  Arkansas  State  Insane  Asylum  at  Littb3 
Rock,  in  1895,  tliere  was  an  outbreak  of  between  20  and  30  cases  possibly 
of  beri-beri. 

In  Great  Britain  the  disease  is  not  infrequent  at  the  seaports. 

At  the  Riclimond  Asylum,  Duldin,  there  have  been  extensive  outbreaks 
in  the  years  1894,  1890,1897,  under  conditions  of  shameful  overcrowding. 

Etiology.— Two  main  views  prevail  as  to  the  nature  of  the  disease — 
that  it  is  an  infection,  and  that  it  is  a  toxivmiia  caused  by  food. 

1.  Beri-hrri  as  an  Acute  Infection. — Baelz  and  Scheube,  with  many  of 
the  Dutch  physicians,  hold  that  the  disease  is  due  to  a  living  germ.  In 
favor  of  this  view,  Scheulje  refers  to  the  fact  tliat  strong,  well-nourished 
young  people  are  attacked,  that  the  disease  has  definite  foci  in  which  it 
prevails,  definite  seasonal  relations,  and  has  of  late  years  si)read  in  some 
countries  as  an  epidemic  without  any  special  change  in  the  diet  of  the 


•  New  York  Medical  Journal,  1807,  ii. 


-~-         .•:!TV-^;3fT:;;:;m 


<:- 


222  SPECIFIC  INFECTIOUS  DISEASES. 

inhabitanls.  So  far  as  seasonal  and  telluric  influences  are  concerned  it  is 
a  disease  wliieli  resembles  malaria,  vitli  whidi,  in  fact,  some  authors 
l,ave  conf..unde(l  it.  It  is  iM-ol.al.ly  not  direetiy  .ontag.ous.  On  he  o  he 
hand,  Sclieube,  Manson  and  others  bring  forward  evidence  to  show  that 
beri-bcri  may  probably  be  e.mveyed  from  one  district  to  anotl-ei. 
^lanv  baet..rioloun(.al  studies  have  been  made  in  the  d.seasi|,  particu- 
larly by  Dutch  physicians,  but  there  is  no  unanimity  as  to  the  results 
and  we  may  say  that  no  specific  organism  has  as  yet  been  determ.ne.l 

"'"  2  ■  The  food  theory  of  beri-beri  is  widely  held  in  Jaiian.  some  believing 
that  rt  is  due  to  the  eating  of  bad  rice,  and  others  tlmt  it  is  associated  with 
the  use  of  certain  fish.  In  favor  of  the  dietetic  view  of  its  origin  is  ad- 
duced the  extraordinary  change  which  has  taken  place  in  he  Japanese 
navy  since  the  introduction  by  Takagi  of  an  improved  <!'«*'  ;"«;;,•"?  | 
larger  portion  of  nitrogenous  food,  and  forlnddmg  the  use  of  lesh  fi  h 
altocrother.  Subsequent  to  this  there  has  certainly  been  the  most  remark- 
able^liminution  in  the  number  of  cases-a  reduction  from  about  a  fourth 
of  the  entire  strength  attacked  annually  to  a  practical  abolition  ot  the 

'^"Trecent  number  of  Janus  gives  the  experience  of  the  Dutch  ph>;sician9 
in  Java,  many  of  whom  regard  rice  as  the  important  cause  of  tlie  disease 
It  is  stated  ti.at  in  the  prisons  of  Java  the  proportion  of  cases  is  1  to  3J 
when  the  rice  is  eaten  comj-letely  shelled,  1  to  1(),()..()  when  the  grain  is 
eaten  with  its  pericarp;  in  some  places  the  disease  has  d.sa,>peared  when 
the  nnshelled  rice  has  been  substituted  for  the  shelled.  M.ura  with  whose 
studies  of  the  disease  all  readers  of  Virchow's  ArcV.iv  are  f.i miliar  regards 
beri-beri  as  a  form  of  chronic  poisoning  due  to  the  use  of  the  flesh  ot  cer- 
tain fish  eaten  raw  or  improperly  prepared.  Grimm,  in  his  recent  mono- 
graph, regards  the  immunity  of  lOnropeans  as  in  great  part  owing  to  the 
fact  that  they  do  not  follow  the  Japanese  cnstom  of  eating  various  kinds  ot 

'''\mon<r  the  most  important  factors  are  the  following:  Overcrowding, 
ns  in  shii.s,  iails,  and  asylums,  hot  and  moist  seasons,  and  exposure  to  wet. 
Europeans  ni.der  good  "hygienic  conditions  rarely  contract  the  disease  in 
beri-beri  regions.  The  natives  and  the  imported  coolies  are  the  most  often 
attacked.  Males  are  more  subject  to  the  disease  than  females,  loung  men 
from  sixteen  to  twenty-five  are  most  often  ad'ected 

SvmDtoms.— The  incubation  period  is  unknown,  but  it  ])robably 
extends  over  several  months.  The  following  forms  of  the  disease  are  recog- 
nized by  Scheube:  .        .  , 

1.  The  incomplete  or  rudimentary  form  which  often  sets  m  with  ca- 
tarrhal symptoms,  followed  by  j.ains  and  weakness  in  the  limbs  and  a  ower- 
ini;  of  the  sensibility  in  the  legs,  with  the  development  of  para^sthosia;. 
Slight  (Tdenia  sometimes  appears.  After  a  time  para^sthesia<  may  develop 
in  other  parts  of  the  bodv,  and  the  patient  may  comi)laiu  o[  palpitation  ot 
the  heart  uneasy  sensations  in  the  abdomen,  and  sometimes  shortness  ot 
breath  There  may  be  weakness  and  tenderness  of  the  muscles.  After 
bstin<-  from  a  few  days  to  many  months,  these  symptoms  all  disappear,  but 


•^«a«W^««»A.«««*«Wa««hi^^ 


■?•      fn 


BERI-BERI. 


223 


rneil,  it  is 
V  authors 
tlio  other 
show  tliat 
another. 
,  partieii- 
le  results, 
etcrniinud 

}  Ijolieviug 
•iattMl  with 
igiii  is  ad- 
;  Japanese 
allowing  a 
fresh  lish 
ist  remark- 
it  a  fourth 
ion  of  the 

physicians 
the  disease. 

is  1  to  39 
he  grain  is 
.'ared  when 
with  whoso 
iar,  regards 
lesh  of  cer- 
ccnt  mono- 
ving  to  the 
(US  kinds  of 

ercrowding, 
sure  to  wet. 
3  disease  in 
'  most  often 
Young  men 

it  ])rohably 
5e  arc  recog- 

in  witli  ca- 
and  a  lower- 
parff'sthesiic. 
may  develop 
iiljiitation  of 
shortness  of 
JcU's.  After 
isaiipear,  but 


with  tliG  return  of  the  warm  weather  there  may  be  a  recurrence.     One  of 
Scheubc's  ]mticnts  sullVrcd  in  this  way  for  twenty  years. 

2.  The  atrophic  form  sets  in  with  much  the  same  symptoms,  but  the 
loss  of  power  in  the  limbs  progrc,<scs  more  rapidly,  and  very  soon  the 
patient  is  no  longer  able  to  walk  or  to  move  the  arms.  The  atroi)hy. 
which  is  associated  with  a  good  deal  of  Jiain,  nuiy  extend  to  the  mus- 
cles of  the  face.  The  (edematous  symptoms  and  heart  troubles  play 
a  minor  rule  in  this  form,  which  is  known  as  the  dry  or   paralytic   va- 

rietv. 

3.  The  Wet  or  Dropsical  Form.— Setting  in  as  in  the  rudimentary  vari- 
ety, the  oedema  soon  becomes  the  most  marked  feature,  extending  over 
the  whole  subcutaneous  tissue,  and  associated  with  elfusioiis  into  the  serous 
sacs.  The  atrojjhy  of  the  muscles  and  disturbance  of  sensation  are  not  sucli 
])rominent  symptoms.  On  the  other  hand,  palpitation  and  rapid  action  of 
the  heart  and  dyspna>a  are  common.  The  wasting  may  not  be  apparent 
until  the  dropsy  disappears. 

4.  The  acute,  pernicious,  or  cardiac  form  is  characterized  by  thrcat- 
enings  of  an  acute  cardiac  failure,  developing  rapidly  after  the  existence 
of  slight  symptoms,  such  as  occur  in  the  rudimentary  form.  In  the  most 
acute  type"  death  may  follow  within  twenty-four  hours;  more  commonly 
the  symptoms  extend  over  several  weeks. 

The  mortality  of  the  disease  varies  greatly,  from  2  or  3  per  cent  to  -10 
or  50  per  cent  among  the  coolies  in  certain  of  the  settlements  of  the  ]\Ialay 

Archi])clago. 

Morbid  Anatomy.— The  most  constant  and  striking  teatures  are 
changes  in  the  pcrii^heral  nerves  and  degenerative  inflammation  involving 
the  axis  cylinder  and  medullary  sheaths.  In  the  acute  cases  this  is  found 
not  only  in  the  peripheral  nerves,  but  also  in  the  pneumogastric  and  in 
the  i)hrenic.  The  fibres  of  the  voluntary  muscles,  as  well  as  of  the  myo- 
cardium, arc  also  much  degenerated. 

Diagnosis.— In  tro])ical  countries  there  is  rarely  any  diiliculty  m  the 
diagnosis.  In  cases  of  peripheral  neuritis,  associated  with  oedema,  coming 
from  tropical  ports,  the  possibility  of  this  disease  should  be  remembered. 
Scheube  states  that  rarely  any  difficulty  offers  in  the  diagnosis  of  the  dif- 
ferent forms.  An  interesting  question  arises  as  to  the  true  nature  of  the 
endemic  neuritis  in  the  Richmond  Asylum  and  at  Tuscaloosa.  Bondurant's 
report  certainly  shows  a  disease  conforming  with  beri-beri  in  a  majority 
of  its  features.  The  statement  is  made  that  the  Dutch  committee  wh.eh 
studied  the  epidemic  at  the  Richmond  Asylum  did  not  regard  the  disease 
as  quite  identical  with  the  tropical  beri-beri. 

Treatment.— ^Inch  has  been  done  to  prevent  the  disease,  particularly 
in  Ja]tan.  There  is  no  more  remarkable  triumph  of  modern  hygiene  than 
that  which  followed  Takagi's  dietetic  reforms  in  the  Japanese  navy.  In 
beri-beri  districts  Europeans  should  use  a  diet  rich  in  nitrogenous  ingredi- 
ents. In  the  dietary  of  prisons  and  asylums  the  experience  of  the  Javanese 
physicians  with  reference  to  the  remarkable  diminution  of  the  disease  with 
the  use  of  unshelled  rice  should  be  borne  in  mind.  In  ships,  prisons,  and 
asvlums  the  disease  has  rarely  occurred  except  in  connection  with  over- 


il&lil^^^^iri0>i?^ii'^,^IS¥^- 


.  ■«-..,  Y-^zr--'-  ■•■".-**»»:• 


224: 


SPECIFIC  INFECTIOUS  DISEASES. 


crowding,  an  t'liMiicnt  wiiioh  prevailed  both  at  the  Richmond  Asylum  and 
at  the  State  Ilo^iiital  for  the  Insane  at  Tuscaloosa. 

Baelz  recommends  in  early  cases  a  free  use  of  the  salicylates,  15  or  50 
grains  four  or  five  times  a  day.  Others  advise  early  free  purgation.  lu 
very  severe  acute  cases,  both  Anderson  and  Baelz  advise  blood-letting. 
The  more  chronic  cases  demand,  in  addition  to  dietetic  measures,  drugs  t>) 
support  the  heart  ami  treatment  of  the  atrophied  muscles  with  electricity 
and  massage. 


XXVII.   ANTHRAX. 

(Splenic  Fever  ;  Charbon  ;  Wool-sorter's  Disease.) 

Definition. — An  acute  infectious  disease  caused  by  the  haciUus  an- 
iliracis.  It  is  a  widespread  affection  in  animals,  particularly  in  sheep  and 
cattle.  In  man  it  occurs  sporadically  or  as  a  result  of  accidental  inocula- 
tions with  the  virus. 

Etiology.— The  infectious  agent  is  a  non-motile,  rod-shaped  organ- 
ism, the  biicilhis  aiifhraris,  which  has,  by  the  researches  of  rollendcr,  Da- 
vaine,  Koch,  and  Pasteur,  become  the  best  known  perha])s  of  all  patho- 
genic microbes.  The  bacillus  has  a  length  of  from  two  to  ten  times  the 
diameter  of  a  red  l)lood-corpuscle;  the  rods  are  often  united.  They  mul- 
tiply by  fission  with  great  rai)idity  and  grow  with  facility  on  various  culture 
media,  extending  into  long  filaments  which  interlace  and  produce  a  dense 
network.  Tiie  spore  formation  is  seen  with  great  readiness  in  these  fila- 
ments; but  an  asjiorogenons  variety  is  known,  and  can  be  jn-oduced  arti- 
ficially in  cultures.  The  bacilli  themselves  arc  readily  destroyed,  but  the 
spores  are  very  resistant,  and  survive  after  prolonged  immersion  in  a  5-per- 
cent solution  of  carbolic  acid,  and  resist  for  some  minutes  a  temperature 
of  212°  Fabr.  They  are  capable  also  of  resisting  gastric  digestion.  Out- 
side the  body  the  spores  are  in  all  i)robability  very  durable. 

Geognii)hically  and  zoologically  the  disease  is  the  most  wides])read  of 
all  infectious  disorders.  It  is  much  more  prevalent  in  Europe  and  in  Asia 
than  in  Anu^'ica.  Its  ravages  among  the  herds  of  cattle  in  Kussia  and 
Siberia,  and  among  sheep  in  certain  ])arts  of  Europe,  are  not  equalled  by 
any  other  aninia)  plague.  In  this  country  the  disease  is  rare.  So  far  as  I 
know,  it  has  never  prevailed  on  the  ranches  in  the  Northwest,  but  cases 
were  not  infrequent  about  Montreal. 

A  protective  inoculation  with  a  mitigated  virus  has  been  introduced  by 
Pasteur,  and  has  been  ado]ited  in  certain  anthrax  regions.  ITankin  has 
isolated  from  the  cultures  an  albumose  which  renders  animals  immune 
against  the  most  intense  virus. 

In  animals  the  disease  is  conveyed  sometimes  by  direct  inoculation,  as 
by  the  bites  and  stings  of  insects,  by  feeding  on  carcasses  of  animals  which 
have  died  of  the  disease,  but  more  commonly  by  feeding  in  pastures  in 
which  the  germs  have  been  preserved.  Pasteur  believes  tliat  the  earth- 
worm plays  an  important  part  in  bringing  to  the  surface  and  distributing 
the  bacilli  which  have  been  propagated  in  the  buried  carcass  of  an  in- 
fected animal.     Certain  fields,  or  even  farms,  may  thus  be  infected  for  an 


,,( ■>  iv  -t. 


ANTHRAX. 


225 


i\um  and 

15  or  t?() 
tiou.  lu 
d-letti!i<;-. 

drugs  t>) 
electricity 


cilhis  an- 
^licep  and 
1  inocula- 

od  organ- 
indcr,  Da- 
all  patlio- 
tinies  the 
riiey  nuil- 
us  culture 
?e  a  dense 
these  fila- 
uced  arti- 
1,  but  the 
n  a  5-per- 
mperature 
ion.     Out- 

es])read  of 
id  in  Asia 
lussia  and 
quailed  by 
■io  far  as  I 
but  eases 

•oducod  by 
fankin  has 
Is  immune 

ulation,  as 
nals  which 
pastures  in 
the  earth- 
listributing 
of  an  in- 
3ted  for  an 


indefinite  period  of  time.  Tt  eocms  probable,  liowcver,  tiiat  if  tlic  carcass 
is  not  opened  or  the  blood  spilt,  spores  are  not  formed  in  the  buried  ani- 
mal and  the  bacilli  quickly  die. 

Animals  vary  in  susceptibility:  the  hcrbivora  come  first,  then  the  om- 
nivora,  and  lastly  the  carnivora.  The  disease  doc:;  not  occur  s])(m<ane- 
ously  in  man,  but  always  results  from  infection,  either  through  the  skin, 
the  intestines,  or  in  rare  instances  through  the  lungs.  It  is  found  in  per- 
sons whose  occu])ations  bring  them  into  contact  with  animals  or  animal 
products,  as  stal)lenien,  shepherds,  tanners,  butchers,  and  those  who  work 
in  wool  and  hair. 

Various  forms  of  the  disease  have  l)ccn  described,  and  two  chief  groups 
may  be  recognized:  the  external  anthrax  and  the  internal  anthrax,  of  which 
there  are  pulmonary  and  intestinal  forms. 

Symptoms.— (1)  External  Anthrax. 

(«)  Malignant  Pnsfule. — Tlie  inoculation  is  usually  on  an  exposed  sur- 
face— the  hands,  arms,  or  face.  At  the  site  of  inoculation  tliere  are,  within 
a  few  hours,  itching  and  uneasiness.  Gradually  a  small  papule  develops, 
which  becomes  vesicular.  Inflammatory  induration  extenc^j  around  this, 
and  within  thirty-six  hours,  at  the  site  of  inoculation  there  is  a  dark  brown- 
ish eschar,  at  a  little  distance  from  which  there  may  be  a  series  of  small 
vesicles.  The  lirawny  induration  may  be  extreme.  The  cedema  ])roduces 
very  great  swelling  of  the  parts.  The  iidlammation  extends  along  tlie  lym- 
phatics, and  the  neighl)oring  lymph-glands  are  swollen  and  sore.  Tlic 
fever  at  first  rises  rapidly,  and  the  concomitant  phenomena  are  luaiked. 
Subsequently  tlie  temperature  falls,  and  in  many  cases  becomes  subnornud. 
Death  may  take  place  in  from  three  to  five  days.  In  cases  wdiich  recover 
the  constitutional  symptoms  are  slighter,  the  eschar  gradually  sloughs  out, 
and  the  wound  heals.  The  cases  vary  much  in  severity.  In  the  luildcst 
form  there  may  be  only  slight  swelling.  At  the  site  of  inoculation  a  papule 
is  formed,  which  rapidly  becomes  vesicular  and  dries  into  a  scab,  which 
separates  in  the  course  of  a  few  days. 

(h)  Maluinant  Anthrax  (Edema. — This  form  occurs  in  the  eyelid,  and 
also  in  the  head,  hand,  and  arm,  and  is  characterized  by  the  absence  of  the 
papule  and  vesicle  forms,  and  by  the  most  extensive  oedema,  which  nuiy 
follow  rather  than  precede  the  constitutional  symptom-  The  oedema 
reaches  such  a  grade  of  intensity  that  gangrene  results,  ami  may  involve  a 
considerable  surface.  The  constitutional  symptoms  then  become  extremely 
grave,  and  the  cases  invariably  prove  fatal. 

The  greatest  fatality  is  seen  in  cases  of  inoculation  about  the  head  and 
face,  where  tlie  mortality,  according  to  Xasarow,  is  26  per  cent;  the  least 
in  infection  of  the  lower  extremities,  where  it  is  5  per  cent. 

In  a  recent  case,  in  a  hair-picker,  there  was  most  extensive  enteritis, 
peritonitis,  and  endocarditis,  which  last  lesion  has  been  described  by 
Eppinger. 

A  feature  in  both  these  forms  of  malignant  pustule,  to  which  many 
writers  refer,  is  the  absence  of  feeling  of  distress  or  anxiety  on  the  part  of 
the  patient,  whose  mental  condition  may  be  perfectly  clear.  lie  may  be 
without  any  apprehension,  even  though  his  condition  is  very  critical. 


■•k*^"" 


S-.WV»«'l'^XTf?trf-??***;''5W».f1»^  •■ 


226 


SPECIFIC  INFECTIOUS  DISEASES. 


The  diagnosis  in  most  instances  is  readily  made  from  the  character  of 
the  lesion  and  the  occni-ation  of  the  patient.  When  in  doul,t,  ihe  exami- 
nation of  the  fluid  from  tlie  ptistule  may  show  the  presence  ot  tlie  antliiax 
haeiUi  Cultures  siiould  be  made,  or  a  mouse  or  gumea-pig  inoculated 
from  the  local  lesion.  It  is  to  be  remembered  that  the  blood  may  not  show 
the  bacilli  in  numbers  until  shortly  before  death. 

l-Z)  Internal  Anthrax.  ,     .   „    ,. 

(a)  Inlestinal  Form,  Mycosis  intestinalis.-ln  these  cases  the  infection 
usually  is  through  the  stomach  and  intestines,  and  results  Irom  eating  tlic 
ilosh  or  drinking  the  milk  of  diseased  animals;  it  may.  however,  lollow  an 
external  infection  if  the  germs  are  carried  to  the  mouth.  Ihc  symptoms 
are  those  of  intense  iK.isoiiing.  The  disease  may  set  m  with  a  cull,  lol- 
lowed  by  vomiting,  diarrlura,  moderate  fever,  and  pains  in  the  legs  and 
back.  In  acute  eases  there  arc  dyspmra,  cyanosis,  great  anxiety  and  rest- 
lessness, and  toward  the  end  convulsions  or  spasms  of  the  muscles  lUt^m- 
orrhage  may  occur  from  the  mucous  membranes.  Occasionally  tliere  are 
small  i.hlegmonous  areas  on  the  skin,  or  petechia  develop.  Ihe  spleen  i^ 
enlarged.  The  blood  is  dark  and  remains  fluid  for  a  long  time  after  death. 
Late 'in  the  disease  the  bacilli  may  be  found  in  the  blood. 

This  is  one  of  the  forms  of  acute  ]ioisoning  which  may  affect  many  in- 
dividuals together.  Thus  Butler  and  Karl  Huber  describe  an  epidemic 
in  which  twenty-five  persons  were  attacked  after  eating  the  flesh  of  an 
animal  which  had  had  anthrax.     Six  died  in  from  forty-eight  hours  to 

seven  days.  ~       ,^         •    t       i 

(h)  Wool-sorfer's  Disease— T\ui^  important  form  of  anthrax  is  tound 
in  the  large  establishments  in  which  wool  or  hair  is  sorted  and  cleansed. 
The  hair  and  wool  imported  into  Europe  from  Eussia  and  South  America 
appear  to  have  induced  the  largest  number  of  cases.    IMany  of  these  shovv 
no  external  lesion.    The  infective  material  has  been  swallowed  or  inhaled 
with  the  dust.     There  are  rarely  premonitory  symptoms.     The  patient  is 
seized  with  a  chill,  becomes  faint  and  prostrated,  has  pains  m  the  back 
and  legs,  and  the  temperature  rises  to  103°  or  103°.     The  breathing  is 
rapid,  and  he  complains  of  much  pain  in  the  chest.    There  may  be  a  cough 
and  signs  of  bronchitis.     So  prominent  in  some  instances  arc  these  bron- 
chial symptoms  that  a  pulmonary  form  ot  the  disease  has  been  <3cscribeii. 
The  pulse  is  feeble  and  very  rapid.     There  may  be  vomiting,  and  death 
may  occur  within  twenty-four  hours  with  symptoms  of  ])rofound  collapse 
and  prostration.    Other  cases  are  more  protracted,  and  there  may  be  diar- 
rhea   delirium,  and  unconsciousness.     The   cerebral   sym])toms  may  be 
most' intense;  in  at  least  four  cases  the  brain  seems  to  have  been  chiefly 
affected,  and  its  capillaries  stuffed  with  bacilli  (Merkel).     The  recognition 
of  wool-sorter's  disease  as  a  form  of  anthrax  is  due  to  J.  IT.  Bell,  of  Brad- 
ford, England.  . 

In  certain  instances  these  profound  constitutional  symptoms  of  internal 
anthrax  are  associated  with  the  external  lesions  of  malignant  pustule. 

The  rag-picker's  disease  has  been  made  the  subject  of  an  exhaustive 
study  by  Eppinger  (Die  TTadernkrankheit,  Jena,  189-1),  who  has  shown  that- 
it  is  a  local  anthrax  of  the  lungs  and  pleura,  with  general  infection. 


''■•-«^aii».jt'«it»iw-*w>'.'^«y«a^^^        ■ia?(*i«Mfi»«i«»«=»s!»SES?j 


g'Amn^mtiiii" 


IlYDUOPIIoniA, 


221 


aractcr  of 
ho  oxami- 
.e  antluax 
inoculati'.d 
not  show 


!  infection 
eating  the 
l'()lh)\v  an 
svmjjtonis 
diill,  i'ol- 
e  legs  and 
!  and  Test- 
es.   Ila^m- 
r  there  arc 
e  spleen  i.s 
iter  death. 

t  many  in- 
II  ejjidemic 
Hesh  of  an 
,t  hours  to 

X  is  found 
d  cleansed, 
th  America 

these  show 

or  inhaled 
D  y)atient  is 
n  the  back 
)reathing  is 

he  a  congli 
these  hron- 
n  described. 
,  and  death 
ind  collapse 
nay  be  diar- 
ms  may  be 
been  chiefly 

recognition 
ell,  of  Brad- 

s  of  internal 
pustule. 
1  exhaustive 
^  shown  that- 
ction. 


The  diagnosis  of  internal  anthrax  is  by  no  means  easy,  unless  the  his- 
tory points  (leilnitely  to  infection  in  the  occupation  of  llie  individual. 

Treatment. — In  malignant  luistule  tlie  site  of  inoculation  slu)ul(i  be 
destroyed  by  the  caustic  or  iiot  inm,  and  powdered  bicliloride  of  mercury 
may  be  sprinkled  over  tlu-  exposed  siirfacc.  The  local  developme  it  of  tlie 
bacilli  al)()ut  the  site  of  inoculation  may  be  |)reventc(l  by  tlie  subcutaneous 
injections  of  solutions  of  carlxilic  ai'id  or  bichloride  of  mercury.  The 
injections  should  be  made  at  various  points  around  the  pustule,  and  may 
be  repeated  two  or  tliree  times  a  day.  The  internal  treatment  should  he 
confined  to  the  administration  of  stimulants  and  jilenty  of  nutritious  food. 
Davies-Collcy  advises  i])ecacuanlia  ))owder  in  doses  of  fro  n  5  to  10  grains 
every  three  or  four  hours. 

In  malignant  forms,  particularly  the  intestinal  cases,  little  can  be  done. 
Active  purgatives  may  be  given  at  the  outset,  so  as  to  remove  the  infect- 
ing material.     Quinine  in  large  doses  has  been  recommended. 


XXVIII.    HYDROPHOBIA. 

{Lyssa ;  liubiiK.) 

Definition.— An  acute  disease  of  warm-})looded  aninuds,  dependent 
upon  a  siieciiic  virus,  and  cummuniealed  by  inoculation  to  man. 

Etiology.— In  man  the  disease  is  very  variously  distributed.  In  Rus- 
sia it  is  common.  Jn  Xorth  (lermauy  it  is  extremely  rare,  owing  to  the 
wi.se  provision  that  all  dogs  shall  be  muzzled;  in  England  and  JM'ance  it  is 
much  more  common.  In  this  country  the  disease  is  very  rare.  Dulles 
could  collect  only  78  cases  in  the  five  and  a  half  years  eiuling  December  151, 
181)3. 

Canines  are  specially  liable  to  the  disease.  It  is  found  most  fretiuently 
in  the  dog,  the  wolf,  and  the  cat.  All  animals  are,  however,  susceptible; 
and  it  is  communicable  by  inoculation  to  the  ox,  horse,  or  pig.  The  dis- 
ease is  propagated  clnefly  by  the  dog,  which  seems  sjiecially  susce])tible. 
In  the  Western  States  the  skunk  is  said  to  be  very  liable  to  the  disease. 
The  iiature  of  the  ])ois()n  is  as  yet  mdvnown.  It  is  contained  chietly  in 
the  nervous  system  and  is  met  with  in  some  of  the  secretions,  particularly 
in  the  saliva. 

A  variable  time  elapses  between  the  introduction  of  the  virus  and  the 
appearance  of  the  symptoms,  llorsley  states  that  tliis  dejiends  npon  the 
following  factors:  "  (a)  Age.  TliC  incubation  is  shorter  in  children  than 
in  adults.  For  obvious  reasons  the  former  are  more  frecpiently  attacked. 
(h)  Part  infected.  The  rapidity  of  onset  of  the  symptoms  is  greatly  de- 
termined by  the  part  of  the  body  which  nviy  hapjien  to  have  been  bitten. 
Wounds  about  the  face  and  head  are  especially  dangerous;  next  in  order 
in  degrees  of  mortality  come  bites  on  the  hands,  then  injuries  on  the  other 
parts'^of  the  body.  This  relative  order  is,  no  doubt,  greatly  dependent 
upon  the  fact  that  tne  face,  bend,  and  hands  are  usually  naked,  while  the 
other  parts  are  clothed;  it  would  also  appear  to  depend  somewhat  upon 
the  richness  in  nerves  of  the  part,     (r)  The  extent  and  severity  of  the 


E^^n^y' >»>aiMk)M«il>t^' 


•^«u.  JaF*-'i*i*' 


r*.^;  ^  «»»t- 


223 


srECIFIC  INFKt'TIOUS  DISEASES. 


w..una.  I'muture  w...in.ls  an-  tl.c  most  .lan-orous;  the  lacerations  are 
fatal  in  nr(.p(.rti..n  t..  tl.o  o.xt.nt  ..i'  tlic  surfair  alT..r.k..l  l'..r  aLsorption  ot 
the  virus.  ((/)  The  animal  cunveyinf,'  the  inlVrticn.  In  order  ..1  decreas- 
ing severity  eon.e:  tirst,  the  wolf;  seeond,  the  eat;  third,  the  dog;  am 
tourth,  other  animals."  Only  a  limited  numl.er  of  those  hitten  l.y  nd.id 
doiis  become  aiTeeted  l.y  the  disease;  aceonlinj:  to  Il-rsley,  not  n.ore  than 
ir,  iH>r  cent  On  the  other  hand,  the  death-rate  of  tlu.se  i.ers..ns  hit  en  hy 
wolves  is  hijrher,  not  less  than  40  per  cent.     Jiabes  gives  the  mortality  as 

from  (iO  to  HO  per  cent. 

The  incubation  period  in  man  is  extremely  variable.  Ihe  axeiage  is 
from  six  weeks  to  two  months.  In  a  few  cases  it  has  been  under  two  weeks. 
It  may  be  prolonged  to  three  months.  It  is  stated  that  the  inci.ba  lon 
may  be  prolonged  for  a  year  or  even  two  years,  but  this  has  not  been  deh- 

nitclv  settled.  . 

Symptoms.— Three  stages  of  the  disease  are  recognized. 

(1)  I'rcmonilnni  shn/r,  in  which  there  may  'ne  irritation  about  the  bite, 
pain,  or  numbness.  The  patient  is  depressed  and  melancholy;  and  com- 
plains of  headache  and  loss  of  appetite.  He  is  very  irntal)le  and  sleepless, 
and  has  a  constant  sense  of  impending  danger.  There  is  olten  greatly 
increased  sensibility.  A  bright  light  or  a  loud  voice  is  distressing  Ihe 
larvnx  may  be  injected  and  the  first  symptoms  of  diniculty  in  swallowing 
are  exiiericnced.    The  voice  also  becomes  husky.    There  is  a  slight  rise  m 

the  temi)erature  and  the  pulse.  ^         •,  ,  •,•. 

(3)  Stiu/e  of  J':.rcilnne,if.—Thh  is  characterized  by  great  exeitahiiity 
and  restlessness,  and  an  extreme  degree  of  hypera'sthesia.     "  Any  afferent 
stimulant— i.  e.,  a  sound  or  a  draught  of  air,  or  the  mere  association  ot 
a  verbal  suggestion— will  cause  a  violent  reflex  spasm.    In  man  this  symp- 
tom constitutes  the  most  distressing  feature  of  the  malady.     The  spasms, 
which  alTeet  particularly  the  muscles  of  the  larynx  and  mouth,  are  exceed- 
in<dy  painful  and  are  accompanied  by  an  intense  sense  of  dyspmea,  even 
when  the  glottis  is  widely  opened  or  tracheotomy  has  been  i)erformed 
(]Ior«lev)     Any  attcnii)t  to  take  water  is  followed  by  an  intensely  painiul 
spasm  of  the  muscles  of  the  larynx  and  of  the  elevators  of  the  hyoid  bone. 
It  is  this  which  makes  the  patient  dread  the  very  sight  of  water  and  gives 
the  name  In/drophohia  to  the  disease.     These  spasmodic  attacks  may  be 
associated  with  maniacal  symptoms.     In  the  intervals  between  them  the 
patient  is  quiet  and  the  mind  nnclonded.     The  temperature  in  this  stage 
is  usually  elevated  and  may  reach  from  100°  to  10^.    In  some  instances  the 
disease  is  afebrile.    The  patient  rarely  attempts  to  injure  his  attendants, 
and  in  the  intense  spasms  may  be  particularly  anxious  to  avoid  hurting 
any  one.     There  are,  however,  occasional  fits  of  furious  mama,  and  the 
paiient  may,  in  the  contractions  of  the  muscle,  of  the  larynx  and  pharynx, 
give  utterance  to  odd  sounds.     This  stage  lasts  from  a  day  and  a  half  to 
three  days  and  gradually  passes  into  the-- 

(3)  Parah/Hc  Stage— U  rodents  the  preliminary  and  furious  stages 
are  absent,  as  a  rule,  and  the  paralytic  stage  may  be  marked  from  the  out- 
get-the  so-called  dumb  rabies.  This  stage  rarely  lasts  longer  than  from 
six  to  eighteen  hours.     The  patient  then  becomes  quiet;  the  spasms  no 


■■'>»*•..>» 


: .  vv^*«;^gsass;^^ss«e^^^«iys£5^a^ 


IIYDROPIIOHIA. 


229 


;rations  are 
)snii>ti()n  of 
of  (li'crcaH- 
0  (log;  ami 
un  by  raUitl 
t  nioro  tlum 
lis  bitten  by 
mortality  as 

('  average  is 
r  two  weei<s. 
3  iiu'iibatiou 
)t  been  ileli- 


Dut  the  bite, 
y:  and  eom- 
md  sleei)less, 
)ften  greatly 
essing.  Tiie 
II  swallowing 
slight  rise  in 

t  excitability 
Any  atTerent 
issoeiation  of 
[n  this  symp- 

Thc  spasms, 
1,  are  exceed- 
yspneea,  even 

])erformed  " 
insely  ])ainfnl 
e  hyoid  bone, 
iter  and  gives 
tacks  may  be 
2en  them  the 

in  this  stage 

instances  the 
is  attendants, 
[ivoid  hurting 
ania,  and  the 

and  pharynx, 
and  a  half  to 

furions  stages 
from  the  ont- 
ler  than  from 
he  spasms  no 


longer  occnr;  unconsciousness  gradually  sujiervenes;  the  heart's  action  be- 
comes more  ami  more  enfeebled,  and  death  occurs  by  syncope. 

Morbid  Anatomy. — Tlie  lesioi;s  are  in  the  eerebro-spinal  system. 
The  blood-vessels  are  congested;  tlii're  is  perivascular  exudation  of  leuco- 
cytes; and  there  are  minute  hiemorrliages.  According  to  (iowers,  these 
are  i)articularly  intense  in  the  me.lulla.  The  pharynx  is  congested,  the 
mucous  membrane  of  the  stomach  is  hypera-mic,  and  not  infrequently  cov- 
ered with  a  l)lo.)d-stained  mucus.  The  larynx,  trachea,  and  bronchi  show 
acute  congestion.  There  are  no  special  changes  in  the  alxlominal  or  tho- 
racic viscera.  The  inoculation  experiments  show  that  the  virus  is  not  pres- 
ent in  the  liver,  sideen,  or  kidneys,  but  is  al)undant  in  the  spinal  cord, 
brain,  and  ])erii)heral  nerves. 

Treatment.— Prophylaxis  is  of  the  greatest  importance,  and  by  a 
systematic  muzzling  of  dogs  the  disease  can  be,  as  in  (iermany,  practically 
eradicated. 

The  bite:!  should  be  carefully  washed  and  thoroughly  cauterized  with 
caustic  potash  or  concentrated  carbolic  acid.  It  is  best  to  keep  the  wound 
constantly  open  for  at  least  five  or  six  weeks.  When  once  established  the 
disease  ishopelessly  incurable.  Xo  measures  liave  been  found  of  the  slight- 
est avail,  consequently  the  treatment  must  be  palliative.  The  patient 
should  be  kept  in  a  darkened  room,  in  charge  of  not  more  than  two  care- 
ful attendants.  To  allay  the  spasm,  chloroform  may  be  administered  and 
morphia  given  hypodermic-ally.  It  is  best  to  use  these  ])owi'rful  remedies 
from  the  outset,  and  not  to  temiiorize  with  chloral,  bromide  of  potassium, 
and  other  less  potent  drugs.  By  the  local  application  of  cocaine,  the  sensi- 
tiveness of  the  throat  may  be  diminished  sullicieiitly  to  enable  the  patient 
to  take  liquid  nourishment.  Sometimes  he  can  swallow  readily,  \utrieiit 
enemata  should  be  administered. 

Preventive  Inoculation.— Pasteur  has  found  that  the  vims,  when  ])ropa- 
gated  through  a  series  of  rabbits,  increases  rapidly  in  its  virulence;  so  tliat 
whereas  subdural  inoculation  fnnn  the  brain  of  a  mad  dog  takes  from  fif- 
teen to  twenty  days  to  produce  the  disease,  in  successive  inoculations  in  a 
series  of  rabbits  the  incubation  ]ieriod  is  gradually  reduced  to  seven  days 
(virus  fi.ir).  The  spinal  cords  of  these  rabbits  contain  the  virus  in  great 
intensity,  but  when  they  are  preserved  in  dry  air  this  gradually  diminishes. 
If  now  dogs  are  inoculated  from  cords  preserved  for  from  twelve  to  fifteen 
days,  and  then  from  cords  preserved  for  a  shorter  ])eriod,  i.  e.,  with  a  pro- 
gressively stronger  virus,  they  gradually  acquire  immunity  against  the  dis- 
ease. A  dog  treated  in  this  way  will  resist  inoculation  with  the  virus  fixe, 
which  otherwise  would  inevitably  have  i)roved  fatal.  IJelying  upon  these 
experiments,  Pasteur  began  inoculations  in  the  human  subject,  using,  on 
successive  days,  material  from  cords  in  which  the  virus  was  of  varying 
degrees  of  intensity. 

There  is  still  some  discussion  as  to  the  fidl  value  of  this  method,  but 
the  statistics  published  annually  from  the  Pasteur  Institute  seem  to  prove 
conclusively  its  importance  as  a  protective  measure  in  man.  The  figures 
given  by  Pottevin,  being  the  cases  treated  in  Paris  from  188G  to  1894  in- 
clusive, show  that  of  13,817  persons  bitten  the  mortality  was  0.5  per  cent. 


rJ^SiV^ 


--^'TM^'-I----: 


r.; 


lii 


go^j  SPECIFIC  INFECTIOUS   DISEASES. 

Of  thc"^o  ]  Mir  woro  l.ittun  on  11k>  licad,  the  luortnlity  being  l.'^«!  per  cent; 
K,;-'  on'tlic  Lands,  with  0.70  per  crnt  ul'  .leatli.;  and  5,71(1  on  oth.r  partH 
„r  tin.  Ihi.Iv,  with  a  mortality  of  O/.'s  per  ciMit.  ■,      ,       i    • 

Diagnosis.-Aflcr  thu  symptoms  of  tho  di^oase  havo  developed  in 
„,au  the  diagnosis  should  olVer  no  especial  dillieullies.  It  is  advisal)lj,  in 
eases  attended  with  any  doni.ts,  as  soon  as  possible  after  the  injury  has  been 
inllided,  to  seeure  the  medulla  ohlonpita  of  the  supposed  rahul  anima  lor 
the  purpose  of  inoeulatiuK  rabbits.  The  sub.lural  inoeulation  of  rabbits 
with  a  small  cpmntity  of  the  eentral  nervous  system  of  a  rabid  animal  will 
lu.  followed  liy  tiie  development  of  tiie  paralytic  iorm  oi  the  disease  in  irom 
liftOi'ii  to  tweiitv  days.  ,     . 

Pseudo-hydrophobia  (Lyssophobia).-'Llus  i.s  a  very  inteiestiug 
alTeetion,  which  may  closely  resemble  hydrophobia,  but  is  really  m.tii.ng 
more  than  a  neurotic  or  hysterical  nu.nifestation.  A  nervous  person  bitten 
by  a  do.'  either  rabid  or  sunposed  to  ))e  rabid,  develops  within  a  lew  months, 
or  eveiriater,  svmi)toms  somewhat  rcsemblin.ij  tlie  true  disease,  lie  is  irri- 
table and  depi'esscd.  He  c.mstanlly  <h-clares  his  condition  to  bo  serious 
and  that  he  will  inevitably  become  mad.  He  may  have  paro.xysnis  in  whuh 
he  savs  he  is  unable  to  drink,  grasj-s  at  his  throat,  and  becomes  eni.jl^uma  . 
The  temperature  is  not  elevaled  and  the  .lisease  does  not  i^rogress.  It  lasts 
much  lon.^'r  than  the  true  rabies,  and  is  amenable  to  treatment  It  is  not 
imiirobable  that  a  majority  of  the  cases  of  alle-ed  recovery  m  this  disease 
have  been  of  this  hysterical  form.  In  a  case  whicli  iiurr  ivported  rom 
niv  clinic  a  few  years  ago  the  patient  had  paroxysmal  attacks  in  wliicli  he 
c.mld  not  swallow.  He  was  greatly  excited  and  alarmed  at  the  sight  o 
water  and  was  extremely  emotional.  The  symptoms  lasted  for  a  couple  ot 
weeks  and  yielded  to  treatment  with  powerful  electrical  currents. 


XXIX.    TETANUS. 

(Lockjaiv.) 

Definition.— An  infecti.)us  malady  characterized  by  tonic  spasms  of 
the  muscles  with  marked  exacerbations.  The  virus  is  ]n-oduced  by  a 
bacillus  which   occurs  in   earth   and   sometimes   in   putrefying  lluids  ami 

manure.  ,  »  ,,         .  t<- 

Etiology.— It  occurs  as  an  idiopathic  alTection  or  follows  trauma,  it 
is  frequent  in  some  localities  and  has  prevailed  extensively  in  epidemic 
form  among  new-born  children,  when  it  is  known  as  tetanus  or  trismus 
neonatorum.  It  is  more  common  in  hot  than  in  temperate  climates,  and 
in  the  colored  than  in  the  Caucasian  race.  This  is  ,,articularly  the  case 
with  tetanus  following  confinement  and  in  tetanus  neonatorum.  In  cer- 
tain of  the  West  Indian  Islands  more  than  one  half  of  the  mortality  among 
the  negro  children  has  been  due  to  this  cause.  St.  Hilda,  one  of  the  west- 
ern Helirides,  had  been  scourged  for  years  by  th.>  "  eight  days  sickness 
amoncT  the  new-l)orn.  Of  12.",  children,  cS4  died  within  f.mrteen  days  ot 
birth"  Since  the  discovery  of  the  tetanus  bacillus,  some  ])hilanthropic  ])eo- 


1 


iirill.      oiiiei^  till.-  iii.-Lv'v^'.T   "i   '■■-   ,   ,    ,,  -T     ■  i 

,1c  in  Glas<-ow  sent  a  nurse  to  the  island,  who  taught  the  midwives  to  use 


i.Saii'itiiiir^Sarrf'f'- 


'i  V,.'  ;'li'  ''■■'<J^'',i J-.i,V>'';f.'»-- '•/'•^'■ii^- -X'^*«'-'^^^'''^*^~" ' 


TETANUS. 


231 


l(\  ]K'r  cent; 
otlior  pans 

cvi'lojH'd  in 
i(lvisul)lj,  i» 
ii\v  lias  been 

I  animal  for 

II  ol'  ralibits 
animal  will 

cast!  in  from 

y  interesting 
ally  nothing,' 
)erson  bitten 
few  months, 
,     Jle  is  irri- 

0  be  serious 
qns  in  which 
l'S  emotional. 
rt'ss.  It  lasts 
it.     It  is  not 

1  this  (liseaso 
'ported  from 

in  whieh  he 
the  sijrbt  of 

r  a  couple  of 

its. 


lie  spasms  ol 
odueeil  by  a 
ig  lluids  and 

s  trauma.  It 
■  in  ei)idemie 
us  or  trismus 
olimates,  and 
hirly  tlic  case 
rum.  In  cer- 
irtality  amnn;: 
0  of  the  west- 
ays'  sickness '' 
irteen  days  of 
inthropic  jh'o- 
idwives  to  use 


iodoform    on    the   navel.      The   disease   has   now    prnct.ca  ly    disappea.ed 
(Turner).     In  a  UKijoritv  of  the  cases  there  is  an  injury  wiueh  may  he  ol 
1,0  „ins    trilling  character.     It  is  more  common  after  punctured  and  cun- 
.used  than  after  incised  wounds,  and  frequently  follows  those  ol  ,he   n.nd 
,„d  feet.    Th.'  symptoms  usually  aj.pear  within  tw<.  weeks  ol  t  le  mjniN      In 
some  military  cam,..igns  tetanus  has  prevailed  extensively,  ''>'*'•;;;';;;;> 
as  in  the  lato  civil  war,  the  cases  have  been  comparatively  lew.      dm,  '  !'•- 
Kanus  is  rare  in  man,  Imt  it  has  sometimes  followed  exposure  to  ..old  o 
.Iceping  on  the  .lamp  ground.     The  .lis..ase  has  o.-currod  alter  pr.donge.1 
u<e  of  the  hvpo.lermic  mr.lle  for  morphia  and  .piinme  injections. 

The  inf.'ctious  nature  of  t..tanns  was  sugg.'sted  by  its  en.lemic  o.-.ur- 
rence  and  from  the  manner  of  its  h..havi..r  in  certain  institutions.     \ct- 
•h  arians  have  long  been  of  this  bcii..f,  as  cases  are  apt    o  occur    ..gether 
Sn  horses  in  one  stable.    On  the  east..,.  ...d  ..f  Long  Island,  where  lormerly 
the  disease  was  verv  piTvalent,  it  is  now  rarely  seen.  ..  , 

The  Tetanus  Bacillus.-The  observations  of  K..senba..h,  >in^olaier,  anil 
Kitasato  have  dem..nstrated  that  there  is  in  (.onnc^tion  with  the  d,sc<iise  a 
.pccifie  organism  which  ..in  be  is<,lated  and  cultivated.     '1  he  bacillus  forms 
a  slender  r<.d.  which  mav  grow  into  long  threads.    One  end  is  often  swoILmj 
and  occupied  bv  a  spore:     It  is  motile,  grows  at  ordinary  te.np..ra  nres,  and 
is  anar.rohic.    The  ba.illi  dev.dop  at  the  site  of  thewound    and  do  m^  .   - 
vade  the  bh.od  and  organs),  where  alone  the  toxine  i.,  mannfac  urod.    W  .  li 
small  cp.antities  of  the  culture  the  disease  may  be  transmit  ..1  t.>  an.ma  > 
whicli  die  with   sympt.m,s  .d'  tetanus.     The  po,son   >«^^^  tox-alb,.m  n   of 
extraordinary   poten.y,   which   h.as   b..en   separat..!   by   Br.eger   -^-\^^ 
in  a  state  of  tolerable  ,,urity.    It  is  perhaps  the  most  viruhmt  poison  known. 
Whereas  the  fotal  dose  of  sti-y.^hnine  for  a  man  weighing  .0  k.lo.  i>  f  om 
30  to  100  milligrammes,  that  of  tlie  tetanus  toxine  ,s  est.mate.I  at  0..3 
milligrammes.     Every  feature  ..f  the  disease  can  be  prodiu'cl  by  it  expen- 
n  nt^illy  without  the  pn-n.e  of  the  bacilli.    The  symptoms  do  "<>    <  --  '^P 
immediatelv,  as  in  the  case  of  ordinary  j.oisons,  but  slowly,  and  it  has  been 
«u-rosted  that  it  acts  only  after  undergoing  some  further  changes  in  the 
bodv-.    Another  point  of  interest  is  the  fact  that  immunity  can  be  procumi 
by    noculating  in  animal  with  the  blood  of  another  which   has  had    he 
d  lease     The  organism  has  been  found  in  the  earth  and  in  imtrefy.ng  finds 
and  Nicolaief  has  caused  the  disease  bv  iiuxudating  with  d,  Terent  sorts  o 
si^face  soil.     Animals  have  been  r.Midered  immune  to    he    .:tanus  poison 
ami  a  curative  serum  has  been  prepared.     This  serum  has  been  usc.d  suc- 
c..ssfully  in  preventing  and  even  curing  the  experimental  form  of  the  dis- 
ease    The  results  in  man  are  as  yet  doubtful.  ,        i    •„ 
Morbid  Anatomy.— No  characteristic  lesmns  have  been  found   in 
the  cord  or  in  the  brain,     ingestions  occur  in  difTcrcnt  parts    and  pen- 
vascular  exudations  and   granular  changes  in   the   nerve-cells  have   b.3en 
found      The  condition  of  the  wound  is  variabl...     The  nerves  are  often 
found'injured,  reddened,  and  sw,dl..n.    In  the  tetanus  neonatorum  the  um- 

l)ilicus  mav  be  inflamed.  _  .     . 

Symptoms. -After  an  injury  the  disease  sets  in  usually  w.thm  ten 
days     In  Yandell's  statistics  in  at  least  two  fifths,  and  m  Joseph  Jones  s 


232 


SPRCIPIC  INFECTIOIS   DISEASKS. 


■|li 


ill  I'uiir  lll'tlis  till'  Hyiiii)ti)ins  occurred  l)of(>ro  tlio  fiftoonth  day.  Tlie  ya- 
tifiit  coiiiiiliiiiis  nt  ih>t  nl'  sli^rlit  stilVncss  in  tlic  iiirk,  or  a  ffdinfr  of  tii^'lit- 
IK'SK  ill  tlif  jaws,  or  (lilliiiilty  in  maslicatioii.  Orcasioiially  cliilly  t'oulin;,'* 
or  Uftiial  rij,'ort*  may  proccdo  tlifno  symptonis.  (ira<hially  a  tonic  tipasni 
of  tlif  iniisi'k's  of  tlicsc  jtarts  develops,  prodnciiif:  tlu'  (•<.n(liti()n  of  trisiiins 
or  lockjaw.  'I'lio  cyi'lirows  may  l)u  raised  and  liio  angles  of  tlii'  moutli 
drawn  out,  cansiiij,'  "tlio  so-calU'd  sardonic  grin — riiius  nanlimints.  In  cliil- 
dron  tlic  simsni  may  l)e  c-onliiu'd  to  these  parts.  Sometimes  the  attack 
is  associated  with  jmralysis  of  the  facial  mn.scles  and  dillicnlly  in  swallow- 

iiijr (li,.  hcad-tt'tanns  of  Hose,  which  has  most  commonly  followed  injnrios 

in'^tjie  nc'ifihhorhood  of  the  iifth  nerve,  (iradiially  the  process  extends 
and  involves  the  mnscles  of  the  hody.  Those  of  the  hack  are  most  all'ected, 
so  that  dnriii},'  the  spasm  the  unfortunate  victim  may  rest  njmn  the  head 
and  heels— a  jmsition  known  as  opiMolunas.  The  rectus  ahdominalis  mns- 
(le  has  hecn  torn  across  in  the  spasm.  Tlie  entire  trunk  and  l!nd)s  may 
he  jierfectly  rijjid — (irllioloiios.  Fle.xion  to  one  side  is  less  common— /^/cz/ro- 
thuloiKis:  while  spasm  of  the  mnscles  of  the  ahdomen  may  canso  the  hody 
to  be  bent  Un-wiWil—eiiiprostlKilonns.  In  very  violent  attacks  the  thorax  i.s 
compressed,  the  res])irations  are  rapid,  and  spasm  of  the  glottis  may  oecnr, 
eansinji  asjihyxia.  The  i)aro.\ysm8  last  for  a  varialtle  period,  but  even  in 
the  intervals  the  relaxation  is  not  complete.  Tiie  slightest  irritation  is 
siitlicicnt  to  cause  a  spasm.  The  ])aroxysms  arc  associated  with  agonizing 
])ain,  and  the  patient  may  be  held  as  in  a  vice,  unable  to  utter  a  word. 
Tsually  he  is  bathed  in  a  profuse  sweat.  The  temperature  may  remain 
normal  throughout,  or  show  only  a  sliglit  elevation  toward  the  close.  In 
other  cases  the  j)yrexia  is  marked  from  the  outset;  the  temperature  reaches 
105''  or  10(i°,  and  before  death  1()!»°  or  110".  In  rare  instances  it  may  go 
still  higher.  Death  either  occurs  durfng  tlie  paroxysm  from  heart-failure 
or  asphyxia,  or  is  due  to  exhaustion. 

The  cephalic  tetanus  (Kopfhtnnm  of  Kose)  originates  usually  from  a 
wound  on  one  side  of  the  head,  and  is  I'.aracterizcd  by  i-titrness  of  the 
muscles  of  the  jaw  and  paralysis  of  the  facial  muscles  on  the  same  side  as 
the  wound,  with  dilhculty  in  swallowing. 

The  prognosis  is  good  in  the  chronic  cases;  of  these,  in  Willard's  table 
only  8  of  33  died;  but  in  the  acute  form,  of  -15  cases,  only  4  recovered. 

Diagnosis. — Well-develojied  cases  following  a  trauma  could  not  he 
mistaken  for  any  other  disease.  The  spasms  are  not  unlike  tliose  of 
strychnia-poisoning,  and  in  the  celebrated  Palmer  murder  trial  this  was 
the  plea  for  the  defence.  The  jaw-muscles,  however,  are  never  involved 
early,  if  at  all,  and  between  the  paroxysms  in  strychnia-])oisoning  there 
is  no  rigidity.  In  tetany  the  distribution  of  the  spasm  at  the  extremities, 
the  peculiar  position,  the  greater  involvement  of  the  hands,  and  the  con- 
dition under  which  it  occurs,  are  sufTicient  to  make  the  diagnosis  clear.  In 
doubtful  cases  cultures  should  be  made  from  the  ]nis  of  the  wound. 

Prognosis. — Two  of  the  Ilii)])ocratic  aphorisms  ex])ress  tersely  the 
general  prognosis  even  at  the  present  day:  "The  spasm  supervening  on  a 
wound  is  fatal,"  and  "  such  ^lersons  as  are  seized  with  tetanus  die  within 
four  days,  or  if  they  pass  these  they  recover." 


GLANDEKH. 


233 


)'.  Tlie  jia- 
ii<;  of  ti^'lit- 
illy  l'c't.'liii;,'.s 
tonic  Hpusiii 
1  of  trismus 

till-     IllOUtil 

(.s.  In  ciiil- 
:  the  attack 
in  siwallow- 
Hod  injiirios 
ross  cxtenils 
lost  aU'ectod, 
1)11  tlio  lioatl 
ninalis  nms- 
l  IiimIks  may 
1011 — pJvuro- 
isc  tiic  l)0(ly 
lie  thorax  is 
;  may  occur, 
but  even  in 
irritation  is 
:h  nj;onizin<? 
tter  a  word, 
may  remain 
le  close.  In 
itnre  reaches 
L's  it  may  go 
heart-failure 

lally  from  a 
fnoss  of  the 
same  side  as 


The  m.)rtiility  in  the  traumatic  cases  is  not  less  than  HO  per  cent  (Con- 
ner); in  tiic  idiojiailiic  cases  it  is  unck'r  .")(>  per  cent,  .\ccording  to  Yandell, 
till,  mortality  is  greatest  in  children.  Tavorahle  in.iicalinns  arc:  lute  onset 
,,f  the  attack,  localization  of  the  spasms  to  llie  muscles  of  tlu'  neck  and  jaw, 
mill  an  ahsence  of  fever. 

Treatment.— Local  treatment  of  tlie  wound  is  essential,  as  the  poison 
is  manufactured  Iii-re.  Tizzoiii  advises  nitrate  of  silver  as  tiie  best  germi- 
( iile  for  tlie  tetanus  hacilius.  'riiorough  excision  and  antiseptic  treatment 
should  he  carried  out.  Tlie  patient  should  he  keiit  in  a  darkened  room, 
ah.solutely  (piiet,  and  attended  by  only  one  iierson.  All  possible  sources 
of  irritation  should  be  avoided.  Veterinarians  api)r<<ciate  the  importance 
of  this  complete  seclusion,  and  in  well-e(piii)ped  inlirmaries  there  may  be 
seen  a  brick  jmiliied  chamber  in  which  the  horses  are  treated. 

When  the  lockjaw  is  extreme  the  ])atient  may  not  be  able  to  take  fooil 
by  the  mouth,  iimier  which  circumstances  it  is  liest  to  use  rectal  injections, 
oV  to  feed  by  a  catheter  passed  througli  tiie  nose.  The  spasm  should  U\ 
controlled  by  chloroform,  which  may  be  repeatedly  exhibited  at  intervals. 
It  is  more  satisfactory  to  keep  the  i)atient  tiioioughly  under  tiie  influence 
of  inori)liia  given  hypodermically.  Chloral  hydrate,  bromide  of  potassium, 
Calabar  Iiean,  curara,  Indian  hemp,  belladonua,  and  other  drugs  have  l)een 
recommended,  and  recovery  occasionally  follows  their  use.  It  is  very  dilli- 
eult  to  estimate  the  value  of  the  blood-serum  therajiy  in  this  disease.  Tiz- 
zoni  and  Cantani  have  used  an  antitoxine  prepared  from  the  blood-serum 
of  imraunized  animals.  The  material,  which  is  now  to  be  ()l)tained  from 
.Merck,  is  in  the  dried  state,  and  comes  in  tubes  containing  4  to  5  grammes. 
It  can  be  bought  in  this  country  from  his  agents.  An  antitoxine  serum 
is  also  pre]iared  by  I?ehring  and  i)y  Koux.  Of  the  iluid  serum  20  to  30  cc. 
may  be  used  for  the  first  dose  and  15  to  20  cc.  every  five  or  ten  hours  after. 
Tizzoni  advises  2.25  grammes  of  his  antitoxine  for  the  first  dose  and  O.C 
grammes  for  subsequent  doses,  (iooderich  has  collected  Hi?  cases  treated 
with  the  antitoxine,  with  (;;5  per  cent  of  recoveries.  The  Tizzoni  product 
has  been  the  most  successful. 


illard's  table 
ecovered. 
ould  not  be 
ke  those  of 
ial  this  was 
ver  involved 
zoning  there 
!  extremities, 
ind  the  con- 
sis  clear.  In 
ound. 

3  tersely  the 
'vening  on  a 
IS  die  within 


XXX.    GLANDERS  {Farcy). 

Definition.— -An  infectious  disease  of  the  horse,  communicated  occa- 
sionally to  man.  In  the  horse  it  is  characterized  by  the  formation  of 
nodules,  chiefly  in  the  nares  (glanders)  and  beneath  the  skin  (farcy). 

Etiology."— The  disease  belongs  to  the  infective  granulomata.  The 
local  manifestations  in  the  nostrils  and  the  skin  of  the  horse  are  due  to 
one  and  the  same  cause.  The  specific  germ,  larUhts  mnlki,  was  discovered 
by  I.oefller  and  Schiitz.  It  is  a  short,  non-motile  bacillus,  not  unlike  that 
of  tubercle,  but  exhibits  dilTerent  staining  reactions.  It  grows  readily  on 
the  ordinary  culture  media.  For  the  full  recognition  of  glanders  in  man 
we  are  indebted  to  the  laliors  of  Rayer,  whose  monograph  remains  one  of 
the  best  descri])tions  ever  given  of  the  disease.  j\Ian  becomes  infected  by 
contact  with  diseased  animals,  and  usually  by  inoculation  on  an  abraded 


Hi  ,..., 


234: 


SPF.CIFIC  INFECTIOUS  PISEASKS. 


m 


surface  of  the  .kin.  Tl.e  oont.gion  n.MV  also  l.o  rece>ve(l  on  the  mucous 
membrane.  In  one  of  the  Montreal  cases  a  gentleman  was  j.ro l.al.  y  in- 
fected by  the  material  expelled  from  the  n.>stril  of  his  horse,  which  was 
not  siisneeted  of  having  the  disease.  i      i      r     i 

Morbid  Anatomy. -As  in  the  horse,  the  disease  may  be  Im'al./ed 
in  the  nose  (glanders)  or  beneath  the  skin  (farcy).  The  essential  lesion 
.s  tlie  granuh.nmtous  tumor,  characterized  by  the  presence  o  numerous 
lymphoid  an.l  epithelioid  cells,  among  ami  in  which  are  seen  the  glanders 
baci  li  These  nodular  masses  tend  to  break  down  rapidly,  and  on  the 
mucous  membrane  result  in  ulcers,  while  beneath  the  skin  they  form  ab- 
«ce-«es     The  glanders  nodules  may  also  occur  in  the  internal  organs. 

Symptoms.-An  acute  and  a  chronic  form  of  glanders  may  be  recog- 
nized in  man,  and  an  acute  and  a  chronic  form  of  farcy. 

Acute  Glanders. -The  period  of  incubation  is  rarely  more  than  three 
or  four  days.  There  are  signs  of  general  febrile  disturbance.  At  the  site 
„r  infection  there  are  swelling,  redness,  and  lymphangitis.  ^^  ithm  two  or 
three  days  there  is  involvement  of  the  mucous  membrane  of  the  nose,  be 
nodules  break  down  rapidly  to  ulcers,  and  there  is  a  muco-puvulent  dis- 
char-re.  An  eruption  of  papules,  which  raj.i.lly  liecome  pustules,  breaks 
out  over  tlie  face  and  about  the  joints.  It  has  been  mistaken  for  varu.la. 
This  ^MXS  carefully  studied  bv  Kaver  and  is  figured  in  his  monograph.  In 
a  Montreal  case  this  copious  eruption  led  the  attending  physician  to  sus- 
pect small-pox,  and  the  patient  was  isolated.  There  is  great  swelling  of 
the  no«e  The  ulceration  mav  go  on  to  necrosis,  in  which  case  the  discharge 
is  very  offensive.  The  Ivmph-glands  of  the  neck  are  usually  much  en- 
larged. Subacute  pneumonia  is  very  apt  to  develop.  This  form  runs  its 
course  in  about  eight  or  ten  days,  and  is  invariably  fatal.     _ 

Chronic  glanders  is  rare  and  difheult  to  diagnose,  as  it  is  usually  mis- 
taken for  a  chronic  coryza.  There  are  ulcers  in  the  nose,  and  often  laryn- 
.real  synnitoms.  It  mav  last  for  months,  or  even  longer,  and  recovery  some- 
times" takes  place.  Tedeschi  has  described  a  case  of  chronic  osteomyelitis, 
due  to  the  bacillus  mallei,  which  was  followed  by  a  fatal  glanders  menin- 
gitis The  diagnosis  may  be  extremely  diihcult.  In.such  cases  a  suspen- 
Mon  of  the  secretion,  or  of  cultures  upon  agar-agar  made  from  the  secre- 
tion should  be  injected  into  the  peritoneal  cavity  of  a  male  guniea-pig. 
At  the  end  of  two  davs,  in  positive  cases,  the  testicles  are  found  to  bo 
swollen  and  the  skin  of  the  scrotum  reddened.  The  testuk^s  continue  to 
increase  in  size,  and  finallv  supimrate.  Death  takes  plac;  after  the  lapse 
of  two  or  three  weeks,  and  generalized  glanders  nodules  are  found  m  the 
viscera  The  use  of  malloin  for  diagnostic  purposes  is  highly  recommended, 
liu^  princiiiles  and  methods  of  apidication  are  the  same  as  for  tuberculin. 

Acute  farcy  in  man  results  usually  from  the  inoculation  of  the  virus 
into  the  skin  There  is  an  intense  local  reaction  with  a  phlegmonous  in- 
flammation. The  Ivmphalics  arc  early  affected,  and  along  their  course 
there  are  nodular  subcutaneous  enlargements,  the  so-called  farcy  buds, 
which  may  rapidly  go  on  to  suppuration.  There  are  pains  and  swelling 
in  the  ioints  and  abscesses  may  form  in  the  muscles.  The  symptoms  are 
tho«e  of  an  acute  infection,  almost  like  an  acute  septicemia.     The  nose  is 


■i.iCj4lS'i'-N'k' ".'■•  ' 


•X>^ 


a(::tinomycosis. 


235 


lio  nmcous 
i'i)l)al)ly  in- 
which  was 

iitial  lesion 
:  mnncroiis 
lie  glanders 
md  on  the 
>y  form  ab- 
ovgans. 
ly  be  recog- 

than  three 

At  the  site 
thin  two  or 
lie  nose,  the 
uvnlent  dis- 
Ailes,  breaks 

for  variola, 
ograjih.  In 
ician  to  siis- 

swelling  of 
he  dise barge 
y  much  en- 
jrni  runs  its 

usually  mis- 

often  laryn- 
covery  sonic- 
)steomyelitis, 
iders  nienin- 
■:es  a  suspen- 
iin  the  seere- 
a  guinea-jiig. 

found  to  bo 
!  continue  to 
tor  the  layise 
found  in  the 
ecouimended. 
•  tulterculin. 

of  the  virus 
eginonous  in- 

their  course 
[  farcy  buds, 

and  swelling 

symptoms  are 

The  nose  is 


not  involved  and  the  superficial  skin  eruption  is  not  common.  The  bacilli 
have  been  found  in  the  urine  in  acute  cases  in  man  and  animals. 

Tiie  disease  is  fatal  in  a  large  proportion  of  the  eases,  usually  in  from 
twelve  to  fifteen  days. 

Chronic  farcy  is  cliaracterizcd  by  the  ]ircsence  of  localized  tumors,  usu- 
ally in  the  extremities.  Tiiese  tumors  break  down  into  abscesses,  and  souie- 
times  form  deep  ulcers,  without  much  inilammatory  reaction  and  without 
s]iecial  involvement  of  the  lyni])hatics.  The  disease  may  last  for  months 
or  even  years.  Death  may  result  from  pya-mia,  or  occasionally  acute  glan- 
ders develops.  The  celebrated  French  veterinarian  Bouley  had  it  and  re- 
covered. 

The  disease  is  transmissible  also  from  man  to  man.  Washerwomen 
have  been  infected  from  the  clothes  of  a  patient.  In  the  diagnosis  of  this 
alTcction  the  occupation  is  very  iuiportant.  Nowadays,  in  cases  of  doubt, 
the  inoculation  sliould  be  made  in  animals,  as  in  this  way  the  disease  can 
be  readily  determined,  ^lallein,  a  product  of  the  growth  of  the  bacilli,  is 
now  used  for  the  purpose  of  diagnosing  glanders  in  animals.  Several  in- 
stances of  cured  glanders  iiave  been  rejiorted  in  animals  treated  with  small 
and  repeated  doses  of  mallein  (Piiavios,  Babes). 

Treatment. — If  seen  early,  the  wound  should  be  either  cut  out  or 
thoroughly  destroyed  by  caustics  and  an  antiseptic  dressing  ajiplied.  The 
farcy  buds  should  be  early  opened,  in  the  acute  cases  there  is  very  little 
hope.     In  the  chronic  cases  recovery  is  possible,  though  often  tedious. 


XXXI.   ACTINOMYCOSIS. 

Definition. — A  chronic  infective  disorder  produced  by  the  actino- 
myces  or  ray-fungus,  the  Streptothrix  actinnmyces. 

Etiology. — The  disease  is  widespread  among  cattle,  and  occurs  also 
in  the  pig.  It  was  first  described  by  Bollinger  in  the  o.x,  in  which  it  forms 
the  affection  known  in  this  country  as  "  big-jaw."  Examples  of  the  dis- 
ease were  common  in  tlic  cattle  killed  at  the  abattoir  in  Montreal.  In  man 
it  was  mentioned  by  von  Langenbeck,  who  observed  the  "sulphur  grains" 
in  the  characteristic  purulent  material.  The  first  accurate  description  of 
the  disease  was  given  by  James  Israel,  and  subsequently  Ponfick  insisted 
upon  tlic  identity  of  the  disease  in  man  and  cattle. 

In  this  country  to  ilay  1,  ISHS,  about  41  cases  have  been  recognized 
(Ruhriih);  in  England  the  disease  is  rare.  It  is  not  uncommon  in  Ger- 
tiiany  ajid  Russia.  To  the  end  of  1892  about  450  cases  had  been  described 
(Leith,  Edinburgh  Hospital  Reports,  vol.  ii).  It  is  nearly  three  times  as 
common  in  men  as  in  women. 

The  parasite  belongs  probably  to  the  Streptothrix  group  of  bacteria. 
In  both  man  and  cattle  it  can  be  seen  in  the  pus  from  the  alfected  region 
as  yellowish  or  opaque  granules  from  otic  half  to  two  millimetres  in  diam- 
eter, which  are  made  up  of  cocci  and  radiating  threads,  which  present 
bulbous,  club-like  terminations.  The  youngest  granules  are  gray  in  color 
and  semi-tran!^l.lcent;  in  these  the  bulbous  extren-'"  '•  are  wanting.  It 
15 


;  1 


23g  SPECIFIC  INFECTIOUS  DISEASES. 

un.  shown  bv  Bostrom  that  the  clubbed  ends  are  the  result  of  a  hyaline, 
d^gonrtWe  clX  taking  place  in  the  fitonts.    The  organ.n.  .  strU. 

"^^lle^Se'has  been  Bucce.fully  cultivated,  and  the  disease  has  been 
inoculated  both  with  the  natural  and  artificially  g^"^"  «''-7?^7;  ..  ^,      -., 

ThrMode  Of  Mection.-There  is  no  evidence  ot  direct  inicct  on  with 
the  Iktli  or  ml  ol  diseased  animals.  The  streptothrix  has  not  been  de- 
tected outs  de  the  body.  It  seems  highly  probable  that  it  is  taken  in  w  th 
he  food  'rie  Bite  of  infection  in  a  majority  of  cases  in  '"-  -^^--^^-^ 
in  the  mouth  or  neighboring  passages.  In  the  cow,  possibly  al.o  in  man, 
barley  and  rye  have  been  carriers  of  the  germ. 

•Morbid  Anatomy.-ln  the  earliest  stages  of  its  growth  the  para 
site^i^'efrtc  to  a  3  granulation  tumor  not  unlike  that  produced  by 
t:  S::iZ^losis,  A.^.  contains    in  a;lditi^i  to  sma     -un     c^ 
epithelioid  elements  and  giant  cells.     After  it  '^''^^^^^^^''^^^)JZ^ 
d  ffvo-it  nroliferation  of  the  surrounding  connective  tissue   and  the  grovsiu 

;°th1.'oinnB  ot  o„o  side  of  tlic  laoc,  or  with  a  chroiuc  onla.scmont  ol  tl.c 

'"-Tttn^o  hnl:;: rr^  in  ..,o™,  .....  ...owing  s,nan  g.w.H 

„i.,r  .rS,  or  Mlowing  disease  ot  the  jaw.    In  '«■"'»',;;-    ;  "^  ^^^ 
,„.,v  oeeur  oilier  as  a  nriniary  or  seeonilary  allection.     Cases     ave  ijecn 

•  LeTot  o;Lca,  access  L  to  ,1,0  gem,.  A"  »='  ""/'-f-lS 
-lipitis  h-m  been  described;  primary  actinomycosis  of  tlie  laige  intestine 
wit  In  tastases  ha  also  bee^  described.  Ransom  has  found  the  aetinomyces 
1  s  ol  The  liver  may  be  affected  primarily,  as  in  the  case  reported 
by  Slmiey  and  Acland.  The  actinomycotic  abscesses  present  a  reticulai 
or  honeycomb-like  arrangement  (LeithV  ,        .„.o    T.i,„es  Israel  de- 

(b)  Pulmonary  Actinomycosis.-In  September,  1878    Jame.  Israe      t 
scribed  a  remarkable  mycotic  disease  of  the  lungs,  which  «" --1"        "^^^^ 
ser  a t  on  showed  to  be  the  affection  described  the  year  before  by  Bollinger 

n  c^Ule     rnce  that  date  many  instances  have  been  reported  m  wh    h 
the  lunas  were  affected.     It  is  a  chronic  infectious  pulmonary  disorder 


msisssm^^'^i^i^t^^f'ii'^--'-^'^'^*'^' 


IV 


ACTINOMYCOSIS. 


237 


'  a  hyaline, 
jiu  is  strik- 

jc  has  been 
1. 

ection  with 
ot  been  de- 
ken  in  with 
d  animals  is 
Iso  in  man, 

h  the  para- 
)ro(luced  by 
round  cells, 
n  size  there 
.  the  growth 
n  for,  ostco- 
ag  to  Israel, 

lid  to  have 
has  l)een  in- 
r  observation 
enient  of  the 

nail  growths, 
es  the  disease 
es  have  been 
ycotic  appen- 
irge  intestine 
e  actinomyccs 
case  re])orted 
lit  a  reticular 

les  Israel  do- 
Libsequent  ob- 
3  by  Bollinger 
rtcd  in  which 
nary  disorder, 
nt,  sometimes 
V  of  the  cases, 
chronic  bron- 
le  actinornyces 

miliary  tubor- 
gi,  surrounded 
■osis  is  not  in- 
!ent  structures. 

disease  of  the 
sscs,  the  latter 


forming  cavities  large  enougli  to  be  diagnosed  during  life.  Actinomycotic 
lesions  of  other  organs  arc  often  present  in  connection  with  the  pulmonary 
disease;  erosion  of  tiie  vertelmr,  necrosis  of  tiie  ribs  and  sternum,  with 
node-like  formatioiit;,  ijubcutaneous  abscesses,  and  occatiionally  metastases  in 
all  parts  of  the  body. 

ISymftoins. — The  fever  is  of  an  irregular  type  and  depends  largely  on 
the  existence  of  suppuration.  The  cough  is  an  important  symptom,  and 
the  diagnosis  in  18  of  tlie  cases  was  made  during  life  by  the  discovery  of 
the  actinomyccs.  Death  results  usually  with  sei)tic  symptoms.  Occasion- 
ally there  is  a  condition  simulating  typhoid  fever.  The  average  duration 
of  the  disease  was  ten  months.  Kecovery  is  very  rare.  Clinically  the  dis- 
ease closely  resembles  certain  forms  of  pulmonary  tuberculosis  and  of  fa;tid 
bronchitis.  It  is  not  to  be  forgotten  in  the  examination  of  the  sputum 
that,  as  Bizzozero  mentions,  certain  degenerated  epithelial  cells  may  be 
mistaken  for  the  organism.  The  radiating  leptothri.x  tlireads  al)out  the 
epithelium  of  the  mouth  sometimes  present  a  striking  reseml)iance. 

((;)  Cutaneous  Actinomycosis. — In  several  instances  in  connection  with 
chronic  ulcerative  diseases  of  the  skin  the  ray-fungus  has  been  found.  It 
is  a  very  chronic  aifectiou  resembling  tuberculosis  of  the  skin,  associated 
with  the  development  of  tumors  which  suppurate  and  leave  open  sores, 
which  may  remain  for  years. 

{d)  Cerebral  Actinomycosis. — Bollinger  has  reported  an  instance  of 
primary  disease  of  the  brain.  The  symptoms  were  those  of  tumor.  A 
second  remarkable  case  has  been  reported  by  Gamgee  and  Delepine.  The 
patient  was  admitted  to  St.  C.eorge's  Hospital  with  left-sided  pleural  effu- 
sion. At  the  post  mortem  three  })ints  of  purulent  lluid  were  found  in  the 
left  pleura;  there  was  an  actinomycotic  abscess  of  the  liver,  and  in  the 
brain  there  were  abscesses  in  the  frontal,  parietal,  and  tem]K)ro-sphenoidal 
lobes  which  contained  the  mycelium,  but  no  clubs.  A  third  case,  rejjorted 
by  0.  B.  Keller,  had  empi/ema  necessitatis,  which  was  opened  and  actino- 
niycetes  were  found  in  the  pus.  Subsequently  she  had  Jacksonian  e])ilepsy, 
for  wliicli  she  was  tre])hined  twice  and  abscesses  opened,  which  contained 
actinomyccs  grains.    Death  occurred  after  the  second  ojjcration. 

Diagnosis. — The  disease  is  in  reality  a  chronic  pya'mia.  The  only 
test  is  the  presence  of  the  actinomyccs  in  the  pus.  ^letastases  may  occur 
as  in  pyajmia  and  in  tumors.  The  tendency,  however,  is  rather  to  the  pro- 
duction of  a  local  purulent  affection  which  erodes  the  hones  and  is  very 
destructive.  In  cattle  the  disease  may  cause  metastases  without  any  suppura- 
tion; thus  in  a  Montreal  case  the  jaw  and  tongue  were  the  seat  of  the  most 
extensive  disease  with  very  slight  suppuration,  while  the  lungs  presented 
numbers  of  secondary  growths  containing  the  organisms. 

Treatment. — Tliis  is  largely  surgical  and  is  practically  that  of  py- 
aemia. Incision  of  the  abscess,  removal  of  the  dead  bone,  and  thorough 
irrigation  are  ajtpropriate  measures.  Thomas«en  has  recommended  iodide 
of  potassium,  which,  in  doses  of  from  40  to  60  grains  daily,  has  proved 
curative  in  a  number  of  recent  cases. 


asesa-^jeseaAtr 


V 


238 


SPECIFIC  INFECTIOUS  DISEASES. 


XXXII.    SYPHILIS. 

Deflnition.-A  specific  disease  of  slow  evolution,  propagated  by  in- 
oculation  (acquired  svpluHs),  or  by   hereditary  transmission   i^^S^f^ 
yphilis).    In  the  acquired   -.mn  tlie  site  of  inoculation  becomes  the  seat    t 
I     ecia   tissue  change-/..Mm«ny  Icsio,,.    Within  two  or  three  months  con- 
tU  tTo  al  synlpton.s^lovelop,  with  affections  of  the  skin  and  mucous  rnem- 
t^^sccLAry  lesions.     After  a  period  of  months  or  F-  S-n. hn  - 
■itous  urowtlis  develop  in   the  viscera,  muscles,  bones,  or  Am-lutianj 
S L     And,  finally,   here  are  certain  diseases,  as  tabes  and  general  paresis, 
thicharfpe^diarly  prone  to  develop  on  the  syphilitic  sod-,ara-  or  rncta- 
syphilitic  affections. 

I.  Gexeual  Etiology  and  Morbid  Anatomy. 
The  nature  of  the  virus  is  still  doubtful.  Lustgarten  found  in  the 
harcl  chancre  and  in  gunnnata  a  rod-shaped  b.icillus  ol  ^J- ^l^^^^g^ 
which  he  claims  is  specific  and  peculiar  to  the  disease.  Ihis  organism 
do  :1;  rLmbles  the  Lgma  bacillus,  which  is  found  ^^^  ^J^^^ 
but  fJom  its  occurrence  in  gummatous  growths  u  '^l''\"  ^  f^;^^  ^^  f. 
they  can  be  identical.  Further  observations  are  required  before  the  qucs 
tinri  ran  be  considered  settled. 

Syphil^  is  peculiar  to  man,  and  cannot  be  transmitted  to  the  lower 
animals.    All  arc  susceptible  to  the  contagion,  and  it  occurs  at  al    ages. 

Modes  Of  Infection. -1(1)  In  a  large  majority  of  all  cases  the  disease  is 
transmitted  by  scxml  congress,  but  the  designation  truncal  disease  {lues 
venerea)  is  not  always  correct,  as  there  are  many  other  modes  ot  inoculation. 
(3)  Accidental  infection.--ln  surgical  and  in  midwifery  practice  phy- 
sicians are  not  infrequently  inoculated.     It  is  surprising  that  mfec  ion 
from  these  sources  is  not  more  common.     I  have  known  personally  of    0 
cases     Midwifery  chancres  are  usually  on  the  fingers,  but  I  have  met  witii 
,me  instance  on  the  back  of  the  hand.    The  lip  chancre  is  the  most  common 
of  these  erratic  or  extra-genital  forms,  and  may  be  acquired  in  many  ways 
apart  from  direct  infection.     Mouth  and  tonsillar  sores  result  as  a  rule 
from  improper  practices.    ^Yet-nurses  are  sometimes  infected  on  the  nipple, 
and  it  oLasionallv  happens  that  relatives  of  the  child  are  aeculentally  con- 
taminated.   One  of  the  most  lamentable  forms  of  accidental  infection  is  the 
transmission  of  the  disease  in  humanized  vaccine  lymph      Ihis,  however, 
is  extremely  rare.    The  conditions  under  which  it  occurs  have  been  already 
referred  to  (see  Vaccination).  ,  -,    .  ^ 

(3)  II credit arn  Transmission. -'Vh\^  may  be.  and  is,  most  comnum 
f~om  (a)  the  father,  the  mother  being  healthy  (sperm  inheritance).  It  is, 
imfortunately,  an  cvery-day  experience  to  see  cases  of  congenital  syphilis 
in  which  the  infection  is  clearly  paternal.  A  syphilitic  father  "i^Y-  ^o^^- 
ever,  beget  a  healthy  child,  even  when  the  disease  is  fresh  and  fuU-blmyn. 
On  he  other  hand,  in  very  rare  instances,  a  man  may  have  had  .sypl^ilis 
when  young,  undergo  treatment,  and  for  years  presentno  signs  of  disease, 
and  yet  hi-Tfirst-born  mav  show  very  characteristic  lesions.    Happily,  in  a 


.WS*i^is®i£S^^f^*?^^^SSSeS^^ 


SYPHILIS. 


230 


ted  by  in- 

t'ongcnital 
the  seat  of 
oiiths  con- 
cous  mem- 
granuloin- 
11 — tciiiarij 
iral  paresis, 
a-  or  mcla- 


Liiid  in  the 
I  in  length, 
IS  organism 
ho  prepuce, 
ossilile  that 
•e  the  ques- 

0  the  lower 
:  all  ages. 

le  disease  is 
lisease  {lues 
inoculation, 
ractice  phy- 
at  infection 
onally  of  10 
ve  met  with 
lost  common 

1  many  ways 
It  as  a  rule 
II  tlic  nipple, 
lontally  con- 
fection is  the 
lis,  however, 
heon  already 

lost  common 
ance).  It  is, 
nital  syphilis 
er  may,  how- 
id  full-blown, 
had  .syphilis 
:ns  of  disease. 
Happily,  in  a 


large  majority  of  instances,  when  the  treatment  has  been  thorough,  the 
oll'spring  escape.  The  closer  tlie  bcgettir  to  the  primary  sore,  the  greater 
tiie  chance  of  infcctiou.  A  man  with  i  liary  lesions  may  beget  healthy 
children.  As  a  general  rule  it  may  l)e  said  that  with  judicious  treatment 
the  traiismissive  power  rarely  exceeds  three  or  four  years. 

{b)  ilaternal  transmission  (germ  inheritance).  It  is  a  remark»1'L  uud 
interesting  fact  that  a  woman  who  has  borne  a  syphilitic  child  is  herself 
immune,  and  cannot  be  infected,  though  she  may  present  no  signs  of  the 
disease.  This  is  known  as  Colics"  law,  and  was  thus  stated  l)y  the  distin- 
guished l)ul)lin  surgeon:  "That  a  child  born  of  a  motiier  who  is  without 
obvious  venereal  symptoms,  and  wiiich,  without  lieing  exjiosed  to  any 
infection  subsecpient  to  its  birth,  shows  this  disease  when  a  few  weeks  old, 
this  child  will  infect  the  most  healthy  nurse,  whetlier  she  suckle  it,  or 
merely  handle  and  dress  it;  and  yet  this  child  is  never  known  to  infect  its 
own  mother,  even  though  she  suckle  it  while  it  has  venereal  ulcers  of  the 
lip.s  and  tongue."  In  a  majority  of  these  cases  the  mother  has  received  a 
sort  of  protective  inoculation,  without  having  had  actual  manifestations  of 

the  disease. 

A  woman  with  acquired  syphilis  is  liable  to  bear  infected  cluldren. 
The  father  may  not  be  affected.  In  a  large  num])er  of  instances  botli 
l)artnts  are  diseased,  the  one  having  infected  the  other,  in  which  case  the 
changes  of  fcctal  infection  are  greatly  increased. 

(c)  Placental  transmission.  Tlie  mother  may  be  infected  after  con- 
ception, in  which  case  the  child  may  be,  but  is  not  necessarily,  born  syph- 

Morbid  Anatomy.— The  primary  Icswn,  or  chancre,  shows:  {n)  A  dil- 
fuse  infiltration  of  the  connective  tissue  with  small,  round  cells,  (h) 
Larger  epithelioid  cells,  (c)  Giant  cells,  (d)  The  Lustgarten  bacilli,  in 
small  numbers,  (e)  Changes  in  the  small  arteries,  chiefly  thickening  of 
the  intima,  and  alterations  in  the  nerve-fibres  going  to  the  part  (Berkley). 
The  sclerosis  is  due  in  part  to  this  acute  obliterative  endarteritis.  Asso- 
ciated with  the  initial  lesions  are  changes  in  the  adjacent  lymi)h-glands, 
which  undergo  hyperplasia,  and  finally  become  indurat(!d. 

The  secondary  lesions  of  syi)liilis  are  too  varied  for  descri])tion  here. 
They  consist  of  condylomata,  skin  eruptions,  affections  of  the  eye,  etc. 

.    The  tertiary  lesions  consist  of  circumscribed  tumors  known  as  gum- 
mata,  and  of  an  arteritis,  which,  however,  is  not  peculiar  to  the  disease. 

G'lnnnmirt.— Syphilomata  develop  in  the  bones  or  periosteum— here 
they  are  called  nodes— in  the  muscles,  skin,  brain,  lung,  liver,  kidneys, 
heart,  testes,  and  adrenals.  They  vary  in  size  from  small,  almost  micro- 
scopic, bodies  to  large,  solid  tumors  from  3  to  5  cm.  in  diameter.  They 
are  usually  firm  and  hard,  but  in  the  skin  and  on  the  mucous  membranes 
they  tend  "to  break  down  rapidly  and  ulcerate.  On  cross-section  a  medium- 
sized  gumma  has  a  grayish-white,  homogeneous  ap])earance,  presenting 
in  the  centre  a  firm,  caseous  substance,  and  at  the  periphery  a  translucent, 
fibrous  tissue.  Often  there  are  groups  of  three  or  more  surrounded  by 
dense  sclerotic  tissue. 

The  arteritis  will  be  considered  in  a  separate  section. 


mfh.. 


■■•jj'-'fr rrfMinf  ■mn-tgW^'-".  <■  ■-"^  ' 


240 


SPECIFIC  INFECTIOUS  DISEASES. 


!«''■■ 


m 


II.    ACQUIRKD   SyPIIILIS. 

Primary  Stage  — This  extends  from  tlie  appeiiranre  of  tlie  initial  sore 
mitil  tlie  onset  of  tiic  contititutional  syini)tonis,  and  has  a  variable  dura- 
tion of  from  six  to  twelve  weeks.  The  initial  sore  a])i)cars  witliin  a  montli 
after  inoculation,  and  it  first  shows  itself  as  a  small  red  papule,  which 
gradually  enhirges  and  breaks  in  tlie  centre,  leaviuju'  a  small  ulcer.  The 
tissue  about  tiiis  Jjecomes  indurated  so  that  it  ultimately  has  a  gristly,  car- 
tilaginous consistence — hence  the  name,  hard  or  indurated  chancre.  The 
size  attained  is  variable,  aiul  when  small  the  sore  may  be  overlooked,  par- 
ticularly if  it  is  just  within  the  urethra.  The  glands  in  the  lym])h-district 
of  the  chancre  enlarge  aiul  become  hard.  Suppuration  both  in  the  initial 
lesion  and  in  the  glands  may  occur  as  a  secondary  change.  The  general 
condition  of  the  patient  in  this  stage  is  good.  There  may  be  no  fever  and 
no  impairment  of  health. 

Secondary  Stage. — The  first  constitutional  symjjtoms  are  usually  mani- 
fested within  three  months  of  the  appearance  of  the  primary  sore.  They 
rarely  develo])  earlier  than  the  sixth  or  later  than  the  twelfth  Aveek.  The 
symi)toms  are:  (a)  Fetter,  slight  or  intense,  and  very  varialtle  in  charac- 
ter. A  mild  continuous  pyrexia  is  not  uncommon,  the  t('mi>erature  not 
rising  above  101°.  The  fever  may  have  a  distinctly  remittent  character; 
but  the  most  remarkable  and  puzzling  type,  which  is  very  apt  to  lead  to 
error  in  diagnosis,  is  the  intermittent  syphilitic  fever.  It  may  come  on 
within  a  month  after  exposure  and  rise  to  104°  or  105°,  with  oscilla- 
tions of  5°  or  (]°  (Yeo).  A  remarkable  case  is  reported  by  Sidney 
rhillips,  in  which  pyrexia  persisted  for  months,  with  paroxysms  resem- 
bling in  all  respects  tertian  ague,  and  which  resisted  quinine  and  yielded 
promptly  to  mercury  and  ])otassium  iodide.  Although  usually  a  secondary 
manifestation,  the  fever  of  syphilis  may  occur  late  in  the  disease.  Prac- 
titioners are  scarcely  alive  to  the  frequency  and  importance  of  sy])hilitic 
fever.  Janeway  has  recently  called  attention  to  cases  in  which  the  diag- 
nosis of  pulmonary  tuberculosis  had  been  made. 

(h)  Ainrmia. — In  many  cases  the  syphilitic  poison  causes  a  pronounced 
anreniia  which  gives  to  the  face  a  muddy  pallor,  and  there  may  even  be  a 
light-yellow  tingeing  of  the  conjunctiva?  or  of  the  skin,  a  ha?matogenous 
icterus.  This  syjihilitic  cachexia  may  in  some  instances  be  extreme.  The 
red  blood-corpuscles  do  not  show  any  special  alterations.  The  blood-count 
may  fall  to  three  millions  per  cubic  millimetre,  or  even  lower.  The  anrpmia 
may  develop  suddenly.  In  a  case  of  syphilitic  arthritis  in  a  young  girl 
following  three  or  four  inunctions  of  mercury  the  blood-count  fell  below 
two  nullions  per  cubic  millimetre  in  a  few  days. 

(r)  Cvtoncous  Lesions. — Skin  eruptions  of  all  forms  may  develop.  The 
earliest  and  most  common  is  a  rash — macular  si/phtUde  or  sijphilitic  roseola 
— which  occurs  on  the  abdomen,  the  chest,  and  on  the  front  of  tlie  arms. 
The  face  is  often  exem]it.  The  spots,  which  are  reddish-brown  and  sym- 
metrically arranged,  ]iersist  for  a  week  or  two.  Next  in  frequency  is  a 
papular  sypliilule,  which  may  form  acne-like  indurations  about  the  face 
and  trunk,  often  arranged  in  groups.     Other  forms  arc  the  pustular  rash, 


•«?vt' 


I 


SYPHILIS. 


241 


initial  sore 
iable  dura- 
n  a  month 
ule,  which 
ilcer.     The 
rristly,  car- 
iicre.    The 
ooked,  par- 
iiph-district 
,  the  initial 
fhe  general 
0  fever  and 

ually  mani- 
sore.  They 
week.  The 
>  in  charac- 
leratiive  not 
t  character; 
it  to  lead  to 
ay  come  on 
,vith  oscilla- 

by    Sidney 

ysms  resem- 

and  yielded 

a  secondary 
sease.  Prac- 
of  syphilitic 
ch  the  diag- 

i  pronounced 
ay  even  be  a 
a?matogenous 
»ctreme.  The 
3  blood-count 
The  ann?mia 
a  young  girl 
mt  fell  below 

develop.  The 
nhilitic  roseola 
t  of  the  arms. 
3wn  and  sym- 
'requency  is  a 
bout  the  face 
jmstidar  rash, 


which  may  so  closely  simulate  variola  that  the  patient  may  be  sent  to  a 
«maU-po.\  hospital.  A  siiiiamotis  si/philide  occiirH,  not  unlike  ordinary 
j.soriasis,  except  that  the  scales  are  less  ahinuhmt.  The  rash  is  more  copper- 
eolorod  and  not  specially  confined  to  the  extensor  surfaces. 

In  the  moist  regions  of  tlie  skin,  siicli  as  the  perinanim  and  groins,  tlie 
axilhe,  between  the  toes,  and  at  tlie  angles  of  tlie  mouth,  the  so-called 
mucous  patches  develop,  which  are  flat,  warty  outgrowtiis,  with  well-dehned 
margins  and  surfaces  covered  with  a  grayish  secretion.  They  are  among 
the  most  distinctive  lesions  of  syphilis. 

Frecpiently  the  hair  falls  out  (alopecia),  cither  in  patches  or  by  a  gen- 
eral thinning.  Occasionally  the  nails  become  ail'ected  (syjihilitic  onychia). 
((/)  Mucous  Lesions.— W'lih  the  fever  and  the  roscoloiis  rasii  the  throat 
and  mouth  become  sore.  The  pharyngeal  mucosa  is  hyperaMiiic,  the  ton- 
sils are  swollen  and  often  ])resent  small,  kidney-shaped  ulcers  with  grayish- 
white  borders.  Mucous  itatches  are  seen  on  the  inner  surfaces  of  the  cheeks 
and  on  the  tongue  and  li|)s.  Sometimes  on  the  tongue  there  are  whitish 
spots  (leucomata),  which  are  seen  most  frequently  in  smokers,  and  which 
Hutchinson  regards  as  the  joint  result  of  syphilitic  glossitis  and  the  n-ri- 
tation  of  hot  tol)acco-smoke.  Hypertrophy  of  tlie  |)apilla>  in  various  por- 
tions of  the  mucous  membrane  produces  the  syphilitic  warts  or  condylo- 
mata which  are  most  frequent  about  the  vulva  and  anus. 

(e)  Other  Lesious.— Iritis  is  common,  and  usually  affects  one  eye  be- 
fore the  other.  It  develojis  in  from  three  to  six  months  after  the  chancre. 
There  may  be  only  slight  ciliary  congestion  in  mild  cases,  but  in  severer 
forms  there  is  great  pain,  and  the  condition  is  serious  and  demands  care- 
ful management.  Choroiditis  and  retinitis  arc  rare  secondary  symptoms. 
Far  affections  are  not  common  in  the  secondary  stage,  but  instances  arc 
found  in  which  sudden  deafness  develops,  which  may  be  due  to  labyrinth- 
ine disease;  more  commonly  the  impaired  hearing  is  due  to  the  extension 
of  inflammation  from  the  throat  to  the  middle  ear.  Epididymitis  and 
parotitis  are  occasional  secondary  lesions. 

Tertiary  Stage.— No  hard  and  fast  lino  can  be  drawn  between  the 
lesions  of  the  secondary  and  those  of  tlie  tertiary  period;  and,  indeed,  in 
exceptional  cases,  manifestations  which  usually  appear  late  may  set  m  even 
before  the  primary  sore  has  properly  healed.  The  special  affections  of  this 
stage  are  certain  skin  eruptions,  gummatous  growths  in  the  viscera,  and 
amyloid  degenerations.  _ 

(a)  The  late  syphilides  show  a  greater  tendency  to  ulceration  and  de- 
struction of  the  deeper  layers  of  the  skin,  so  that  in  healing  scars  are  left. 
They  are  also  more  scattered  and  seldom  symmetrical.  One  of  the  most 
characteristic  of  the  tertiary  syphilides  is  rupia,  the  dry  stratified  crusts 
of  which  cover  an  ulcer  which  involves  the  deeper  layers  of  the  skin  and 
in  healins  leaves  a  scar. 

(Ii)  Gvmmafa.— These  may  develop  in  the  skin,  subcutaneous  tissue, 
muscles,  or  internal  organs.  The  general  character  has  been  already  de- 
scribed. When  they  develop  in  the  skin  they  tend  to  break  down  and 
ulcerate,  leaving  ugly  sores  which  heal  with  difficulty.  In  the  solid  organs 
they  undcrcro  fibroid"  transformation  and  produce  puckering  and  deformity. 


'■{<fei4  "" 


\.  ..  ,  , 


212 


SPECIFIC  INFECTIOUS  DISEASES. 


m 


i      .1 


i  ■■  1  \ 


On  tltc  mucous  membranes  these  tertiary  lesions  lead  to  ulceration,  in  the 
healing  of  which  cicatriccis  are  formed;  thus,  in  the  larynx  great  narrow- 
ing may  result,  and  in  the  rectum  ulceration  with  fibroid  tliickening  and 
retraction  may  lead  to  stricture. 

(r)  Amyloid  Defienemtioti. —^y\)h\\\s  plays  a  most  important  rolf  in 
the  production  of  this  affection.  Of  2[-l  instances  analyzed  by  Fagge,  7(i 
had  syphilis,  and  of  these  4:^  had  no  bone  lesions.  It  follows  the  acquired 
form  and  is  very  common  in  association  with  rectal  syphilis  in  women.  In 
congenital  lues  amyloid  degeneration  is  rare. 

((/)  I'ara-  or  Metasyphililic  AlJedions.—Vcria'm  disorders  not  actually 
syphilitic,  yet  so  closely  connected  that  a  large  proportion  of  the  cases  have 
had  the  disease,  arc  termed  by  Fournier  parasyphilitic  (Les  Alfections 
I'arusyphilitiques,  1H!)4).  These  alfections  arc  not  exclusively  and  neces- 
sarily caused  liy  syphilis,  and  they  are  not  inlluenced  by  specific  treatment. 
The  chief  of  them  arc  locomotor  ataxia,  dementia  paralytica,  certain  types  , 
of  epilepsy,  and,  we  may  add,  aiterio-sclerosis. 

III.    CONGEXITAL    Svi'IIIUS. 

With  the  exception  of  the  primary  sore,  every  feature  of  the  acquired 
disease  may  be  seen  in  the  congenital  form. 

The  intra-uterine  conditions  leading  to  the  death  of  the  fretus  do  not 
liere  concern  us.  The  child  may  be  born  healthy-looking,  or  with  well- 
marked  evidences  of  the  disease.  In  the  majority  of  instances  the  former 
is  the  case,  and  within  the  first  month  or  two  the  signs  of  the  disease 

appear.  .  ,.,,,,       i  -i  j 

Symptoms.— (fl)  At  Birth.— When  the  disease  exists  at  birth  the  chitd 
is  feebly  developed  and  wasted,  and  a  skin  eruption  is  usually  present, 
commonly  in  the  form  of  bullffi  about  the  wrists  and  ankles,  and  on  the 
hands  and  feet  (pemphigus  neonatorum).  The  child  snuflles,  the  lips  are 
ulcerated,  the  angles  of  the  mouth  fissured,  and  there  is  enlargement  of 
the  liver  and  spleen.  The  bone  symptoms  may  be  marked,  and  the  epiphy- 
ses may  even  be  separated.     In  such  cases  the  children  rarely  survive 

long. 

(h)  Early  Manifesfatio7is.~WhQn  born  hcaltiiy  the  child  thrives,  is  fat 
and  plump,"  and  shows  no  abnormity  whatever;  then  from  the  fourth  to 
the  eighth  week,  rarely  later,  a  nasal  catarrh  develops,  sypliililic  rJnititis, 
which  impedes  respiration,  and  produces  the  characteristic  symptom  which 
has  given  the  name  snuffles  to  the  disease.  The  discbarge  may  be  sero- 
purulent  or  bloody.  The  child  nurses  with  great  difiiculty.  In  severe  cases 
ulceration  takes  place  with  necrosis  of  the  bone,  leading  to  a  depression 
at  the  root  of  the  nose  and  a  deformity  characteristic  of  congenital  syi)hilis. 
This  coryza  may  be  mistaken  at  first  for  an  ordinary  catarrh,  but  the  co- 
existence of  other  manifestations  usually  makes  the  diagnosis  clear.  The 
disease  may  extend  into  the  Eustachian  tubes  and  middle  ears  and  lead 

to  deafness. 

The  cutaneous  lesions  develop  with  or  shortly  after  the  onset  of  the 
snuffles.    The  skin  often  has  a  sallow,  earthy  hue.    The  eruptions  are  first 


fe§^?^^.aa^l5!SPi«^S?«5i^ii*f.'" 


SYPHILIS. 


243 


ion,  in  the 
lat  narrow- 
coning  and 

tnt   rob    in 

Faggo,  7(i 

10  aomiireil 

ronion.    In 

,ot  actually 

I  cases  have 

Ail'octions 

and  ncces- 

trcatinont. 

irtain  types 


he  acquired 

litus  do  not 

'  with  well- 

the  former 

the  disease 

;h  the  child 
illy  present, 
and  on  tlio 
the  lips  are 
irgement  of 
the  epiphy- 
rely  survive 

irives,  is  fat 
le  fourth  to 
itic  rhinitis, 
iptom  which 
nay  be  sero- 
severe  cases 
a  depression 
lital  syi)hilis. 
bnt  the  co- 
clear.     The 
firs  and  lead 

onset  of  the 
ions  are  first 


noticed  about  ilio  nates.     There  may  be  an  erythema  or  an  oczomatoua 
condition,  but  more  commonly  there  are  irregular  reddish-l. nnvu  patches 
with  well-deliiUMl  edges.    A  i)apular  sy|)hilide  in  this  region  is  by  no  means 
uncommon.     Fissures  develop  about  the  lips,  either  at   the  angles  of  the 
mouth  or  in  the  median  line,     'i'liese  rhaijodcs,  as  they  are  called,  are  very 
characteristic.     There  may   he  nuirked  ulceration  of  the  muco-cutaneous 
surfaces.     The  secretions  "from  these  mouth  lesions  are  very  virulent,  and 
it  is  from  this  source  that  the  wet-nurse  is  usually  infected.   ^Not  only  the 
inirse,  but  meml)ers  of  the  family,  may  bo  contaminated.     There  are  in- 
stances in  which  other  children  have  been  accidentally  inoculated  from 
a  syi)hilitic  infant.    The  hair  of  the  head  or  of  the  eyebrows  may  fall  out. 
The  syphilitic  oinjrhia  is  not  uncommon.     Enlargement  of  the  glands  is 
not  so  freciuent  in  the  congenital  as  in  the  ac.iuired  disea.se.     When  the 
cutaneous  lesions  arc  marked,  the  contiguous  glands  can  usually  be  felt. 
As  pointed  out  by  (iee,  the  spleen  is  enlarged  in  many  eases.    The  condi- 
tion may  persist  for  a  long  time,    luilargement  of  the  liver,  though  often 
present,'is  less  significant,  since  in  infants  it  may  be  due  to  various  causes\ 
These  are  among  the  most  constant  symptoms  of  congenital  syphilis,  and 
usually  develop  between  the  third  and  twelfth  weeks.     Freiiuently  they 
are  preceded  by  a  period  of  restlessness  and  wakefulness,  iiarticularly  at 
night.    Some  authors  have  described  a  peculiar  syphilitic  cry,  high-pitched 
and  harsh.     Among  rarer  manifestations  are   haemorrhages— the  si/phihs 
hwmorrhmjira  neonatorum.     The  bleeding  may  be  subcutaneous,  from  the 
mucous  surfaces,  or,  when  early,  from  the  umbilicus.     All  of  such  cases, 
however,  are  not  syphilitic,  and  the  disease  must  not  be  confounded  with 
the  acute  luemoglobinuria  of  new-born  infants,  which  Winckel  describes 
as  occurring  in  epidemic  form,  and  which  is  probably  an  acute  infectious 

disorder. 

(r)    Late    J/flni/cs/a/ioHs.— Children    with    congenital    syi)iiilis    rarely 
thrive.     Usually  they  ])rcsent  a  wizened,  wasted  apjjearance,  and  a  pre- 
maturely aged  face.     In  the  cases  which  recover,  the  general  nutrition 
may  remain  good  and  the  child  may  show  no  further  manifestations  of 
the  disease;  commonly,  however,  at  the  period  of  second  dentition  or  at 
puberty  the  disease  reappears.     Although  the  child  may  have  recovered 
from  the  early  lesions,  it  does  not  develop  like  other  children,    (h'owth  is 
slow,  development  tardv,  and  there  are  facial  and  cranial  characteristics 
which  often  render  the  disease  recognizable  at  a  glance.    A  young  man  of 
nineteen  or  twenty  may  neither  look  older  nor  be  more  developed  than  a 
])oy  of  ten  or  twelve.     Fournier  describes  this  condition  as  infant,ili!>m. 
Tlie  forehead  is  prominent,  the  frontal  eminences  are  marked,  and  the 
skull  may  be  very  asvmmetrieal.    The  bridge  of  the  nose  is  depressed,  the 
tip  retrouf<i^f      The  li])s  are  often  prominent,  and  there  arc  striated  lines 
running  from  the  corners  of  the  mouth.    The  t^rth  are  deformed  and  may 
present  appearances  which  Jonathan  Hutchinson  claims  arc  specific  and 
peculiar.     The  u])i)er  central  incisors  of  the  permanent  set  are  the  teeth 
which  give  information.     The  specific  alterations  are— the  teeth  are  peg- 
shaped,  stunted  in  length  and  breadth,  and  narrower  at  the  cutting  edge 
than  at  the  root.    On  the  anterior  surface  the  enamel  is  well  formed,  and 


244 


SPECIFIC  INFECTIOUS  DISEASES. 


not  orodod  or  lionoycnmljod.  At  the  cuttinp  cdjxc  there  is  a  sinplc  notch, 
usually  shallow,  soiiietinies  deojt,  in  which  the  deiitiiio  is  exposed. 

Anionj;  late  manifestations,  jmrtieidarly  apt  to  appear  about  puberty, 
is  the  interstitial  kcrdlilix,  whieh  usnally  liejriiis  as  a  slight  steaniiness  of 
the  cornea',  which  present  a  groimd-giass  appt'araiice.  It  ail'eets  both  eyes, 
though  one  is  attacked  before  the  other.  It  may  ])ersist  for  montiis,  and 
usually  clears  coinpletely,  though  it  nuiy  leave  opacities,  which  ])revent 
clear  vision.  Jritih  may  also  occur.  Of  ear  ujJecHunK,  apart  from  those 
whieh  develop  as  a  sequence  of  the  ])haryngeal  disease,  a  form  occurs  about 
the  time  (d'  puberty  or  earlier,  in  which  deafness  comes  on  rapidly  and  per- 
sists *in  spite  of  all  treatment.  It  is  unassociated  with  obvious  lesions, 
and  is  probably  labyrinthine  in  character.  Bone  lesions,  occurring  oftencst 
after  the  sixth  year,  are  not  rare  among  the  late  manifestations  of  hereditary 
syphilis.  The  tiliia'  are  most  frequently  attacked.  It  is  really  a  chronic 
gummatous  periostitis,  which  gradually  leads  to  grefit  thickening  of  the 
bone.  The  nodes  of  congenital  syi)iiilis,  which  are  often  mistaken  for 
rickets,  are  more  connnonly  diiruse  and  ail'ect  the  bones  of  the  U])per  and 
lower  extremities.  They  arc  generally  symmetrical  and  rarely  painful. 
They  may  develop  late,  even  after  the  twenty-first  year. 

Joint  lesions  are  rare.  Clutton  has  described  a  symmetrical  synovitis 
of  the  knee  in  hereditary  syphilis.  Knlargcment  of  the  s|)leen,  sometimes 
witli  the  lymph-glands,  may  be  one  of  the  late  manifestations,  and  may 
occur  either  alone  or  in  connection  with  disease  of  the  liver. 

(iummata  of  the  liver,  brain,  and  kidneys  have  been  found  in  late 
hereditary  syjihilis. 

Is  syjihilis  transmitted  to  the  third  generation?  The  general  ojiinion 
is  that  the  recorded  cases  scarcely  stand  criticism.  Occasionally,  however, 
cases  of  pronounced  congenital  syphilis  are  met  with  in  the  children  of 
])arcnts  wlio  are  ])erfectly  healthy,  and  who  have  not,  so  far  as  is  known, 
had  syphilis,  and  yet,  as  remarked  by  Coutts,  who  reported  such  a  group 
of  cases,  tiiey  do  not  bear  careful  scrutiny.  This  is  the  opinion  of  tlie  lead- 
ing syphilogra])hers.  Personally,  I  have  never  met  with  even  a  suspicious 
instance.  On  the  other  hand,  I  know  now  a  number  of  perfectly  liealthy 
cliildren,  one  of  whose  grandfathers  was  syphilitic. 


■A: 


lY.  Visceral  Syphilis. 

A,  Syphilis  of  the  Brain  and  Cord. — The  following  lesions  occur: 
(1)  Gummata,  forming  definite  tumors,  ranging  in  size  from  a  pea  to 
a  walnut.  They  are  usually  multi])le  and  attached  to  the  ])ia  mater,  some- 
times to  the  dura.  Very  rarely  they  are  found  unassociated  with  the  me- 
ninges. When  small  they  present  a  uniform,  translucent  ap]iearance,  but 
when  large  tlie  centre  undergoes  a  fibro-caseoiis  change,  while  at  the 
peri])hery  there  is  a  firm,  translucent,  grayish  tissue.  They  may  closely 
resemble  large  tuberculous  tumors.  The  growths  are  most  common  in  the 
cerebrum.  They  may  be  multiple  and  may  even  attain  a  considerable  size 
without  becoming  caseous.  Occasionally  gummata  undergo  cystic  degen- 
eration.    In  the  cord  large  gummatous  growths  are  not  so  common.     In 


--(3*fe'. 


4ifSkis^^?^" 


■'^^^^;pmsm:mmi?r 


SYPHILIS. 


245 


igle  notch, 

•a. 

t  ])iil)crty, 
iiininess  of 
both  eyes, 
onths,  and 
.•h  j)rovt'nt 
['roni  those 
■curs  about 
ly  and  per- 
ms lesions, 
ng  oftencst 
'  hereditary 
,'  a  chronic 
ing  of  tlie 
istaken  for 
upper  and 
ly   painful. 

al  synovitis 
,  sometimes 
s,  and  may 

ind  in  late 

!ral  oi)inion 
iy,  however, 
children  of 
s  is  known, 
ich  a  gronp 
of  the  Icad- 
a  suspicioiis 
ctly  healthy 


occur: 

im  a  pea  to 
nater,  some- 
lith  the  nie- 
earance,  but 
i-hilc  at  the 
may  closely 
nmon  in  the 
iiderable  size 
;y.stic  degen- 
ommon.     In 


an  instance  recently  reported  by  mo  a  tumor,  from  throe  eighths  to  one 
lourth  of  an  inch  in  diauH.ter,  was  completely  within  the  cord  opposile 
the  fourtii  cervical  nerve,  and  there  were  numerous  gummata  lu  the  cauda 

'^'^'''i?)  (hnnnuilaus  }rnn,ujilis.-V\n^  constantly  occurs  in  the  neighbor- 
]>ood  of  ti>e  larger  growths,  and  there  ^-^^y  ^^^^^^^^^^^f^^^'^  "^''"^^ 
several  centimetres  in  extent,  in  which  the  pia  is  .nldtrated  and  the  arteues 
greatly  thickene.l.    This  by  no  means  uucunuu.n  form  may  run  a  subacute 

or  a  chronic  course.  ,.      i  i     ,i       ..(„.;,.. 

(3)  Gummtilous  Arkrilis.—'Thc  lesions  may  be  contmcd  to  the  a.teii.s 
which  present  the  nodular  tunu)rs  to  be  descrilied  herealter. 

(4)  Foci  of  srkrosi^,  which  Lancereaux  holds  may  be  distinguished  irom 
non-si)ccillc  forms  by  a  much  greater  tendency  of  the  neuroglia  elements 
to  undergo  fatty  transformation,  ami  by  the  secondary  alterations  as  areas 
of  softening,  which  occur  in  the  neighborhood.  Neither  the  ditluse  nor 
the  nodular  cerebral  sclerosis,  met  with  particularly  in  children,  appears 
to  have  any  special  relation  to  inherited  syphilis. 

(,-,)  Whether  a  localized  encephalitis  or  myelitis  can  result  from  the 
action  of  the  svphilitic  poison  without  involvement  of  the  blood-vessels  is 
doubtful.  In  a  case  of  multii-le  arterial  gummata  recent  y  in  my  ward, 
Thomas  found  in  the  lumbar  region  of  the  cord  foci  ot  mllammatory  soft- 

''''fccomJan,  Chauges.-ln  the  brain  gummatous  arteritis  is  one  of  the 
common  cau'ses  of  softening,  which  may  be  extensive,  as  when  the  muM 
cerebral  artery  is  involved,  or  when  there  is  a  large  patch  of  sy,.hd  tic 
meningitis,  in  such  instances  tlie  process  is  really  a  men.ngo-eiicepha- 
litis  and  the  svmptoms  are  due  to  the  secondary  changes  in  the  brain-sub- 
stance, not  directlv  to  the  gumma.  In  the  neigliborhood  of  a  gummatous 
.rrowth  intense  encephalitis  or  myelitis  may  develop,  and  witliin  a  lew  days 
change  the  clinical  picture.  Gummatous  arteritis  niay  lead  o  weakening 
of  the  wall  of  the  vessel  and  rupture  with  meningeal  Inemorrhage. 

Svuhilitic  disea.se  of  the  nerve-centres  may  occur  in  the  inherited  or 
acquired  form,  more  commonly  in  the  latter.     In  tlio  congenital  cases  the 
tumors  usually  develop  early,  but  may  be  as  late  as  the  twenty-fi.t  jeir 
(11    C   Wood)     In  the  acquired  form  the  nerve  lesions  belong,  as  a  rule, 
0  the  late  manifestations,  and  patients  may  have  quite  forgotten  the  ex- 
istence of  a  primary  infection,  and  in  very  many  instances  the  secondaij 
manifestations  have  been  slight.     Ileubner,  to  wliom  we  owe  so  much  in 
connection  with  this  subject,  has  seen  them  as  late  as  the  thirtieth  yea, 
On  the  other  hand,  in  exceptional  instances,  they  may  occtir  very  early,  and 
vere  convulsions  with  hemiplegia  have  been  reported  within    hree  month 
oTtho  primnrv  sore.    The  discussion  at  the  Eoyal  Medica    and  Chirurgical 
Society  (B    ^1.  J.,  lS!)r>.  vol.  i).  and  Lydston's  paper  (Jour.  Am.  Med. 
Assoc,  ISnr,,  vol.  i),  show  that  various  affections  of  the  nervous  system 
are  bv  no  means  uncommon  during  the  secondary  s  acre  of    he  disease. 

sLpt<m..-Th.  chief  features  of  cerebral  svphilis  are  those  of  tumor, 
which  will  be  considered  subsequently  under  that  section.  They  may  be 
classified  here  as  follows: 


;=3&_ 


240 


SPECIFIC   INFECTIOUS  DISEASES. 


(1)  I'sycliiiiil  IVatiirc-s.  A  su.l.kn  imd  violent  .-iisa  of  (loliruim  may 
Ik'  tlu'  lirst  svmptcni.  In  .'llu'i'  iiistiiiurs  prior  to  tlu'  (uciirrfiur  ^ol  do- 
liriuni  llinr  have  Iktii  lawladu.-,  alteration  of  riianutrr.  and  loss  .)!  i.umu- 
,„y.  'I'hc  loiidition  may  Ik-  accomi.ani.'d  l.y  convuUiuns.  liiore  may  be  no 
neuritis,  no  imlsv,  and  no  !ocalizin<?  symptoms.  .,    ,    .  , 

(•>)  .More  c'ommonlv  following;  licadadus  giddiness,  or  an  o.xcited  state 
wliieh  mav  amount  to  .lelirium,  the  patient  has  an  eialei.tio  i^eizure  or 
develops  l.emipl.'gia,  or  there  is  involvement  of  the  nerves  ol  the 
base.  Some  of  these  oases  display  a  i-rolonj^ed  torpor,  a  speeial  feature  ..t 
hrain  svphilis  to  whieh  hoth  Uu/./ard  and  Jlenhner  have  referred,  wlueli 
uuiy  persist  for  as  h-ng  as  a  n>onth.  JI.  V.  Wood  describes  \v.tb  this 
a  state  of  automatism  oeeurrinfj  i)artieularly  at  nitiht,  m  which  the 
patient    l)ehaves    like    a    '"restless    noeturnal    automat. m    rather    tiian    a 

man."  ,         ^.  ,  ,.         mi 

(a)  A  clinical  j.icture  of  general  paralysis— dementia  paralytica.  Hie 
qnesti.m  is  still  in  dispute  whether  this  syphilitic  encephalopathy,  which 
so  closolv  resembles  general  paralysis,  is  a  distinct  and  independent  a  lec- 
tion Mickle,  who  has  carefully  reviewed  the  snbject,  concludes  that 
syi.hilis  may  directly  ])roduce  the  inflammatory  changes  in  the  brain,  wliile 
,n  other  instances  it  directly  ])redisposes  to  this  ailection.  It  is  a  some- 
what remarkable  feature  that  the  cases  which  present  the  clinical  picture 
of  general  paresis  are  most  frnpiently  those  which  have  not  had  any  local- 
izing symptoms,  and  they  may  not  have  convulsions  until  the  disease  is 

well  advamed.  ^   i      ■ 

(-1)  Many  cases  of  cerebral  svphili>'  display  the  symptoms  of  lirain 
U,„,or— lieadache,  oj.tic  neuritis,  vomiting,  and  convnlsions.  Of  these 
symptoms  convulsions  are  the  most  important,  and  both  Fournier  and 
Wood  have  laid  great  stress  on  the  value  of  this  symptom  m  i)ersons  over 
thirty  The  first  svmi.toms  mav,  bowevcr,  rather  reseml.le  those  of  em- 
bolism or  thrombosis;  thus  there  may  be  sudden  hemiplegia,  with  or  with- 
out loss  of  consciousness. 

The  symptoms  of  spinal  siipliilis  are  extremely  yaried  and  may  he 
cansed  bv"  largo  gummatous  growths  attached  to  the  meninges,  in  which 
case  the  feainrcs  arc  those  of  tnmor;  by  gnmmatous  arteritis  with  second- 
ary softenin'^;  by  meningitis  with  secondary  cord  changes;  or  by  scleroses 
developincr  late  in  the  disease,  the  relation  of  which  to  syphilis  is  still  ob- 
scure. Erb's  syphilitic  myelitis  will  be  considered  under  the  spastic  para- 
plegias. ,    ,   .,  1 

Dhqtiosis.—Tho  history  is  of  the  first  importance,  but  it  may  be  ex- 
tremely diflicnlt  to  get  a  reliable  account.  Careful  examination  should  be 
made  for  traces  of  the  primary  sore,  for  the  cicatrices  of  bubo,  for  scars  of 
the  skin  eruption  or  throat  ulcers,  and  for  bone  lesions.  The  character 
of  the  symptoms  is  often  of  great  assistance.  They  are  multiform,  vari- 
able and  often  such  as  could  not  be  explained  by  a  single  lesion;  thus 
there  may  be  anomalous  spinal  symptoms  or  involvement  of  the  nerves  of 
the  brain  on  both  sides.  And  lastly  the  result  of  treatment  has  a  definite 
bearing  on  the  diagnosis,  as  the  symptoms  may  clear  up  and  disappear  with 
the  use  of  antisyphilitic  remedies. 


BY  IM II  LIS. 


247 


iliriuin  may 
unoe  <>l'  tlt'- 
)Srt  of  iiii'in- 
j  may  1)0  no 

'xcitcd  state 
2  seiziiri'  or 
■ves  of  the 
il  feature  of 
MTcd,  whieh 
;s  with  this 
whicli  the 
her    than    a 

lytiea.  Tlie 
)athy,  whieh 
Mident  alfee- 
;u:hi<les  that 
hrain,  wliilo 
t  is  a  some- 
nical  picture 
iid  any  h)eal- 
lie  disease  is 

ms  of  ])rain 
s.  Of  tliese 
''oiirnier  and 
])ersons  over 
tlioso  of  em- 
ivith  or  witli- 

and  may  he 
;es,  in  whieli 

with  second - 
r  by  sc]eroi?es 
lis  is  still  oh- 

spastic  para- 

t  may  ho  ex- 
ion  should  ho 
'),  for  scars  of 
riie  character 
dtiforni,  vari- 
c  lesion;  thus 
the  nerves  of 
has  a  definite 
lisappear  with 


li.  Syphilis  of  the  Lung. 

Thi/is  a  very  rare  disease.  Vmw<A  twenty-five  years  1  have  no  sun 
„,ore  than  half  a'dozen  speein.ens  in  Nshieh  tljere  was  no  M"^-  '''""«  ;>;^^' 
nature  of  tlu'  troul.le.  Fowler  states  that  he  has  recently  visited  the  muse- 
ums of  the  London  hospitals  and  at  the  !{..val  Colle,.;  -t  Si.r.'oons,  and  ea 
,1  Hi  onlv  twelve  speeinu.ns  illustratin,^  syplnli.ie  lesions  ol  the  Inn, 
„t  win<ii  are  doul.tful.  For  the  most  full  and  sat.stactory  consuleiat.on 
of  pulmonary  syphilis,  the  reader  is  referred  to  cliapter  xxxvu  of  iM.Nsler 
and  Codlee's  work  on  Diseases  of  the  Lung's.  ,      ,,.. 

Elioh.i!i  ami  Morbid  .lm,/.m//.-Syphilis  of  the  lun^'  occurs  under  the 

followins^lorms:      ^^^^^^^^^^^^^.^^  ^^^  ^^^^,  ^^^,^^^^,_     ,^.^^.^  ,,^^,_^.  ,„^^,^,j  ,,        „,, as  or 

an  entire  lun;.,  which  then  is  firm,  heavy,  and  airless,  even  though  the 
c.hild  may  have  hoen  horn  alive.  On  section  it  has  a  frray.sli-wh.te  aiM-ar- 
„,'_  !,,  so-called  white  he,.atixation  of  Virchow.  'Hh"  chief  el.an.e  is 
in  the  alveolar  walls,  whieh  are  greatly  thickened  and  infiltrated  so  th 
.,s  Waizner  expressc.l  it,  the  condition  rcsemhles  a  dilTus,^  sATl'doina.  In 
he^ea!^"  st^^s.  for  example  in  a  seven  or  ei,ht  months'  fo-tus,  there  may 
he  scattered  miliarv  foci  of  this  induration  chiefiy  about  the  arteries,  ihe 
air-cells  are  filled  with  desquamated  and  swcdlen  epithelium. 

(2)  In  the  form  of  definite  numwala,  whicli  vary  in  size  from  a  pc^a  to 
a  froo  e-e-.     They  occur  irrej^ularly  scatterul  through  the  lunf.    hut    as 
a  rule,  ar^more  numerous  toward  the  root.    They  presen    a  grayish-yellow 
Gaseous  appearance,  are  dry  and  usually  inilu.ddc.d  in  a  translucon  ,  more 
^  less  fi  m,  connective  tissue.     In  a  case  froiii  niy  wards  <  ^-j"''-       y 
Councilman,  there  was  extensive  involvement  of  the  root  of  the  lung, 
kinds  of  connective  tissue  passed  inward  from  the  tlnckeiied  pleura    nd 
between  these  strands  and  surrounding  the  gummata  there  was  '"  P''^"- 
uttled  red  pneumonic  consolidation.     In  the  caseous  nodules  there  is 
tyX^  hvaline  degeneration.     (Nmucilman  describes  as  the  F'-ry  1™, 
atrophy  r.f  the  alveolar  walls  with  hyaline  degeneration  of  the  eap.l  ai  u^, 
no    to  svphilitic  endarteritis,  which  is  well  marked,  and     o  which  the 
eln    are  attributed.    The  bronchi  are  usually  involved,  au     ---;;;' 
the  gummata  there  may  be  a  dilTusc  broncho-pneumoma,  whah  doe.  not 
TDoear  to  have  any  peculiar  characters.  ,,      /.i 

^  '   3    A  "  niority  of  authors  follow  Virchow  in  rocogniznig  the  fibrous 
ipteSittil    .noumonia  at  the  root  of  the  lung  and  passing  ^l-J  tlie  bron- 
ehi  and  ves  els  as  probably  sy,.hilitic.    This  mueh  may  bo  said,  thatin  ce  - 
in  ca' es  ^nimma  a  are  a;sociatcd  with  those  fibroid  changes      ^^.^n,  tins 
Xll^;^  alone  is  found  in  persons  with  -11-mnrked  s,,  iditic  histoi^  J 
with  other  visceral  lesions.     It  seems  m  many  instances  to  be  a  pure  y 
elot^c  process,  advancing  sometimes  from  the  pleura,  more  common  y 
from  the  Voot  o    the  lung,  and  invadin.  the  interlobular    issue,  gradually 
rol  "crmorc  or  less  ^tensive  fibroid  cliauge.    It  rarely  nn^lves  more 
tian  a  l^rtion  of  a  lobe  or  portions  of  the  lobes  at  the  root  of  the  lung. 

Tlip  bronchi  are  often  dilated.  ,   -i    .       j.-  „ 

!C/"/  -— Ts  there  a  syphilitic  phthisis,  an  ulcerative  and  destr^ictn^ 

disease    due  to  lues?     Personally  I  have  no  knowledge  of  such  an  afToc- 


2^g  SPECIFIC  INFECTIOUS  DISEASES. 

,K.™„„m.  in  adults,  simnl^ling  acute  pncunu.uic  l'"  "^  »;, ^  ""  "'    ' 
Sr:' »t  "l..-o„io  in.c',,.iti«l  l.noumouia.    Tl.c  .l.itc  luunnuotua  .s  u.,- 

S      >  °  "l/nJi-uc  i.  plaoo.1  «  by  „o  ""-"''""'"Z-Jlt^^l 

uiscu^i..       i       1  flinro  nrp  Snails  01  OhroillC  llllOl- 

pcculinntio.     The!  l,„io„s  of  .„.hilis  and  tubotcalosis  coulrt  ot  c„u,.o  o»- 

exist  in  a  hinp. 

c.  Syphilis  of  the  Liver.  rri,;^  ,« 

ThS^  occurs  in  three  ionns:  (a)  DitJusc  Syplnhhc  IIeiKdais.--T\u^  is 
„  J  c™n  h.  cases  of  congenital  syphilid    The  liver  F-orves^s  IWn 
"s  larc^e    liard,  and  resistant.     Sometimes  it  has  a  yellow  look    compar a 
by  Ssseau  to  sole-leather,  or  an  appearance  not  nn hke  the  a,ny  o.d 
U  .>r     ['arelnl  inspection  shows  grayish  or  whitish  pom  s  and  hnes  co i- 
^;nd^4  to  the  interlobular  new  growth.    ^^^^<-^^^^'J^^:Zi 
in  the  connective  tissue  is  scon,  and  m  many  places  foci  ot  small  ccuc 
nml^ti:"     Sometimes  these  nodules  are  visibl.  fonn-^^^^"  ^^^^ 
gummata  which  in  cicatrizing  produce  more  or  less  deformity.     Larger 

n";t™:^,;:l:^A:  n::lt  of  congenital  syphHis  th^e  may  occur  in 
chillod  or  in  adult  life.    In  ac,uired  syphilis  they  rarely  eonu.  on  befor 
t  0    econd  year  after  infection.     Tn  the  early  stage  there  are  pale  graji.h 
odn  ervan'ng  in  size  from  a  pea  to  a  marble.    The  larger  present  yelloy 
^0  Sre    a    ffrst;  l)nt  later  there  is  a  "  pale  yellowish,  cheese-like  nodule 
0    irm  u  ar  ontlin  ,  surrounded  by  a  fibrous  zone,  the  outer  edge  of  wlnc^i 
t  s  K'w  n  the  lolndar  tissue,  the  lobules  dwindling  gradually  m  its  grasp. 
Thi    fibrous  zone  is  never  very  broad;  the  cheesy  centre  varies  in  consist- 
ence a  .ristle-like  toughness  to  r   pulpy  so.'tness;  it  is  sometunc, 
mortar-X    fr^m  cretaceous  change  "  (Wi>Ks).    When  numerous,  the  most 
ex  .'ive  leforinitv  of  the  liver  is  produced  in  the  gradual  healing  of  these 
™ta     On  the  surface  there  are  deep,  scar-like  depressions  and    he  en- 
frorgan  mav  be  divided  into  a  cluster  of  irregular  masses,  held  together  b^; 


SYPHILIS, 


249 


have  seen 
onuugh  to 
icli  writers 
!  syphilitie 
Clinioiilly, 
11  raroly  be 
)i'  brouc'lii- 
)iiiii  is  iisu- 

lat  hos])ital 
he  extreme 
J  test  upon 
"With  pul- 
0  the  readi- 
chiectasy  in 
eumonia  of 
form  of  th« 
k'here,  when 
ironic  inter- 
are  present, 
y  experience 
IS  no  special 
)f  course  co- 


/(.<(  — This  is 
■ves  its  form, 
ik,  comiiared 
tlie  amyloid 
lid  lines  eor- 
rreat  increase 
'  small-celled 
firm  miliary 
lity.     Larger 

may  occur  in 
imo  on  before 
I  pale  grayish 
resent  yellow- 
?e-like  nodule 
3dge  of  which 
y  in  its  grasp, 
ies  in  consist- 
is  sometimes 
rons,  the  most 
'aling  of  those 
IS,  and  the  en- 
ild  together  b^; 


fibrous  tissue.  To  this  condition  the  term  hotyroid  has  been  given,  from 
its  resemblance  to  a  biiiuii  of  grapes.  As  a  rule,  the  gummata  gradually 
undergo  fibroid  traiisl'oniiation.  They  may,  however,  soften  and  liquefy, 
and,  according  to  Wilks,  may  form  a  lluctuating  tumor. 

(f)  Occasionally  the  syphilitic  changes  arc  chiclly  manifested  in  Glis- 
son's  shealh,  in  a  tiiickeiiing  of  the  capsule,  ])ro(luciiig  periliepatitis,  and 
increase  in  the  connective  tissue  in  the  pmial  canals,  so  that  on  section 
the  organ  jircsents  a  inimber  of  branching  librous  scars  whicli  may  cause 
considerable  deformity. 

Symptoms. — The  sym|)tonis  of  sy])liilitic  hejiatitis  are  very  variable. 
In  the  new-born  icterus  is  not  uncoinmon,  but  tlie  condition  of  the  liver 
can  scarcely  be  recognized.     In  the  adult  there  are  three  groups  of  cases: 

The  patient  presents  a  picture  of  cirrhosis  of  the  liver;  there  are  di- 
gestive disturbances,  slight  icterus,  loss  of  weight,  and  ascites.  If  signs 
of  syphilis  are  pres' nt  in  otlier  organs,  the  condition  may  be  suspected, 
or  if  after  removal  of  the  fluid  the  liver  is  felt  to  be  extremelv  irreirular. 
the  diagnosis  may  be  made  almost  with  certainty.  These  cases  are  com- 
mon, and  with  })roper  treatment  get  well;  they  form  an  important  con- 
tingent of  the  reputed  recoveries  in  ordinary  cirrhosis  of  the  liver. 

In  a  second  group  of  cases  the  patient  is  ana-mic,  passes  large  quan- 
tities of  i)ale  urine  containing  albumin  and  tube-casts;  the  liver  is  en- 
larged, perhaps  irregular,  and  the  sideen  also  is  enlarged.  Dropsical  symp- 
toms may  supervene,  or  the  patient  may  be  carried  otV  by  some  intercurrent 
disease.  Extensive  amyloid  degeneration  of  the  spleen,  the  intestinal  mu- 
cosa, and  of  the  liver,  with  gummata,  are  found. 

Thirdly,  the  gummata  may  form  an  irregular  tumor  on  the  right  or 
left  lobe,  perhaps  with  very  few  or  very  oljscure  syni])tonis.  The  diagnosis 
may  be  doubtful  until  some  other  evidence  of  syphilis  develops.  I  have 
recorded  several  illustrative  cases  in  my  Lectures  on  Abdominal  Tumors. 

Tiie  (liatjnosis  of  syphilis  of  t'le  liver  is  very  important,  since  upon  it 
the  ])ro))er  treatment  depends.  Jf  witli  a  history  of  infection  the  liver 
is  enlarged  and  irregular,  and  the  general  health  fairly  good,  the  condi- 
tion is  i)rol)at)ly  syphiloma. 

n.  Syphilis  of  the  Digestive  Tract. 

Tlie  a'sapliagiis  is  very  rarely  affected.  Stenosis  is  the  usual  result. 
Syphilis  of  the  stomach  is  excessively  rare.  Flexner  has  reported  a  remark- 
able case  in  association  with  gummata  of  the  liver.  lie  has  collected  14 
cases  in  the  literature.  Sy|)hilitic  ulceration  has  been  found  in  the  small 
intestine  and  in  the  ca?cum. 

The  most  common  seat  of  sy])hilitic  dif  ise  in  this  tract  is  the  rectum. 
The  affection  is  found  most  commonly  in  women,  and  results  from  the 
development  of  gummata  in  tlie  submucosa  above  the  internal  S))hincter. 
The  process  is  slow  and  tedious,  and  niay  last  for  years  before  it  finally 
induces  stricture.  The  symptoms  arc  usually  those  of  narrowing  of  the 
lower  bowel.  The  condition  is  readily  recognized  by  rectal  examination. 
The  history  of  gradual  on-coming  stricture,  the  state  of  the  ))atient,  and 
the  fact  that  there  is  a  1  nrd,  fi1)rous  narrowing,  not  an  elevated  crater-liko 
ulcer,  usually  render  ea,y  the  diagnosis  from  malignant  disease.    In  medi- 


X 


SPECIFIC  INFECTIOUS  DISEASES, 

looked,  and  only  discovered  post  mortem. 

not  Recognized,  though  oceasionally  u.  1;-;-;/;'^^;;  ^^  ^^  Outgrowths 
form  is  present,  as  is  not  nnconnnon  ,n  -'"  ""^^^Vreported  by  Janeway 
on  the  valves  in  connection  with  f^^'^^^^'^ZI^on.^  he  lesions 
and  others.  In  a  recent  study  o  he  ^^^Zio^^^,,,,  or  dif- 
into:  (1)  (Unnmata,  recent  or  old;  ^   /;'         "™^^^  I.  Adler 

fuse;  3  amyloid  degeneration;  and  (t)  <-"  "^\^ "/Z; jf  .''^eart  arc  com- 
.laims  tLt  dumges  in  the  Wood-vessels  o^th^  ^a  o^  ^^  ^^^^^^^^  ^,,. 
nion  both  in  congenital  and  acquired  sM'bdis,  e^cn 

ical  symptoms  or  gross  lesions.  Dandridgo  and 

Eupture  may  take  place    as  m  ^1^^  ^J«J^^1«  {  ^,^,,1^;  in- 

Nalty,  or  sudden  death,  as  in  the  cases  of  La  ky  ai  a  lu 

^d Sudden  death  is  frequei^,  --"'"^^^t  lAaT^    ^    o S^t  role 
Syplnlis  of  ,M  ^^rl^'-^^-'^yf^^l^^X^Z.  piLccsses  will 

Z ;^S;SM^:t:rri  r^^:;;;^:..  syphiUtic  arter^s,  which 

snbendothelial  tissue.  Tlie  new  growth  1^^'  ^  "  J  ^  obi  orating.  The 
n.ay  gradually  lUl  the  entire  '!^^^^^}^^^^^':J^^%lus  "form  of 
media  and  adventitia  are  also  inhltrated  '^  ^  f ';^;/^^^^'  ,,i,ti,  ^f  syphi- 
endart^itis  ^--^-^^j^  J-^'^;::  ,;:,::;J'S^:^  t^^^idored  paSog- 
'-'  ^^'  ^^^rhowe^er  he  ar  Jummata  in  other  parts,  or  if  the  con- 
dZr^  J'to  i;;li  -Ld  exis^  in  adjacent  arteries,  the  process  may 
be  regarded  as  syphilitic.  involvement   of   the 

^'"f ;  i  '■  'Z'd  ;       >>  1      *...Tli;o  ™,.l.or  ^';.o„  a„d  may  bo  found 

ClinicaUy  Ac  nation  is  ""*  ,"™f::!*;  ^„„,„i„„    ,„„   ,,„„„    earctully 

,    ?\  t:'L  g£  ;  ;:rifc  r         In-  Lir.  of  Montreal.    Tt  i.  «tin,a.<.d 

studied  by  llie  inencn  \mii«-i  .  ^  flcvelop  m 

to  oconr  in  the  «™""y  t£,"nt  .  r  on™;  nitial  iosion.  Tl.o 
„.„m  thrco  to  --'  '■— '';,;™'  ,:„l'  linnria  may  porsi.t  for  montl.s 
ontloolt  ,s  good,  *  ""^'      "",,,,„,,  ,,„.„,„,„.    I„  a  few  instaneo,  sy,*- 


svrniLis. 


251 


ptoms,  par- 
itirely  ovcr- 


I  syphilis  is 
disease  this 
Outgrowths 
by  Janeway 
the  lesions 
lized  or  dif- 
s.  I.  Adler 
art  arc  coin- 
vithout  clin- 

ndridgo  and 
0  Gould;  in- 
Mracck). 
nportant  role 
processes  will 
tcritis,  whicli 

ration  of  tlie 
3  lamina,  and 
.'rating.  Tlie 
This  form  of 
istic  of  syphi- 
iered  pathog- 
or  if  the  con- 
}  process  may 

emcnt  of  the 
he  artery,  pro- 
isiderable  size, 
ch  seem  to  ho 
distinctive  of 
may  be  found 
lin. 

n  the  kidneys, 
itons   hepatitis., 
ered  cicatrices. 

been  carefully 
It  is  estimated 
may  develop  in 
al  lesion.  Tlie 
ist  for  months; 
instances  syph- 
ree  weeks.    The 


lesions  arc  not  specific,  hut  are  similar  to   those   in   other  acute  infec- 
tions. 

(i.  Syphilitic  Orchitis. — This  affection  is  of  special  significance  to  the 
physician,  as  its  detection  frequently  clinches  the  diagnosis  iii  obscure 
internal  disorders.     Syphilis  occurs  in  the  testes  in  two  forms: 

(«)  The  (jiDiiiitaluits  grouili,  forming  an  indurated  mass  or  group  of 
masses  in  the  substance  of  the  organ,  and  sometimes  diflicult  to  distin- 
guisii  from  tid)ereulous  disease.  The  area  of  induration  is  harder  and  it 
ail'ects  the  body  of  the  testes,  while  tubercle  more  commonly  involves  the 
epididymis.  It  rarely  tends  to  invade  the  skin,  or  to  break  down,  soften, 
and  su})purate,  and  is  usually  painless. 

(h)  There  is  an  intcrslilial  orchitis  regarded  as  syphilitic,  which  leads 
to  fibroid  induration  of  the  gland  and  gradually  to  atrophy.  It  is  a  slow, 
[irogressive  change,  coming  on  without  paiji,  usually  involving  one  organ 
more  than  another. 

General  Diagnosis  of  Syphilis. — There  is  seldom  any  doubt 
tonccrning  the  existence  of  syphilitic  lesions.  The  negative  statements 
(if  the  patient  must  be  taken  with  extreme  caution,  as  persons  will  lie 
deliberately  with  reference  to  prinuiry  infection,  when  it  is  in  their  best 
interest  to  make  a  straightforward  truthful  statement.  It  is  to  be  remem- 
bered that  syphilis  is  common  in  the  community,  and  there  are  probably 
more  families  with  a  luetic  than  with  a  tuberculous  taint.  It  is  possible 
that  the  primary  sore  may  have  been  of  trifiing  extent,  or  urethral  and 
masked  by  a  gonorrlura,  and  the  patient  may  not  have  had  severe  secondary 
symptoms,  but  such  instance^  ire  extremely  rare.  In([uiries  should  be 
made  into  the  history  to  ascertain  if  the  patient  has  had  skin  rashes,  sore 
throat,  or  if  the  hair  has  fallen  out.  Careful  ins]icction  should  be  made 
of  the  throat  and  skin  for  signs  of  old  lesions.  Scars  in  the  groins,  the 
result  of  buboes,  may  be  taken  as  positive  evidence  of  infection  (Hutchin- 
son). The  cicatrices  on  the  legs  are  often  copper-colored,  though  this  can- 
not be  regarded  as  peculiar  to  syphilis.  The  bones  should  be  examined  for 
nodes.  In  doubtful  cases  the  scar  of  the  primary  sore  may  bo  found,  or 
there  may  be  signs  of  atrophy  or  of  hardening  of  the  testes.  In  women, 
special  stress  has  been  laid  upon  the  occurrence  of  frequent  miscarriages, 
which,  in  connection  with  other  circumstances,  are  always  suggestive. 

In  the  congenital  disease,  the  occurrence  within  the  first  three  months 
of  snuffles  and  skin  rash  is  conclusive.  Later,  the  characters  of  the  syphi- 
litic facies,  already  referred  to,  often  give  a  clew  to  the  nature  of  some 
obscure  visceral  ^esion.  Otiier  distinctive  features  are  the  symmetrical  de- 
velopment of  noaes  on  the  bones,  and  the  interstitial  keratitis. 

In  doubtful  cases  much  stress  is  laid  by  some  writers  upon  the  thera- 
peutic test,  by  placing  the  patient  upon  antisyphilitic  treatment.  In  the 
case  of  an  obstinate  skin  rash  of  doubtful  character,  which  has  resisted  all 
other  forms  of  medication,  this  has  much  greater  weight  than  in  obscure 
visceral  lesions.  I  have  on  several  occasions  known  such  marked  improve- 
ment to  follow  large  doses  of  iodide  of  potassium  that  the  diagnosis  of 
syphilitic  lesion  Mas  greatly  strengthened,  but  the  subsequent  course  and 
the  post  mortem  have  shown  that  the  disease  was  not  syphilis. 
16 


SPECIFIC  INFECTIOUS  DISEASES. 

the  social  evil  remauas  the  grea    ^^\^^^^^^^  ,f  ,j.j,hiU..    Two  meas- 
blended  uith  it  is  the  ^^^^^^^  .so  v      th^o  her  adnunistrative. 
^.res  are  available-the  one  P     "^^^^^^^^^^^  ,,,,  ^s  physicians,  arc  espe- 

Personal  purity  is  the  P^rM'^^^'^      "  '^^  ^' j^,,j  eondition  (to  some 
eially  bound  to  advocate      Contn.e  c^^^  ^^  b^^^^a  1_^  ^^^^  ^^^^^^  ^^^  ^^ 

harder  than  to  others),  but  it  can  jc  do      ,  ^^^^^^^  ^^^^^.^^      ^cr- 

les.on  upon  young  and  dd  ^vho  ^^^;"^     '^    ^^  ^^  ^.^n,  but  it  the  former 
lainly  it  is  better,  as  St.  Tau   ^^y^,  t'  "^;"^    ^^^^J^  ^.J,,,  ,,pon  which  a 
is  not  feasible  there  are  othej-  "^    ^^  ^^^^^^^^^^^^  °^^        two  of  the  five  means 
young  man  may  light  fires.    I^^\'"  ^  1' ;  ,      u'l  Panurgo,  carnal  concupis- 
by  which,  as  the  physician  ^^^"f '  "^'f  ^  ^"  ;  ,      ,f  i^.ly  and  hard  work  ot 
c  nee  may  ))e  cooled  -""l  q"^llf  "j  '^^^^        ,  ^.,J.  n,an  will  find  that 
,,i„a.    Idleness  is  the  --^^^'^^^^  Z^J  p.s^ions  which    though 
absorption  in  any  P^  ■^-^^f  \, fj^,  v  ncies  of  our  civilization  always  ob- 
natural  and  proper,  cannot  ^  t'\«  ^^'» 

tain  natural  and  proper  ff^^"^''"^^:^^  ,vstematic  regulation  of  prost.tu- 
The  second  measure  is  a  ngid  '"i;   ;^>:;';     guarding  citizens  against 
tion.     The  Btate  accepts  t^-pons^y^^^|-;^ 
small-pox  or  cholera,  but  in  ^  «k.v    ^^t  ^    yi  ^^^^  ^^^  ^^^^^^^^  ^^^^^^, 

too  complex  and  has  hitherto  baffled    o    tu  ;,    .o.^ible,  to  carry 

tion,  segregation,  and  regulation  ^^•'^^.  "  ;  ,^  ^.lo-Saxon  communities 
out  on%ire  other  hand,  P^^^^'V^^El"  V  >ile  this  feeling,  thoiigh 
at  least,  is  as  yet  f  ^^l"^  ^g'^  J.^^  n  ideration,  the  choice  lies  be- 
unrrasonable,  as  I  think,  is  "^"^itl  a  to  ^^  .videspread 

tween  two  ovilB-liconsnng^^  even  imp         tly^^^  ^^^^^  ^^^^^^^  ^  ^^^^ 

disease  and  misery.     If  the  f  !^"^''^  '^  ^^^^,,,  that  in  countless  m- 

forbear;  but  the  physician  behind  thj^^^  ^^^^^^^^^^  ^^^^         , 

stances  syphHiB  l»««.;"-«"f  ^\^\^r  uff  rin--     It  i^  for  them  he  advocates 
infants,  often  entailing  life-lon,  sutlerin„. 

protective  measures.  i    -f  +i,at  virions  constitutions  react  very 

^     Treatment.-We  miist  adn  t  tlu.^  varmns_^^^_^,^^^^^^^  ^^^^^^  ^^^ 

differently  to  the  fi^*^^°V'?orv  treatment   display  for  years  no  traces  of 
receiving  brief  and  unsatisfatorytratm^^^^^^       l^^y^  thoroughly  and  sys- 

the  disease.     On  the  ^^^^^jj^"^',^^^^^^^^^  time  to  time  show  we  1- 

tomatically  treated  from  the  outset  .o  from  ^^^    ^^^    ^^^^^^^^   ^^^   ^^^^ 

marked   indications   of   ^^P'"^''- J 'j"._%ii„htly  from  secondary  symp- 
opinion  that  persons  ^v'^oj^ave  suffered  very  si         y         ^^  ^^^^  ^^^^^ 

tims  are  more  prone  to  have  ^^    ^f  ^;;^;f  ™   „,,,t  amenable  of  all  dis- 
When  we  consider  that  syph  1         «"J  «*  ^J  ^  ,,^,^^  come  under 

eases  to  treatment,  it  -  J'-^^'^^^J^  com^^^^^^  ^"  ^''''  P''*' 

the  charge  of  the  f  y^^"^';."^      "ho  Cai^^l  with  treatment,  cannot  un- 

from  carelessness  of  the  P^^^™  ;;\^  ^^^^^m^  after  all  the  symptoms 

derstand  why  he  shou  d  cont  nue  to  tal  e^^    _  ^^  ^^^^  .^  ^^  ^^^^^^  „„ 

IStin^r  n^e!;;;^  in  eJ^^i^star^ce  that  acquired  syphilis  is  not  cured 


SYPUILIS. 


253 


!  beginning 
and  of  this 
at  sohition, 
inextricably 
Two  ineas- 

is,  arc  espe- 
on  (to  some 
to  nrge  this 
exual.     Ccr- 
i  the  former 
pon  which  a 
le  five  means 
aal  concnpis- 
lard  work  of 
will  find  that 
hich,  though 
jn  always  ob- 

1  of  prostitu- 
tizens  against 
)lem  has  been 

hantl,  inspec- 
sible,  to  carry 
1  commnnities 
eeling,  thongh 
choice  lies  be- 

or  widespread 
^  I  would  say, 
n  countless  in- 
rs  and  helpless 
n  he  advocates 

ions  react  very 
!  who,  although 
ars  no  traces  of 
nighly  and  sys- 
:imG  show  well- 
;rounds   for   the 
secondary  symp- 
E  the  later  stage. 
}nable  of  all  dis- 
hich  come  under 
ts,  in  great  part, 
nent,  cannot  nn- 
all  the  symptoms 
0  blame  for  not 
)hilis  is  not  cured 


in  a  few  months,  but  takes  at  least  two  years,  during  whicli  time  tlic  pa- 
tient sliould  1)0  under  careful  supervision.  Tiie  treatment  of  the  disease 
is  now  practically  narrowed  to  the  use  of  two  remedies,  justly  termed  spe- 
cifics— namely,  mercury  and  iodide  of  potassium.  The  f(jrmer  is  of  special 
service  in  the  secondary,  the  latter  in  the  tertiary  manifestations  of  the 
disease;  but  they  are  often  comhined  with  advantage. 

Mercury  may  be  given  by  the  mouth  in  the  form  of  gray  powder,  the 
hydrargyrum  cum  creta,  which  Hutchinson  recommends  to  be  given  in 
pills,  one-grain  doses  with  a  grain  of  Dover's  powder.  One  pill  from  four 
to  six  times  a  day  will  usually  sullice.  I  warmly  endorse  the  excellent 
results  whieh  aie  obtaiiu'd  by  this  method,  under  which  the  patient  often 
gains  rapidly  in  weight,  and  the  general  health  improves  remarkably.  It 
may  l)e  continued  for  nu)nths  without  any  ill  eU'ects.  Other  forms  given 
l)y  the  mouth  are  the  ])ilules  of  the  biniodide  (gr.  jV),  or  of  the  jjrotiodide 
(gr.  ^),  three  times  a  day.  "  If  mercury  be  begun  as  soon  as  the  state  of 
the  sore  permits  of  diagnosis,  aiul  eontinucd  in  snuill  but  adeipiate  doses, 
the  patient  will  usually  escape  both  sore  throat  and  eruption  "  (Jonathan 
llutcliinson). 

Inunction  is  a  still  more  cfTcctive  means.  A  drachm  of  the  ordinary 
mercurial  ointment  is  thoroUf^hly  rubl)ed  into  the  skin  every  evening  for 
six  days;  on  the  seventh  a  warm  bath  is  taken,  and  on  tlie  eighth  the  mer- 
curial course  is  resumed.  At  least  half  an  hour  should  be  given  to  each 
inunction.  It  is  well  to  ai)i)ly  it  at  diiferent  places  on  successive  days. 
The  sides  of  the  chest  and  abilomen  and  the  inner  surfaces  of  the  arms 
and  thighs  are  the  best  positions. 

The  mercury  may  be  given  by  direct  injection  into  the  muscles.  If 
])roper  precautions  are  taken  in  sterili/ing  the  syringe,  and  if  the  injec- 
tions are  made  into  the  muscles,  not  into  the  subcutaiieous  tissue,  abscesses 
rarely  result.  One  third  of  a  grain  of  the  bicliloride  in  twenty  drops  of 
water  may  be  injected  once  a  week,  or  from  one  to  two  grains  of  calomel  in 
glycerin  ('^!0  minii.is). 

Still  another  method,  greatly  in  vogue  in  certain  parts  of  the  Continent 
and  in  institutions,  is  fumigation.  It  may  be  carried  out  elTectively  by 
means  of  Lee's  lamp.  The  patient  sits  on  a  chair  wraiiped  in  blankets, 
with  the  head  eXj/osed.  The  calomel  is  volatilized  and  deposited  with  the 
vapor  on  the  patient's  skin.  The  process  lasts  about  twenty  minutes,  and 
the  patient  goes  to  bed  wrapped  in  blankets  without  washing  or  drying  the 
skin.  A  patient  under  mercurial  treatment  should  avoid  stimulants  and 
live  a  regular  life,  not  necessarily  abstaining  from  business.  Green  vege- 
tables and  fruit  should  not  be  taken.  Salivation  is  to  be  avoided.  The 
teeth  should  be  cleansed  twice  a  day,  and  if  the  gums  become  t"nder,  the 
breath  fetid,  or  the  tongue  swollen  and  indented,  the  drug  should  be  sus- 
pended for  a  week  vv  ten  days. 

In  congenital  sy;-)hilis  the  treatntent  of  cases  born  with  h\\\]x  and  other 
signs  of  the  disease  is  not  satisfactory,  and  the  infants  usually  die  within  a 
few  days  or  weeks.  T\u  cliild  should  be  nursed  by  the  mother  alone,  or, 
if  this  is  not  feasible,  should  be  hand-fed.  but  under  no  circumstances 
should  a  wet-nurse  be  employed.     The  child  is  most  rapidly  and  thor- 


t^ 


SPECIFIC   INFECTIOUS  DISEASES. 
„.,gMy  bro„sht  »n,lcr  tl,o  influence  ot  11,0  Jrng  1,,  immcUon     The  mor- 

of  the  biniodidc  of  mercury  (p-.  j),  of  pota.suuu  '«^\\^^*;    ^  b  •  ,  a       ^^^^ 
(  ?  ii)     Of  this  a  dose  for  a  child  under  three  is  Irom  hve  to  ten  drops  thct 
[t^.  Zy,  gradually  increased.    Vnder  these  n,ea.u.s,  ^---j  X; 
genital  syphilis  nsnally  improve   with   great   rap.d.ty.      J '^^  "/'^^^^^^^/^ 
fhould  be  continued  at  intervals  for  many  nionths,  ma  '    ^  ;  fj  *«jf  •-; 
these  patients  carefully  during  the   per.od   «f  -3/^;    f '^'"^  '"^ 
nubertv  and  if  necessary  to  ])lace  them  on  spcciiic  taatmen  . 
^     In  the  treatment  of  the  visceral  lesions  of  syphihs,  which  come  more 
distinct!    wmnn  the  province  of  the  physician,  iodi  e  ^J^^^^ 
cuual  or  even  greater  value  than  mercury.     Under  its  use  "'^ers  rapmiy 
heal   gt  mmatous  tumors  melt  away,  and  we  have  an  illustration  of  a  spe- 
cm  'a'    ronly  equalled  by  that  of  mercury  in  the  secon  ary  s  ages   b> 

iron  in  certainVms  "^  --";;^ ^  ^.^j^'-^J  ^ll^^  ^Uhe^^^^^^ 

rule  well  borne  m  an  initial  dose  of  10  grains,  or  w  min  m 

solution-  given  in  milk  the  patient  does  not  notice  the  taste.     It  snoiUQ 

""t^  %^m.  4p.tit.  i«  ...e*^  t.,e  «---;«  r^^^ 

r'^^vlrim  Tirirotr  '£)  »f  „  "nneniiitaH.  .nd  ^,«ill» -" 
Niemcyerj  pill  (as  it  "^  o"™  ,  recurring  ascites,  on  whom 

wmmmm 

mmmmmB 

diScrreeable  effects.    Skin  eruptions  also  are  frequent.    I  Ime  knmvn  pa 

-™  ?'^  '"i^n  «;:".:l"'^.^r;ioT:n;':he"^or:Iit'^r 

^;  ''Thrit  Bh-W  ifhotn^n  nrind,  is  the  earliest  possiUc  limit,  and 


GONORRHCEAL  INFECTION. 


255 


The  mer- 
not  a  very 
iiother.     It 
ay  powder, 
ciated  ^vith 
um  is  most 
it'll  consists 
,  and  water 
drops  three 
ases  of  con- 
medication 
ell  to  watch 
ion  and   at 

come  more 
assium  is  of 
cers  rapidly 
on  of  a  spe- 
•y  stages,  by 
,     It  is  as  a 
ihe  saturated 
!.     It  should 
In  syphilis 
Seguin,  who 
lat  tho  drug 
jderate  doses, 
mercury  and 
Addison's  or 
d  squills  will 
tes,  on  whom 
'd  and  irregu- 
intermissions, 
ropsy  and  an 
dly  the  iodide 
m.     It  is  less 
cuts  possess  a 
jorne.    Severe 
most  common 
ive  known  pa- 
hout  suffering 
icne  eruption, 
irjuira.     Some 
[utchinson  has 

y  physician  is 
ty  of  two  full 
acting  of  mar- 
iible  limit,  and 


there  should  be  at  least  a  year  of  comi)lete  immunity  from  all  manifesta- 
tions of  the  disease. 

In  relation  to  life  insurance,  an  individual  with  syphilis  cannot  be  re- 
garded as  a  lirst-class  risk  unless  he  can  furnish  evidence  of  prolonged  and 
thorough  treatment  and  of  immunity  for  two  or  three  years  from  all  mani- 
festations. Even  then,  when  we  consider  the  e.xtraordimiry  frcciuency  of 
the  cerebral  and  other  com]rlications  in  persons  who  have  had  this  disease 
and  who  may  even  have  undergone  thorough  treatment,  the  risk  to  the 
company  is  certainly  increased. 


XXXIII.    GONORRHCEAL    INFECTION. 

Gonorrhoea,  one  of  the  most  widespread  and  serious  of  infectious  dis- 
eases, presents  many  features  for  consideration.  As  a  cause  of  ill-health 
and  disability  the  gonococcus  occupies  a  position  of  the  very  first  rank 
among  its  fellows.  While  the  local  lesion  is  too  often  thought  to  be  trilling, 
in  its  singular  obstinacy,  in  the  possibilities  of  permanent  sexual  damage 
to  the  individual  himself  and  .still  more  in  the  "grisly  troop"  which  may 
follow  in  its  train,  gonorrhceal  infection  does  not  far  very  far  short  of 
syphilis  in  importance. 

The  immediate  and  remote  effects  of  the  gonococcus  may  be  considered 
under — 

I.  The  primary  infection. 

II.  The  spread  in  the  genito-urinary  organs  by  direct  continuity  of 
surface. 

III.  Systemic  gonorrhceal  infection. 

I.  The  primary  lesion  wc  need  not  here  consider,  but  we  may  call 
attention  to  the  frequency  of  the  complications,  such  as  periurethral  ab- 
scess, gonorrhceal  prostatitis  in  the  male,  and  vaginitis,  endocervicitis,  and 
inflammation  of  the  glands  of  Bartholini  in  the  Icmale. 

II.  Perhaps  the  most  serious  of  all  the  sequels  of  gonorrhoea  are  those 
which  result  from  the  spread  by  direct  continuity  of  tissues,  particularly 
in  women,  in  whom  gonorrhceal  sali)ingitis  lias  been  shown  to  be  a  not 
infrequent  event.  I\[etritis  and  ovaritis  are  also  occasionally  met  with, 
and  peritonitis,  due  to  the  escape  of  pus  from  the  Fallopian  tubes,  has  been 
described.  Equally  important  is  the  development  of  cystitis,  which  is 
probably  much  more  frecpiently  the  result  of  a  mi.Kcd  infection  than  due 
to  the  gonococcus  itself.  A  great  risk  is  the  extension  upward  through 
the  ureters  to  the  kidneys.  The  pyelitis,  like  the  cystitis,  is  usually  a 
mixed  infection. 

III.  Systemic  Go\oRmi(EAL  Ixfectiox. 

1.  Gonorrhwal  Septiccemia  and  Pycvmia. — The  fever  associated  with  the 
primary  disease  is  not  an  indication  of  a  general  infection,  but  probably 
follows  the  absorption  of  tnxines.  The  presence  of  the  gonococcus  has 
been  demonstrated  in  the  blood  in  a  few  cases,  usually  in  connection  with 
some  local  lesion,  as  in  Thayer's  and  Blumer's  case  from  my  wards,  in 


I 


I 


Qgg  SPECIFIC  INFECTIOUS  DISEASES. 

vvhich  the  pationt  smcu.nl.od  to  an  acute  endocarditis.     Instances  of  se- 
:;;  ra^dly   fatal   genend    infection   in   g--rluca  are   p.^.    y   al.     s 
asso dated  with  foci  of  suppuration  in  tlu^  ur.nary  tract     '    ^■'^\«";3 ^ 
in  Montreal  on  a  reniarkal.le  case  of  rapid  gonorrlueal  seps.    in  a  jou.fe. 
an     vlH,  within  ten  days  of  the  primary  lesion  was  seized  with  se.eie 
S;  Ir  d  high  fever.    He  rapidly  hecan.e  unconscious   the  1--  ^-^^.d^ 
and  he  fell  into  a  condition  of  profov.nd  toxa-nua  and  died  early  on  the 
norn  n.*o    the  fourth  day  from  the  chill.    At  the  autopsy,  which  was  xnad 
^iri^elve  hours  after  death,  there  was  an  acute  "-f '  ^  ^^^^.^'^ 
prostatic  ahscess  not  more  than  '•  or  3  cm.  m  diameter.     Ihe  hlood  Nvas 
S      rr    hlack,  and  unlike  anything  I  have  ever  seen  hc^fore  or  since 

.„on/»<v.?  lhulorardilis.-\l.  L.  MacDonnell  found  4  cases  of  endo- 
onrdm^    n  27  instances  of  gonorrh.val  arthritis.     Two  renmrknl)le  case 
hat  le  n     Jp  ^te       ron.  n^y  wards  lately  hy  Thayer  and  lUumer  and 
Tlnve    and  liear.    Thcv  are  of  special  interest,  as  in  hoth  the  gonococc. 
w  re     o  r  d  trom  the  hlood  during  life  and  after  death    rom    he  afTected 
Z^Xvov  and  Lazear  have  analyzed  30  instances  of  fatal  uleera^.v 
InLrditis  in  gonorrlnea.    Of  these,  23  were  in  men,  8  m  women.    As  a 
rnir  he  Arthritis  preceded  the  cardiac  affection,  hut  in  a  nnmher  of  in- 
2te^thfc'"diac^oluplieation  occurred  without  or  hefore  the  develop- 

""o/'Sf cSZcT:ions,  pericarditis  occiirred  in  7  of  the  fatal  cases. 
Apiite  nivocarditis  was  present  in  Councilman  s  case. 

^"o  G  rLal  ArlluUis.-^n  many  respects  this  is  the  -ost  damaging 
di^ahling  and  serious  of  all  the  complications  of  gonorrhc«a.  It  not  on  y 
omr  1    he  adult,  hut  in  children  after  the  gonorrhceal  '^•^"^""^tmt  . 

Tt     ccur    more  frequently  in  nuiles  than  in  females.     In  a  series  o    2oi 
It  occuis  moic  iii-4ii^""j  .         „i„,.   nn  nnaoe  wore  hetweeu 

twenty  and  t  "^ty  jears  o   :^^  ^,^^,^.^  ^^.^^^  ^  ^^^^^hral  discharge 

of  gonori  uca.     In  .U8  ol  ^^«^^^  1^  ^^^^^^.^      ,,  ,,,,,  ,,i,en  it  has 

while  in  hospital.  It  ^J  ^l^^^^^";;,,^.^;,  ,f  ..^t  intensity  may  develop 
become  chronic.  A  S""""';*; '\,7^ '"\„  „ia  „leet  in  her  husband.  As  a 
in  a  newly  married  --"-"ted  in  ^  nthrVs  ories  three  or  more  joints 
rule,  many  jomts  are  affected.     Jn  ^"^^"["l'  j    j      ^^^^^j^,  j,,  attack- 

were  afTected  -  1^5  case,  one  pu  t^  n  ^  ^^  ^,^ 

Z:::^^^:  ^^^^^  ^^-   tcmporo-maxmary   and   sacro- 

the  ^l^"-^t"f;  , V£^;^;^  "  I   la    b    n  suggested  that  the  simple  arthritis 

'•"""  " -tiT  iollt-s  a  "oration  of  ptomaines  from  the  urethral  discharge, 
or  synovitis  follov\s  «'  ^"^    "        \  ^^^^^  to  infection  with  pus  or- 

^^■'"'  '''  '^:^^::^^^^^^y^o:-  that  the  gonococcus  itself  may 
ganisms.    I    has  "?^^    '^  ^.™"  '  /  ;„  the  peri-arthritic  exudate.     Within 


GONORRIICEAL  INFECTION. 


257 


ices  of  se- 
jly  always 
m  avitoi>sy 
n  a  young 
dth  severe 
r  ])ersisted, 
rlv  on  the 
1  was  made 
nd  a  small 
blood  was 
ir  since. 
's  of  cndo- 
knble  casus 
Uumor  and 
e  gonococc'i 
the  affected 
.1  ulcerative 
•men.    As  a 
inber  of  in- 
lie  develop- 

fatal  cases. 

,t  damaging, 
It  not  only 
mjunctivitis. 
cries  of  252 
■ere  between 
acute  attack 
ral  discharge 
I  when  it  has 
may  develop 
sband.    As  a 
•  more  joints 
lar  in  attack- 
atism.  as  the 
{    and   sacro- 

is  often  peri- 
i'hen  effusion 
ire  commonly 
uration  some- 
mple  arthritis 
ral  discharge, 
I  with  pus  or- 
CU8  itself  may 
date.  Within 
s  in  pure  cul- 


ture in  7  ca^^cs  of  gonorrlueal  arthritis  in  the  Johns  Hopkins  Ilosiutiil. 
Soiuetimes  the  cultures  an-  lU'gative;  in  other  instanci's  there  is  a  mixed 
infection  with  stapliylococci  or  streptococci. 

Clinical  Course.— Variability  and  obstinacy  are  tlie  two  most  dis- 
tinguishing features.    Tlie  foUowiiig  are  the  most  important  clinical  forms: 

{a)  Arlliralijic,  in  which  there  are  wandering  pains  about  the  joints, 
without  redness  or  swelling.    These  persist  for  a  Icng  time. 

{h)  rah/aiihrilir,  in  which  several  joints  become  alfected,  just  as  in 
subacute  articular  rheumatism.  The  fever  is  slight;  the  local  iuUamma- 
tion  may  fix  itself  in  one  joint,  but  more  commonly  several  become  swollen 
and  tender.    In  this  form  cerebral  and  cardiac  complications  may  occur. 

(r)  Acule  (luiion-limil  arlliritit>,  in  which  a  single  articulation  becomes 
suddenly  involved.  The  pain  is  severe,  the  swelling  extensive,  and  due 
chiefly  to  i>eri-articular  a'dema.  The  general  fever  is  not  at  all  proportion- 
ate to  the  intensity  of  the  local  signs.  The  exudate  usually  resolves, 
though  su[i[iuration  occasionally  supervenes. 

{(I)  Chiviiir  Jfi/drarlliimis.—'ThU  is  usually  mono-articular,  and  is  par- 
ticularly  apt  to  involve  the  knee.  It  comes  on  often  without  pain,  redness, 
or  swelling.  Fornuition  of  pus  is  rare.  It  occurred  only  twice  in  \)G  cases 
tabulated  by  Xolen. 

{(■)  Bursal  and  Synovial  Fi^rw.— This  attacks  chiefly  the  tendons  and 
their  sheaths  and  the  bursiu  and  the  periosteum.  The  articulations  may 
not  be  affected.  The  bursa;  of  the  patella,  the  olecranon,  and  the  tcndo 
Achillis  are  most  apt  to  be  involved. 

(/■)  Scpticcrmic. — In  which  with  an  acute  arthritis  the  gonococci  invade 
the  blood,  and  the  picture  is  that  of  an  intense  septico-pyannia,  usually 
with  endocarditis. 

The  disease  is  much  more  intractable  than  ordinary  rlicumatism,  and 
relapses  are  extremely  common.    It  may  become  chronic  and  last  for  years. 

Complications. — Iritis  is  not  infreciuent  and  may  recur  with  suc- 
cessive attacks.  The  visceral  complications  are  rare.  Endocarditis,  peri- 
carditis, and  pleurisy  may  occur. 

Treatment. — The  salicylates  are  of  very  little  service,  nor  do  they 
often  relieve  the  pains  in  this  affection.  Iodide  of  potassium  has  also  proved 
useless  in  my  hands,  even  in  large  doses.  A  general  tonic  treatnient  seems 
much  more  suitable — (punine,  iron,  and,  in  the  chronic  cases,  arsenic. 

The  local  treatment  of  the  joints  is  very  important.  The  thermo- 
cautery may  be  used  to  allay  the  pain  and  reduce  the  swelling.  In  acute 
cases,  fixation  of  the  joints  is  very  beneficial,  and  in  the  chronic  forms, 
massage  and  passive  motion.  I  have  seen  very  good  results  follow  in  a  few 
cases  the  use  of  the  dry  hot  air.  The  surgical  treatment  of  this  affection, 
as  carried  out  nowadays,  is  more  satisfactory,  and  I  have  seen  strikingly 
good  effects  from  incision  and  irrigation. 


V 

i; 


258 


SPECIFIC  INFECTIOUS,  DISEASES. 


XXXIV.   TUBERCULOSIS. 

I.  Gkn'kual  Etiology  and  Morbid  Anatomy. 

Definition.— An  infective  disease,  caused  by  tlie  bacillus  tuhcrculosis, 
the  lesions  of  wliieli  are  clmracterized  by  nodular  bodies  called  tubercles 
or  diffuse  infiltrations  of  tul)erculou9  tissue  wliicli  undergo  caseation  or 
sclerosis  and  may  linally  ulcerate,  or  in  sonic  situations  calcify. 

Etiology.— 1.  Zoological  Distribution.— Tuberculosis  is  one  of  the 
most  widesjjread  of  maladies. 

In  cold-blooded  animals  it  is  rare,  owing  doubtless  to  temperature  con- 
ditions unfavorable  to  tlie  development  of  the  bacillus.  Among  reptiles 
in  confinement  it  is,  however,  occasionally  seen  (Sibley).  In  fowls  it  is  an 
extremely  common  disease,  but  there  are  differences  in  avian  tuberculosis 
sufficient  to  warrant  its  separation  from  the  ordinary  form. 

Among  domestic  animals  tuberculosis  is  widely  but  unevenly  distrili- 
uted.  Among  ruminants,  bovines  are  chieily  all'ected.  The  percentage 
for  oxen  and  cows  at  the  Berlin  abattoir  in  the  year  18!)'i-'t)3  was  15.1.  In 
this  country  much  has  been  done,  particularly  in  Massachusetts  and  Penn- 
sylvania, to  determine  the  presence  of  the  disease  in  the  dairy  herds,  for 
which  purpose  the  tuberculin  test  has  been  extensively  employed.  The 
results  show  a  widespread  prevalence  of  the  disease. 

Of  r),2!)7  cattle  slaughtered  in  Maryland  only  159  were  tuberculous 
(A.  W.  Clement).  Of  15,500  slaughtered  at  the  Brighton  abattoir,  Boston, 
only  29  were  tuberculous  (A.  Burr).  The  tuberculin  test  has  shown  in 
some  places  a  percentage  of  from  15  to  30. 

In  sheep  the  disease  is  very  rare.  In  pigs  it  is  common,  but  not  so 
common  in  this  country  as  in  Europe.  In  the  inspection  of  1,000  hogs, 
wiiich  was  made  by  A.  W.  Clement  and  myself  in  ]\Iontreal  in  ISSO,  tuber- 
culosis was  seen  only  once  or  twice.  At  the  Berlin  abattoir  in  188r-"88 
there  were  (i,393  jiigs  affected  with  the  disease. 

Horses  are  rarely  attacked.  Dogs  and  cats  are  not  prone  to  the  disease, 
but  cases  arc  described  in  which  infection  of  pet  animals  has  taken  place 
from  phthisical  masters.  Among  the  semi-domestic  animals,  such  as  the 
rabbit  and  guinea-pig,  the  disease  under  natural  conditions  is  rare,  al- 
though these  animals,  particularly  the  latter,  are  extremely  susceptible  to 
the  disease  wbcii  inoculated.  Among  ajies  and  monkeys  in  the  wild  state, 
tuberculosis  is  unknown,  but  in  confinement  it  is  the  most  formidable  dis- 
ease with  which  they  have  to  contend. 

The  important  etiological  fact  in  connection  with  tuberculosis  in  ani- 
mals is  the  widespread  occurrence  of  the  disease  in  bovines,  from  which 
class  we  derive  nearly  all  the  milk  and  a  very  large  proportion  of  the  meat 

used  for  food. 

2.  General  Statistics  of  the  Disease  in  Man.— Tuberculosis  is  the  most 
universal  scourge  of  the  human  race.  It  prevails  more  ])articularly  in  the 
large  cities  and  wherever  the  poinilation  is  massed  together.  One  seventh 
of  all  deaths  are  due  to  it.  In  the  United  States  Census  Report  for  1890, 
102,188  deaths  M-ere  reported  to  be  due  to  consumption.     At  a  low  esti- 


I 


TUBERCULOSIS. 


250 


uhercidosis, 
1  tubercles 
iseation  or 

iiie   of  the 

rature  coii- 
ng  reptiles 
ivls  it  is  an 
ubereulosis 

ily  distrib- 
perccntage 
IS  15.1.  In 
and  Ponn- 
hcrds,  for 
lyed.     The 

tuberculous 
jir,  Boston, 
s  shown  in 

but  not  so 
1,000  hogs, 
1880,  tuber- 
n  188:-88 

the  distase, 
taken  place 
such  as  the 
is  rare,  al- 
sceptible  to 
3  wild  state, 
:iiidable  dis- 

losis  in  ani- 
from  wliieh 
of  the  meat 

is  the  most 
ilarly  in  the 
One  seventh 
rt  for  1890. 
a  low  esti- 


mate one  can  say  that  at  least  ITiO.OOO  persons  die  annually  in  the  United 
States  of  sonu!  form  of  tuberculosis.  An  estimation  based  on  tiie  Census 
Kcport  gives  the  total  number  of  persons  in  this  country  infected  witii 
tuljcrculosis  as  l,or)0,000,  or  1  in  every  (JO  of  the  jxipulation  (Vaughan). 

Geographical  posilion  has  very  little  inlluence.     The  disease  is  perliaps 
more  ])revalent  in  the  temi)crate  regions  than  in  the  tropics,  but  altitude- 
is  a  more  potent  factor  than  latitude;  in  tlie  high  regions  of  the  Alps  ami 
Andes  and  in  the  central  plateau  of  Mexico  the  death-rate  from  tubercu- 
losis is  very  low. 

The  in/lueiire  of  race,  which  has  l)ecn  much  studied,  is  probaldy  less 
owing  to  any  inherent  ditTerences  than  to  the  conditions  under  which  the 
individuals  live.  The  Indians  of  this  continent  are  very  ])rone  to  the  dis- 
ea.'se.  Matthews  states  that  the  death-rate  in  the  older  reservations  in  the 
East  was  three  times  as  great  as  that  of  the  Indians  still  living  in  the 
Northwest.  In  tiiis  country  the  Irish  and  the  iu>grocs  apjiear  specially 
prone  to  the  disease;  on  the  other  hand,  the  Hebrews  possess  a  relative 
immunity.  For  the  six  years  ending  May  31,  1890,  the  average  annual 
death-rate  from  consum])tion  in  New  York  city  ])er  100,000  of  po|)idation 
was:  For  the  Irish,  (Jl.j.T3;  for  the  colored,  531.35;  for  tlio  (jcrinans, 
3"^8.80;  for  tlie  American  whites,  205.11;  and  for  the  Ilussian-Polish  Jews, 
76.72  (J.  S.  Billing.s). 

The  Decrease  of  Tiihercvlosis. — E.  F.  "Wells,  who  has  tabulated  an  im- 
mense body  of  statistics  on  this  subject,  states  that  the  evidence  is  in  favor 
of  a  very  positive  decline  in  the  prevalence  of  the  disease.  While  the  last 
decennial  census  of  the  United  States  does  not  show  any  decrease,  yet  in 
nuiny  of  the  larger  cities  there  has  been  a  striking  diminution.  The  question 
has  been  considered  very  carefully  by  James  B.  Russell,  of  Glasgow,  in  his 
Sanitary  History  of  that  city.  One  or  two  of  the  sentences  from  his  report 
may  be  quoted  witli  advantage:  "  Between  the  five  years  ISTO-'Tl  and  tiie 
five  years  1890-'94  llurc  was  a  decrease  of  41  per  cent  in  the  death-rate. 
If  we  start  from  the  maximum  ])eriod  of  fatality  (18n0-'01).  the  decrease 
amounts  to  44  per  cent.  The  acce])tance  of  the  doctrine  that  every  case 
of  phthisis  is  the  result  of  a  specific  infection — that,  consequently,  no  one 
is  foredoomed  to  have  phthisis  or  any  other  form  of  tul)erculous  disease — 
gives  great  jn'ccision  to  our  ideas  of  prevention."  He  attributes  a  good  deal 
to  the  difTusion  of  the  knowledge  that  the  existence  and  distribution  of  the 
tuljcrcle  bacillus  is  tlie  first  condition  of  infection,  and  also  to  the  success- 
fid  administrative  ciTorts  in  securing  "ventilation,  especially  of  houses  and 
byres;  tlie  removal  of  dampness  by  subsoil  drainage  and  precautions  adapted 
to  the  foundations  and  walls  of  houses;  the  abolition  of  dark  spaces  and 
inclosures;  the  dissemination  of  direct  sunlight." 

The  diminution  of  pulmonary  tubercidosis  in  ^Massachusetts  is  remark- 
able, the  death-rate  having  fallen  from  42  per  10,000  inhabitants  in  1853 
to  21.8  per  10,000  in  1895.  A  remarkable  reduction  has  also  taken  place  in 
New  York. 

3.  The  Bacillus  Tuberculosis. — The  history  of  tlie  discovery  of  the 
bacillus  presents  many  points  of  interest.  Confidently  expected  by  such 
observers  as  Villemin,  Chauvcau,  Cohnheim,  and  others,  and  claimed  to 


2C0 


SPECIFIC  INFECTIOUS  DISEASES. 


! 


! 


havo  l)i>on  (Icinonstratfd  hy  many,  notably  l-y  Klebs  and  Aufrccht,  it  rc- 
iiiaiiUMl  for  Koch  to  dt'inonstiato  its  oxi^tonce  and  its  invariable  association 
with  the  disi'aso.  The  invc8tij,'atioiis  wliidi  ho  had  i)rc>viously  made  upon 
anthrax  and  oxporinK'ntal  traumatic  inl'cctions,  l)y  perfecting  the  methods 
of  research,  jiaved  the  way  for  this  brilliant  discovery.  His  preliminary 
article  *  and  his  more  elaborate  later  work  f  sh(.uld  be  carefully  studieil  by 
any  one  who  wislies  to  ai)i)reciate  the  value  of  scientilie  methods,  it  forms 
one  of  the  most  masterly  demonstrations  of  modern  medicine.  Its  thor- 
oughness appears  in  the  fact  that  in  the  years  which  have  elapsed  since  its 
appearance  the  innumerable  workers  on  the  sul)ject  havo  not,  so  far  as 
1  know,  added  a  solitary  essential  fact  to  those  presented  by  Koch. 

Morphuhqical  Characters.— The  tubercle  bacillus  occurs  usually  as  a 
short,  lino  rod,  often  slightly  bent  or  curved,  and  has  an  average  length  of 
nearly  half  the  diameter  of  a  red  blood-corpuscle  (3  to  4  /a);  more  rarely  it 
shows  lateral  outgrowths  or  simple  branches.  When  stained  it  often  presents 
a  beaded  aiipearance,  which  some  havo  attributed  to  tlic  presence  of  spores. 
With  the  basic  aniline  dyes  it  stains  slowly,  except  at  the  body  tem- 
perature, but  retains  the  dye  after  treatment  with  acids— a  characteristic 
which  separates  it  from  all  other  known  forms  of  bacteria,  with  the  excep- 
tion of  the  bacillus  of  leprosy. 

Modes  of  (trotrlh.— It  grows  on  blood-sorum,  glycerin-agar,  boudlon,  or 
on  potato— most  readily  «,ii  the  first.  The  cultures  must  be  kept  at  blood- 
heat.  They  grow  slowb,  and  do  not  a])pear  until  about  the  end  of  the 
second  week.  The  coloiiies  form  thin,  grayish-white,  dry,  scale-like  masses 
on  the  surface  of  the  culture  medium.  Successive  inoculations  may  be 
made  from  the  cultures,  and  at  the  end  of  an  indefinite  series  material 
from  one  of  them  inoculated  into  a  guinea-pig  will  produce  tuberculosis. 

Variations.— (a)  In  Form.— The  small  branching  forms  are  found  not 
infrecjuontly  in  tuberculous  lesions.  Some  investigators  claim  to  have  pro- 
duced more  complex  structures,  resembling  the  "  driisen  "  of  the  actino- 

myces. 

(h)  In  Ytnilcnce. — Koch  Mas  of  the  ojjinion  that  tubercle  bacilli  from 
various  sources  possess  the  same  degree  of  virulence.  Theobald  Smith  has 
found  cultures  of  bovine  tuberculosis  more  highly  virulent  for  rabbits 
than  cultures  of  sputum  bacilli.  The  morphology  of  the  organisms  from 
the  two  sources  was  also  different.  Arloing  and  his  students  have  long 
claimed  that  material  from  scrofula  and  bone  tuberculosis  is  less  virulent 
than  from  other  varieties  of  human  tuberculosis. 

The  bacillus  tuberculosis  avium  tends  to  appear  in  more  irregular 
forms,  grows  more  readily  and  more  rapidly  in  artificial  cultures,  and  is 
more  resistant  to  age  and  high  temperature,  and,  while  highly  pathogenic 
for  the  hen,  produces  only  local  inflammatory  processes  in  mammals.  It 
is  probable  that  infection  with  avian  tuberculosis  sometimes  occurs  in  man 

(Pausini).  .    ,    , 

Products  of  the  G rouih. —Liiilc  is  yet  known  of  the  chemical  charac- 


*  Berliner  klinische  Woclicnsehritt,  1882. 

f  Mittheilungcn  a.  il.  k.  Gesundheitsamte,  Bd.  2. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


1.0 


I.I 


1.25 


■-IM 



•IT  iia 


u 


|||M 
2.0 

1.6 


Photographic 
Sciences 
brporation 


C 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


-b 


•N? 


\ 


iV 


\\ 


■'''^^ 


fv 


4^ 


'(O 


"^^ 


^ 


&? 


i/-l 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  canadien  de  microreproductions  historiques 


•■■■J*: 


-  - 


TUBERCULOSIS. 


2C,l 


ters  of  tho  nialcri.ils  wliioh  result  from  ilic  ;:n)\vtli  of  tjio  IuIhtcIo  bacilli. 
Koch'ti  tiilicrciiliii  is  stnti'd  to  lie  a  -iyci'rin  extract  of  tlic  cuitiiivs.  Ciook- 
sliank  and  lliTroiiii  have  scpai^atcd  an  alluiniosc  and  a  |it(>niaitu'. 

JJislrihiilii.il  <.f  l/w  J!,irilli.—T\n-  liacilli  air  found  in  all  tuheividous 
lesions;  in  sonu'  in  nn.„t  abuiulaiiee,  in  others  sparsely.  Tlicv  are  par- 
ticularly numerous  in  actively  developin<:  tubercles,  liut  in  the  chronic 
tuberculous  ])roce.sses  (d'  lympli-^dands  aiul  of  the  joints  they  are  scant  v. 
When  !•  tuberculous  focus  communicates  with  a  vein  or  witli  Ivmph-ves- 
sels,  the  bacilli  may  lie  spread  widely  throu;,diout  the  body.  In  old  lesions 
they  may  not  be  found  in  the  sections,  and  the  demonstration  (d'  the  true 
nature  nny  be  possible  only  by  culture  or  inoculation. 

The    lliicilli    outside    liie    V^w///.— J'atients    with    advanced    |iulnumary 
tubeivulosis  throw  oil'  in  the  expectoration  countless  nnllions  of  the  bacilli 
daily.     Some  idea  of  the  extraordinary  uundjers  may  be  jjained   fnun  the 
studies  of  Xuttall.      From   a   jiatient   with   moderately   a<!van<'e(l   disease, 
the  amount  of  wluxso  expectoration  was  from  70  to  ];iO  cc.  dailv,  he  esti- 
mated by  his  method  that  there  were  in  si.xteen  counts,  between  dannary 
Kith  and  .March  1st,  from  one  and  a  half  to  four  and  a  third  billions  of 
bacilli  thrown  off  in  the  twenty-four  hours.     These  fi,<,nires  emphasize  the 
danger  a.ssociated  with  phthisical  s])uta  unless  most  carefully  dealt  with. 
AVhen  expectorated  and  allowed  to  dry,  the  si)utum  rapidly  beconu's  dust, 
and  is  distrilnded  far  and  wide.     'J1ie  observations  nuule  by  t'ornet  under 
Koch's  supervision  are  in  this  connection  most  instructive^.     He  collected 
the  dust  from  the  walls  and  bedsteads  of  various  localities,  and  determined 
its   virulence   or   inuocuousiu'ss   by    iiuiculation    into   susceptible   animals. 
Material  was  gathered  from  'U  wards  of  7  hos|)itals,  3  asylum.*,  2  prisons, 
from  the  surroundings  of  (;•.>  iihthisical  ].atients  in  ])rivate  practice,  aiul 
from  2!»  other  localities  in  which  tuberculous  ])atients  were  only  transient 
frequenters  (out-i)atie!it  dejiartments,  streets,  etc.).     Of  118  diist  sami)les 
from  hospital  wards  or  the  rooms  of  ])hthisical  patients,   10  were  infective 
and  produced  tuberculosis.     Xegative  results  were  obtained   with   the  3!) 
dust  samjdes  from  tlie  localities  occasionally  occu])ied    by  consum|)tives. 
Virulent  bacilli  were  obtained  from  the  dust"  of  the  walls  of  1,-)  out  of  '.'! 
medical  wards.    It  is  interesting  to  note  that  in  2  wards  with  manv  phthis- 
ical patients  the  results  were  negative,   indicating  that  the  dust'  in  such 
regions  is  not  necessarily  infective.     The  infectiousness  of  the  dust  of  the 
medical  and  surgical  divisions  of  a  hospital  is  in  the  i.ioportion  of  TH.fi  to 
12.5.     In  a  room  in  which  a  tuberculous  woman  had  lived  the  dust  from 
the  wall  in  the  neighborhood  of  the  bed  was  infective  six  weeks  after  her 
death.     Xo  bacilli  were  found  in  the  dust  of  an  inhabit ion-chaud.er  for 
eonsum])tives.     The  exi)eriments  of  Strauss  at  the  Charite  Hospital,  Paris, 
are  imjMirtant.     In  the  nostrils  of  2!)  assistants,  nurses,  and  ward-tenders 
he  ]daeed  ]dugs  of  cotton-wool  to  collect  the  dust  of  the  wards.     In  !)  of 
the  29  cases  these  contained  tubercle  bacilli  and  proved  infective  to  ani- 
mals.    The  question  of  the  increase  of  tuberculosis  among  the  permatu'iit 
residents  of  health   resorts  frecjuented   l)y  eonsum])tives   is  one   of  great 
interest.      Gardiner   has   studied    the    problem    at    Colorado    Springr,    in 
which  for  twenty  years  tuberculous  patients   have  been   livinl^  and   he 


SPECIFIC  INFECTIOUS  DISEASES, 


202 

finds  tlie  nnmhov  of  Ciis.v  of  tulicrcnlosis  ori-iiiatinp  in  tlio  fity  In  he  very 

i^inail. 

J'snidn-hthvrnilosis.-WhlU'  lesions  irscnililiiif,'  tlu>  n..<lul.s  of  tubercu- 
losis, l)iit  duo  to  a  variety  of  l)a.tcria,  proto/oa.  aiul  ncniatodos,  avo  not  un- 
coininon  in  animals,  ].soudo-1niKT(  iiions  prnccsscs  are  very  rare  m  human 
l.ein;.'s.  Flexncr  *  lias  (ieseribed,  under  tiu'  nauu'  pseu(lo-hi()erculosi.f 
hoinhnx  shrphillirira,  a  eondition  in  human  beings  in  whieh  the  lungs  pre- 
sented the  apjiearance  of  a  caseous  pneumonia  and  numerous  tuijcrclc-hkc 
nodules  existed  in  the  iK'rit(ma'nm.  The  micro-organism  round  in  the 
lesions  was  a  streptothrix,  which  dilfcred  greatly  from  the  known  forms 
of  the  liacillus  tu!>ercu!osis  and  streptothrix  actinomyccs. 

4.  Modes  of  Infection.— («)  Jlcmlihtry  T mnsm is.-iim,.— The  i)ossil)U' 
methods  of  transmission  of  the  germ  in  direct  inheritance  are  three- 
transmission  by  the  sperm,  transmission  by  the  ovum,  and  transmission 
through  the  blood  by  means  of  the  ])lacentci. 

There  is  no  cliniCal  evidence  to  support  the  view  that  direct  transmis- 
sion can  occur  through  the  sperm.  In  order  that  the  disease  could  be  trans- 
mitted bv  the  s].erm  it  would  be  necessary  that  tiie  tubercle  hacilli  should 
lodge  in"  the  individual  sjn'rmatozoon  which  fecuiidati's  the  ovum.  The 
chances  that  such  a  thing  could  occur  are  extremely  small,  looking  at  the 
snl)iect  from  a  numerical  point  of  view,  although  we  know  that  tuheri  le 
hacilli  do  occasionally  exist  in  the  semen;  tlu'y  become  still  smaller  when 
wo  consider  that  the"  spermatozoiiu  is  made  up  of  nuclear  material,  which 
the  tubercle  bacillus  is  never  known  to  attack.  Experimentation  is  all 
..pi)osed  to  sperm  transmis^ion,  the  work  of  Gartner  and  others  showing 
that  the  voiuu'  of  health v  female  rahhits  imi)regnated  l)y  tuherculous  males 
are  never  tuberculous,  eVeii  though  the  females  themselves  often  contract 

the  disease.  .    i      i> 

The  p(w<ibilitv  of  transmission  bv  the  ovum  must  he  acceptc(L  l.anm- 
oarten  has  in  one  instance  been  able  to  detect  the  tnl>ercle  bacillus  m  the 
mum  of  a  female  rahhit  which  he  had  artificially  fecundated  with  tuhercu- 
l.uis  <enien  The  work  of  rasteur  on  pihrine  has  shown  the  i)ossibility  ol 
this  form  of  transmissi.m  in  the  lower  lorms,  though  the  .picstion  as  to 
what  elfeet  such  inoculation  would  have  upon  the  human  ovum  cannot  ()i 

course  be  answereil.  ...  ..   , 

I'robablv  the  almost  constant  method  of  transmission  in  congenital 
tnherculosi.i  is  Ihnuiiih  the  hlood  current,  the  tubercle  bacilli  penetrating 
bv  wav  of  the  placenta.  Certain  authors  hold  that  in  these  cases  the  pla- 
(..Miti'it-clf  is  invariablv  the  seat  of  tuberculosis,  and  tubercles,  indeed, 
have  been  demonstrated 'in  several  cases;  but  there  are  undoubted  instances 
in  which,  with  an  ai.paivntly  sound  placenta,  both  the  placental  1'  ""<1  a"' 
tli.>  betal  organs  contained  tubercle  bacilli,  notwithstanding  the  lact  that 
the  organs  also  aiipeared  normal. 

7Vs-.,7;/f'  J.nlrnni  of  Ihr  Tiihnrlr  ^,Vm,s^— r.aumgarteii  and  his  followers 
,n.«ume  that  the  tubercle  l>acilli  can  lie  latent  in  the  tissues  and  subse- 
(pienllv  develop  when,  for  some  reason  or  other,  the  individual  resistance 


'  Journal  of  E.xporiincntal  Medicine,  1893. 


■;\- 


TunrnuTLosis. 


2t)3 


city  In  1)L'  very 

lies  of  tubercu- 

(los,  nro  not  iiii- 

I'iin'  ill  luiniiin 

■ntli)-liil)crciili)sis 

I  the  lungs  prr- 
ms  tulicrclt'-likt' 

II  ','u\in(l  ill  till' 
Hi  known  i'orins 

, — 'I'he  ])ossil)U' 
nco  aro  three — 
nd    triinsinit^sion 

direct  transmis- 
e  could  be  triins- 
■le  liacilli  should 
the  oviun.  Tlie 
1,  looking  at  the 
i)W  th;il  tul)ercle 
ill  t^nialler  when 

material,  which 
mentation  is  all 
[  others  showing 
id)ercnl(nis  males 
L's  often  contract 

iccepted.  r)anm- 
le  bacillus  in  the 
:ed  with  tnbercu- 
the  ])()ssil)ility  of 
le  ([uestion  as  to 
.  ovum  cannot  of 

ini  in  congenital 
acilli  jienetrating 
ese  cases  the  jila- 
lubereles,  indeed, 
doid)te(l  instances 
acental  blood  and 
ing  the  fact  that 

and  his  followers 
:  issues  and  subse- 
lividnal  resistance 


is  lowered.  lie  likens  such  lases  of  latent  tuberculosis  to  the  late  hercdi- 
ary  I'oniis  of  syphilis,  and  explains  the  huk  id'  (h'velopmcnt  of  the  germs 
ly  the  greater  resisting  power  of  tlie  tissues  of  ehildreii.  In  the  discussion 
111  lalcnni  before  the  K'oyal  ^ledical  and  Cliirurgii'al  Society  of  JiOiidon, 
Kingston  Fowler  c.\[)resscd  the  sensilije  o|iini(in  that  it  was  not  necessary 
seriously  to  consider  tiie  (iiiestion  id'  latency  in  tuberculosis  until  direct 
transmission  from  mother  to  child  was  proved  to  be  of  freipient  occur- 
rence, llaumgarten  bases  his  lu'lief  in  germ  Iransmissioii  upon  two  main 
factors — the  great  frcMpiency  of  the  diseasi'  in  early  life  and  the  localization 
(d'  tuberculous  lesions  in  children. 

The  mortality  from  tuberculosis  in  the  llrsi  years  of  life  is  relatively 
high.  Of  'i,Tu{\  autopsies  made  on  children,  "JT.S  jier  cent  who  died  in  the 
first  year  were  tuberculous  (I'.olz).  Of  1<S-^'  autopsies  on  children  one  year 
or  under,  17"  were  tubi'reuhHis  (Comby).  'I'he  localization  of  tuberculous 
lesions  in  childn'ii  in  the  boiu's  or  joints  is  very  cominon,  Cuopp's  sla- 
ti.iics  showing  that  out  of  "v'DS  tuiiercnhuis  cliihlreii  cd'  from  a  few  days 
to  twelve  years  of  age,  I-IT  had  bone  or  joiid  tul)erculosis,  and  only  is  of 
these  showe(l  evidence  of  visceial  disease.  liaumgarten  is  (d'  the  opinion 
that  the  accidental  conveyance  of  tubercle  l)acilli  to  these  points  would  not 
account  for  such  a  largo  proportion  of  cases,  and  expresses  the  view  that 
the  bacilli  have  been  present  since  birth  and  have  develoiied  when  fav(U'- 
able  conditions  oU'ercd.  The  evidence  in  favor  of  Uaumgarteirs  view  is 
both  clinical  and  e.\|)erimental. 

I'he  clinical  evidence  exists  in  the  form  of  undoubted  cases  of  con- 
genital tuberculosis,  of  which  there  are  now,  in  man  alone,  about  "^'0  ex- 
amples in  the  literature;  besides  these,  a  number  of  spontaneous  c-ases  of 
congenital  tuberculosis  in  the  lower  animals  have  been  reporteil. 

A  numbi'r  of  labcu'atory  workers  have  been  al)le  to  show  that  congenital 
tuliercnlosis  can  be  ))rodiiced  experimentally,  the  most  iirominent  of  these 
being  (liirtner.  who  ^' as  able  to  cause  tuberculosi.s  in  young  mice  by  inocu- 
lating the  mother  with  tuberculosis,  either  into  the  ])eriloneal  cavity  (U' 
into  the  blood  stream.  ^lafucci  has  shown  that  after  injecting  eggs  with 
avian  tuberculosis  the  disease  may  remain  latent  in  the  chick  for  weeks  or 
even  months. 

Against  Banmgarten's  theory  are  the  facts  that  tlu'  percentage  of  cases 
of  congenital  tu'oerciilosis  is  extremely  small,  and  that  in  the  great  majority 
of  instances  tlu^  organs  of  fcvtnsos  born  of  tuberculous  mothers  give  nega- 
tive results  when  inocnlated  into  gninea-jiigs. 

\o  circnmstanco,  perha])s,  has  contributed  more  ro  the  belief  in  the 
hereditary  transmission  of  the  disease  than  the  freipieiicy  with  which  tuber- 
culosis is  met  with  in  the  ascendants  of  those  affected.  The  estimates  range 
from  10  ]ier  cent  to  35  per  cent,  or  even  in  some  instances  to  Hd  per  cent. 
Some  of  the  statistics  on  this  ]ioint  are  worth  (juoting:  In  1, ()()()  cases  Wil- 
liams found  IS.l  jier  cent  with  family  predis]iopition,  VI  ])er  cent  with 
l)arental,  1  ])er  cent  with  grandiiarcntal.  and  31.1  y)er  cent  with  collateral 
heredity.  Of  STjO  cases  in  which  Solly  made  very  careful  iiupiiries  on  this 
point,  there  were  28.8  per  cent  with  jtarental.  T.d  jier  cent  with  <:rand- 
parcntal,  and  19. 2  per  cent  with  a  history  of  ccdlateral  heredity.     Of  A'll 


I 


^^^ 


201 


SPECIFIC  INFECTIOUS  DISEASES. 


case's  at  the  Johns  Hopkins  Jlospilal,  tlicve  wtro  ~u)  in  which  th.>  m-.thyr 
had  had  tuhciculosis,  r.V'  in  Nvhich  tho  lather  had  been  atVected,  and  lOo  m 
,vln.-h  a  liroiiur  or  sisl.T  had  luul  the  disease.  The  question  ot  lanuly  m- 
i'clion  is  liie  all-iniiM.rtant  one,  and  Hilton  Fajj-e  very  wisely  remarks  thai 
it  is  iiMi.ossilde  1..  draw  a  line  between  liereditary  and  aeeidental  tnl.ereii- 
losis  as  iiaturallv  the  ehildren  of  an  alTeeted  parent  are  nmre  liable  to  acri- 
,l,.ntal  eontainin'alioii.  In  a  reeent  earel'ul  study  of  heredity  m  phthisis. 
Squire  eoiHlude>  that  tliere  is  but  a  suiail  ditVerenee  between  the  n.eidenee 
of  the  disease  in  tlie  oiVspring  of  i-lilhisieal  and  noii-phtiusieal  parents. 

AVhile  tile  demonstration  of  tiie  eontagiousness  of  tuberetilosis  as  m 
some  (piarters  intensified  the  dread  with  wliieli  the  disease  is  re-ardei  , 
tiie  terrible  Mr  of  liereditary  tranMiiis>ior.  las  been  in  -reat  part  almlislied. 
to  the  great  gain  of  sulVering  hnmanily. 

(/,)  Jnonihilinii.—'VUv  iiib'ctive  nature  of  tubermlosis  wa-^  iirst  demon- 
strated bv  Villemin,  who  showed  e.m<'lii>ively  in  ISd:.  that  it  eould  l,e  trans- 
mitted to  animals  by  inoeulation.  The  beautiful  experiments  ot  (  ohnheim 
and  Salamonson,  who  ].rodueed  tuliereulosis  in  the  eyes  .d'  gumea-pigs  and 
rabbits  bv  inoeulating  fresh  tulu'rele  into  the  anterior  ehaniber,  eoniirmed 
and  ext.'lided  ViUeiiiiirs  ori-inal  observations  and  paved  the  way  tor  lie 
iveei.tion  of  KoehV  aiinouneemeiit.  It  is  now  universallv  eoneeded  that 
onlti  tuberculous  matter  ean  i)roduee,  when  inoculated,  tuberculosis.  In 
man  tuberciilo>is  is  not  .d'ten  transmitted  by  inoculation,  and  when  it  .Iocs 
ocrur  tiie  dis,.ase  usually  remains  local.  This  mode  of  infectmn  is  seen  m 
persons  whose  occupation  brings  them  in  contact  with  dead  bodies  or  ani- 
mal products.  Demonstrators  of  morbid  anatomy,  butcher.-,  and  baudlers 
of  hides  are  subject  to  a  local  tubercle  of  the  skin,  which  forms  a  reddened 
ma<s  „f  oranulati.ui  tissue,  usually  eapi-ing  the  dorsal  surfaces  of  the  hands 
or  fm.^ers  This  is  the  so-called  post-mortem  wart,  tlu>  rnnira  „erro;ini,ra 
of  WUks.  The  d.^monstralion  -d'  its  nature  is  shown  by  the  presence  ot 
tubercle  liacilli.  and  bv  inoculation  experiments  in  animals. 

The  statement  that  T.aennee  e.mtracted  i.btliisis  from  this  source  is 
,,,,.bablv  false,  since  he  did  not  die  until  twenty  years  after  tju-  mocula- 
lion  ami  in  the  interval  presented  no  inanifestati.ms  ^  le  possibility,  ho^^- 
over  of  general  infection  must  be  borne  in  mmd  (.erber  reports  that 
,,,.^^,;.  „,,i.UMilal  inoculation  in  the  hand  from  a  case  ol  phthisis  ,e  ha 
for  months  a  "  Leichen-lnbercle,"  which  was  exe.sxHi.  Shortly  afterward 
tiie  Ivmph-.dands  of  the  axilla  became  enlarged  and  painful  and  ^vhen  re- 
moved showed  cliaracteristic  tnberenlons.  changes,  with  bacilli. 

Tn  tlie  lurforman.'e  of  the  rite  of  circumcision  children  have  luvn  aeci- 
dentallv  inoculated.  Infe^ction  in  these  cases  is  probably  idways  a^^nciated 
with  disease  in  the  operator,  and  occurs  in  connection  with  the  habit  ..t 

cleansing  the  wound  by  suction.  .,-,,,  ■  <■ 

Otlun-  means  of  inoculation  have  lunm  des<>nbed:  as  he  w,>aring  of 
ear-rin.^s  washing  the  clothes  of  phthisical  patients,  the  bite  of  a  tubercu- 
lous subject,  or  iimculation  from  a  cut  by  a  broken  s,ut-glass  of  a  consump- 
tive: and  (Verny  has  reported  two  cases  of  infection  by  transplantation  of 

'^'"it  has  been  urged  by  the  opponents  of  vaccination  that  tuberculosis,  as 


icli  the  inothcr 
U'd,  and  105  in 
n  ui'  I'liniily  in- 
ly ivniarks  thiit 
dontul  tnlicRU- 
V.  lialik'  to  aci-i- 
ity  in  [)lithisis, 
u  the  i:icidt.'nei' 
ical  ]iai'ontfi. 
L'l'cido^is  '  as  in 
ise  is  regarded, 
jiart  abnlished, 

la-  first  dcnion- 
:  c'oidd  1)0  trans- 
its of  ("olinhoini 
guinea-pigs  and 
mber,  eoniirn\ed 
the  way  for  the 
V  eoncediMl  that 
ulu'rculosis.  In 
nd  whi'n  it  does 
ret  ion  is  seeii  in 
(1  hodies  or  ani- 
rs,  and  handlers 
orms  a  reddened 
ces  of  tlio  liands 
•nira  nerro'iPiiim 
the  presenee  of 

11  this  sonree  is 
fter  the  inoenla- 

pnssi!)ility.  how- 
•her  re])orts  that 

phthisis  ho  ha.l 
iliortly  afterward 
id.  and  when  ro- 
aeilli. 

11  have  heen  aeoi- 
always  assoeiated 
vith  the  liahit  of 

;  the  wearing  of 
l)ite  of  a  tnheren- 
ass  of  a  eonsninp- 
ransplantation  of 

it  tnhercnlosis,  as 


"^, 


TrHKllCL'LOSIS. 


205 


Mel!  as  syphilis,  may  he  thus  eonvcyed,  hut  of  this  tliero  is  no  evidence, 
anil  thi>  iynipli  from  the  ve.-ielrs  of  revaccinated  eon>uni;itives  has  liecn 
shown  hy  many  ohscrvers  to  Ik'  non-infecti\o.  it  may  he  said,  on  the  whole, 
tliat  inoeulatioii  in  man  plays  a  trilling  n'llf  in  llie  transmission  of  luher- 
eulosis. 

((■)  hifvrluin  hi/  Iiihiihilloii. — A  lielief  in  tiie  ei<iitagionsness  of  pul- 
monary tuhereulosis  has  existed  from  tlie  days  of  the  early  (ireek  physi- 
eians,  and  has  persisted  among  the  Latin  races.  The  investigations  of 
('oriiel  all'ord  eomlnsivo  ])r()(d'  that  the  dust  i>\'  a  ■oom  or  other  loealitv 
frecpientcd  hy  patients  with  pulmonary  tniieriiilosis  is  infeciive.  'i'lie 
hacilli  arc  attached  to  fine  particles  of  dust  and  in  this  way  gain  entrance 
to  the  system  through  the  lungs. 

I'liigge  denies  that  the  haeillus-eimtaining  dust  is  the  dangerous  cle- 
ment in  infection.  J'l.Nperimcntallv  he  has  onlv  succeeded  in  nrodueiu"- 
the  disease  when  there  is  soiue  lesion  in  the  respiratory  tract,  lie  thinks 
that  the  danger  of  infection  hy  the  dry  sputum  is  very  improhahle.  On 
the  other  hand,  he  thinks  that  the  ini'ection  is  chielly  conveyed  hy  the  free, 
liiiely  divided  particles  of  sjiutum  proiliucd  in  the  act  of  coughing,  and 
that  these  tiny  fragments  are  suspended  in  the  atmos|)here.  Those  who 
cough  veiy  much  and  with  the  mouth  ojumi  are  most  liable  to  infect  the 
sniTonnding  air. 

It  is  well  remarked  hy  Cornet,  ''The  consuinpfi\e  in  himself  is  alnnst 
liarmless,  and  only  boeomes  harmful  through  bad  habits."  Jt  has  been 
fully  shown  that  the  expired  air  of  consumptives  is  not  infective.  The 
virus  is  only  contained  in  the  sputum,  which  when  dry  is  widely  dissemi- 
nated in  the  form  of  dust,  and  constitutes  the  great  niedinm  for  the  trans- 
mission of  tho  disease.  "  In  order  to  he  air-borne  the  sputum  must  be 
dried  and  broken  W])  into  dust.  If  discharged  into  a  handkerchief,  it 
sjieedily  dries,  especially  if  it  is  put  into  the  ])ocket  or  bt'ueath  tho  pillow. 
In  the  last  stages  of  consninj)tion  tho  patient  beeomes  weak,  the  s[nifum 
is  ox])elled  imperfectly,  i)illows,  sheets,  and  handkerchiefs  are  soiled.  If  a 
male,  the  bt'ard  or  moustaeho  is  smeared.  I^ven  in  the  hamls  of  the  cleanly, 
without  sjiecial  ])recaufons,  sncli  circumstances  all  tend  to  the  |)roduction 
aronnd  tho  jiatient  of  a  halo  of  infected  dust  maintained  by  every  process 
of  bedmaking  or  of  cleaning  which  includes  tho  ])ernicious  process  hapi)ily 
described  as  'dusting.'  In  the  hands  of  the  careless  and  the  dirty  the  in- 
fectivity  is,  of  course,  greaily  aggravated.  It  attains  its  inaNimum  of  in- 
tensity where  the  filthy  habit  of  spitting  on  the  lloor  prevails,  especially 
if  it  is  carpeted  "  (Jjunes  V>.  I?iiss(>ll). 

'Hie  following  are  some  of  the  facts  in  favor  of  infection  by  inhala- 
tion: 

(1)  Primary  tnl)ercnhnis  lesions  are  in  a  majority  of  all  cases  connected 
with  the  respiratory  system.  Tho  frequency  with  which  foci  are  met  with 
in  the  lungs  and  in  tho  bronchial  glands  is  extraordinary,  and  the  statis- 
tics of  the  Paris  morgno  show  that  a  considerable  ])ro]>ortion  of  all  |)ersoiH 
dying  of  accident  or  by  suicide  ]irosent  evidences  of  the  disease  in  these 
])arts.  The  ])ost-mortem  statistics  of  hos]iitals  show  the  same  widespread 
]irevalence  of  infection  throngh  tho  air-passages.     liiggs  reports  that  more 


^^k 


206 


SPECIFIC  INFECTIOUS  DISEASES. 


ll,an  (10  nvv  cent  of  l.is  post  niorlnns  sl.nwnl  l.'sion.  of  ,n.ln,...iary  lul.or- 
Pilosis.     In  l-.T.  aiitnpsirsat  tlu'  F.uin.llin-  lln>i.ital.  Nvvv  \  .-rU,  the    .n,n- 
ohial  s^lan.ls  wct.  tulu.vuluus  in  .vctv  .aso.     In  a.lnlts  tlu.  '"•'••h'";''  ^l"';"^ 
may  lu"  inlVctcl  and  the  indivi.hial  rcMnain  in  ......1  health.     H.  I  .  L"<'m.> 

luun.l  in  S  ..r  ;!(!  rases  in  v.l-.ich  thciv  uriv  nn  si-ns  of  old  ..r  ivcrnl  lubcr- 
ruions  k'sinns  that  the  hronehial  -lan.ls  wero  inlVctive  to  rabhits 

(•.')  The  ti-.rater  pivvaUMur  ol  Inhenulosis  in  institutions  m  whuh  the 
residents  are  eonlined  and  restrieted  in  the  matter  of  fresh  air  a r,d  a  tree 
(,,,„,  life-eonditions  whieh  would   favor,  on  the  one  han.l    the  presenee 
of  the  haeilli  in  the  atnu-splu're.  an.l,  on  the  other,  lower  the  vital  resis- 
anee  of  the  individual.     The  investigations  of  Cornet  upon  the  .leath-rate 
from  eonsun.i-tion  auion^  certain  reli-ious  orders  devoted  to  nursing  give 
some  striking  faets  in  illustration  of  this.     In  a  review  of  ;.S  elo)>ters,  em- 
braeing  the  average  .nnnber  of  -l.t)-.'S  residents,  among  '.'.OH'.*  dea  hs  in  the 
course  of  Iwenty-live  years.  l,;5-^(»  ((;-.>.SS  per  eenl)  were  iruu.  luherenlos,^. 
In  s..ine  cloisters  mor'e  than  three  fourths  of  the  deaths  are  Iron,  this  dis- 
ease, and  the  mortality  in  all  the  residents,  up  to  the  fortieth  year,  is  greatly 
above  the  average,  tlie  increase  being  due  entiivly  to   the   pivyalenco  ol 
tuberculosis.     It  has  been  stated  tliat  nurses  are  not  nunx.  jirone  to  the  dis- 
ease than  other  individuals,  but  Cornet  says  that  of  100  nurses  deceased,  (..3 
died  o\-  tuberculosis.     The  more  perfect  the  prophylaxis  and  hygienic  ar- 
ramrcnients  of  an   asylnin   or   institution,  the  lower  the  death-raie   Irom 
tuberculosis.     The  mortality   in   i.ris.uis  has  been  slunvn  by   l.aer  to   h, 
four  times  as  great  as  outside.     ^Phe  death-rate  from  phthisis  is  estimate 
at  ].-,  per  cent  of  the  total  mortality,  whih-  in  prisons  it  constitutes  IroinlO 
to  50  per  cent,  and  in  some  countries,  as  .\ustria,  over  00  per  cent.     l;lu  k 
bas' studied   the  distribution  of  the  deaths  from  tubercul(,s,s  m  a  singe 
citv  ^vard  in   Philadelphia  for  t\v..n1y-llve  years.     His  reseaiv  les  go  lar  to 
show  that  it  is  a  housi  disease.    About  .;i  per  cent  -d  iniected  houses   ,a  o 
had  more  than  one  case.     Less  than  one  third  ol  the  houses  ot  the  ^^..  d 
became   infected   with   tuberculosis  during  the  tweuty-hye  years   pnoi     o 
1888      Yet  more  than  one  half  of  the  deaths  fnun  this  .  i.-.'ase  duvnig  tlu 
vear'lS8S  o<.curr..l  in  those  iufcted  houses.    There  are   lu.wever.  opposing 
■facts      The  statistics  of  the  Ilrompton  Consumption  Hospital  show     ui 
doctors,  nurses,  and  attendants  arc  rarely  attacked.    Pettweiler  <"h.nns  that 
no  case  of  tuber..ulosis  lias  heen  contracted  among  his  nurses  or  attendant^ 
at   Falkenst..in.     On   the  other  hand,   in   the  Pans  hospitals  tubenulo-i. 
decimates  the  attendants.  *,,,!.    f„r 

(3)  Special  danger  exists  wlien  the  conta.'t  is  very  mtnna  e  Mi,.h,  for 
in^tance.  as  betw.H.n  man  and  wife.  On  this  pent  much  diilerence  of 
opinion  exists,  but  the  figures  seem  to  indicate  that  under  these  circum- 
stances the  husluind  or  wife  is  ni.U'h  more  liable  suhsequently  to  die  of 
consumption.  Of  -Vi^  eases  of  pulmonary  tubercu  osis  at  the  Johns  ITop- 
Idns  Hospital,  in  >.'5  either  husband  or  wife  had  been  afTocted  with  ,t  <u 
had  died  of  tubercuh.sis.  Tn  response  to  a  question  as  to  -"  l'^;"' ^^^^f 
bv  the  Collective  Investigation  Committee  ot  the  i'.ntish  Medual  Woci,,- 
tion  there  were  201  replies  in  the  affirmative,  among  which  wore  L,S  cases 
of  supposed  contagion  through  marriage.     Weher's  cases  are  of  spccu^l  m- 


TUHEKCULOSIS. 


20 


>i 


rnonary  IuIut-- 
orU,  tlie  liriiii- 
•oiu'liial  ^'liiiuls 
11.  I'.  Ldoinis 
r  n'l'c'iil  lulii'i'- 
iihliits. 

s  ill  wliirli  the 
air  ar.-l  a  i'ri't' 
1.  the  itivsoiico 
he  vital  iTi-ist- 
llii'  (IcalU-ralc 
o  luirsiiig  give 
S  c'loisters,  em- 
it deaths  in  the 
ui  tulxTciildsis. 
'  Troin  llii!'  dis- 
year.  is  greatly 

>  prevaleiiee  nl' 
rone  to  the  dis- 
sert deceased,  (i3 
nd  hygionie  ar- 
leatli-raie  i'roin 
by   Jkier  to   lie 

isis  is  estimated 
stitiites  I'roin  -H> 
jter  cent.  Fliek 
osis  in  a  single 
iiehes  go  far  to 
■ted  houses  have 
ises  of  the  Murd 

>  vears  jirior  to 
sease  during  the 
iwever,  opposing 
?pital  show  that 
eiler  elaims  that 
■;es  or  attendants 
tals  tuhereiilosis 

limnte.  such,  for 
icli  diifereneo  of 
cr  these  cireum- 
nently  to  die  of 
the  Johns  ITop- 
feotcd  with  it  or 
contagion,  asked 
:\Iedieal  Associa- 
■h  wore  158  cases 
arc  of  special  in- 


terest.    One  of  his  patient.<  lost  four  wives  in  succession,  one  lost  three, 
and  four  lost  two  (aeh. 

((/)  Infcrliiin  bij  Mill,:— Tho  milk  of  an  animal  sulfering  from  tuher- 
eiilosis may  eojitaiii  the  virus,  and  is  ciipahle  of  eominiini  ating  the  dis- 
ease, as  shown  hy  (Jerlaeh,  Uang,  Bollinger,  and  others.  Striking  illustra- 
tions of  this  are  sometimes  alforded  in  the  lower  animals.  The  pigs,  for 
instance,  of  a  tuberculous  sow  have  been  shown  to  jireseiit  intestinal  tuber- 
culosis of  the  most  exipiisite  form.  Of  late  years  the  experimental  jiroof 
has  been  entirely  conclusive.  Jt  was  formerly  thought  that  the  cow  must 
present  tuherciilous  disease  of  the  udder,  but  i-lrnst  has  shown  that  the 
liacilli  may  be  ]ircsent  and  the  milk  be  infective  in  a  large  jiroportion  of 
cases  in  wiiich  there  is  no  tuberculous  mammitis;  an  observation  made  also 
by  Ilirschberger  and  others.  This  author  states  tiic  interesting  fact  that 
an  owner  of  a  lierd  known  to  be  tulu  rciiloiis  withdrew  the  milk  from 
market  and  used  it  witiiout  boiling  to  fatten  his  pigs,  which,  alniost  with- 
out exception,  iiecame  tuberculous,  so  that  the  whole  stock  had  to  be 
slaughtered.  Sidney  .Martin  could  not  induce  the  disease  artilicially  in 
animals  inoculated  or  fed  with  milk  of  tuberculous  cows  with  liealthy 
udders.  IWitter  made  from  the  milk  of  tuberculous  cows  has  jiroved  in- 
fective (]?ang).  There  is  no  reason  to  believe  that  young  children,  or 
even  adults,  are  less  susceptible  to  the  virus  than  calves  or  pigs,  so  that  the 
danger  of  the  disease  from  this  source  is  real  and  serious.  The  great  fre- 
(juency  of  intestinal  and  mesenteric  tuberculosis  in  children  no  doubt  finds 
here  its  explanation.  As  noted  in  Woodhead's  analysis  of  \-27  cases  of  fatal 
tuberculosis  in  children,  the  mesenteric  glands  were  involved  in  100. 

((')  Infection  hij  Meat. — The  meat  of  tuberculous  animals  is  not  neces- 
sarily infective.  The  results  of  experiments  with  the  flesh  of  cows  are 
not  in  accord.  This  mode  of  infection  jirobably  jdays  a  minor  nVe  in  the 
etiology  of  human  tuberculosis,  as  usually  the  flesh  is  thoroughly  cooked 
before  eating.  The  ])ossibility,  however,  must  be  borne  in  mind,  and  it 
would  certainly  be  safer  in  the  interests  of  a  community  to  eonfi.scate  the 
carcasses  of  all  tuberculous  animals.  Exy)eriments  in  Hcdlinger's  labora- 
tory show  that  the  flesh  of  tulierculous  subjects  is  very  inft>ctive  to  gninea- 
jiigs.  Martin  suggests  that  when  the  meat  is  infective  it  commonly  ac- 
(piircs  this  projierty  by  accidental  contamination  with  tuberculous  matter 
during  its  removal. 

T).  Conditions  Influencing  Infection.— («)  (7cHnv;/.— Knviiomnent  is  an 
all-important  jwdisposing  factor,  llwellers  in  cities  are  much  more  prone 
to  the  disease  than  residents  of  the  country.  Not  only  is  the  liability  to 
infection  very  much  greater,  but  the  conditions  of  life  are  such  that  the 
powers  of  resistance  are  apt  to  be  weakened.  As  already  stated,  sunlight 
is  one  of  the  most  powerful  agents  in  destroying  the  tubercle  bacillus,  so 
that  in  imiierfectly  ventilated  dwellings  and  workshops,  and  in  residences 
in  close,  dark  alleys,  and  in  tencTnent  houses  the  liability  to  infection  is 
very  much  increased.  The  influence  of  environment  was  never  better 
demonstrated  than  in  the  now  well-known  experiment  of  Tnidean,  who 
found  that  rabbits  inoculated  with  tuberculosis  if  confined  in  a  dark,  damp 
place  without  sunlight  and  fresh  air  rapidly  succumbed,  while  others 
17 


I- 


208 


sPK^Fic  iNFp:cTiors  I)Isp:ases. 


tmitoa  in  the  san.o  wav.  but  allow..,!  t<.  run  wiM,  .ithor  remvoiva  or  .linw..l 
.rv  slif^ht  lo.i..n..  Tlu.  ...rni-ants  of  i.risons,  asyUun.,  and  roorhou... 
oo  oftc^,  i.HUr.1,  in  l.arnuks  and  lar,..  workshops,  are  .n  the  position  ol 
Tru.U.au-s  rahl.its  in  th.  .■.•liar,  and  under  ..n-liUuns  n.o.t  ;'v^>^" ''^  ;' 
i-„..(or  the  develop.nent  of  tl.o  l.adUi  vvhieh  u>ay  have  lodged  ,n  then  t,>.  . 
The  freHn..nt  respiration  <.l'  air  already  hreathed,  upon  wn.eh  Mael  .  n,a 
of  Uelfast  laid  so  n.ueh  stress,  appears  to  render  the  lungs  less  eapahle  ol 

resisting  infection.  •  ,      j  i     ,.,;,,  r 

Soiland  looalitv  are  believed  hy  n.any  to  have  a  very  nnportant  heanng 
on  the  (leveloi.ment  of  tuhereulosis.  The  observations  ol  lenry  1  l.o«- 
diteh  in  this  eountrv  and  of  lU.ehanan  in  Kugland  show  that  the  disease 
prevails  more  widely  in  the  wet,  ill-drained  distriets-an  ••-••-;^;^  ;:^  '';;!'; 
U..iated  with  hei.d.tened  vulnerability  and  greater  l.alnbty  to  eatanlul 
atVeetions  of  all  kinds.  The  iniluenee  of  the  dwelhng  has  been  already 
r  ferred  to  in  connection  with  Fliek's  work.  No  s.ngle  eondU.on  is  o 
greater  i.nportanee  than  tliat  whieh  relates  to  the  proper  arrangement  and 
ventilation  of  the  dwelling  houses.  ,        v  •  .,„.„.';,.„ 

(h)  Individual  rmlispo,ition.-Th,  lathers  of  n.ed.e.ne,  nio  e  p.mi  u- 
larlv  Hippocrates,  Areta-us,  and  Calen,  laid  great  stress  upon  the  bod, 
eonforniition  of  those  prone  to  consumption.     A  great  deal  was  wntb  n 
on  the  so-called  hahilu,  i>hlhisi,u.,  which  Ihppoerates  desenlu.    in  the       - 
kwin-^  tern.s:  "  The  form  of  body  peculiar  to  subject,  oi  phthisical  con  - 
ints  was  the  smooth,  the  whiti.h,  that  resembling  the  lentil;  the  red- 
1     the  blue-eved,  the  hnico-phlegmatic;  and  that  with  the  .capjiUe  hav- 
::;i      appearance  of  wings."     mdoubtedly  the  h.ng    narrow,  ilat  diest 
l-nk  de,.re  sed  sternum  is  commonly  enough  seen  m    uberculous  pat    nt> 
t  the  e  are  only  too  many  individuals  with  perfectly  well-shaped  chesU 
.t     .11  victims  annually  to  the  disease.     The  tubeivulous  or  scn^ofidou. 
d    the<is.  npon  which  fornu^rly  so  nmch  stress  was  laid.  -^  "^>^v  ^'^J^'""^; 
s     ,^v  a;  an  indication  of  a  type  of  conformation  ,n  winch     -J;--  -^ 
moreVnlncrable  and  less  cai-able  of  resisting  miection.       .ei.eke  .  im   > 
^    ons  on  the  viscera  of  phthisical  patients  indicate  that  the  hear    is    ela- 
tivelv  «nnll   the  arteries  proportionately  narrow,  and  the  pulmonary  a.tcv 
d  ir    i   '•  tian  the'aoda.    He  suggests  that^this  may  lead  to  increase 
Tiho  intrapulmonarv  blood  pressure,  and  so  ^^^^or  cat^irrhal  p  occ^>. 
Th     ung  vol  nne  he  found  relatively  greater  in  those  afTected  with    nher  u- 
lo  is     A  study  of  the  composite  portraiture  of  pulmonary  tuberculosi.     a. 
en  made  by  Calton  and  Mabome.l.    Tn  412  patien  s  they  separated  t.o 
tvpeVo    Le-one  ovoid  and  n.arrow,  the  other  broad  and  coarse-featured 
!^f"C  ponds  in  an  interesting  way  to  the  diat^.etic  states  f onm.  y 
,V  ;,  i.edinamelv.  the  tuberculous,  with  thin  skin,  Wight  ey^^S  »val  face, 
an    hm^^^^^^        bones;  and  the  scrofuh>us  with  thick  lips  and  nose,  opaque 
n   1  Pe.  thick  bones,  and  heavy  figure.    These  conditions    on  whu      . 
m    k     iTss  was  formerly  laid,  indicate,  as  Fagge  states,  nothing  more  t  u.n 
dd^L:v    f  constitution:  incomplete  growth,  and  im,u;rfcct  '^--M--  • 

OYl„iJun,rc  of  A,r.-^o  age  is  exempt.     The  disease  is  met  vMth  u 
thetick  in.  and  in  vhe  octogenarian.    Pulmonary  tubcrcuosis  occui.  mo-t 
frciuentlv  '  as  stated  bv  Hippocrates,  from  the  eighteenth  to  the  thntv- 


mm 


'^' 


TL'JIKRC'ULOSIS. 


2i]d 


oroil  or  showoil 
11(1  poorli<)u>c.~. 
the  position  ol' 
st  l'avoral)lo  to 
ill  tlioir  tissue.'-, 
ich  ^liicl  oniuK' 
loss  oapiil)le  nl' 

portaiit  lii'aring 
Homy  1.  J>o\v- 
Ihat  tlio  dii-ea.so 
icrcase  which  is 
ity  to  catavriial 
;is  bi'fii  already 
coiidition  is  nf 
iTangeiueiit  and 

V,  more  particu- 
iipon  the  Ijodily 
loal  was  written 
rilied  in  the  I'ol- 
phthisieal  corn- 
lent  il;  the  red- 
.hc  ficapnUe  hav- 
arrow,  ilat  chest 
rculous  patients, 
ell-shaped  chests 
ins  or  scrofulous 
is  now  regarded 
■h  the  tissues  are 
lUiieke's  investi- 
the  heart  is  rela- 
[)nlinonary  artery 
y  lead  to  iiurease 
tarrhal   jn'ocesscs. 
ted  with  tuhercu- 
,•  tuberculosis  has 
ley  separated  two 
d  coarse-featured, 
c  states  formerly 
lit  eyes,  oval  face, 
and  iKise,  opacpie 
ions,  on  which  so 
lothin,':;  more  than 
et  devclojunciit. 
so  is  met  with  in 
ulosis  occurs  ino.-t 
ith  to  the  thirty- 


I' I  til  year.  From  the  llfih  to  tl.c  h.iul,  vcar  imlivi.hials  aiv  less  prone  to 
llie  disease.  At  diircreiit  ages  dillVrcnt  .,rgans  are  more  prone  to  h-  in- 
w.lved.  Durnig  the  first  d.rade  the  Loiies,  meulMges.  ,n.d  Ivrnph-glamls 
are  more  lrc(piently  alle.i,.,!  than  at  subsecpieiit  periods. 

(J)^V.r.— The   inlhience  of  se.v   is   vry  slight.      Women   ar.'    perhaps 
somewhat   more   fre.pi,.ntly   attacked    than    men,    p.,ssil,lv    from    the    fact 
that  in  a  more  s.'.lciitary.   indoor  life  they  are  more  liahle   to  infecli,m 
I  regnancy  and   lactation  also  are  two  conditions  which  arc  n.)l  to  lower 
perhaps,  the  resistance  of  tiie  organism.  ' 

(,)  I'urr.—The  negro,  who  it  is  stated  is  not  specially  prone  to  tiie  dis- 
ease in  AInca,  is  in  America  and  in  the  West  indies  vcrv  sui.ject  to  tnher- 
cidosis.     The  relative   inimunily  of  tiie  .lews  has   heen"  mentioned   (page 

_(/■)  Ocrupalinu  is  an  imp,,rtant  predisposing  factor.  The  inlialation 
"t  impure  air  in  occupations  associate.!  with  a  very  (histv  atmosphcro 
reiHk.rs  the  lungs  le.<s  capahje  of  resisting  infection.  The' incidence  of 
pulmonary  tulierciilosis  annrng  tiie  workers  in  mills  and  factories  is  very 
high,  and  certain  occupations,  such  as  those  of  glass-workers,  stone-cutters 
and  coal-nmiers,  and  the  wIm.I.-  group  .,f  trades,  which  lead  to  pncuinouo- 
Ivoniosis,  iavor  the  development  of  tuiicrculosis. 

in)  Certain  heal  condilioiis  inllucnce  infection,  among  which  the   fol- 
lowing are  the  most  important: 

Catarrhal  hronchiti.<.  The  inlhience  of  catarrh  of  the  respiratory  i.as- 
sag..s  m  pulm.mary  tulH.rciil.,sis  is  well  recognized.  Jlow  often  is  a  iic- 
eclcd  cold  hlamcd  as  the  starling-point  of  the  .liscase!  It  seems  to  act 
.y  _h>"ering  the  resistance  and  favoring  the  c.nditions  which  ,.„ahlc  tlie 
mci  h  eit lier  to  enter  the  system  or,  when  once  in  it,  to  develop  Th.. 
liability  ol  lymphatic  tuhcrculosis  in  children  is  prol.ahly  a.ssociafed  with 
the  common  catarrhal  ])rocc.«scs  in  the  t.msils,  throat,  anil  hroiichi 

eerta.n  of  the  specific  fevers  predispose  to  tuhcrculosis,  among  which 
nieasles  and  whooping-cough  stand  pre-eminent.  They  are  often  a-oci- 
ated  with  a  bronchial  catarrh.  In  some  .d'  the  cases  it'  is  prohahly  not  a 
fresh  inlcclK.n  which  follows,  hut  the  blading  of  a  smouldcrin-  fire  Ty- 
phoid lever  IS  thought  by  some  to  predispose  to  tuberculosis,  but  my  cxpcri- 
eiice  IS  o].poscd  to  this  view.  Of  other  allVclions,  influenxa,  variola/and 
syphilis  are  all  believed  to  favor  the  development  of  the  disease.  Diaiietes 
as  IS  well  known,  very  often  terminates  in  pulmonary  tuberculosis  iiar- 
ticularly  m  young  jier.sons.  '  ' 

Chronic  heart-disease,  arterio-sclerosis,  aneurism  of  the  aorta,  f.n-nw  of 
ehronie  nephritis,  cirrhosis  of  the  liver,  and  the  various  forms  of  ceivbro- 
spinal  sclerosis,  all  are  conditions  which  favor  infection.  Tt  is  remarkable 
.11  how  many  of  the  subjects  of  flu'se  disorders  in  general  hospital  pra.'ticr 
tlie  iatal  event  is  a  terminal  acute  tuberculosis,  most  fre.nienfly  of  tb,. 
>eroiis  membranes.  Subjects  of  congenital  or  acquired  cut ra.^tio'n  of  the 
orifice  of  the  ])iilmonary  artery  usually  die  of  tuberculosis.  D,,  the  other 
iian.i,  mitral  valve  disease,  particularly  stenosis,  is  stated  to  ania-onizo  the 
<  isease  (J.  l-].  (irahani).  Tn  children  catarrhal  cntero-colitis  i.robablv  favors 
the  development  of  tabes  nicsenterica. 


Hi* 


270 


SPKCIFK-  INFECTIOUS  DISKASRS. 


T!'.'  .>.!!•.:.■..,,.  „r  lui'i.miitvsis  mid  plciirisy  will  lie  ivf. nv«l  U>  later.        ^ 
Tnu.i.m.     Snr-c(.iis  liavJ  laid  ^Mvat  stress  uixm  tl.is  as  an  eliologua. 
factor  in  tnlK.nul..us  pn..Tss..s.     Kxi.erinu.nts  indicate  that   t.ssnes  vvln.l, 
iuivo  been  bruised,  and  wl.i.h  w.iil.l   in  health   have  readdy  and  raind.s 
.lestrnved  or^anisn.s,  i-nnnot.'  iluMr  j^n.wth   under  the  altered  eonditio.i^ 
I'robai.lv  in  the  case  of  tuberculosis  lnll..uin-  inunna  the  injure,    part  i- 
r.,r  a  time  a  hni.^  miuoris  n'sislcniiw,  and  if  lia.'illi  are  present  they  ina> 
bv  it  receive  a  stimulus  to  jrrowtb  or  un.ler  the  altered  conditions  be  eapal.lc 
of  nuiltiplvin^r.    Not  only  in  arthritis,  but  in  pulmonary  tuherculusis,  trau- 
,„atis,n  nmv  plav  a  ,,art.     The  .piestion  has  been  thorou^dily  s  udied  by 
Mendel.s..hn,  who  reports  !•  eases  in  which,  without  traetnre  ol  the  rib  ov 
iaeoration  of  the  lunjr,  tubere.dosis  developed  shortly  al't|T  eontusi.m  ol 
the  ..hest.     Operation  ujion  tuberculous  lesions  may  be  loUmved  l.y  a  },'en- 
eral  infection.     Heseition  of  a  struni-uis  joint  is  oeeasionally  followed  i>y 
acute  tuberculosis.     Of  s:57  resections,  ^'^5  ended  fatally,  '^G  with  acute 
tuberculosis  (Wartinanu).  „  ™   ,  i 

General  Morbid  Anatomy  and  Histology  of  Tuberculous 

Lesions.  „  ,       „,,  ,  ., 

(1)  Distribution  of  the  Tubercles  in  the  Body.— i  he  organs  of  the 
body  are  variously  alVecle.l  bv  tui>ercul..sis.  In  adults,  the  lunp  may  be 
regarded  as  the  seat  of  election;  in  chihlren,  the  lymph-j,'lands.  liones,  and 
ioTnts  In  1,000  autopsies  there  were  '.'Tr.  cases  with  tuberculous  lesions. 
\Vitli  but  two  or  three  exceptions  the  liin>rs  were  alVected.  The  distril)ii- 
tion  in  the  other  orpins  was  as  follows:  I'cri.  ardimu.  7;  peritona.nm,  'Su. 
brain,  :U:  spleen,  "i:?;  liver,  Vl;  kidneys,  \V>-  intestines,  (m;  heart,  -1;  and 

generative  organs,  S.  „    ,  i  vi' 

The  tubcnMlosis  which  comes  under  the  care  ef  the  surgeon  bas  a  dil- 
forent  distribution,  as  sli-.wn  by  the  following  llgures  from  the  \\  iiiv.burg 
clinic  Among  S,sr;5  ])atients,  1,-.\S7  were  tuberculous,  with  the  following 
distribution  of  lesions:  I'.oues  and  joints,  1,037;  lympli-glands,  19(1;  skiii 
and  connective  tissues.  77;  mucous  nienibranes,  10;  genito-nnnary  or- 
gans, 20. 

(3)  The  Changes  produced  by  the  Tubercle  Bacilli.  ^ 

(a)  The  No,lnh,r  Talvrrlc.-Tho  body  which  wo  term  a  "tubercle 
presents  in  its  carhi  formalUm  notlmuj  ,lislh,rlire  or  peruhar,  eilhrr  in  i/s 
cowpnnenis  or  in  their  arran<jement.     Identical  structures  are  ].ro.  need  by 
other  parasites,  such  as  the  actinomyces,  and  by  the  strongylns  m  the  lungs 

'ThTresearclies  of  r.aumgarten  have  enabled  us  to  follow  in  detail  tlie 
evolution  of  a  tubercle.  ,.,    ■  -i        ^■ 

(a)  The  multiplication  of  the  tubercle  bacilli,  winch  is  rapid  and  is 
accomimnied  by  their  dissemination  in  the  surrounding  tissues  partly  by 
growth,  partly 'in  the  lymph  currents. 

(S)  The  multiidication  of  the  fixed  cells,  especially  those  of  connectne 
ti^sue  and  the  endothelium  of  the  capillaries,  and  the  gradual  production 
from  them  of  rounded,  cuboidal,  or  polygonal  bodies  with  vesicular  nuclei 
-the  epithelioid  cfZte-inside  some  of  which  the  bacilli  are  soon  seen. 

(■y)  From  the  vessels  of  the  infected  focus,  leucocytes,  chiefly  poly- 


vi\  to  later. 
H  an  t'tiologuii! 
it  tissues  wliiel. 
lily  ami  rapiiil} 
ored  ediidilion- 
iujiiretl  jiart  i- 
resent  they  mav 
itions  be  capahle 
ilx'rciilosis,  trau- 
iihlv  stiidieil  liv 
iro  of  the  rill  ov 
ter  e(Uitiisii)ii  nl" 
lloweil  hy  a  geii- 
ally  followed  by 
',  -^6  with  acute 

f  Tuberculous 

2  organs  of  the 
he  lungs  may  he 
lands,  hones,  ami 
bereulous  lesions. 
1.  The  distrihu- 
peritonaMun,  ;5<I: 
j,");  heart,  -1;  and 

urgeon  has  a  dif- 
>ni  the  Wiir/.hurg 
■ith  the  following 
glands,  190;  skin 
;enito-urinary   or- 


rni  a  "  tuberele  " 
tliar,  cillwr  in  ilt< 
i  are  ])rodueed  by 
gylus  in  the  lungs 

illow  in  detail  the 

h  is  rapid  and  is 
;  tissues  jiartly  by 

hose  of  oonneotive 
rradual  ])roduction 
th  vesicular  nuclei 
are  soon  seen, 
■ytes,  chiefly  poly- 


TunEUcuLo.si.s;. 


271 


nuelear,  migrate  in  nundiers  timl  aeciimidate  about  the  fiiei'*  of  infeelion. 
I'hey  do  not  sul)divi(le.  Many  uiidi'rgo  rapid  deslruelion.  l.iiler,  as  th<' 
liltle  tuberele  grows,  the  leucocytes  are  ehielly  of  the  moniinucieju'  variety 
(lymiiiioeytes),  whii'h  do  not  undergo  the  rapid  degeni'ialioti  of  the  poly- 
niielear  forms. 

((5)  A  reticulum  of  (iiu'i's  is  foi'uied  i>y  the  libi'illiUion  and  rarefaition 
iif  the  connective-tissue  matrix.  This  is  most  appiii'cnl,  us  a  rule,  at  ihi' 
margin  of  tlie  growth. 

(c)  In  some,  hnl  not  all,  tulieiclcs  ijianl  alls  arc  formed  by  an  iiU'rease 
in  tile  piot(i|ila>m  and  in  the  nuclei  of  an  imlisidua!  ceil,  or  jiossiblv  l»y 
the  fusi((n  of  several  cells,  'i'lie  giant  cells  seem  to  be  in  inverse  ratio  to 
the  nundier  and  virulence  of  the  baiilli.  in  Inpus,  joint  tuberculosis, 
and  scrofulou.s  glands,  in  which  the  bacilli  arc  scanty,  the  giant  cells  are 
numci'ous;  while  in  miliary  tubercles  and  all  lesions  in  which  the  bacilli 
are  abundant  the  giant  cells  are  few  in  number. 

The  bacilli  then  cause,  in  the  first  place,  a  proliferation  of  the  iixed 
elements,  with  the  production  of  epithelioid  and  giant  cells;  and,  secondly, 
an  inllammatoiy  reaction,  a.ssociated  with  exudation  of  leucocytes.  Jlow 
far  the  leucocytes  attack  and  destroy  the  bacilli  has  not  hei'U  (lefinit(dy 
settled — ^letschink(df  clainung,  JJaumgarti'U  denying,  an  active  jihago- 
cytosis. 

(;>)  The  Degeneration  of  Tubercle. — Tlu're  are  two  chief  forms  of  de- 
generati(»n: 

((()  C  lineal  ion. — .\t  the  central  jiart  of  the  growth,  owing  to  the  direct 
action  of  the  bacilli  w  their  products,  a  jirocess  (d'  coagulation  necrosis 
goes  on  in  the  cells,  which  lose  their  oulliiu',  liecomc  iricgular,  no  longer 
take  slains,  and  arc  finally  converted  into  a  homogeneous,  structureless 
substance.  rrocee(|ing  fidin  the  centre  outward,  the  tubercle  juay  he  grad- 
ually converted  into  a  ydlowish-gray  body,  in  which,  however,  the  bacilli 
are  still  abundant.  No  blood-vessels  are  found  in  them.  Aggregated  to- 
gether these  form  the  cheesy  masses  so  common  in  tuberculosis,  which 
may  undergo  softeidng.  fibroid  linutation  (encapsulation),  or  calcification. 

(h)  Sch'r(i)iis. — With  the  necrosis  of  the  cell  elements  at  the  centre  of  the 
tubercle,  hyaline  transformation  ])roceeds,  together  with  great  increase  in 
tile  fibroid  elements;  so  that  the  tubercle  is  converted  into  a  firm,  hard 
structure.  Often  the  change  is  rather  (d'  a  libro-caseous  nature;  but  the 
sclerosis  ])redonnnates.  In  some  situations,  as  in  the  jieritonaMim,  this 
seems  to  be  the  natural  transformation  of  tuln'icle,  and  it  is  by  no  means 
rare  in  the  lungs. 

In  all  tubercles  two  processes  go  on:  the  oiu> — ca.seation — ilestructive 
and  dangiM'ous;  and  the  other — sclerosis — conservative  and  lu'aling.  The 
ultimate  ri'sult  in  a  given  case  depends  upon  the  ca|)abilities  of  the  bodv 
to  restrict  and  limit  the  growth  of  the  bacilli.  There  are  tissue-soils  in 
which  the  bacilli  are,  in  all  probability,  killed  at  once — ihc  sn'd  has  fallen 
hji  Ihc  waysiih'.  There  are  others  in  which  a  lodgment  is  gained  and  more 
or  less  damage  done,  but  finally  the  day  is  with  the  con.servative,  protecting 
forces — Ihe  need  lias  fallen  iipnn  shuni  i/munil.  Thirdly,  there  are  tissue- 
soils  in  which  the  bacilli  grow  luxuriantly,  caseation  and  softeidng,  not 


272  SPECIFIC  INFECTIOUS  DISEASES. 

limitation  and  i=clorosis  im'vnil,  and  the  day  i^  with  the  invaders— //ic  seed 
//((.s'  fallen  iiiuni  ijaud  <inniml. 

T\w  action  of  the  l)ai'illi  injected  directly  into  the  hlo<Ml-ves?els  illus- 
trates inaiiv  points  in  tlic  histolojry  and  patliolojry  of  tnhorculosis.  If  into 
tiie  vein  of  a  ral)liit  a  imrc  culture  of  the  bacilli  is  injected,  the  microbes 
accumulate  cbicily  in  the  liver  and  spleen.  The  animal  dies  usually  with- 
in two  weeks,  and"  tlie  or^rans  apjiarently  show  no  trace  of  tul)ercles.  .Micro- 
scopicallv,  in  both  spleen  and  liver  the  young  tubercles  in  process  of  I'orma- 
tiiui  are"  very  numerous,  and  karyokinesis  is  going  on  in  the  liver-cells. 
After  an  injection  of  a  more  dilute  culture,  or  one  whose  virulence  has 
bejn  mitipat'ed  by  age,  instead  of  dying  within  a  Anlnight  the  animal  sur- 
vives for  five  or  six  weeks,  by  which  time  the  t'jbercles  are  apparent  in  the 
sjileen  and  liver,  and  often  in  the  other  organs. 

(4)  The  diffused  Inflammatory  Tubercle.— This  is  most  frequently  seen  in 
the  lungs.  Oidy  a  great  master  like  Virchow  cou^'i  have  won  tlie  profes- 
sion fro'in  a  belief  in  the  nuihi  of  plillm^is,  which  the  genius  of  Laeunec 
had,  on  anatomical  ground,  announced.  Here  and  there  a  teacher,  as 
Wilson  Fox,  jirotcsted,  but  the  heresy  prevailed,  and  we  repeated  the  strik- 
ing ajdiorism  of  Niemeyer,  "  The  greatest  evil  which  can  hapiien  to  a  con- 
sum])tive  is  that  he  should  become  tuberculous."  It  was  thought  that  tiie 
products  of  any  simple  inllammation  might  become  caseous,  and  that  ordi- 
nary catarrharimeumonia  terminated  in  phthisis.  It  was  ])eculiarly  fitting 
that  from  (iermany,  in  which  the  dualistic  heresy  arose,  the  truth  of  Laeii- 
nec's  views  slumld  receive  incontestable  proof,  in  the  demonstration  by 
Koch  of  the  etiological  nnity  of  all  the  various  processes  known  as  tuber- 
culous and  scrofulous. 

Infiltrated  tubercle  results  from  the  fusion  of  many  small  foci  of  in- 
feetion— so  small  indeed  that  they  may  not  be  visibh'  to  tiie  naked  eye,  but 
which  histoloiricallv  are  seen  to  be  comimsed  of  scattered  centres,  sur- 
rounded by  areas  in  which  the  air-cells  are  filled  with  tiie  i.rodncts  of  exu- 
dation and  of  the  proliferation  of  the  alveolar  epithelium.  Vnder  the  milu- 
ence  of  the  bacilli,  caseation  takes  ]dace,  nsually  in  small  grouj.s  of  lobules, 
occasionallv  in  an  entire  lobe,  or  even  the  greater  luirt  of  a  lung.  In  the 
early  staireof  the  process,  the  tissue  has  a  gray  gelatinous  appearance,  the 
qraii  vi/Ut ration  of  Laennec.  The  alveoli  contain  a  sero-fibrinous  fluid  with 
"celi^  and  the  septa  are  also  infiltrated.  These  cells  accumulate  and  undergo 
coagulation  necrosis,  forming  areas  of  caseation,  the  infiHratwn  tubercuhiise 
lavne  of  Laennec,  the  scrofuhnis  or  cheesy  pneumonia  of  later  writers. 
There  may  also  bo  a  diffuse  iniiltration  and  caseation  without  any  special 
foci,  a  widespread  tuberculous  pneumonia  induced  by  the  bacilli. 

After  all,  the  two  processes  are  identical.  As  Banmgarten  states: 
"There  is  no  well-marked  difT'ercnce  between  miliary  tuliercle  and  chronic 
caseous  ]menmonia.  Speaking  histologically,  miliary  tulierculosis  is  noth- 
ing else  than  a  chronic  caseous  miliary  ])neunionia,  and  chronic  caseous 
pn'ounionia  is  nothintr  but  a  tuberculosis  of  the  lungs." 

(5)  Secondary  Inflammatory  Processes.— (a)  The  irritation  caused  by 
the  bacilli  invariablv  produces  an  inflammation  which  may,  as  has  been 
described,  be  limited"  to  exndation  of  leucocytes  and  serum,  Init  may  also  be 


1 


nvatlers — (he  seed 

Idod-vospols  i\\\\>- 
.'I'culosis,  If  into 
ted,  the  mierobes 
lies  usually  witli- 
tul)ei'elos.  ^Jieri)- 
proeess  of  fornia- 
in  the  liver-cells, 
ose  virulence  hus 
it  the  animal  sur- 
■e  apparent  in  tlie 

'requently  seen  in 
e  won  tiie  profes- 
jenius  of  Laennee 
lere  a  teaelier,  as 
repeated  the  strik- 

liapjien  to  a  eon- 
;  thoujiht  that  the 
)us,  and  that  ordi- 
s  ])eeuliarly  fittinij: 
the  truth  of  Laen- 

denioustration  by 
s  known  as  tuher- 

•  small  foci  of  in- 
the  naked  eye,  hut 
cred  centres,  sur- 
le  ])roducts  of  exu- 
.  I'nder  the  inilu- 
•jjrouiis  of  lolmles, 
of  a  lung.  In  the 
us  appearance,  the 
filn-inous  fluid  with 
iiulate  and  undergo 
'Iratimi  tuhcrculctise 
a  of  later  writers, 
vithont  any  special 
le  bacilli. 

?aumgarten  states: 
il)ercle  and  chronic 
iberculosis  is  noth- 
nd  chronic  caseous 

•ritation   caused  l)y 

may.  as  has  been 

im,  Init  may  also  be 


TUBERCrLOSIS. 


273 


much  more  extensive,  and  wliich  varies  with  varying  conditions.  We  find, 
for  example,  about  the  smaller  tuiiercles  in  the  hmgs,  pneumonia — either 
catarihal  or  librinuus,  jn'olilVriilion  of  the  connective-tissue  elements  in  the 
M'pta  (whicii  also  iiecome  inliltratcd  with  round  cells),  and  changes  in  the 
blood  and  lyni]ili-vessels. 

(h)  In  processt's  of  minor  intensity  the  inflammation  is  of  the  slow 
reactive  nature,  wliich  results  in  the  production  of  a  cicatricial  connective 
tissue  whicli  limits  and  restricts  the  development  of  the  tubercles  and  is 
llie  essential  conservative  element  in  the  disease.  It  is  to  be  remembereil 
that  in  cbi'onic  ]iuliiionary  tuberculosis  much  of  the  fibroid  tissue  which  is 
jiresciit  is  not  in  any  way  associated  with  the  action  of  the  bacilli. 

((■)  .Sujipurati(ui.  Do  the  bacilli  themselves  induce  suii|)uration?  In 
so-called  cold  tulierculous  abscess  the  material  is  not  histologically  ])us, 
but  a  (/('//;-(cS-  consisting  of  broken-down  cells  and  cheesy  material.  It  is 
moreover  sterile— that  is,  does  not  contain  the  usual  pus  organisms.  The 
]iroducts  of  the  tulici'cle  bacilli  are  probably  aiile  to  induce  sujipuration, 
as  in  joint  and  bone  (ul)i'rcidosis  pus  is  freciiiently  produced,  although  this 
may  lie  due  to  a  mixed  infection.  Koch,  it  will  be  remembered,  states 
that  the  '"  tuberculin  "  is  one  of  the  best  agents  for  tlu'  iirodiiction  of  ex- 
]ierimental  suppuration.  In  tuberculosis  of  the  lungs  the  suiipuration  is 
largely  tiie  result  of  an  infection  with  ])us  organisms. 

II.  Ac'iTE  TriiKiiCi'i.osiR. 

The  truly  infective  nature  of  tubercle  is  best  shown  in  this  alTeetion, 
whicli  is  characterized  by  an  eruption  of  miliary  tubercles  in  various  parts 
of  the  body.  The  clinical  ])icture  varies  with  the  general  or  localized  dis- 
tribution of  the  growths.  The  tubercles  are  found  iqion  the  pleura  and 
jieritonieum;  in  the  lungs,  liver,  kidneys,  lymph-glands,  and  spleen;  upon 
the  memitranes  of  the  brain,  occasionally  in  the  choroid  coat  of  the  eye, 
and  in  the  bone-marrow.  They  may  be  abundant  in  some  organs  and 
scanty  in  otisers.  Thus,  in  the  meninges  of  the  brain  they  may  he  thickly 
set,  while  there  are  few  or  none  in  the  abdominal  viscera  or  in  the  lungs. 
On  the  other  hand,  the  lungs  may  be  studded  with  granulations  while  the 
meninges  of  the  brain  arc  free.  In  other  cases,  again,  the  distribution  is 
uniform  in  all  the  viscera. 

The  cliolofjii  has  lieen  in  part  considered,  and  the  mily  additional  state- 
ment necessary  is  that  in  a  great  majority  of  all  cases  it  is  an  auto-infeclion, 
arising  from  a  pre-existing  tuberculous  focus,  which  may  be  latent  and  un- 
sus])ccted.  The  following  are  the  most  common  sources  of  general  infec- 
tion: Local  disease  of  tiie  lungs,  which  may  be  (piite  limited  and  unpro- 
ductive of  symptoms;  tuberculous  alTcction  of  tlic  lymph-glands,  ]iarticu- 
larly  in  children;  and  tuberculosis  of  the  bones  and  of  the  kidneys.  Of 
these  sources  ]terhaps  the  most  common  are  the  tracheal  and  bronchial 
lymjih-glands,  mIucIi  are  so  often  the  seat  of  local  tuberculosis.  Weiirort 
has  shown  that  in  many  cas(>s  the  infection  results  from  the  rupture  of  a 
caseous  pulmonary  nodule  into  a  vein,  or  of  a  caseous  bronchial  gland  into 
one  of  the  itulmonary  veins.     \  general  infection  may,  as  shown  Ijy  Pon- 


I 


274 


SPECIFIC   IXFECTIOUS   DISEASES. 


f.ck,  result  from  invasion  of  ll>o  thoracis  duot  l.y  tubercles.     ^^ '^^^     '^ 
care  the  sonreo  of  infoetion  can  usually  l.o  discovered  at  ].,.st-nu)rteni  ex- 
anunation.     Ti.e  connection  between  tuberculous  lynu.ii-glan.ls  and  vems 
has  often  been  den,onstrat..i.     In  n.any  instances  j    .s  unpossd,  o  to    ay 
what  deternunes  the  su.lden  and  violent  onset  of  the  disease      It  mo   1 
seem  sometin.es  as  if  general  rather  than  local  conditions  inlluenced  tl  . 
outbreak.     After  certain  fevers,  particilarly  measles  and  wu.o,„ng-couj.h 
"d;ildren-airee.tions.  it  is  true,  which  are  associated  with  l<>ng-e  mtinue 
bronchitis-miliary  tuberculosis  is  not  nnco.nnu.n.     'lie  pro,.    ati(,n  an 
constitutional  weakness  which  follow  protracted  tevers  IrcHU.ntly  seem  in 
the  adult  to  be  a  iiredisposiiifj;  cause.  v   -i    i 

Clinical  Forms. -For  practical  purposes  the  cases  may  be  d.vulu 
int.)  those  with   the  symptoms  of  andr  <jmnal  infcdion  without  special 
localization;  cas(.s  with  marked  pulmonary  symptoms;  and  cases  witli  rerc- 

hral  or  cercbro-siiliinl  symptoms.  ,.-,.■■  ,  i,,.„.„  ,„., 

Other  forms  have  been  recognized,  hut  this  division  covers  a  laig.,  ma- 

ioritv  of  the  cases.  ,  ■        ^  e  c 

Takincr  any  scries  of  cases  il  will  be  found  that  the  meningeal  form  o 
acute  tuberculosis  exceeds  in  numbers  the  cases  with  general  or  marked 

Dulmonarv  symptoms.  .     .    ,  * 

1.  General  or  Typhoid  Forin.-.'^//»^/^/.;m.s.-The   patient   here  presents 
the    symptoms    of    an    infecti.ms    disease    with    few    if    any    local    signs. 
The  aises  simulate  and  are  frequently  mistaken  for  tyi.hoid  fever.     Altei 
a  period  of  failing  health,  with  loss  of  appetite,  the  ,mt lent  becomes  fever- 
ish and  weak.     Occasionally  the  disease  sets  in  mon<  abrn,.t  y,  but  m  ma 
instances  the  anamnesis  closely  resembles  that  ol    tyi-hmd    i.yer.      .Nose- 
bleeding,  however,  is  rare.     The  temperature  increases,  1  he  puU3  hecoines 
rapid  and  feelde,  the  tongue  dry;  delirium  becomes  ">=';'1-;V''';'     V;/   ;.',; 
are  flushed.     The  i^ulmonary  symptoms  may  be  very  slight  ;uMiall)   b.on- 
chiti-  exists  but  not  more  severe  than  is  common  with  typhoid  lever      Hit 
mi;is  seldom  dicrotic,  but  is  rapid  in  proporti<m  to  the  Py-'-    I'^  -IjJ 
he  most  striking  feature  of  the  tem],eratnre  is  the  irregu  a.  tv     and   it 
seen  from  the  ou'tset  there  is  not  the  steady  ascent  noted  in  tv^hoid  feve, 
Theri    usually  an  evening  rise  to  103°,  sometimes  104°,  and  a  morning 
remission  of  from  two  to  three  degrees.    Sometimes  the  pyrexia  is  intenu.  - 
tent,  and  the  thermometer  may  register  below  norma    during  the  ea 
m    nin.^  hours.    The  inverse  type  of  temperature,  m  which  the  rise  take. 
■    in  the  morning,  is  held  by  some  writers  to  be  more  frequent  in  gen- 
r     tuberculosis  tluin  in  other  diseases.     In  rare  instances  there  may  he 
1^  e       1  0  fever.    On  two  occasions  I  lune  liad  a  patient  admitted  to  my 
li-^sTu  a  condition  of  prof<n,nd  .lebilily.  will,  a  history  of  illness  of  from 
In-ci  to  four  weeks'  durlitiou,  with  rapid  pulse,  flushed  cheeks,  dry    ongue, 
nml  V  ry  ^li^'l't  elevation  in  temperature,  in  whom  (post  mor  em)  tlic  con- 
•      dition  proved  to  he  general  tuberculosis.     In  one  instance  there  was  tol- 
X^exie^ive  disease  at  the  right  apex.     Eeinliold,   from   I  aumler  s 
c     ic  has  recently  called  attention  to  these  afebrile  forms  of  acute  tuber- 
culous    In  !1  of  52  cases  there  was  no  fever,  or  only  a  transient  rise. 

Iifa  considerable  number  of  these  cases  the  respirations  arc  increased 


TUBERCULOSIS. 


:a) 


With  special 


isl-iu()rU'in  ox- 
iiuls  and  veins 
possible  to  sny 
liise.     It  would 

inlhienced  the 
.hooping-eough 

long-e  )ntiniie(l 
prostration  and 
(U  iitly  seem  in 

may  he  divided 
without  special 
cases  with  cerc- 

k'crs  a  large  nia- 

ningeal  form  of 
leral  or  marked 

it  here  presents 
my    local    signs, 
lid  fever.     After 
t  lieconies  fcver- 
tly,  hut  in  many 
id    fever.     Nose- 
i(>  judse  becomes 
il  and  the  cheeks 
it;  usually  bron- 
liioid  fever.     The 
tyrexia.    IVrhajis 
egularity;  aiul  if 
in  typhoid  fever. 
',  and  a  morning 
'rexia  is  intermit - 
during  the  early 
ich  the  rise  takes 
frequent  in  gen- 
ces  there  may  he 
t  admitted  to  my 
of  illness  of  from 
iceks,  dry  tongue, 
mortem)  the  con- 
ice  there  was  tol- 
,   from   Biiumler's 
ns  of  acute  tuber- 
msient  rise. 
:ions  are  increased 


in  frequency,  particularly  in  the  early  stage,  ami  there  may  be  signs  of  dif- 
fuse bronchitis  ami  slight  cyanosis.  Chcyne-Stokes  breathing  dcvt'lops 
toward  the  close. 

Active  delirium  is  rare.  More  commonly  there  are  torpor  and  dulness, 
gradually  dceiiening  into  coma,  in  which  the  patient  dies.  In  smue  eases 
the  ]udmonary  symptoms  become  more  marked;  in  others,  meningeal  or 
cerebral  features  develop. 

J)l(i)jii(isis. — The  dilferential  diagnosis  between  general  miliary  tuber- 
culosis without  local  manifestations  and  typhoiil  fever  is  extrenu'ly  dilli- 
cult.  A  point  of  importaiu-e,  to  which  reference  has  already  been  maile, 
is  the  irregularity  of  the  temperature  ciirvc.  The  greater  fretpu'ucy  of 
the  respirations  and  the  tendency  to  slight  cyanosis  is  much  more  com- 
mon in  tuberculosis.  'I'here  are  cases,  however,  of  typhoid  fever  in  whicli 
the  initial  iironchitis  is  severe  and  may  lead  to  dyspmea  and  distui'i)ed 
oxygenation,  'i'he  cough  may  be  slight  or  absent.  Diarrlnea  is  rare  in 
tul)cre\dosis;  the  bowels  are  usually  constipated;  but  diarrluea  may  occur 
and  persist  for  days.  In  certain  cases  the  diagnosis  has  been  complieate(l 
still  further  by  the  occurrence  of  blood  in  the  stools.  Mnlargemeiit  of  the 
sjilcen  occurs  in  genei'al  tubercidosis,  but  is  neitlu'r  so  early  nor  so  marked 
as  in  ty])hoiil  fever.  In  children,  however,  the  enlargement  may  be  con- 
siderable. The  mine  may  show  traces  of  albunnn,  and  unfortunately 
Mhrlicirs  diazo-rcaetion.  which  is  so  constant  in  tyjjhoid  fever,  is  also  MU't 
with  in  general  tuberculosis.  The  absence  of  the  characteristic  roseola  is 
an  iin|)ortant  fcatui'c.  Occasionally  in  acute  tid)ereulosis  reddish  spots 
may  develop  and  for  a  time  ca.(se  dilliculty,  but  they  do  not  come  out  in 
erojis,  and  rarely  have  the  characters  of  the  true  typhoid  eruption.  Herpes 
is  ])erha]>s  mote  c(unmiin  in  tuberculosis.  Toward  the  close,  petechia'  may 
ai)peiir  on  the  skin,  ]iarticularly  about  the  wrists.  A  rare  event  is  jaundice, 
due  ]iossibly  to  the  eruption  of  tubercles  in  the  liver.  Tt  is  to  be  remem- 
bered that  the  lesions  (d"  acute  tuberculosis  and  of  ly|)hoi<l  fever  have  been 
demonstrated  in  the  same  body. 

In  a  fi'W  instances  the  presence  of  tuber(de  bacilli  has  been  demon- 
strated in  the  blood,  which  in  dcndttful  cases  should  therefore  be  examineil. 
The  spleen  has  been  punctured  and  cultivations  made  to  d<'termine  the 
))resence  or  absence  (d'  the  tyi)hoid  bacilli,  but  in  the  acute  splenic  tumor 
this  is  a  dangerous  ]H'ocedure.  'llie  eye-grounds  should  be  carefully  exam- 
ined for  choroidal  tubercles.  The  blood  may  show  a  slight  lencocytosis,  but 
in  the  very  acute  cases  where  there  are  no  suppurating  foci  this  is  absent. 
The  Widal  reaction  is  now  a  most  im])ortant  hclji  in  the  diagnosis. 

2.  Pulmonary  Form. — Siimploms. — From  the  outset  the  pulmonary 
symptoms  are  marked.  The  italient  may  have  had  a  cough  for  uKmtlis  or 
for  years  without  much  im])airnu'nt  of  health,  or  he  may  b(>  known  to  be 
the  subject  of  chronic  pulmonary  tuberculosis.  In  other  instances,  ])articu- 
larly  in  children,  the  alTeetion  f(dlows  measles  or  whooping-cough,  and 
is  of  a  distinctly  broneho-])mmmonic  type.  The  disease  l)egins  with  the 
symptoms  of  dilfuse  bronchitis.  The  cough  is  marked,  th(>  expecloratiou 
mnco-]mndent,  occasionally  rusty.  Tlannoiitysis  has  been  noted  in  a  few 
instances.     From  the  outset  dyspnum  is  a  striking  feature  and  may  be  out 


276 


SPECIFIC  INFECTIOUS  DISEASES. 


of  jiropnrtion  to  the  intiMisity  of  the  j-hysiciil  sij^ns.    There  i^^  innro  or  less 
oyiuiosis  of  the  hps  and  Ihijier-tiiis,  aiul  the  eheeks  are  siilTused.     Apart 
from  eiiiphysonia  and  tlie  hiter  stajres  of  severe  pneumonia  1  knmv  of  no 
other  i.nlmonarv  condition  in  whiili  tlie  cyanosis  is  so  marked.     The  phys- 
ical signs  are  tiiosc  of  bronchitis.     In  ciiihlrcn  Ihere  may  he  defective  reso- 
nance at  tiie  l)ascs,  from  scattered  areas  of  broncho-pneumonia;  or,  wluit  is 
(■.pmllv  sugtiestive,  areas  of  hyper-resonance.     Indeed,  tlie  percussion  note, 
].artic"ularlv  in  the  fnmt  of  tlie  chest,  in  some  cases  of  miliary  tuberculosis, 
is  full  and  clear,  and   it  will  be  note<l  (p"st  mortem)  that  the  lungs  are 
unusually  voluminous.     This  is  probably  the  result  of  more  or  less  wide- 
spread acute  enu.hvsema.     On  auscultation,  the  rfiles  are  either  sibilant 
and  sonorous  or  small,  line,  and  crepitant.    There  may  be  line  crepitatu,.', 
from  the  occurrence  of  tubercles  on  the  jileura  (Jiirgensen).     In  children 
there  may  be  liigh-i)itclied  tubular  breathing  at  the  Imses  or  toward  the 
root  of  the  lunir.     Toward  the  close  the  rfiles  may  lie  larger  and  more  mu- 
cous.   Tiie  tcmiu'rature  rises  to  h)r  or  103°,  and  may  present  the  inverse 
tyiie.     The  pulse  is  rapid  and  feeble.     Tn  the  very  acute  cases  the  spleen 
ii  always  enlarged.     Tlie  disease  may  prove  fatal  in  ten  or  twi'lve  days,  or 
may  l)e  protracted  for  weeks  or  even  months. 

"niiniiiosis.—'nw  diagnosis  of  this  form  olfers  less  dilliculty  and  is  more 
fretiuently  made.  There  is  often  a  history  of  previous  cough,  or  the  patient 
is  known  to  be  the  subject  of  local  disease  of  the  lung,  or  of  the  lymph- 
glands,  or  of  the  bones.  In  children  these  symptoms  following  measles 
or  whooping-cough  indicate  in  the  majority  of  cases  acute  miliary  tuber- 
culosis, with  or  without  hroncho-pneumonia.  Occasionally  the  sputum  con- 
tains tubercle  bacilli. 

The  choroidal  tubercle  occurs  in  a  limited  number  of  cases  and  may 
help  the  dia-mosis.  :More  imp<irtant  in  an  adult  is  the  combination  ot 
dyspn.ea  with  cvanosis  and  the  signs  of  a  dilfuse  bronchitis.  In  .^  .mo  in- 
stances the  occurnnice  of  cerebral  symi)toms  at  once  gives  a  clew  *o  the 
nature  of  the  trouble. 

3.  Meningeal  Form  {Tiihrrnihus  .¥(•«(«////(>•.  nasihr  Mciiiii(iilis).—  nn^ 
afTecli.m,  which  is  also  known  as  acute  hydr.K'ephalns  or  "water  on  the 
brain  "  is  essentiallv  an  acute  tuberculosis  in  which  the  meiidiranes  of  the 
brain.  s(mietimes  of  the  cord,  bear  the  brunt  of  the  attack.  Our  first  ac- 
curate knowledge  of  tliis  affection  dates  from  the  i.ublication  ol  l{obert 
\VbvtiV  nb.-ervations  on  the  Dropsy  (d'  the  Krain,  Edinburgh,  ITCS.^  The 
literature  is  very  fullv  given  in  the  last  edition  of  r.arthez  and  Sannee. 

Tlunigh  (luersant'had  as  early  as  \S'i7  used  the  name  granular  meuin- 
r/N's  for  This  form  of  inllammation  of  the  meninges,  it  was  not  until  1830 
that  Papavoine  demonstrated  the  nature  of  the  granules  and  noted  their 
occurrence  with  tul)ercles  in  other  jtarts. 

In  is;?t3  ami  Is:]:'.,  W.  W.  (ierhard,  of  riiiladelphia,  made  a  very  carclul 
«tudv  of  the  disease  in  the  Thildren's  Hospital  at  Paris,  and  his  publica- 
tions, more  than  those  of  any  other  author,  served  to  jdace  the  disease  on 
a  firm  anatomical  and  clinical  basis. 

There  are  several  special  cUohqiral  factors  in  connection  with  this  form. 
It  is  much  more  common  in  children  than  in  adults.    It  is  rare  during  tlio 


is  innro  or  los.s 
H'lisotl.     Apaii 

I  know  of  11(1 
■d.  The  \Aiyi- 
dofcctivo  reso- 
ia;  or,  what  i~ 
I'lviissioii  not^^ 
•V  tubcroiilosis, 

\\\v  lungs  ai'o 
(•  or  h'ss  wide- 

cMtlior  sil)ihint 
line  crepitatit./ 
).     In  (.'hildrca 

or  toward  Ih.' 

and  more  imi- 
eiit  the  inverse 
ases  tlie  spU'eii 
twi'lve  days,  or 

Ity  and  is  more 
,  or  tlie  imtieiit 
of  the  ]ymj)h- 
lowing  measles 
miliary  tuber- 
he  sputum  eon- 
cases  and  may 
coTiibination  of 
s.     In  .-  >mo  in- 
s  a  clew  *')  the 

iiin(iilis). — 't'liis 
"  water  on  the 
■mliranes  of  the 
:.  Our  first  ac- 
ation  of  Kobert 
rgh.  nCS.  The 
aiul  Sannee. 
grainihir  mcnin- 
3  not  nntil  1830 
and  noted  their 

le  a  very  careful 
and  his  iiublica- 
e  the  disease  on 

1  with  this  form. 
!  rare  durinjr  the 


TUBERCULOSIS.  277 

first  year  of  life,  more  frequent  lietwecn  the  >eeond  and  the  (ifth  years. 
Ill  a  majority  of  the  eases  a  i'ocns  of  old  tuberculous  disease  will  be  fmmd, 
eommoiily  in  the  bronchial  or  mesenteric  elands.  In  a  few  in>tances  the 
airectioii  seems  to  be  primary  in  the  mcnin;:cs.  It  is  very  dillicult,  how- 
ever, in  an  ordinary  post  mortem  to  make  an  exhaustive  search,  and  the 
lesion  may  be  in  the  bones,  sometimes  in  the  middle  ear,  or  in  the  genito- 
urinary organs.  In  those  instances  in  which  no  primary  focus  has  been 
discovered  it  has  been  sii;rgestcd  that  the  bacilli  vvi\r\\  llie  meninges  through 
the  criliril'orm  plate  of  the  ethmoid  from  tlu'  upper  jiarl  of  the  nostrils,  but 
this  is  not  |iroliable. 

Miirhiil  .[iKtlniinj. —  Tuberculous  meningitis  presents  a  very  character- 
istic picture.  The  meninges  at  the  basi'  are  most  invidved,  hence  the  term 
basilar  meningitis.  The  parts  al)out  the  o[)tie  chiasm,  the  Sylvian  lissures, 
and  the  interpeiluncular  space  are  all'ected.  There  may  be  only  slight  tur- 
bidity and  matting  of  the  membranes,  and  a  certain  stickiness  with  serous 
inliltration;  ]}ut  more  commonly  there  is  a  turbid  exudate,  llbrino-purulent 
in  character,  which  covers  the  structures  at  the  base,  surnuinds  the  nerves, 
extends  out  into  the  Sylvian  lissures,  and  appears  on  the  lateral,  rarely  on 
the  upper,  surfaces  of  the  hemispheres.  The  tubercles  may  be  very  appar- 
ent, ])articiila!ly  in  the  Sylvian  lissures,  np])earing  as  small,  whitish  nodules 
on  the  membranes.  They  vary  much  in  number  and  size,  and  may  be 
dillicult  to  find.  The  amount  of  exudate  bears  no  delinite  relation  to  the 
abundance  of  tubercles.  The  arteries  (d'  the  auti'rior  and  ])ostcrior  )icr- 
forated  spaces  should  l)e  carefully  withdrawn  and  searched,  as  upon  them 
nodular  tubercles  may  be  found  when  not  present  elsewhere.  Jn  doubtful 
cases  the  middle  cerebral  arteries  should  bi'  very  carefully  removed,  sju'cad 
on  a  glass  ]ila(e  with  a  black  background,  and  exaiuincd  witii  a  low  ob- 
jective, 'i'lie  tubercles  are  then  seen  as  mulular  enlargements  on  the  smaller 
arteries.  The  lateral  ventricles  are  dilated  (acute  hydrocephalus)  and  con- 
tain a  turbid  fluid;  the  ependynia  may  ho  softened,  and  the  septum  luciduin 
and  fornix  are  usually  broken  down.  The  convolutions  are  often  flattened 
and  the  sulci  obliterated  owing  to  the  increased  intra-ventriciilar  pressure. 
There  is  a  tuberculous  endarteritis  with  the  formation  of  intimal  tuber- 
cles, due  to  imidantaticm  of  bacilli  from  the  blood  (llektoen).  I'ndifera- 
tion  in  the  adventitia,  with  invasion  of  the  media  ami  intinia  arc  common, 
forming  nodular  circumscribed  tubercles.  The  lumen  of  the  vessel  is  nar- 
rowed and  thrombosis  may  result.  The  meninges  are  not  ahme  involved, 
but  the  eontignons  cerebral  substance  is  more  or  less  (edematous  and  infil- 
trated with  leucocytes,  so  that  anatomically  the  condition  is  in  reality  a 
men  i  iifjo-enrcphaUl  is. 

There  are  instances  in  which  the  acute  ])roccss  is  associated  with  clironio 
meningeal  tuberculosis;  cases  which  may  for  months  jircscnt  the  clinical 
})icturc  of  brain  tumor. 

Although  in  a  majority  of  instances  the  process  is  cerebral,  the  s|)inal 
meninges  may  also  he  involved,  ])articularly  those  of  the  cervical  cord. 
There  are  eases  indeed  in  which  the  symjitoms  are  chieily  s|)inal.  A  sailor, 
who  had  fallen  on  the  deck  three  weeks  before  his  death,  was  admitted  to 
the  ^Montreal  (ieneral  Hospital.     He  presented  signs  of  meningitis,  chieily 


.1 


SPECIFIC  INFECTIOUS  DISEASES. 


278 

spinal,  whi.l.  won.  .umually  atfil.utnl  to  tnunnati.m      Tluj  ,..>t  ,nor,n. 

;        ,.v    ..•..ptiu,,  ..!•  ...ilia.'y  lul.c..vU.s  will.  n.,.c.h  Unind  Iv.npli  osor  th 
^^u";  Spinal  \,....n,„.s.     'riu..v  w....  s„.all.h..sy  n.asscs  al  iho  a,...c.  ul 

""^v"'X..s.-'r„lH..vulnns    ,.u...inj.i.is    pr.sont.   a..   oxt.vmcly    .omiAcx 
,Ii„  ;.!  Utwc.     It  will  he  best  to  d.M  ril.e  ti.o  fonn  iound  ..j  .■l..ia..n 
Pnl  n....al  .yn.,>l....,s  a.v  ........o...     Th.  .l..!.    may  have    a...  m J.^- 

i„„  i,,altl.  r...'  s-.n.c'  weeks,  ..,•  „.ay  l.e  .•o,.vales..e..t    .-m  meas  e.  o    wh  o.- 
;.  n     1.      I.,  ...a..v  i..sta.ues  there  i.  a  history  of  a  h.ll         ,.e  eh.iagel. 
u,      ^Ul..ss,  ,H.:.vish.   irritai,le,  loses   its  appetite    a.,.l   the  d.spos.fo, 
\.;;„;  letely  eha.„e.     Sy.,.p,o,ns  pointi.,,  to  the  <!--  -y .    ;-  - 
i„  Vithe.-  ....it  .  su<Me.,lv  With  a  eo.iv.ilMo.,,  or  ...O.V  e..„.mnnl.>  Nv.th  ha- 

ai.        :  ,.ti>...  a..i    r.:ver,  th.ee  e.se.,tial   sy„.p,o...s  of   the   -.s.4    ^v^,  e 
uv     •..■elv  ah  e..t.     The   imi..   ...ay  he  i..te„se  an.l   a-oiHZ..ig.      Ihe  child 

t.  a   d'  to  its  head'a„d  oeeaMo,.ally.  whe,.  .he  pa...  Weonu.  ^^ursc^ 

i;     s      s,ort,  s„d.le„  e..y,  the  so-ealled  hy.lroeephahe  e,.y.     -;;";!' -■,^- 

dil.l  se.ra,..s  eo,.ti>,..o„sly  „..til  utterly  exha„sted      1  saw  ..    N\ p  1 

,     .hia  a  ease  of  l,asila,.  me-un^^itis  i..  a  jjirl  of  th..- teen,  who    or  t h.eo 

'       ,    .  ..ot   ,...der  the  inlh.eneo  of  a  powerf.,1  sedat.ve  <.r  ol   ehlor.  - 

:   „;    s       n.  ed  at  the  lop  of  her  voiee  so  as  to  he  hea..l  a  s,..a.v  or  mo  e 

:":    The  vonnti,.,  is  Jitl.o.U  appa.vnt  eaaso,  am    ,s  -1^T-'l-    ;;•  ^^ 

"■       ;l      .,   d  <1  w      Th     r L  .  >tio.,s  are  rarely  altered.     During  sleep  the 
ehU:        r       e      Lid  dI:t..r.K'd.     The.,  u.ay  he  twitehn.gs  of  the  nu^es, 

?;;!f::^-;;;r;i;e;;;-;:t=r^^^^^^^^^ 

,.,,Uin.is..o,,4er,..a,.l<edth^^ 

tlu;    msc.les   .r  oue  side  or  of  one  lin.h.    The  temperature  .s  ^'""^  1^'    '^"|^ 
I  MU)°  tn  1()-'  5°       V  hlotehv  ervthema  is  not  uncommon  on  the 

':SJ'^U  t       (i    n>  -md    is  ^.awn  aoJoss-tho  skin  of  any  region  a  red  1... 
tZ.  ont  qui 'k!;.  the  so-ealled  lnrl,e  rnrM.  wl.ieh,  however,  has  no  d.ag- 

"'i'  ^r'l!;;rneriod    or  ^ta^^e  of  parahisi.,  the  eon.a  i,.oreases  and  the 

r,;     nn.^     e^  <1      r  -vulsi..ns  are  not   inf.-equcnt,  and  there  arc 

ch.ld  '•  ""^        ,     ';  ;;  ;^  ^,,,  ,„,,,,!,,  of  the  hack  and  neck.    S,.asnis  may 
spasn.od.ceontiact.onsott.nl  .^  ^^  ^^^^^  ^^^^,^^^ 

occur  .n  the    -^- "f  ^  ^  ^     "^    ^hecome  dilated,  the  eyelids  are  only 
nu.scles  may  he  prese  '    <^  P"1  ^^  ^^^^^  ^^^  ,„rnea>  are  only 


TUIJRKCULOSIS. 


279 


I'  jinst  inortom 
brain,  aiul  an 
•miili  ovor  till' 
.  UiL'  iipift'S  tit 

ini'ly    conipli'x 

in  ciiihln'n. 
c  boon  ill  I'ail- 
isU's  or  whuoi)- 
Tae'  cliiUl  gots 
tho  disiio.sili'tn 
L'  may  thou  sot 
)nly  with  licatl- 
ic  onsi't  wiiicli 
ng.  The  child 
l)i'cnnies  wors-o, 

Sonictiini'S  tho 
■  in  Wost  I'hil- 
,  who  i'or  tiiroo 
0  or  of  ohloro- 

sijnaro  or  inoro 
•licnth'iit  of  tak- 
■r  i?*  ^li^rht,  hnt 
id,  snhsoquently 
)nrin<!;  (^loop  tho 

of  tlio  ninsc'los, 
I  in  proat  torror. 
jse  arc  tlic  chief 
c  of  irrilalion. 
mptonis  subside; 
3tcd,  boat-shapod 

chihl  no  h)ngcr 
n  roused  is  more 
d  utters  an  occa- 
int  nuiy  devoktp. 
r,  or  ri-ridity  of 
is  varialdc,  ranp;- 
iicommon  on  tlic 
region  a  red  line 
ever,  has  no  diag- 

increascs  and  tlic 
it,  and  there  are 
}ck.  Spasms  may 
ysis  of  the  ocular 
c  eyelids  arc  only 
e  corncoD  are  only 
ievelop,  the  pulse 


leeonics  rapid,  and  tlic  diild  may  >ink  inio  a  typhoid  .-tatc  with  tiry  tongue, 
iiw  (h'liriuiii,  and  iiivoluniary  iNis.siges  of  urine  and  licrcs.     'I'bo  tcmpi'ra- 


lurc  often  becomes  t-ultnnrmal,  siid<ing  in  rare  instances  to  I);i'  or  IM 


In 


-oine  ca.-es  tiierc  is  an  ante-mortem  elevation  of  ti'Mipt  laturc,  the  ['vwv  rising 
■  )  10(j°.  'I'iie  entire  duration  of  the  disease  is  from  a  fortMigbl  to  throe 
or  four  weeks.  A  loucocylosis  is  not  infrcipu'iitly  present  throughout  tho 
disease. 

'riierc  are  ca^cs  of  tub-erciilous  meningitis  which  pursue  a  more  rapid 
tiiursc.  They  set  in  with  great  violcmc,  often  in  persons  apimrcntiy  in 
good  health,  and  jnay  ])rovo  fatal  within  a  lew  days.  In  those  instances, 
miire  commonly  seen  in  adults,  the  convex  surface  of  tho  brain  is  usually 
involved.  Tlii'rc  are  again  instances  which  arc  essentially  chronic  and 
disjilay  symptoms  uH  a  limited  meningitis;  sometimes  with  prouoimccd 
psychical  symptoms,  and  sometimes  with  those  of  cerebral  tumor. 

There  are  certain  features  whicli  call  for  special  c<;nin\cnt. 

The  irregularity  ami  slowness  of  the  pulst'  in  the  early  and  middle 
stages  of  the  disease  are  points  iipon  which  all  authors  agrei'.  Towni'd  the 
close,  as  the  lu'arl's  action  beconu's  weaker,  the  jndsations  arc  more  fre- 
(jucnt.  'i'iie  temperature  is  usually  elevated,  but  there  are  instances  in 
which  it  does  not  rise  in  the  whole  couise  of  the  disease  much  above  KKI". 
It  may  b(!  extremely  irregular,  and  the  oscillations  are  often  as  much  as 
throe  or  four  degrees  in  the  day.  Toward  the  close  the  temperature  may 
sink  to  f);")",  occasionally  to  !)  1°,  or  there  may  be  hyperpyrexia.  In  a  case 
of  I'.iiumler's  tho  tcmiioratnre  rose  before  death  to  Is.T"  "c.  (110. 7°  V.). 

The  ocular  symptoms  of  the  disease  are  of  s])ecial  importance.  In  the 
early  stages  narrowing  of  the  pupils  is  the  rule.  Toward  the  close,  with 
increase  in  the  intra-cranial  pressure,  the  pupils  dilate  and  are  irregular. 
There  may  be  conjugate  deviation  of  the  eyes.  Of  octdar  palsies  tho  third 
nerve  is  most  freqiu'utly  involved,  sometimes  with  ])aralysis  of  the  face, 
limbs,  and  hyimglossal  nerve  on  the  oiiposite  side  (syndrome  of  Weber),  duo 
to  a  lesion  limited  to  the  inferior  and  internal  jiart  of  the  cms.  The 
changes  in  the  eye-grounds  arc  very  important.  Neuritis  is  the  most  com- 
mon. According  to  Oowers,  the  disk  at  first  beeonu's  full  colored  and  has 
luizy  outlines,  and  the  veins  are  dilated.  Swelling  aiul  striation  become  pro- 
nounced, but  the  neuritis  is  rarely  intense.  Of  '2(\  cases  studied  by  (lar- 
lick,  in  6  the  condition  was  of  diagnostic  value.  The  tubercles  in  tho 
choroid  are  rare  and  nuich  less  frc([uently  seen  during  life  than  ])ost-mortem 
figures  would  indicate.  Thus  Litton  found  them  (post  mortem)  in  39  out 
of  52  cases.  They  were  present  in  only  1  of  tho  20  cases  of  tuberculous 
meningitis  examined  by  Oarlick.  TIcinzcd  examined  with  negative  results 
•11  cases. 

Among  the  motor  symiitoms  convulsions  are  most  common,  but  there 
are  other  changes  which  deserve  s])ccial  mention.  A  tetanic  contraction 
of  one  linil)  mav  persist -for  several  days,  or  a  caialeptic  condition.  Tremor 
and  athetoid  movements  are  sometimes  seen.  The  paralyses  are  either 
lieniiplegias  or  monoplegias.  TTcmiplegia  may  result  from  disturbance  in 
the  cortical  branches  of  the  middle  cerebral  artery,  occasionally  from  soften- 
ing in  the  internal  capsule,  due  to  involvement  of  the  central  branches. 


'a 


280 


SPECIFIC  INFECTIOUS  DISEASES. 


Of  iMonopli'gias,  tluit  of  tlic  Uuv  is  i>vy\v,iy^  most  ((.innioii,  ami  if  on  the 
ri"lit  sick'  it  iiiiiy  ucciir  witli  ii|.IiiiHa.  In  two  of  my  cases  in  adults  apliaMa 
(l^vdopod.  Mnic'liial  m(.n(.|.K'^^ia  may  hv  a>>oriat('d  witli  it.  In  tlu'  nioiv 
cluonic  oiisos  the  svmptonis  iiiTsist  lor  mouths,  and  tiu'iv  may  lu'  a  char- 
actoristir  Jarksonian  cpilri-sy  wiicu  the  IuIhtcU's  involvL'  thr  meninges 
of  tlu'  motor  corti'X. 

'I'ho  dia-uosis  of  iul Tculous  meningitis  is  rarely  ililli' nit.  and  points 
mu.n  whieirsiurial  stress  is  to  he  hud  are  the  existence  ..f  a  tuh.'reulou< 
focus  in  tiu'  h,,dv,  the  mode  of  onset  and  the  symptoms,  and  the  eviden.e 
ohtained  on  liunhar  puncture.  The  iluid  withdrawn  is  usually  turhid.  and 
in  it.  on  centrifugalizing.  the  hacilli  may  he  discovered.  A  sterde  IIukI, 
which  is  sometimes  preseid,  also  favors  the  diagnosis  of  tuherculous  menin- 
gitis. .  ,  , 

The  i>n>^iiinsi.^  in  this  form  of  meningitis  is  always  most  serious.  I  lia\e 
neither  seeii  a  case  which  1  reganlcd  as  tuherculous  recover,  nor  have  I 
seen  i-ost-mortem  evidence  of  i-ast  disease  of  this  nature.  Cases  of  recovery 
have  heen  reported  l)y  relial)le  authorities,  hut  they  are  extremely  rare,  and 
there  is  ahvavs  a  reasonalde  douht  as  to  the  correctness  of  the  diagnosis. 
The  dilTerenfial  features  and  treatment  will  he  considered  m  connection 
with  acute  meningitis. 


III.  TriM'RcrLosis  of  the  Lymphatic  Systkm. 

1.  Tuberculosis  of  the  Lymph-glands  {Sn-ofuht). 

Scrofula  is  tuhercle,  as  it  has  heen  shown  that  the  haciUus  of  Koch  is 
the  essential  element.     Formerly  special  attention  was  given  to  dillerent 
tvpes  of  scrofula,  of  which  two  important  forms  were  recognized— the  san- 
guine, in  which  the  child  was  slightly  huilt,  tall,  with  small  limhs,  a  line 
clear  skin,  soft  silkv  hair,  and  was  mentally  very  bright  ami  intelligent; 
and  the  phlegmatictviie,  in  which  the  child  was  short  and  thick-set,  with 
coarse  features,  mudd'v  complexion,  and  a  dull,  heavy  asjiect.     It  is  not  yet 
definitely  settled  whether  the  virus  which  i)rodiices  the  chronic  tul)erculous 
adenitis'or  scrofula  dilTers  from  that  which  ■)roduees  tuherculosis  in  other 
]iarts,  or  whether  it  is  the  local  conditions  in  the  glands  which  account 
i'or  the  slow  development  and  milder  course.     The  exi.eriments  of  Arloing 
would  indicate  that  the  virus  was  attenuated  or  milder,  iov  he  has  shown 
that  the  caseous  material  of  a  lymph-gland  killed  guinea-pigs,  while  ral)- 
hits  escajwl.     The  gninea-iiig,  as  is  well  known,  is  the  more  susceptible 
animal  of  the  two.    The  observations  of  Lingard  are  still  more  conclusive, 
as  showing  a  variation  in  the  virulence  of  the  tubercle  bacillus,     (hiinea- 
pi..s  inoculated  with  ordinary  tubercle  showed  lynii»hatic  infection  within 
the  first  week,  and  the  animals  died  within  three  months;  infected  with 
material  from  scrofulons  glands,  the  lym].hatic  enlargement  did  not  ap- 
i)ear  until  the  second  or  third  week,  and  the  animals  .survived  for  six  or 
^even  months,    lie  showed,  nun-eover,  that  the  virulence  of  the  infection  ob- 
tained from  the  .scrofulous  glands  increased  in  intensity  by  i^assing  through 
a  scries  of  ouinca-iugs.     Kve's  experiments  show  that  scrofulous  material 
Invariablv  in-oduccs  tuberculosis  in  guinea-pigs  and  very  often  in  rabbits. 


y\ 


TUBEUCULOSLS. 


US  I 


and  if  on  the 

adult::  aphasia 

Jn  tlu'  uiDTc 

may  ln'  a  diar- 

tlu'  iiu'iiiiigt"' 

lilt,  iind  |i(iinls 
I'  a  tul)"i'cul()iis 
1(1  till'  ovidtMUc 
ill;,  tui'iiid.  ami 
A  stfiiU'  tliiid, 
.Tculoiis  nicnin- 

gerious.  I  have 
•er,  nor  have  I 
ascs  of  recovery 
cinoly  rare,  and 
i  the  diagnosis. 
1  in  (.onuection 


I'M. 

illus  of  Koch  is 
^011  to  dill'cront 
niizt'd — the  san- 
all  linihs,  a  line 
and  intelligent; 
1  thick-set,  with 
■t.    It  is  not  yet 
onic  tuberculous 
reulosis  in  other 
;  which  account 
lents  of  Arloing 
»r  he  has  shown 
•pigs,  while  rah- 
iiiore  susci'ptihle 
more  conclusive, 
U'illus.     (hiinea- 
infcction  within 
s;  infected  with 
icnt  did  not  aji- 
I'vived  for  six  or 
the  infection  oh- 
]iassing  through 
"ofulous  material 
>ften  in  rabbits. 


Tubenulniis  adenitis  is  met  with  at  all  agrs.  It  is  more  common  in 
children  iIkiii  in  adults,  but  it  is  not  infretiuent  in  the  middle  period  of 
life,  and  may  oci  ur  in  old  ago. 

The  lulii'rcle  bacillus  is  ubiiiuitoiis.  All  are  exjiosed  to  infection,  and 
upon  the  local  conditions,  whether  i'av<u'alile  or  unfavorable,  depend  the 
fate  of  those  organisms  which  Iind  lodgnient  in  our  bodies.  It  is  possible, 
of  course,  that  tuberculous  adenitis  may  be  congenital,  but  siuli  instances 
must  be  extremely  rare.  A  special  predisjiosing  factor  in  lymphatic  tuber- 
culosis is  catarrhal  inllaniniation  of  the  mucous  menibranes,  which  in  itself 
excites  slight  adenitis  of  the  neighboring  glands.  In  a  child  with  eon- 
stanily  recurring  iiaso-]iliaryngeal  catarrh,  the  iiacilli  which  lodge  on  the 
mucous  membranes  Iind  in  all  probability  the  gateways  less  strictly  guanh'il 
and  are  taken  up  by  the  lymphatics  and  passed  to  the  nearest  glaiuls.  The 
ini])ortance  of  the  tonsils  as  an  infection-atrium  has  of  late  been  urged. 
Jn  conditions  of  health  the  local  rcsi.-taiice,  or,  as  .some  would  put  it,  the 
]tliagocytes,  would  be  active  enough  to  deal  with  the  invaders,  but  the  irri- 
tation of  a  chronic  catarrh  weakens  the  resistance  of  the  lyuipli-tissue  and 
the  iiaeilli  arc  enalile(l  to  develoj)  and  gradually  to  change  a  simple  into 
a  tuberculous  adenitis.  The  friMpieiit  association  oi  tuberculous  adenitis 
of  the  bronchial  glands  with  whooping-cough  and  with  measles,  and  the 
frequent  develo])nient  id'  tubercle  in  the  mesenteric  glands  in  children  with 
intestinal  catarrh,  iind  in  this  way  a  rational  explanation.  After  all,  as 
Vireliow  ])oiuted  out,  an  increased  vulnerability  of  the  ti.-;sue,  however 
brought  about,  is  the  important  factor  in  the  disease. 

The  following  are  some  of  the  features  of  interest  in  tuberculous  ade- 
nitis: 

('0  The  ]f)cal  character  of  the  disease.  Thus,  the  glands  of  the  neck,  or 
at  the  bifurcation  of  the  bronchi,  or  those  of  the  mesentery,  may  be  alone 
involved. 

(b)  The  tendency  to  spontaneous  healing.  In  a  largo  proportion  of 
the  cases  the  battle  which  ensues  between  the  bacilli  and  the  tissue-cells  is 
Ifuig;  but  the  latter  are  finally  successful,  and  we  find  in  the  calcifieil 
remnants  in  the  bronchial  and  mesenteric  lymph-glands  evidences  of  vic- 
tory. Too  often  in  the  bronchial  glands  a  truce  only  is  declared  and  hos- 
tilities may  break  out  afresh  in  the  form  of  an  acute  tuberculosis. 

(r)  '^riie  ti'iidency  of  tuberculous  aih'iiilis  to  ])ass  on  to  siijipuration. 
The  freipiency  with  which,  ])articiilarly  in  the  glands  of  the  neck,  wo  find 
the  tuberculous  processes  associated  with  ]uis  is  a  special  feature  of  this 
form  of  adenitis.  Tn  nearly  all  instances  the  jnis  is  sterile.  Whether  the 
sup]iuration  is  excited  by  the  bacilli  or  by  their  ]iroducts,  or  whether  it  is 
the  result  of  a  mixed  infection  with  ])us  organisms,  which  are  subsequently 
destroyed,  has  not  been  settled. 

((/)  The  existence  of  an  uidiealed  focus  of  tulierculous  adenitis  is  a 
constant  menace  to  the  organism.  It  is  safe  to  say  that  in  three  fourths  of 
the  instances  of  acute  tuberculosis  the  infection  is  derived  from  this  source. 
On  the  other  hand,  it  has  been  urged  that  scrofula  in  childhood  gives  a  sort 
of  ])rotection  against  tuberculosis  in  adult  life.  We  certainly  do  meet  with 
many  persons  of  exceptional  bodily  vigor  who  in  childhood  had  enlarged 


«■* 


282 


' 


"Imids,  liiit   tlu'  cvidciut 
vii'W  is  not  confhisivc. 
Clinical  Forms. - 

cxcciitiiiiiiil  iiistaiKi's  \\( 


SPECIFIC   INFECTIOUS  DISEASES. 

Miirl'ui)  l.riiiLTs  forwanl   in  .-upiioit 


\\  hie 


1.  Generalized   Tuberculous    Lymphadenitis— In 

IIihI  (lill'uso  tiiluTiiilosis  of  lu'iuiy  all  tlic'  lyiniili- 
"f,'lanlls  of  the  ImmIv  with  little  or  no  involvonu'nt  of  utlicr  piiits.     Tlu'  mo^1 
(.Ntrcnic  cases  of  it,  wliieli  I  have  seen,  liave  l.eeii  in  ne-n.  patients.     Two 
well-niarke.l  cases  ..ccnrml   at   the   I'hila.leli.hia   Hospital,      in   a   woman. 
Ilu.  chart    fn.m   April,   ISSH,   niitil   .March,   l.^.^l*,  showed   persisle  it  fever, 
nni'-in-  from  JDl"  to  10^,  ..cea.-ionally  risin-  to  l^r.     On  Decemhor  i(.t  . 
the'-diuids  on  the  rijiht  side  of  the  neck  were  removed.     Alier  an  attack 
of  ervsipelas,  on  Fehruary  ITlh,  she  gradnally  sank  and  died  March  ,.th. 
The  hiif's  iiresenled  only  one  or  two  puckered  spots  at  the  apices,      llie 
bronchiaT,   retro-peritoneal,  and   mesenteric   {.daiids  were  greatly   enlarged 
and  caseous.    There  was  no  intestinal,  uterine,  or  hone  disease.     The  con- 
tinuous high  fever  in  this  ease  depended  apparently  upon  the  tuhercu  on 
adenitis,  which  was  much  more  extensive  than  was  supposed  during  lile. 
^u  1he<e  instances  (he  enlargement  i;-  most  marked  in  the  retro-peritoneal. 
l„,,„chial.  and  mesenteric  glands,  but  may  he  also  present  in  the  groups  ol 

external  glands.    Occurring  acutelv,  it  presents  a  l-ieture  resembling  i g- 

kin's  disease.  In  a  ease  which  died  in  the  Montreal  (Icm'ial  Hospital  this 
dia-'nosis  was  made.  The  cervical  and  axillary  glan.ls  were  enormously  en- 
larged, and  death  was  caused  by  inllltralion  of  the  larynx.  In  inlants  and 
children  there  is  a  form  of  general  lubereulons  adenitis  in  which  the  vari- 
ous "i-oujis  of  glands  are  successively,  more  rarely  simultaneously,  involved, 
aiurin  which  death  is  caused  either  by  cachexia,  or  by  an  acute  infection 

of  the  meniuires. 

2.  Local  Tuberculous  Adenitis.— (r/)  ('«;t(Vy//.— This  is  the  most  com- 
m(m  form  met  with  in  children,  it  is  seen  imrtieularly  among  the  poor 
and  those  who  live  continumisly  in  the  impure  atmosphere  of  badly  venti- 
lated lodgings.  Children  in  foundling  liosjiitals  and  asylums  arc  specially 
j.rone  to  the  disease.  In  this  country  it  is  most  common  in  the  negro  race. 
As  already  stated,  it  is  often  met  with  in  catarrh  of  the  nose  and  throat,  or 
chronic  enlargement  of  the  tonsils;  or  the  child  may  have  had  eczema 
of  tlin  scalp  or  a  purulent  otitis. 

The  snbmaxillarv  glands  are  first  involved,  and  are  popularly  spoken 
of  as  enlarged  Irnich.  They  are  nsually  larger  mi  one  side  than  on  the 
other.  As  tliey  increase  in  size,  the  individual  tumors  can  be  felt;  the 
surface  is  smooth  and  the  consistence  firm.  They  may  remain  isolated,  but 
more  eomnuuilv  they  form  large,  knotted  masses,  over  which  the  skin  is, 
as  a  rule,  freely  movable.  In  many  cases  the  skin  nltimately  becomes 
adherent.'and  inllammation  and  snpi)i"iration  occur.  An  abscess  ])oints  and, 
unless  opened,  bursts,  leaving  a  sinus  which  heals  slowly.  The  disease 
is  frequently  associated  with  coryza,  with  eczema  of  the  seal]),  ear,  or  lips, 
and  wiih  conjunctivitis  or  keratitis.  When  the  glands  are  large  and  grow- 
in'^  actively,  there  is  fever.  The  subjects  are  nsually  amfmic,  iiarticularly 
if'suppnrati'on  has  occurred.  The  progress  of  this  form  of  adenitis  is  slow 
and  tedious.  Pea  lb,  however,  rarely  follows,  and  many  aggravated  cases 
in  cbildren  ultimatelv  get  well.    Tv'ot  only  the  submaxillary  group,  but  the 


TrnRRcrLosis. 


2s;? 


support  <> 

phadenitis.—  1 1 
till  till'  lyiiipli- 

iirts.    Tlu'  iiin.-i 

patients.     Twii 

111   a   witiiiaii. 

llTsisll'  it    i'l'VtT, 

l)cci'inbor  Kitli 
A I  lor  an  uttac-k 
lied  March  r.th. 
lie  apices.  The 
n'eatly  eiikir^'ed 
ioasc.     Tho  con- 

tlie  tiihercidoii  • 
)se(l  diiriii;,'  lii'e. 
retro-peritmieal, 
in  the  ^xronps  of 
'seiidilinjf  Ilod^f- 
iiil  Hospital  this 
'  enorniitusly  eii- 
In  infants  and 

which  tlie  vavi- 
eously,  involved, 
1  aeuto  infection 

1  the  most  coni- 
anionfi  tho  jioor 
e  of  hadly  vciiti- 
Lims  arc  specially 
n  the  ncuro  race. 
ise  and  throat,  or 
lave  had   eczema 

popularly  spoken 
side  tlian  on  the 

can  he  felt;  the 
nain  isolated,  but 
liich  the  skin  is, 
timately  becomes 
bsccss  points  and, 
;\y.  The  disease 
^calj),  ear,  or  lips, 
0  large  and  <rro\v- 
x^mic,  ])articiilarly 
jf  adenitis  is  slow 

afrtrravated  cases 
ry  group,  Init  the 


glands  above  the  (laviele  and  in  the  posterior  cerviral  triangle,  may  be 
mvohed.  In  other  in.-tances  tiie  cervical  and  axillary  glands  are  invidved 
togetlu'r.  forming  a  cniitimioiis  chain  which  extends  beneath  the  clavicle 
and  the  pectoial  mii-cle.  With  tjicm  the  bronchial  glands  may  al>o  lie 
enlarged  ami  ca.-e(iii<.  Not  iiifrcipieiilly  the  enlargement  ol'  tlie  supra- 
clavicular and  axillary  group  oH  glands  on  one  side  precedes  the  devclop- 
iiieiit  of  a  tMbereiiloiis  pleurisy  or  of  pulmonary  tidiercidosis. 

(/*)  TniiiirD-linincliiftl. — 'J'lie  mediastinal  lymph-glands  constitute  lilters 
in  which  lodge  the  various  foreign  particles  which  escajie  the  normal 
phagocytes  of  bronchi  ami  lungs.  Among  these  foreign  particles,  and  prob- 
aldy  attached  to  them,  tubercle  bacilli  are  not  uncommon,  and  we  liud 
tubercles  and  caseous  matter  with  great  freipieiicy  in  tiie  mediastinal 
glands,  particularly  those  aliout  tlie  bronchi  it  is  staled  that  this  process 
IS  always  secondary  to  a  focus,  however  small,  in  the  lungs,  but  my  experi- 
ence does  not  bear  out  such  a  stalemeiit.  As  already  mentioned,  Xorth- 
rup  found  tliem  involved  in  every  one  of  I'.'T  ea>es  at  tlie  New  York  Found- 
ling ilo>|Htal.  This  tulierciiloiis  adenitis  may,  in  the  broncliial  glands, 
attain  the  dimensions  of  a  tiiiiKU'  (d'  large  size,  jiiit  even  when  this  occurs 
there  may  be  no  pressure  symptoms,  in  children  the  bronchial  adenitis 
is  ajit  to  be  associated  with  su|ipuration.  The  ell'ects  of  these  enlarged 
glands  are  very  varied,  and  for  full  details  the  reader  is  referred  to  the 
elaborate  section  in  the  Traite  of  IJarlhez  and  Sannee  (tome  iii).  It  is  suf- 
(Icieiit  liere  to  say  that  there  are  instances  (Ui  record  of  comi)ression  of  the 
superior  cava,  of  the  pulnionary  artery,  and  of  the  azygoH  vein.  The  trachea 
and  bronchi,  though  often  tlatleneil,  are  rart'ly  seriously  compressed.  The 
pneumogastrie  nerve  may  be  involved,  ])articularly  the  recurrent  laryngeal 
branch.  Mow  im])ortant  really  are  the  perforations  of  the  eidarged  ami 
softeneil  gland>  into  the  lironchi  or  trachea,  or  a  sort  of  secondary  cyst 
may  be  formed  between  the  lung  and  the  trachea.  Asphyxia  has  been 
caused  by  blocking  of  the  larynx  by  a  caseous  glaii'l  which  has  ulcerateil 
through  the  bronchus  (^'oclckel'),  and  Cyril  Ogle  has  reported  a  case  in 
which  the  ulcerated  gland  practically  occluded  both  bronchi.  I'erfora- 
tions  of  the  vessels  are  much  less  common,  but  the  |iii!monary  artery  and 
the  aorta  have  been  openi'd.  Perforation  of  the  (esophagus  has  been  de- 
scribi'd  in  several  cases.  One  of  the  most  serious  ell'i'cts  is  infection  of  the 
lung  or  jileiira  by  the  caseous  glands  situated  deep  along  llie  bronchi.  This 
may.  as  is  id'ten  clearly  seen,  be  by  direct  contact,  and  it  may  be  dilficult 
to  determine  in  some  sections  where  the  caseous  bronchial  gland  terminates 
and  the  piiluKUiary  tissue  begins.  Tn  other  instances  it  takes  |)lace  along 
the  root  of  the  lung  and  is  subpleiiral.  Among  other  seciuences  may  be 
mentioned  diverticulum  of  the  (esophagus  loUowing  adhesion  of  an  enlarged 
gland  ami  its  subsecpient  retraction;  and,  in  the  case  of  the  anterifir  medi- 
astinal and  aortic  groujis.  the  frecpient  jirodiiction  of  pericarditis,  either 
by  contact  o"  by  rupture  of  a  softened  gland  into  tho  sac. 

A  serious  danger  is  systemic  infection,  which  takes  place  through  the 
vessels. 

((■)  Mpspiilrrir :  Tahrfi  mrsmfn-ira. — Tn  this  affection,  tho  abdominal 
scrofula  of  old  writer.^;,  the  glands  of  the  mesentery  and  retro-peritonanun 
IS 


■I 
I 

T 


„j^j  SrUriFIC   INFECTIOUS   DISKASKS. 

,„,,,„„.,  .,nl;u-...l  n.,.1  ens,.,!.;  .no,v  nuvly  th.y  M,it.ir;.t..  ov  '.'l'il>-     ;^ 

inL..     it  .»av  iK.  I,  prinunv  Lmum  as^nHat..!  will.  mt.-tn,al  .alarrl..  n, 

•.,.]„.  ,.,i„„,v  .as...  arv  v.t.v  .nnunnn   in  .•inl.l.vn    as  ,nav  K.  ^..th.   nl 
,n,M,  \V.l..liH.a.rs  il.MUvs  al.va.lv  ,iN...,.     Ti...  ,.■.......!  ,nvnlv..nu.nt  ..1  tl 

XuuU  inl..rl..r.s  s,.nuu>lv  u,ti,  nutriti.-M.  an.l  tlu-  i.at...nts  ar..  ,.u,.y,  wa>l...l. 
n       i...    TlH.alnlunu.nis..nlar,,.lan.ltynM.nu.i..;dunTi.n.a.sa<nn 

:;.;.ilVa,un.thestn..isa,..,l,inan,loir..nsiv...     ^^^^J^'  ^  ;^;^^;^X-:Z 
l,„t  tl...  ^'cncral  wastinjr  a...l  .l.^l-ility  nw  tl..'  ..."st  .■l.a.'u.y.M..     .at.       . 
TUr  ....hu-ov.!  jrlan.ls  .........t  ..i't...  !..■  iVlt,  nwii.,.  to  tl...  .l-st.....!..!  ...... 

,    ,  of  ,h.:i..;..ls.    'riH.s.  ..as.,  a.'..  ..r.....  spols....  ..f  ..s  ...msnn.,.t..  a  ..    t    ■ 

:..is.  lu.t  i„  a  n.a,in,.ity  of  ll......  .I..'  i.-l-'^.i-.'S  .lo  n.-t  pr..s..„t  n  ..^^^^^^ 

l...i„n^      I.,  a  .■.M>si.l..i'al,l..  .......Iut  ..f  ti.c  ...s-.s  .,1   talu.s  n...M..,t....  ••    tl 

|:.n,",ia..,-..  i^  ..!-  i..yolv..,l.  a.ul  i..  su.!.  tl...  alnlo.......  .s  la,',.,  and  l.a...l. 

ami  noiliilfs  u.av  lie  tVlt.  ,  , 

,„  „,„„s  ,ui...,v.,l..ns  .lis..as..  .,!'  tl,.>  .......nt.......  ,1a...  s  ,„ay  ...r        >  • 

,,,i,na>v   air..lion.   ..'   i..   ass,...iati.H.    with    ,u,l...o„a.y    .l.^'as..       (.a...l.    . 
l,iv...  a  n...,a,-kaM..  i..sta,...c.  .-I'  Ih.  ki...l  i..  >.   .'.a-,  a^-l  tw..nty-.>... .     I.  - 

:,.,„.■..<  ..!■  ll.i^  sort  a,...  n..t   ,.,.<•...,........   \n  th..  lit....at...v.      i.a>-v  tu....n> 

,','y  oxi-t   will.....t   t,.lK.rul.n.s  .lis..ase.   i,.   tl...   i..t...tii..s  ..,•  ...  a..y  „tl,...- 

'"'■-n,,  .lia,M...sis  ..!•  l.u.al  and  -(■■..■.■a!  t..l)(n.c...l....s  a.lrnitis  I'.......  ly.ni^l.a.l.- 

iioiiia  will  \h'  siihswiuiMitly  oonsi.l..n..l. 
2  Tuberculosis  of  the  Serous  Membranes. 
General  Serous  Membrane  Tuberculosis. -Tl...  s,.,..n,<  ,„..n,lu.a....s  may 

1...  ,hi..llv  i].v(.lv...l.  either  sinu.ltaneously  ...•  c.ns.H.utivc.h'.  l".''.'.''^'  "  "H^" 
tiiK-tive  ati.l  n.a.lilv  v.vn^uh^U.  .liLhal  tyiK-  of  t.ilH.,v„l..s.s.      i  he.v  n.'e 
,,,....  ,n-..u,.s  ..!•  ..a:..s.       Fi.'st.  Ih-s..  i,.  whic.h  a„  a<.ut..  luhe,.c.ul..s.s  .. 

,„.nt.ma...il.  and   ,.1.......  .l..v..l..,,s  n.pi.Uy.  .-ans...    l.y  hu-al  d.soaso  of  the 

;„lu.s  in  won.e,..  o.'  oi'  the  nu..liasti..al  ..r  l.n.n.h.a    ly.ni  .-.-lan.ls      S.  •- 
on.llv   .•as..s  in  whi.-l.  the  <1is.>as.  is  more  eh.'onie,  with  ...x...lat...n  ...to  hot,, 
,K.,il.n,a......  an.l   plen..,..  the  f..rmalion  of  eh.'.'sy  n,a.s..s    a...l   the  ...c..-- 

;,.„,.e  of  i,l.-..n.tive  an.l  sui.p...'ative  processes.     '1  1...-.1  y.  there  are  case,  in 
whi..h  tl...  i.l.....'o-i'f"t""i^al  ailVetion   i-  still  more  eh.-on.e    the  tuherele.- 

■    .1  an.l  iilnoi.l.  the  meml.ran..s  n.,..  h  tl.i.  k..n...1,  an.l  w.th  h.tle  ..r  no 
exudate.     1..  anv  one  of  these  thr....  f.>.n,s  the  i^erieanl......   n.ay  he  in- 

volved  with  the  i.l.-nr.T  and  perit-.tneum.     It  is  ini]>ortant  to  bear  m  m.nd 
^,,„  „,.,,..  ,„ay  1,..  in  the^e  eases  no  vi^coraUnberculosis. 

Tubercvi"«l8  of  the  Pleura. -l.  Aet.te  tnberenlons  pl.urisy.  It  is  d.l- 
'  fienlt  in  Ih^ present  state  of  .ntr  knowledge  to  estimate  the  proy.nrtion  of 
instances  of  aciit-.  pleurisy  dne  to  t,.bercnl..s<s  (see  Aen  e  Plenr.sy).  he 
ca.e«  are  rarelv  fatal.  In  th.-  st.,dy  of  those  ,n  the  J.dins  1  opk.ns  IL-s- 
pital.  wl.i.l.  1  ma.le  for  th.>  Shattnek  Lecture  (P..)st.m  Med.  and  Sui-. 
lournal  ^^'X^Y  tl...re  were  three  gr.mps  of  cases:  (a)  Acute  tuberculous 
'u]rm\<x  with  subse.pient  chronic  course,  (h)  Secndary  and  terminal 
forn..^'of  a.utc  pleurisy  (these  are  not  uncommon  in  hospital  practice). 


tmam 


TniKKCl'LoSIS. 


itr  (.ilfily.     A 
■  II.  iiml  i>  ol'ti'ii 

(•    dinl    (if    ntllii 

liiiiil  ciitiiirli.  iM 

li;lV    111'    ^'MtlllTril 
iilvcliicllt    of    till 

IT  |niiiy,  wii^lt'il, 
iirrliii'ii  is  a  (nii- 
iiiiiilcrato  IVvfi', 
■tcrislic  IVaturcs. 
(listciulcil  foiiili- 

lSllIll|ltii   11    111'   tllf 

•si'Ut  uiIhtcuIous 
ini'sciiti'rira  tlu' 
larL'i'  and  lianl. 

-  iiiiiv  (icciir  ii>  11 

isi'iisi'.      (iiiinliirr 

twciity-Diif.     Iii- 

liiirp'  tuuiiir- 

or  ill  any  otluT 

5  from  lyniiiluKlo- 


mcinltratus  may 
:y.  forminjr  a  dis- 
iliisis.  Tlioro  arc 
ulicrfiilosis  of  the 
•id  disease  of  llie 
ii|ili-,ii'lnnds.  Sfi'- 
udation  into  liotli 
■s,  and  tile  neenr- 
llicri'  are  cases  in 
inic.  tlie  tuliereles 

witii  little  or  no 
•diiiiii  may  be  in- 
it  to  bear  in  mind 

dinirisy.  It  is  dif- 
the  iiroportioii  of 
tc  Pleurisy).  The 
hns  irn])kins  TTos- 
n  ^led.  and  Suri:. 
.\ente  tiiberenlmi< 
lary  and  terminal 
hnsjiital  practice). 


.And  (/ )  ii  i'nrm  of  a  Mc  tidicnidons  sii]iinirati\i'  ]ilrni'i>y.  .\  con-idi  iiddc 
niiiiihiT  of  ihr  |iiiridriil  |ilciiri.-ic.-,  dc>i;:iialcd  a>  iatiiil  and  tliroiiic,  an' 
laii.-cd  by  tidicnit'  liacilli.  biii  tlic  fact  is  not  mi  v\  uh  iy  rc(iiL.'nizcd  that 
tlicic  is  an  acute,  iildralivc.  and  >ii|i|iiiralivc  di>ca-c  whicli  niay  rnii  a  \cry 
ra|ad  cciir-c.  '\'\\f  |i|iiirisy  .>;c|s  in  ai'rii|i||y.  wiili  |>ain  in  tlic  .>idc.  fc\cr, 
coii;:li.  and  .-oniciinics  with  a  chill,  'riicrc  may  he  imlhinL'  to  >ii;:j;c«t  a 
Iidicrciilniis  |iroce.«s,  ami  the  sniijcct  may  have  a  tine  |i|iy>it|iie  and  cmnc 
of  healthy  >tock.  •.'.  The  >nliaciitc  and  chionie  tidiercidou>  |ilcuri-ics  are 
nioi'e  coiiiinoii.  'j'lie  lar^'est  ^ironp  of  cases  ci)m|trise.-  those  with  seni- 
lihriiioir-  clVii,~ion.  The  onset  is  in>idioiis,  the  tnic  character  of  the  di^aM' 
is  fre(|iicnily  oMrlonkcd,  and  In  alino>t  every  instance  there  arc  tiiiicicii- 
loiis  foci  in  the  liin;_'s  and  in  liie  liroiiehial  ^dands.  These  are  cases  in 
\\hieh  the  termination  is  (d'ten  in  |Mdmonary  tidicrcidosis  or  ;reneral 
miliary  tulicrculo.-is.  In  not  a  few  of  them  tlie  I'Xiidate  lieeome.s  puru- 
lent. 

.\nd.  la>tly,  there  is  a  chrimic  adhoive  pleurisy,  i  |  "imary  proliferative 
form  which  is  of  lonj:  standinu'.  may  lead  to  very  ^n-eat  thickciiini.'  of  the 
inendiranc.  and  snineliincs  to  inva>ion  of  the  Inn;;'.  I''or  a  fuller  con>idei-a- 
lioii  the  reader  is  referred  to  my  Shaltuck  I.eitnre  or  to  the  siction  mi 
tuhereiilo>is  in  l.ooniis  and  'I'hompMin's  System  of  Medicine. 

Scfnihhirii  tnlierciiloiis  pleuri.-y  is  very  coniinon.  The  \  i-eeral  lavcr  is 
always  involved  in  pulmonary  tuherciilosi<.  .\dlicsions  iisnally  form  and 
a  chronic  jileiii'lsy  results,  which  may  lie  siinjile.  hut  nsiially  tnbcrcics  are 
seattered  tliroii^h  the  adhesions.  An  acute  tnherculdiis  pleurisy  niav  re- 
sult from  direct  extension.  'I'iie  lliiid  may  lie  sero-iiiuinous  or  Inemor- 
rhajrie,  or  may  become  jiurulent.  And,  lastly,  a  very  common  event  in 
])iilmonary  tiiherciilosis  is  the  perforation  of  a  superdeial  spot  of  softeiiimr, 
and  the  ])roduction  of  jH/D-piicnniolliora.r. 

The  <.feneral  symptomatolo^'y  of  these  forms  will  be  eonsidered  under 
disease  of  the  pleura. 

Tuberculosis  of  the  Pericardium. — Miliary  tubercles  may  occur  as  a 
part  of  a  jicneral  infection,  l)ut  the  term  is  properly  limited  to  those  cases 
in  which,  either  as  a  primary'  or  secondary  ]irocess,  there  is  extensive  dis- 
ease of  the  membrane.  Tuberculosis  is  not  so  common  in  tiie  pericai'dinin 
as  in  the  ]ileiira  and  peritonanim,  Imt  it  is  certainly  more  common  tiian 
the  literature  would  lead  ns  to  suppose.  Seventeen  cases  had  come  under 
my  observation  to  January,  ISO.I  (American  doiirnal  of  the  Medical  Sci- 
ences). 

We  may  recoiinize  four  £]rrou])S  of  eases:  First,  those  in  which  the  con- 
dition is  entirely  latent,  and  the  disease  is  discovered  aecidentally  in 
individuals  who  have  died  of  other  afl'eetions  or  of  chronic  piilmonarv 
tuberculosis. 

A  second  arou]).  in  which  the  synijifoms  are  those  of  cardiac  insuf- 
ficiency followiiiLr  the  dilatati(m  and  hypertrophy  consequent  upon  a 
chronic  adhesive  pericarditis.  The  symjitoms  are  those  of  cardiac  dropsv, 
and  pu^'frest  either  idio])athic  liypcrtrophy  and  dilatation,  or,  if  there  is  a 
loud  blowinjr  systolic  murmur  at  iho  apex,  mitral  valve  disease,  either  in- 
suiTieicncy  or  stenosis.     There  arc  cases  of  adherent  pericardium  in  which 


-    " 


286 


SPECIFIC   INFECTIOUS   DISEASES. 


a  bruit  is  lK.,.nl  wluH.  .rHnuLlcs  the  nnnbling  prrsYsK.  ..  muPuur  (Hal. 
White).     'I'he  cuiuliti..n  of  adhorent  pericanlium  is  uM.ally  overluoku*  . 

1,/a  tl,inl  group  the  clinical  ,,ic,ure  is  that  of  an  acute  "t-";;;!''^ - 
either  ..^....1  <.r  with  cerebro-spiual  n.anil'eslatiuns,  wh.ch  ha^  ha.l  l^ 
;,nin'   [nnn  the  tuherculous  pericardium  or  tuberculous  mediastuud  ly.nph- 

""'"'fiourth  group,  with  syuiptonis  of  acute  pericarditis,  i^^J^'^^;;..';;;;:;;  ;;; 
.hicii  the  alfection  is  acute  and  aecouuuvniod  wUh  more  «^    ^    -'  ;^' 
of  a  sero-r.hrinous,  ha-morrhagie,  or  purulent  character.     Iheie  mav  be 
suspicion  whatever  of  the  tuberculous  nature  of  the  trouble 

(,/)  Tuberculosis  Of  the  PeritonjEtim.-ln  connection  ^uth    ->'  ■      ' 
chronu.  pulmonary  tuberculosis  it  is  not  uncommon  to  Imd  t  le  peutomu  i 

udded\vith   small  gray  granulations.     They  are  ->-^-^^ly  l-^"  ^, 
the  serous  surface  of  tuberculous  uUers  of  the  intestines.     Apait  f  .  m 
these  conditions  the  membrane  is  often  the  seat  of  extensive  tuberculous 
disease,  which  occurs  in  tiie  following  iorms: 

(1)  Acute  milian,  (uherculosis  witli  ser(,-iibrin<.us  or  bbKuly  "'l^Y   «":,i 
(•>)  Chronic  tuhercnhsi>^,  characterized  by  larger  growtlis    which  tend 
to  caseate  and  ulcerate.    It  may  lead  to  perforation  of  the  mtes  inal  coil.. 
The  exudate  is  ])urulent  or  sero-i-urulent,  and  is  often  sacculatecL 

(;5)  Chronic  /imnd  iuhercnhsis,  Avhich  may  be  subacute  from  the  onset, 
,u-  which  mav  represent  the  final  stage  of  an  acute  miliary  eruptior.  ihe 
tubercles  are'  liaid  and  pigmented.  There  is  little  or  no  exudation,  and 
the  .  rous  surfaces  are  matted  together  by  adhesions.  .     ^     ,      . 

The  process  mav  1)e  ,uMmary  and  local,  which  was  the  case  in  o  of  my 
n  i.ost  m.ulems.  in  children  the  infection  appears  to  pass  Irom  he  intes- 
tines and  in  a.lults  this  is  the  source  in  the  cases  associated  witli  chronic 
nhthi-is  In  women  the  disease  extends  commonly  from  the  I'alloi.ian 
tubes!  in  at  least  3U  or  10  per  cent  of  the  instances  of  laparotomy  m  Uus 
afTecti<m  reported  bv  gyinvc.dogists  the  infection  was  iroin  them,  ihe 
prostate  or  the  seminal  vesicles  may  be  the  starting-pom  .  In  many  cases 
the  perit.unvum  is  involved  with  the  pleura  and  pericardium,  particularlv 
with  the  former  membrane.  ,  i      •     i 

It  is  interesting  to  note  that  certain  morbid  conditions  of  the  abdominal 
organs'  predispose  to  the  development  of  the  disease;  thus  patient^  with 
ei,Tho<i'  of  the  liver  verv  often  die  of  an  acute  tuberculous  peritonitis. 
The  freciuencv  with  which  the  condition  is  met  with  in  operations  upon 
ovarian  tumors  has  been  commented  upon  by  gynaecologists  Many_  cases 
bave  followed  trauma  of  the  abdomen.  A  very  .nterc'sting  feature  is  the 
development  of  tuberculosis  in  hernial  sacs.  The  condition  is  not  verv 
„n,ommon.  In  a  majority  of  the  instances  it  has  been  discovered  ace,- 
;i"„tally  during  the  operation  for  radical  cure  or  for  strangulation.  In 
":  instances  the  sac  alone  was  involved. 

Tt  is   -renerallv   stated  that  males  are  attacked   oftener  than   female-;.. 
T„  mvo^n  serie's  of  21   cases,  15  wore  males      The  recent  laparotomies 
however,  which  have  been  performed  in  this  disease  have  been  chiedy  in 
fern  les    so  that  in  the  collected  statistics  I  find  the  cases  to  be  twice  as 
mmerous  in  females  as  in  males;  in  the  ratio,  indeed,  of  131  to  GO. 


TrnERri'Losis. 


28; 


imnMUir  (Halo 

overlookcil. 
lie  tuileR•^llll^i^, 
ii'h  \y<\<  liiul  it> 
diastiuiil  lyinpli- 

iu'IikU'S  ciisot^  in 

)!•    k'SS   CvVKliltiuU 

;iun-e  niiiy  be  no 
)le. 

ith  miliary  and 

the  ijcriluniuuni 

intly   i)R'si'nt  on 

{}:•.     A\r,n't  from 

i.<ive  Inberculons 

oody  oxndation. 

ilhs,  which  tend 

c  intestinal  coils. 

■cnlatcd. 

e  from  the  onset, 

y  eruption.     The 

o  exudation,  and 

G  case  in  5  of  my 
ss  from  the  intes- 
atod  with  chronic 
im  the  Falloi)ian 
a])arotomy  in  this 
i'rom  them.  The 
t.  In  many  cast's 
dium,  particularly 

<  of  the  al)doniinal 
hns  ])atients  with 
xnilous  ])eritonitis. 
n  operations  upon 
trists.  ^lany  cases 
linjl  feature  is  tlie 
dition  is  not  verv 
Ml  discovei'ed  aci-i- 
strangulation.     In 

^nor  than  fen\ales. 
i>cent  laparotomies, 
five  been  chiefly  in 
asps  to  be  twice  as 
.f  131  to  GO. 


TnlKMvulons  peritonitis  ..cciirs  at  all  ages.  Ft  is  coininon  in  cliildren 
associated  with  intestinal  ami  mesenteric  diseiise.  'I'lie  incidence  is  most 
frequent  lietween  the  a«res  of  twenty  and  lurty.  It  may  occur  in  advanced 
life.      In  niie  of  my  cases  tin    patient    was  ei-ihty-two  years  of  aLre. 


;557  oases  collected   from  the  litei'atiire,* 


Of 


there  wei'e  under  ten   vi'ars,   »'" 


between  ten  and  twenty,  V.");  from  twenty  to  thirty,  isr;  between  thirty 
and  forty,  Tl;  from  forty  to  fifty,  (11;  from  fifty  to"  sixty,  1!»;  from  sixty 
to  seventy,  I;  abovi'  seventy,  ti.  In  Anu-rica  it  is  more  common  in  the 
negro  than  in  the  white  race. 

Symptoms.— In  certain  special  features  the  tul)erculous  varies  eon- 
siderably  from  other  forms  of  peritonitis.  It  j.reseiits  a  symptom-complex 
of  extraordinary  divcrsitv. 

In  the  first  jilace,  the  process  may  l)e  lalciil  ami  not  cause  a  sinirle 
symptom.  Such  are  the  cases  met  with  accidentally  in  the  operation  for 
hernia  or  for  ovarian  tumor.  In  direct  contrast"  are  the  instances  in 
which  the  onset  is  so  sudden  and  violent  that  the  diagnosis  of  nilcn'li^ 
or  licniid  is  made.  The  operation  for  strangulated  hernia  has.  indeed, 
been  performed.  .Many  cases  .'^et  in  acutely  with  fever,  abdominal  ten- 
derness, and  the  sym|)toms  of  ordinary  acute  peritonitis.  Cases  with 
a  slow  onset,  abdominal  tenderness,  tympanites,  and  low  continuous 
fever  resemble  li/p/K,!,!  frrrr  very  closely,  ami  may  lead  to  error  in  diaLT- 
nosis. 

Asriirs  is  frecpient,  lint  the  elTusion  is  rarely  large.  It  is  sometimes 
luTmorrhagic.  In  this  form  the  diagnosis  may  rest  between  an  acute  miliary 
caiuHT,  cirrhosis  of  the  liver,  and  a  chronic  sim])le  iieritoniti.s — conditions 
which  usually  olfer  no  s])eeial  dilliculties  in  diilVrentiation.  A  most  impor- 
tant point  is  the  simultaneous  ]U'esence  of  a  ])lcurisy.  The  tul)ercnlin  test 
may  be  used.  Tj/iii/xniilcs  may  be  jiresent  in  the  very  acute  cases,  wlien 
it  is  due  to  loss  of  tone  in  the  intestiiu's,  owing  to  inllamimitory  indllra- 
tion;  or  it  may  occur  in  the  old,  long-standing  cases  when  universal  adhe- 
sion has  taken  ])lace  l)elween  the  ))arietal  and  visceral  layers.  Fever  is  a 
marked  sym])tom  in  tlu>  acute  cases,  and  tlie  tem])eraturc  mav  reach  103=' 
or  101°.  In  many  instances  the  fever  is  slight.  In  the  more  chnmic  cases 
subnormal  temperatures  are  common,  and  for  days  the  temperature  mav 
not  rise  above  97°,  and  the  morning  record  nuiy  be  as  low  as  [)."). ,5°.  An 
occasional  symptom  is  pigmentation  of  the  skin,  which  in  sonu^  cases  has 
led  to  the  diagnosis  of  Addison's  disease.  .\  striking  peculiarity  of  tu1)er- 
culous  jieritonitis  is  the  fre(iuency  with  which  either  the  condition  simu- 
lates or  is  associat(Hl  with  tiinior.     These  mav  be: 

(/i)  Onirnfnh  due  to  puckering  and  rolling  of  this  membrane  until  it 
forms  an  ehmgated  firm  mass,  attached  to  tlio  transverse  colon  and  Ivinij 
athwart  the  up]K'r  part  of  the  abdomen.  This  cord-like  structure  is  found 
also  with  cancerous  peritonitis,  but  is  much  uu)re  common  in  tuberculosis. 
Gairdmu-  has  called  s]iecial  attention  to  this  form  of  tumor,  and  in  children 
has  seen  it  undergo  gradual  resolution.  A  resonant  percussion  note  nuiv 
sometimes  be  elicited  above  the  mass.     Though  usually  situated  near  the 


*  Johns  Hopkins  ITospital  Reports,  vol.  ii. 


288 


SPECIFIC  INFECTIOUS  DISEASES. 


un.l.ilions,  tlu.  oniontul  inas.  may   [..nn  a  pr-nuncnt   tun.or  in   tho  riglit 

'^'"\l!^tin'Mr,l  cnuJalion,  in  whi.h  tlu-  olfu^iun  is  linntcl  and  .onnncl 

„„a  ji,,  ,,,.l,.n>inal  ..r  pelvic.  or,.,ns.     This  oncystnl  .xu.laU.  -  '""^^         " 

„  i„  „,,  nu.hile  zone.,  and  has  I'minontly   hcvn  mistaken     or  uvana 

unu,,'      It  n,av  ocvu,,v  the  .nti.v  anterior  portion  of  the  per.tona.nn    or 

there  luav  he  a  Uiore  limited  saeenlar  exudate  ..n  <me  sule  or  t K>  othd. 

SmIu.;  He  complotoly  within  ti>e  pelvis  proper,  associated  wth  tui,ereulou. 

iliM-ise  of  tlie  Fallopian  tuhes. 

ro  cases  the  tnn.or  forn.ations  may  he  due  to  ,reat  re  ractum 
,.,  t     ,i,„H,„  of  the  intcsli.al  roil.     The  sn.all  mtest.no  >s  lonnd  sho  t- 

.1,  ,he  wJls  onornu.nsly  thickened,  and  the  cnt.re  cod  n,ay    "'-  '^  * 
1      ,     I     „  M,r.nn4   tiie  H.ine    yivin-  on  exanunation  the  idea  .d   a  solnl 
;;;;  /ttrtall  in;::;;mM.nly:  ...t  the  enure  l.we,  froni  tl.  duode- 
,„„  ,.,  „,,  „,,,„„,  l.as  heen  found  forming  sucii  a  hard  imdnla    tumo 
,  >    Mc^cHlcrir  .,h,mh,  which  occasionally  form  very  hu-v.  tumor-1  ke 
,„a^S        n"  omn^nlv  found  in  children  than  in  adults.     This  condition 
V        confined  to  th;  ahdominal  .lands.     Ascites  may  coexist       I  he  con- 
i    u    mn*    he  distinguished  from  that  in  children,  in  whu-h   with  ascites  or 
K        n^  ome,i.:.s  hoth-therccan  ho  felt  irregular  mulular  massos,du. 
■       C  caseons  formati.nis  I.etween  tho  intestinal  coils     ^o  d.niht  ,n  a  co  - 

li  dde  nnmhcr  of  cases  of  the  so-,.allod  tabos  mosontorica,  partieularl     . 
t  with  cnlar,^omont  and  hardness  <,f  the  abdomon-  ho  condition  which 

e  French  call  ;,nvv,.-thcre  is  involvement  also  of  the  1-^t-cum 
Tho  d{<u,nosis  .d'  these  peritoneal  tumors  is  some  ime>  \ci>   d.llicu    . 
Tho  omental  mass  is  a  less  frequent  source  of  error  than  any  "^hor;    n  t 
as  alrcadv  mentioned,  a  similar  condition  may  occur  ni  cancer.     1  Ik      > 
i„,nortant  problem  is  the  diaf:nosis  <d'  the  saccular  exudation  from  o  auan 
"n.or.     In  fully  one  thinl  of  the  recorded  cases  o    laparotomy  m  tub  r- 
,,,lous  pcriK.nitis,  tho  diajxnosis  of  cystic  ovarian  disease  ^^'^^^^^^^^^ 
Th,  ,no.t  sufXfiostivo  imints  for  consideratum  are  tiie  hist..ry  oltl  e  pation 
,   ,       e  evidence  of  <.ld  tuberculous  lesions.     The  physical  condition  js  no 
,1    help,  as  in  many  instancos  tho  patients  have  boon  robust  and 
tl     .ourishJd.      Irrcnlar   febrile   attacks,   ,astro-intes(inal    J-turbanc^ 
and  pains  are  more  conim.Hi  in  tuberculous  disease.     I  nless  lullamed  the.e 
Ju    Iv  not  much   fever  with  ovarian  cysts.     Tho  local  si.ns  are  very 
lecoptive.  and  in  cor.ain  cases  have  conformed  in  every  particular  to  those 
of  cv<tic  (li<ea-o      The  (nitlines  in  saccular  exudation  are  rarely  s.,  \Nell 
defined      Tho  i-ositicm  and  form  may  bo  variable,  owing  to  alterations  in 
1     Le  of  tho  coils  of  whi<h  in  parts  tho  walls  are  con.posod.     .Nodular 
dloc^v  masses  mav  sometimes  be  felt  at  tho  periph.M-y.     IV].---  -d  the 
va-nnnl  wall  is  mentioned   as  occurrin.tr  in  ^'^^y^tc.!  per.tmi. tis;  but   .     is 
at>  fouml  in  ovarian  tnm-n-.    T.astly.  the  coudition  of  tho  Fallopian  t  1.  -, 
of  tho  lunjis  and  of  the  pleurae  should  be  lliorou-rhly  oxamin.M        1  be  a.s.  - 
h  ion  of  salpin.rilis  with  a.  ill-deilned  anomalous  mass  ,n  the  abdomen 
sJioidd  anmso  su;;m.iou.  as  should  also  involvement  of  the  plema.  the  apex 
of  one  lunji,  or  a  testis  in  the  male. 


TrBERCULOSIS. 


2S!> 


m 


ho  ritrlil 


I  ami  confiiu'il 
lie  lursi'iitery, 
'  is  iimsl  I'tiiii- 
•11  I'm-  ovarian 
icriloiurum,  "i" 
or  tl-J  utlicr. 
ill  tulifrL-uliius 

:iTat  retraction 
s  I'oimd  s-liort- 
\\\  form  a  iirni 
idea  of  a  solid 
•om  the  duode- 
dular  tinnor. 
ru'e,  tiinior-like 

Tliii^  eondition 
xist.     'riio  con- 
.  witli  ascites  or 
ular  masses, due 
doiilit  in  a  con- 
,  particularly  in 
condition  which 
oritonu'um. 
s  very  diiUcult. 
any  other;  but, 
icer.    The  most 
)n  from  ovarian 
otomy  in  tnber- 
had  been  made, 
■y  of  the  ])atient 
condition  iri  not 
joen  robust  and 
nal    disturbance, 
:s  iiillamed  there 
1  si,uiis  are  very 
irticidar  to  those 
•e  rarely  so  well 
to  alterations  in 
iposed.     Nodular 
)ei)rcssion  of  the 
tonitis;  Imt  it  is 
•  Fallopian  tubes, 
lined.     'I'lu-  asso- 

iii   th(>  abdomen 
!  plcuia.  the  apox 


I\'.     I'n.MONAIiY    'rtliKIIcrLOSIS    (l'lllll!sl,-i,    <'iillSII))lliliiili). 

Tiiree  clinical  j.n'oups  may  be  conveniently  reco,u'ni/.e(l:  (1)  hilnriiiltt- 
pni'uniDiiii-  jililliisis — acute  phthi.-is;  (".')  rhn^iiiv  iiliriulirc  iiltllii.'<ls ;  and  ('■>) 
fdirvid  plilliisis. 

-\ccordinji;  to  the  mode  (d'  infection  there  arc  two  distinct  tvpcs  of 
lesions: 

('0  When  the  bacilli  reach  the  lun^s  ihroii;:h  the  illood-vc^^cls  or  Iviu- 
|iliatics  the  primary  ie.-ion  is  usually  in  the  ti->ues  of  the  alveolar  walls,  in 
the  caiiillary  voscis,  thi'  epithelium  o\'  the  air-i'clls.  and  in  the  connective- 
tissue  framework  of  the  septa.  The  proce.-s  of  cell  (livi>ion  proceeds  as 
already  dcscrihed  in  the  ,<;vneral  hist(do<;y  of  tubiMvle.  'I"he  irritation  of 
the  bacilli  produces,  within  a  few  days,  the  small,  ^'ray  miliary  nodidcs 
involving  several  alveoli  and  consisting  largely  of  round,  cuboidal,  uni- 
nuclear epithelioid  cells.  Depending  upon  the  numher  of  bacilli  which 
reach  the  lung  in  this  way.  either  a  localized  or  a  general  t iiberculosis  is 
e.xcited.  'I'he  tubercles  may  be  uniformly  .scattered  throiigii  iioth  lungs 
and  form  a  part  <d'  a  general  miliary  tuberculosis,  or  they  may  be  coiiliiied 
to  the  lungs,  or  even  in  great  part  to  one  lung.  Tiio  changes  which  the 
tuliercles  undergo  have  already  been  referred  to.  The  further'  stages 
may  be:  (1)  Arrest  of  the  process  of  cell  division,  gradual  sclerosis  of  the 
tubercle,  and  ultimately  coiiiplett'  llbniid  transfo-'Maiion.  (-j)  Caseation 
of  the  centre  of  the  tuliercle.  extension  at  the  pi  ry  by  ])rolifer;!tion  of 

the  epithelioid  and  lymiilioid  cells,  so  that  ti.  idividual  tubercles  or 
small  groups  ln'conie  conlliieiit  and  form  dilfiise  areas  which  undergo  case- 
ation and  softening,  (.'i)  Occasionally  as  a  result  of  intense  infection  of  a 
loealizeil  region  through  the  blood-vessels  the  tubercles  are  thickly  set. 
The  intervening  tissue  becomes  acutely  inllamed,  the  air-cells  are  lllled 
with  the  products  of  a  descjnainative  pneumonia,  and  many  lobules  are 
involved. 

(/')  When  the  bacilli  reach  the  lung  tliroitgh  the  bronchi — itdialation 
or  aspiration  tuherculosLs — the  picture  dilfers.  The  smaller  bronchi  and 
bronchioles  are  more  extensively  alTected;  the  ])roeess  is  not  conlined  to 
single  grou]>s  of  alveoli,  but  has  a  more  lobular  arrangement,  and  the 
tuberculous  masses  from  the  outset  are  larger,  ni'ire  dilfuse,  and  may  in 
some  cases  invcdve  an  entire  lobe  or  the  greater  part  of  a  lung.  It  is  in 
this  nir)de  of  infection  that  wc  .see  the  characteristic  peri-bronchial  granu- 
lation>  and  the  areas  of  the  ,so-calhMl  nodular  broncho-jmeumonia.  These 
broiuho-pnenmonic  areas,  with  on  the  one  hand  caseation,  tdceration,  ami 
cavity  formation,  and  on  the  other  sclerosis  ami  limitation,  make  up  the 
essential  elements  in  the  anati^mical  picture  of  titlierculons  jihthisis. 

1.  Acute  Pneumonic  Tuberculosis  of  the  Lungs. 

Tliis  form,  known  also  by  the  name  of  gnllopiiKj  coiisiimpl!i)iK  is  met 
with  both  in  children  and  adult.*.  In  the  former  many  of  the  cases  are 
mistaken  for  simple  broncho-pneumonia. 

Two  types  may  be  recognized,  the  pnciunonic  and  hroncho-pncumoiiic. 


290 


SPECIFIC  INFECTIOUS  DISEASES. 


(o)  111  llu'  imruniniiir  form  uwv  Inhc  iiuiy  lie  iiiv(.lv.Hl,  or  in  f^nino  in- 
staiurs  an  cntiiv  lun-.     Tlu'  oi-an  i.  hravy.  llu'  alVr.tcd   i.-rlinn  airl.»: 
tlR.  i.l.'uni  is  usually  eovoml  with  a  tliin  fxudatr,  aii.l  on  >vv\un\  tlic  pirluiv 
ivscuLk's  d.-sclv  tiiat  of  ..nlinarv  li..i.ati/.ati..n.    The  fulL^wm-  is  an  rxtnui 
In.n,  liu.  iM-st-innrtcin  irpcrt  of  a  cax^  in  wliicii  .U'alli  mrurml  twcnty-niiu' 
,|avs  alter  the  onset  of  the  illness,  liavin-  all  the  eliaraeters  ol  an  aeiit.' 
i,i;eii„i..nia:  -  L.'tt  luii-  wei-lis  l.r-OO  -rainnies  (.L.nble  the  wei-ht  oi  tiie 
;„ln.,.  oroaii)  aii.i  is  heavy  aii.l  airless,  erepitant  only  at  the  anterior  mai- 
Uins     Section  slu.ws  a  small  eavitv  the  size  of  a  walnut  at  the  apex,  aoont 
Vvhieh  are  seattere.l  tnher.les  in  a  e<.nsnli,late.l  tissue.     The  greater  part 
„f  the  lung  i.resents  a  gravish-white  ai-i'-'aranee  due  to  the  a-n-egation 
of  tnhereles  wliieh  in  some  plaees  have  a  eontinnous,  nnilorm  api)earanee, 
in   others   are   surronnded   hy   an   injected   and    consolidated    limg-lissue. 
Toward  the  margins  of  the  h)wer  Inhe  strands  of  this  llr.n  red<lish  tissue 
separate  ana-mie,  dry  areas.     There  are  in  the  right   lung  three  or  lorn- 
small  groups  of  tuhereh's  hut   no  caseous  masses.      Ihe  l.ronchial  glands 
nre   not   tuherculous.-     Here  the  intense  lo.'al   infeeth.n  was  due  to  the 
small  h.cns  at  the  apex  of  the  lung.  i)roiml.ly  an  asi.iratKUi  jirocess. 

Oiilv  the  most  careful  inspection  may  reveal  the  juvsence  oi  miliary 
tuhercles  or  the  attenthm  mav  he  arreste.l  hy  the  detection  of  tuhercles  m 
tl„  „tlu.r  lung  .u'  in  the  hroiuhial  glands.  The  jirocoss  may  involve  .m  y 
one  lolu-  There  may  he  older  aivas  which  are  of  a  peculiarly  yellowish- 
whit.'  color  and  distinctly  caseous.  The  most  remarkable  picture  is  pre- 
sented hy  cases  of  this  kind  in  which  the  disease  lasts  for  some  months. 
A  lohe  or  an  entire  lung  mav  he  enlarged,  lirm,  airless  throughout,  and 
eonverted  into  a  dry,  yellowish-white,  cheesy  substance.  Cases  are  iii.'t 
with  in  which  the  entire  lung  from  apex  to  base  is  in  this  condition,  with 
perhaps  only  a  small,  narrow  area  of  air-eimtaining  tissue  on  the  margin 
More  comiiH.nly,  if  the  case  has  lasted  for  two  or  three  months,  rapid 
softenin-'  has  taken  place  at  the  apex  with  extensive  cavity  I.H'ination 

In  a  recent  study  A.  Fraenkel  and  Tmje  found  tubercle  bacilli  alone 
in  11  of  VI  cases,  'i'liev  suggest  that  in  these  cases  of  infection  l)y  asjnra- 
lion  the  large  areas  of  exudative  innammati(Ui,  at  some  distance  even  from 
the  seat  of  growth  of  the  bacilli,  are  due  to  the  j.resence  of  some  dilfusible 

l)oison  in-oduced  by  the  germs.  ,        .  ,         ,  .„  „     • 

Symptoms.— The  attack  sets  in  abrui.tly  with  a  chill,  usually  m  an 
individual  who  has  enjoyed  good  health,  although  in  many  cases  the  ons.'t 
has  been  preceded  bv  exposure  to  cold,  or  there  have  been  del)ilitating  cir- 
cum-tauces  The  tc'miieratnro  rises  rapidly  after  the  chill,  there  are  pain 
in  the  side  and  cou-h.  with  at  first  mucoid,  subsequently  rusty-colored 
expectoration  which  may  contain  tubercle  bacilli.  The  dyspn.ea  may  be- 
cmiie  extreme  and  the  i^tient  may  have  sudocative  attacks.  Tb(>  i)hysical 
examination  shows  involvement  of  one  lobe  or  of  one  lung,  with  signs  of 
consolidation,  dulness,  increased  fremitus,  at  first  feeble  or  supprej^ed 
vesicular  murmur,  and  subse.piently  well-marked  bronchial  hn.athmg.  The 
upper  or  lower  lohe  mav  be  involved,  or  in  some  cases  the  entire  lung. 

\t  this  time,  as  a  rule,  no  susi.icioii  enters  the  mind  of  the  in-actitionor 
that  the  case  is  anything  but  one  of  frai'.k  lobar  imenmonia.     Occasionally 


TUBERCULOSIS. 


291 


or  in  soino  in- 
jKirlidii   iiirli'ss; 
lidii  the  iiiclun' 
U'j:  is  an  (.'Xtnut 
[■(■(!  twi'iity-nino 
LTS  oT  iui  ac'Uti' 
'  wciirlit  of  tiu' 
(•  antcriDT  niav- 
tho  apex,  ai)ont 
lu'  <rroator  juirt 
tlio  ajij:n'j,'ati()n 
)rin  aiipoavanoo, 
tc'd   Uinji-lissno. 
II  rcddisii  tii-sito 
g  throe  or  lour 
ironchial  jiiands 
was  (hit'   to  tlio 
1  ])rocoss. 
HMici'  oi'  miliary 
1  of  tubcrck's  in 
lav  iiivolvo  only 
liarly  yellowish- 
;  i)ictiire  is  pro- 
)r  some  months, 
thron.diont,  and 
Cases  arc  met 
;  condition,  with 
'  on  the  maruin. 
c  months,  rajiid 
ly  I'ormation. 
rcle  hacilli  alone 
I'clion  by  asjiira- 
-tance  even  from 
if  some  dill'usil)le 

ill.  usually  in  an 
y  cases  the  onset 
1  debilitatinij;  cir- 
II.  there  are  pain 
itly  rusty-colored 
lyspno'a  may  bc- 
\s.  The  physical 
nijf.  with  signs  of 
le  or  suppres'^ed 
1  breathing.  The 
e  entire  lung, 
f  the  ])ractitioner 
Ilia.    Occasionally 


there  may  be  susjiicious  circumstanees  in  tlie  hisldpy  of  the  patient 
or  in  his  family;  but,  as  a  rule,  no  sticss  is  laid  upon  them  in  view  of 
the  inti'usc  and  characteristic  mndc  of  onset.  Uelween  the  eighth  atid 
lentil  day.  instead  of  the  expected  crisis,  the  condition  becomes  aggravated, 
the  temperature  is  irregular,  and  liie  pulse  more  rapid.  'I'here  may  be 
sweating,  and  the  exiiectoration  becnnies  niucn-jiurulent  and  greenish  in 
color — a  point  of  special  im])ortance.  to  which  Traulpc  called  attention, 
l-'.ven  in  the  second  or  third  week,  wilii  the  persistence  of  these  sym|iloms. 
the  physician  tries  to  console  iiimself  \\\\h  the  iilca  that  the  case  is  one  of 
unrtsolve(l  pneumonia,  and  that  all  will  yet  be  well,  (iradmdly.  Iiowever, 
the  severity  of  the  symptoms,  the  presence  of  ]ihysical  signs  indicating 
softening,  the  existence  of  elastic  tissue  and  tubercle  bacilli  in  the  sputa 
]>resent  the  mournful  proofs  that  the  case  is  one  of  acute  pneumonic 
jihthisis.  Death  may  occur  before  softening  takes  place,  even  in  the  second 
or  third  week.  In  other  cases  there  is  extensive  destruction  at  the  ajicx, 
with  rapid  formation  of  cavity,  and  the  case  may  drag  on  for  two  or  three 
months  or  may  become  one  of  chronic  ])hthisis. 

DiagnOSiSi — It  is  by  no  means  widely  recognized  in  the  profession 
that  there  is  a  form  of  acute  phthisis  which  may  closely  simulate  ordimiry 
]nieuiiuinia.  Waters,  of  ].,iverpool,  gave  an  admirable  description  of  these 
cases,  and  called  attention  to  the  diUlculty  in  distinguishing  them  from 
ordinary  pneumonia.  Certaiidy  the  mode  of  onset  all'ords  no  criterion 
whatever.  A  healthy,  robustdooking  young  Irishman,  a  cab-driver,  who 
had  been  kept  waiting  on  a  cold,  blustering  night  until  three  in  the  morn- 
ing, was  seized  the  lu'xt  afternoon  with  a  violent  chill,  ami  the  bdlowing 
dav  was  admitted  to  my  wards  at  the  T'niversity  Hospital.  I'hiladelphia. 
lie  was  nuuh'  the  subject  of  a  clinical  lecture  on  the  fifth  d.iy,  when  there 
was  absent  no  single  feature  in  history,  symptoms,  or  physical  signs  of 
acute  lobar  pneumonia  of  the  right  n])per  lobe.  It  was  not  until  ten  days 
later,  when  bacilli  were  found  in  his  expectoration,  that  we  were  made 
aware  of  the  true  nature  of  the  case.  1  know  of  no  criterion  by  which 
cases  of  this  kind  can  be  distinguished  in  the  early  stage.  Th(>  tul)ercle 
bacilli  may  not  be  present  at  first,  but  in  one  of  Fracid<el  and  Trojc's  eases 
they  existed  alone  in  the  typical  ])neumonic  sputum.  A  point  to  which 
Traube  called  attention,  and  wliich  is  also  referred  to  as  important  l)y 
llerard  and  Cornil,  is  the  absence  of  brealh-sounds  in  the  consolidated 
region:  b\it  this,  I  am  sure,  does  not  ludd  good  in  all  cases.  The  tnl)ular 
breathing  may  be  intense  and  marked  as  early  as  the  fourth  day;  and 
again,  how  common  it  is  to  have,  as  one  of  the  earliest  and  most  suggestive 
symptoms  of  lobar  pnc\imonia,  suppression  or  enfeel)Iement  of  the  vesicular 
murmnri  In  many  cases,  however,  there  are  suspicious  circumstances  in 
the  on^et:  the  patient  has  been  in  bad  health,  or  may  have  had  previous 
]udmonary  troulile.  or  there  are  recurring  chills.  Careful  examination 
of  the  sputa  and  a  study  of  the  ])liysical  signs  from  day  to  day  can  alone 
determine  the  true  miture  of  the  case.  A  ])oinl  of  smne  moment  is  the 
character  of  the  fever,  which  in  true  i»neunuinia  is  nmr(>  continuous.  ]iar- 
ticularly  in  severe  cases,  whereas  in  this  form  of  tidjerculosis  remissions  of 
1.5°  or  'i°  are  not  infrequent. 


-     - 


2D2 


SPECIFIC  INFECTIOUS  DISEASES. 


(//)  Ariilc  liihnriih,ii.-<  hnnirli'i-piinnnniiln  is  iikuv  ciunninii.  inuliculiirly 
in  children,  and  fnrius  ;,  ina.i..ritv  ..f  tlif  .-ascs  .d'  phlhl^U  jlnrlilo.  or  "  gal- 
loping consuini.tion."  It  is  an  afuto  caseous  l,n.nelio-i.ueiiiiioina.  startiiig 
in  the  smaller  tubes,  whieh  heeome  Idoeked  with  a  eiiee.-y  suhstaiue,  wlule 
the  air-eell.s  „f  the  lohule  are  lilled  with  the  products  of  a  catarrhal  i>ncu- 
nionia.  In  the  early  stages  the  areas  have  a  grayish-red.  later  au  oinupie- 
white  caseous  appearance.  J'.y  the  fusion  ol  contiguous  n.as>es  an  eixnv 
lohe  niav  he  renih^re.l  nearly  solid,  l)ut  re  can  usually  he  seen  ',et\veen 
the  -nuliis  areas  of  crepitant  air  tissue.  is  not  an  uuconnnon  jucture 

in  the  acul..  i.hthisis  of  adults,  hut  it  .^  1  more  frequent  in  childrc.i 
The  followino-  is  an  extract  from  the  jiost-mortem  report  ol  a  ca>e  on  a  chiM 
,,,,.,,,1  i„„r  mouths,  which  died  in  the  sixth  week  of  illness:  "On  section,  the 
rhdit  upper  lol)e  is  occupied  with  caseous  masses  from  T)  to  IV  mm.  m  diame- 
ter separated  from  each  other  hy  an  intervening  tissue  of  a  d.eep-rcd  color. 
The  bronchi  are  lilled  witii  cheesy  substance.  The  mi.ldle  and  lower  h.bes 
are  .studded  with  tulierclcs,  many  (d'  wliich  are  becoming  caseous,  lowanl 
the  diaphragmatic  surface  of  the  lower  lobe  there  is  a  small  cavity  the  size 
of  ■!  marble  The  left  lung  is  more  crepitant  and  uniformly  sxudded  witli 
tnl)crcles  of  all  sizes,  some  as  large  as  peas.  The  bronchial  glands  are  very 
lar-'-e,  and  one  contains  a  tuberculous  abscess."' 

There  is  a  form  of  tuberculous  aspiration  |)neum<mia,  to  whu  ii  l.aum- 
Irr  has  called  atteuth.n,  developing  as  a  se.iueiice  of  luemoptysis.  and  due 
to  the  aspiration  of  blood  and  the  contents  of  pulmonary  cavities  into  the 
liner  tube-  Following  the  luvmoiitysis,  which  may  have  occurred  m  an 
in.lividual  without  suspected  lesion,  there  are  fever,  dyspneea,  and  signs 
of  a  <lilfiise  broncho-pneumonia.  Some  of  thesx)  cases  run  a  very  rapid 
c.nir«e  and  are  examples  -d'  galloping  consumption  following  luvinoptysis. 
This  accident  mav  occur  not  alone  early  in  the  disease.  l)ut  may  follow 
luvniorrha-e  in  a  \vidl-dcvelo[)ed  case  of  pulmonary  tuberculosis. 

In  chiidren  the  enlar<:cd  bronchial  glands  usually  surround  the  root  (d 
the  lung,  and  even  pass  d.rply  into  the  substance,  and  the  lobules  are  often 
involved  I'v  direct  contact.  .    ,       r 

In  other  cases  the  caseous  broncho-])neumonia  mvcdves  groups  ol  alveoli 
,,r  lobules  ill  dilVerent  pcniions  of  the  lungs,  more  commonly  at  both 
apices,  forming  areas  from  1  to  3  cm.  in  diameter.  The  size  of  the  mass 
deiiends  lar-ndv  upon  that  of  the  bronchus  involved.  There  are  oases  which 
prolmldv  should  come  in  this  category,  in  which,  with  a  history  ol  an  acute 
ill,K-s  of  from  four  to  eight  weeks,  the  lungs  are  extensively  stu.bled  with 
h,r-e  orav  tubercles,  ramring  in  size  from  5  to  10  mm.  In  some  instances 
thc're  are"ch.-esy  masses  the  size  of  a  cherry.  All  of  these  are  grayish-wlute 
in  color,  distinctly  cheesy,  and  between  the  adjacent  ones,  ].articularly  m 
the  lower  lobe,  tliero  may  bo  recent  pneumonia,  or  the  condition  of  lung 
which  has  been  termed  splenization.  In  a  oaso  of  this  kind  at  the  Phila- 
deli.hia  Hospital  death  took  place  about  the  eighth  week  from  the  abru])t 
onit  of  the  illness  with  liannorrhage.  There  wore  no  extensive  areas  of 
consolidation,  but  the  cheesy  nodules  wore  uniformly  scattered  throughout 
both  Innos.    No  softening  had  taken  idaco. 

Secondary   infections  are   not   uncommon;    but   Trudden  was   able  to 


11.  iiiuticuliirly 
iriilii.  or  "  il'il- 
iiniiiii,  stiirtiii.i; 

|li>t;lliri',  while 
•iitarrhal  imi'ii- 
liT  an  opaciuo- 
a SSI'S  an  en  tiro 

(_'    Sfl'll    '.'OtWl'l'll 

iiimiiDii  incturi' 
lU   111  chililivn. 

caM'  en  a  cliilil 
On  section,  tlu' 

mm.  in  tliame- 

ilet'it-ri'd  color, 
uul  lower  lobes 
seoiis.     Towanl 

cavity  the  size 
ly  siUuUlcd  with 
''lands  are  verv 

r*  *■ 

()  wliii  ii  iiiiiim- 
)ptysis.  and  dne 
•avities  into  tiie 
occurred  in  an 
iiKea,  and  signs 
in  a  very  rapid 
ing  iKvinoptysis. 
hut  may  follow 
•iilosis. 

lund  tiio  root  of 
ohiiles  are  often 

Li'roups  of  alveoli 
iimoidy  at  hotli 
size  of  the  mass 
>  are  cases  which 
;tory  of  an  acute 
_'ly  studded  with 
11  some  instances 
ire  grayish-white 
;,  ]iarticularly  in 
indilion  of  lung 
lid  at  the  Phila- 
from  the  abru])t 
xti'usive  areas  of 
tered  throughout 

don  was   able  to 


TUBEIICULOSIS. 


203 


-how  that  the  tubercle  bacillus  could  |iroduce  not  only  distinct  tubercle 
nodules,  but  also  the  varioii.<  kinds  of  exudative  |iheiioineiia,  the  exudates 
\aryiiig  in  a|i|icarance  in  dill'ereiit  cases,  which  |ihciioineMa  occurnd  aliso- 
liitely  without  the  intervention  (d'  other  organi>iii.--.  The  fait  that  tin-e 
latter  had  imt  subsei|iieiilly  cre|it  in  was  >hown  by  cultures  at  the  auto|i<y  oii 
the  aH't'cted  animal. 

Symptoms.  —  The  ^ym|llo|lls  of  acute  broiicho-ieu.uiuoiiic  |ihthi-is 
are  vt'ry  vai'ial)le.  In  adults  the  disease  may  atta<k  per-ous  in  gond  licaltii, 
but  who  are  overwoi'ked  or  "run  down"  from  any  cause.  Ihcmoirhage 
initiates  the  attack  in  a  b'w  cases.  There  may  be  repeated  chills;  the 
lemperatiire  is  high,  the  \i[i\>v  rajiid,  and  the  respirations  are  iiicfea>cd. 
The  loss  of  iK'sli  and  strength  is  very  striking. 

'I'he  physical  signs  may  at  lirst  he  iini'ertain  and  indeHiiite,  liut  tinally 
there  are  areas  of  impaired  resonance,  usually  at  the  apice-;  the  breath- 
sounds  are  harsh  and  tubular,  with  numerous  rales.  The  sputa  may  early 
show  clastic  tissue  and  tubei'clo  bacilli.  In  the  acute  cases,  within  three 
weeks,  the  i>alient  may  be  in  a  marki'd  tyjihoid  state,  with  dtliriiim.  dry 
tongue,  and  liigh  fever.  J)eath  may  occur  wilbiii  three  weeks,  in  other 
cases  the  onset  is  severe,  with  high  fever,  rapid  lo>s  of  llesh  and  strength, 
and  signs  (d"  extensive  unilateral  or  bilateral  disea-e.  Sol'teniiig  take-^  place; 
there  are  sweats,  chills,  and  progressive  emariation,  and  all  the  b-atures  of 
jilitliisis  /liiridd.  Six  or  eight  weeks  later  the  patient  may  begin  to  im- 
prove, the  fever  lessons,  the  general  symptoms  aliate,  and  a  case  whith 
looks  as  if  it  would  certainly  terminate  fatally  within  a  b'w  wi^eks  drags 
on  and  becomes  I'hronic. 

]n  ihili/rrii  the  disease  most  commonly  follows  the  infectious  diseases, 
particularly  measles  and  whooping-cough.*  The  prob'ssioii  i>  gradually 
recognising  the  fact  that  a  majority  of  all  such  cases  are  tuberculous. 
At  least  llin't'  (/rditps  cd'  these  tuberculous  broncho-piieumonias  may  be 
recognized.  In  the  first  the  child  is  taken  ill  suddenly  while  teething 
or  during  convalescence  from  fever;  the  tt'iiiperature  rises  rapidly,  the 
cough  is  severe,  and  there  may  be  signs  of  consolidation  at  one  or  both 
apices  with  lales.  Death  may  occur  within  a  few  days,  and  the  lung  shows 
areas  of  broncho-pneumonia,  with  ])erha]is  here  and  there  scattereil  o|ia(pie 
grayish-yellow  nodules.  ;\Iacroscopically  the  aU'ection  does  not  ImAi  tuber- 
culous, but  histologically  miliary  gramilations  and  bacilli  may  bo  found. 
Tubercles  are  usually  jire.sont  in  the  bronchial  glands,  but  the  appearance 
of  the  broncho-pneumonia  may  be  exceedingly  dece[itive,  and  it  may  re- 
quire carcd'ul  microscopical  examination  to  determine  its  tuberculous  char- 
acter. The  second  (jrtivp  is  representod  by  the  case  of  the  child  previously 
(pioted,  which  died  at  the  sixth  week  with  the  ordinary  syni])toins  of  severe 
broncho-piunnnonia.  And  the  iliird  (jvoup  is  that  in  which,  during  the 
convalescence  from  an  infectious  disease,  the  child  is  taken  ill  with  fever, 
cough,  and  shortness  of  breath.  The  severity  of  the  symptoms  abates 
within  the  first  fortnight;  but  there  is  loss  of  flesh,  the  general  condition 
is  bad,  and  the  jdiysical  examination  shows  the  itrcsence  of  scattered  rales 

*  "Tussis  convulsiva  vestibuluin  tnbis"  (Willis). 


d^ 


'J94 


SPECIFIC  INFECTIOUS  DISEASES. 


tliroii-Iioiit  the  liiiifTS,  and  lioro  and  llicro  arciis  of  (K'frctivo  rc^onanco. 
Till'  cliiM  lias  sweats,  the  tVvcr  hccoiiics  hvctic  in  cliaractcr,  and  in  many 
ctisi'S  tlif  (diniial  pittnro  gradually  di'Vi'lnjis  into  that  of  rliroiiii'  phthisis. 


2.  Chronic  Ulcerative  Tuberculosis  of  the  Lungs. 

rndiT  this  heading  may  ho  gnrnju'd  the  <rivat  majority  of  cases  of  pul- 
nionary  tuliereiilosis,  in  whieh  the  lesions  proeeed  to  nleeration  ami  solten- 
iiig,  aiid  ultimately  prodiico  the  well-known  picture  of  chro.iic  iihthisis. 
At'"lirst  a  strictlv  tulierciiloiis  all'ection,  it  ultimately  heconies,  in  a  majority 
(d'  cases,  a  mixed  disease,  many  of  the  most  pn.mineiit  symptoms  of  whieh 
are  due  to  septic  infection  ffoni  purulent  foci  and  cavities. 

Morbid  Anatomy.— Inspection  (d'  the  lungs  in  u  case  of  chronic 
jilithisis  shows  a  remarkalde  variety  of  lesions,  comprising  nodular  tuber- 
cles, dilVuse  tuberculous  inliltration,  caseous  masses,  pneumonic  areas,  cavi- 
ties of  various  sizes,  with,  changes  in  the  pleura,  bronchi,  and  bronchial 

glands. 

1.  The  Distribution  of  the  Lesions.— For  years  it  has  lieen  recognized 
that  the  most  advanced  lesions  arc  at  the  apices,  and  that  the  disease  pro- 
gresses downward,  usually  more  rapidly  in  one  (d'  the  lungs.  This  gen- 
eral statement,  which  has  passed  current  in  the  text-books  ever  since  the 
masterly  descriiition  of  Laennec,  has  recently  been  carefully  elaborated 
by  Kingston  Fowler,  wlio  finds  that  the  disease  in  its  onward  progress 
through  the  lungs  iollows,  in  a  majority  of  the  cases,  distinct  routes.  In 
the  upp'''"  1"''*'  <•"'  I"''">i"T  1''^'""  '^  ""^'  '^^  "  '■"^^'  ^^^  ^^^^  e-xtrcme  apex, 
but  from  an  inch  to  an  incli  and  a  half  below  the  summit  of  the  lung,  and 
nearer  to  the  jiosterior  and  external  borders.  The  lesion  here  tends  to 
spread  (b)wnward,  i>ro!iably  from  inhalation  of  the  virus,  and  this  accounts 
for  the  frequent  circumstance  that  examination  Ijchind,  in  the  supra- 
s])inous  fossa,  will  give  indications  of  disease  before  any  evidences  exist  at 
the  apex  in  front.  Anteriorly  this  initial  focus  corresponds  to  a  spot  just 
lielow  the  centre  (d'  the  clavicle,  and  the  direction  of  extension  in  front 
is  alomr  the  anterior  aspect  of  the  upper  lolie,  along  a  line  running  about 
an  inch  ami  a  half  from  the  inner  ends  of  the  Urst,  .second,  and  third  inter- 
spaces. A  second  less  common  site  of  the  ]»riinary  lesion  in  the  apex  "  cor- 
respomls  on  the  chest  wall  with  the  first  ami  second  intersiiaees  below  the 
outer  third  of  the  clavicle."  The  extension  is  downward,  so  that  the  outer 
part  of  the  upiier  lobe  is  chiefly  involved. 

Tn  the  middle  lobe  of  the  right  lung  the  affection  usually  Iollows  disease 
of  the  ui)i)er  lobe  on  the  same  side.  In  the  inv(dvement  <d'  the  lower  lobe 
the  tirst  secondary  inliltration  is  about  an  in"h  to  an  inch  and  a  half  below 
the  posterior  extremity  of  its  apex,  and  corresiwnds  on  the  chest  wall  to  a 
sjiot  oi>posite  the  fifth  dorsal  spine.  This  iiuolvement  is  of  the  greatest 
importance  clinically,  as  "  in  the  great  majority  of  cases,  when  the  physical 
si(rns  of  the  disease  at  the  ajtex  are  suiliciently  definite  to  allow  of  the  diag- 
nosis of  phthisis  being  made,  the  lower  lobe  is  already  an'eeted."  Fxamina- 
tion,  therefore,  should  be  made  carefully  of  this  posterior  ai)ex  in  all  sus- 
picious cases.     In  this  situation  the  lesion  spreads  downward  and  laterally 


tuhkuculosis. 


205 


tivc  ri'^onanco. 
',  niitl  in  miiiiy 
•oiiic  phthisis. 

S. 

)!'  cases  of  pill- 
ion and  soi'tcn- 
iroiiic  ]thtiiisis. 
S  in  a  majority 
itonis  ol'  which 

•asc  of  chronic 

nodular  tulicr- 

mic  areas,  cavi- 

and  livonciiial 

iccn  rccof^nizcd 
he  disease  i)ro- 
i;zs.     This  iivn- 

evor  since  the 
uUy  olahorated 
nward  ]»rogress 
tict  routes.  In 
;  oxtreme  apex, 
if  tiie  Inng.  and 
I  hero  tends  to 
id  this  accounts 

in  the  siipra- 
idencos  exist  at 
s  to  a  spot  jnst 
ension  in  front 
'  runnin.i:  ahont 
and  tliird  inter- 

tlie  apex  "  cor- 
paces  heh)\v  tlie 
f)  tliat  the  outer 

V  follows  disease 
f  the  lower  lol)e 
ind  a  half  helow 
'  chest  wall  to  a 

of  the  fxreatest 
hen  the  jihysical 
How  of  the  dia.u- 
ted."    Exaniina- 

ai)ex  in  all  sus- 
ird  and  laterally 


alonp  {\\v  line  of  the  iiiterloliular  septa,  a  line  wliirli  is  niarkid  hy  the 
verteiiral  lionler  of  the  >(apula.  when  the  hand  is  placed  on  the  opposite 
scapula  and  (he  eliiow  raised  aiiove  the  level  of  the  shoulder.  Once  jires- 
tiit  in  an  ajtex,  the  ilisea>e  usually  extends  in  time  to  the  opposite  upper 
lohe;  hut  not,  as  a  rule,  until  the  apex  of  the  lower  lohe  of  tlie  lung  lirst 
allVcted  has  ceeii  attacked. 

Of  iv'T  cases  ahove  mentioned,  the  right  apex  was  involved  in  l*'.',  the 
left  in  J;;(i,  l.oih  in   11  1. 

i>esioiis  of  the  hase  may  he  primary,  though  this  is  rare.  Tercy  Kidd 
makes  the  |iroporti(in  of  liasic  to  apicic  jilithisis  1  to  r)iM),  a  smaller  numinT 
than  cxi.-ted  in  my  scries.  In  very  chronic  cases  there  may  he  arrested 
lesions  at  theaiiex  and  more  recent  lesions  at  the  iiase. 

'2.  Summary  of  the  Lesions  in  Chronic  Ulcerative  Phthisis. — (n)  Mili- 
arij  'I'liliii-flcs. — 'i'hcy  have  one  of  two  distrihulions:  (1)  A  dissemination 
due  to  asjiiration  of  tuberculous  nuUerial,  the  tubercles  being  situated  in  the 
air-cells  or  the  walls  of  the  sm  Her  luonchi;  (v')  the  distriliution  due  to 
dissemination  of  tubercle  bacilli  by  the  lymph  t'lirrcnt.  the  tubcrc  les  being 
scattered  about  the  old  bici  in  a  radial  manner — the  secondary  crop  of 
l.acnnec.  .Much  more  rarely  there  is  a  scattered  di>,-eminatioii  from  in- 
fection here  and  there  of  the  smaller  vessels,  the  tubercles  then  being 
situated  in  the  vessel  walls.  Sometimes,  in  cases  with  cavity  formation  at 
the  apex,  the  greater  jiart  of  the  lower  lobes  presents  many  groups  of  lirm. 
sclerotic,  miliary  tubercles,  which  may  indeed  form  the  distinguishing  ana- 
tomical ft'aturc — a  chronic  miliary  tnberc  ulosis. 

{!))  'rithviriilotis  llr(iiirli(i-i)iiniiiioiiia. — In  a  large  |)ro|H)rtion  of  the  cases 
of  chronic  phthisis  the  termiiud  bronchiole  is  the  jxiint  of  origin  of  the 
]trocess,  coiise(piently  we  lind  the  smaller  bronchi  and  their  alvetdar  terri- 
tories lilocked  with  the  accumulated  jiroducts  of  inllammation  in  all  sti-ges 
of  cfisi'dlidii.  At  an  early  period  a  cross-si'ction  of  an  area  of  tuberculous 
broncho-pneumonia  gives  tlie  most  characteristic  appearame.  The  central 
bronchiole  is  seen  as  a  small  orilice,  or  it  is  plugged  with  cheesy  contents, 
while  surrounding  it  is  a  casi'ous  nodule,  the  so-called  peribronchial  tuber- 
cle. The  longitudinal  .section  has  a  somewhat  dendritic  or  foliaceous  ap- 
]>earance.  The  conditio  of  the  picture  depends  much  upon  the  slowiu'ss 
or  rapidity  with  which  the  jtrocess  has  advanced.  The  b)llowiiig  changes 
may  occur: 

llrcralioii. — When  the  caseation  takes  ])lace  rapidly  or  ulecrati<ui  occurs 
in  the  bronchial  wall,  the  nuiss  nuiy  break  down  and  birni  a  small  cavity. 

Sclcrosift. — In  other  instances  the  jjrocess  is  more  chronic.  Fibroid 
changes  gradually  jjroducc  a  sclerosis  of  the  aiVected  area,  a  condition 
which  is  sometimes  called  rirrh(ms  noilosn  inhoruJoaa.  The  sclerosis  may 
be  cimfined  to  the  margin  of  the  nuiss,  forming  a  limiting  capsule,  within 
M-bich  is  a  unib)rm,  firm,  cheesy  substance,  in  which  lime  salts  are  often 
deposited.  This  reiircsenls  the  healing  of  one  of  these  areas  of  caseous 
bnmcho-imeumonia.  It  is  only,  however,  when  complete  fibroid  trans- 
formation or  calcification  has  occurred  that  we  can  really  speak  of  healing. 
In  manv  instances  the  colonies  of  miliary  tubercles  about  these  masses 
show  that  the  virus  is  still  active  in  them.     Subsequently,  in  ulcerative 


!; 


2UC 


SIMU'IFIC  INFKCTIOUS  DISEASES. 


1 


procpsiso?,  tlioHO  ciIcMrfou-  iMKlics— luii-->toiu-,  as  they  luv  sum-'liiiirs  oalU'd 
— may  lie  i'.\|H'ctiirat(iI.  . 

(,')  /'/M7n/(<-/M'».— All  iiMiM.rtaiit  tliou^'li  sccciidary  pliico  is  (hchi.U'.I 
l,v  inllinniuiitinii  ..f  tlu'  alvfoli  siim.i.iuliii-  the  tulMT.I.s  wliU'li  l^trnmr 
lilKd  Milh  i^i.ith.'linid  tells.  Tlu'  (■..iis..li.lati..n  may  cMcH'l  l"r  s,.in.'  .ii- 
fiiK-c-  aiM.ul  the  lull,  ivulc.iis  fnci  an.!  iiiiito  tlu'iii  int..  amis  ol  uiulorm  cm- 
(^oli.lalioii.  Allhnu-ii  in  s(,imc  instamos  this  inllaniniatory  |.rn,rss  may  he 
Mnn.U-.  in  mlKr^  it  is  nn.lo.il.f.lly  siHrilir.  It  is  pxcitc.l  hy  tlu-  uii.orelo 
l,acilli  an.l  is  a  mauifrstalinn  of  tluir  acti-m.  It  may  \m'<vu\  a  very  varud 
api-caniiur:  in  son.,  insta.ucs  ivs,.,ul.liii-  .Insc'ly  ..nl.nary  n.l  "■i.ati/a- 
tiun.  in  ..tluTs  Loin-  mmv  li.Mn..-riuMUis  and  inliltvatcl.  \hv  su-ca  U-l  ih//  - 
fralinn  Ivhrrcukusr  ..I'  Larniu'c  In  otluT  .as.s  tlu"  mnt.nts  nl  th.  alvonj. 
umlcriro  lattv  (Ic-oncratioii,  and  aiM'far  ..n  tlir  cut  suriatr  as  npaqur  white 
or  vcdlowish-whito  hodifs.  In  oavly  l-hthisis  mn.li  uf  tlu-  cnns.didati.m  is 
duo  to  this  inicnnHmio  inliltrati..n,  which  may  surn.nnd  h.r  s<.nu'  diMaiur 
tlu'  smallrr  lulicrciilous  i'oci.  _  ,11 

(,/)  (V/////VS.— A  vomica  is  a  cavity  in  the  lun-  tissue,  produced  by 
necrosis  and  ulceration.  It  ditr.^rs  materially  from  the  hnmclue.tatic  l..nii. 
Tlu.  pro.rss  usually  h.-ins  in  the  wall  of  the  hronchus  in  a  tnhenulous 
area  Dilatation  isV'oduccd  1)V  retained  secretion,  and  necrosis  and  ulcera- 
tion of  the  wall  occur  with  f,n'adi^'il  destruction  of  the  eoiiti-uous  tissues. 
]W  exten-ion  of  the  necrosis  and  ulceration  the  cavity  increases,  eonti-u- 
„us  ones  unite,  and  in  an  allVcted  re-ion  there  may  he  a  series  «t  sinall 
excavati.uis  communicalinir  with  a  hroiu'hus.  In  nearly  all  iiu^tances  the 
proee--  extends  from  the  hronchi.  thou-h  it  is  pos.sihlo  for  necrosis  an.l 
ioftenin-'  to  take  place  in  the  centre  .^f  a  caseous  area  without  primary 
involvement  of  the  bronchial  wall.     Three  f.nnis  of  cavities  may  he  reco-- 

The  firsh  uhrrntiir.  soon  in  nonte  idithisis.  in  wliich  there  is  no  limiting: 
niemhrane.  hut  the  walls  are  made  up  of  s.dtened,  necrotic,  and  caseous 
lua-e^  Small  vomica'  of  this  sort,  situated  just  heiieath  the  ideura,  may 
rupture  an<l  cause  pneumothorax.  In  cases  of  acute  tuherculo-|meunionie 
phthisis  thev  mav  he  larjre,  oceupyin,<:  the  jzreater  p.nlion  of  the  upi.er 
h.l...  In  the  chronic  ulcerative  i.hthisis.  cavities  of  this  sort  are  mvariahly 
pre-enl  in  those  ].ortions  of  the  lun-r  in  which  the  disease  is  advancing'. 
\t  the  an.'x  there  mav  he  a  larfre  old  cavity  with  well-defined  walls,  while 
at  the  aiiterior  marjrin  of  the  upper  lohes,  or  in  the  apices  of  the  lower 
lohe<  there  are  recent  ulceratinji  cavities  communicating  with  the  hronchi. 

Cirilirs  irUli  ]yrll-,lrfln,'d  Walls.— \  majority  of  the  cavities  111  the 
chronic  form  of  phthisis  have  a  well-de(ined  limiting  mend.rane.  the  inner 
surface  of  which  .-..nstantlv  produces  pus.  The  walls  arc  crossed  hy  trahec- 
ula>  which  reiiresent  remnants  of  bronchi  and  hlood-vessels.  Kven  the 
vomica,  with  the  w..ll-dcfined  walls  extend  oradually  hy  a  slow  necrosis 
and  d.-truction  of  the  contiguous  lung  tissue.  The  couhmts  are  usually 
purulent  similar  in  character  to  the  grayish  nummular  sputa  coughed  up 
hv  i.hthisical  ].atients.  Not  infre.,ueutly  the  niemhrane  is  vascular  or  it 
mav  he  luvmorrha-ie.  Oeeasionally.  when  ganirnme  has  occurred  in  the 
wail  the  contents  are  horribly  f^^'^'^l-    These  cavities  may  occupy  the  greater 


TI'DEUCI'LOSIS. 


297 


>ini 


liinrs  calU'il 


CO    is   oit'iiiiic'l 
wliiili   lu'cdiuc 

I  lor  soiiii'  (li>- 
if  uiiirnnii  cnll- 
|inurss  iiii\y  111' 
by  till-  uiliirili' 
it  a  very  varied 
y  iTil  iu'pati/.a- 
.'  su-calUii  iii/il- 
Is  nl'  llii'  alvfKJi 
lis  ()iia(iiK'  wiiito 
nmsiiliilatioii  is 
r  soiiii'  (listaiicc 

ic,  |ir(i(liici'(l  liy 
icliii'ctatic  I'driii. 

II  11    tll!H'l'(ul(lUS 

rosis  anil  iilii'i'a- 
iitifiiioiis  tissues. 
LTcascs,  coiiti^'u- 
i  series  of  small 
ill  instances  the 
i'or  necrosis  anil 
rtithont  i)riniary 
'S  may  be  reeoj:- 

>re  is  no  limiting: 
)tie,  and  caseous 
the  jilenra,  may 
rculo-pneumonie 
1)11  of  the  ii|)])er 
)rt  are  invariably 
ise  is  ailvancin<r. 
ined  walls,  while 
CCS  of  the  lower 
vith  the  bronchi. 
}  cavities  in  the 
ibrane.  the  inner 
Tossed  by  trabec- 
ssels.  Even  the 
•  a  slow  necrosis 
tents  arc  usually 
puta  couched  up 
is  vascular  or  it 
occurred  in  the 
iccujiy  the  greater 


pnrtinu  nf  the  api\.  fniiiiiiiL;  ail  irregular  serio  wliiili  cniumunii  ate  with 
each  othei'  and  with  the  linnirhi,  m'  the  eiiiiie  upper  \n\>r  rxiipt  the  an- 
terior margin  may  be  excavated,  I'nrming  a  tiiin-walled  cavity.  In  rare 
instances  the  piMcc.--;  has  |iroceeded  {>>  total  exiavaliim  of  the  lung,  not  a 
remnant  i>i  which  remains,  except  |irrliap>  a  narniw  >ti'ip  at  the  antrrinr 
margin.     In  a  ca-e  uf  this  kind,  in  a  young  giii,  the  cavity  held    In  tliiid 

UllllCCS. 

(Jiiii^rriil  Ciiriliry., — \\'lieii  (jiiitc  small  and  ^lll'roullded  by  dense  cica- 
tricial tissue  coiiimiinicating  with  the  liroiichi  tiu'y  birm  tiie  (iki trices 
fisliilciisi's  of  J.aeiiiiec.  Occasionally  one  apex  may  be  represented  by  a 
series  of  these  .-mall  cavities,  surriuiiided  liy  iK'Hm'  libroiis  ti>siie.  The  lin- 
ing niemhraiie  uf  these  old  cavities  may  be  (piite  smonth,  alniu^t  like  a 
miiciiiis  meiiiliraiie.     Cavities  of  any  size  do  not  heal  ciuupletely. 

Cases  are  often  seen  ill  which  it  has  been  supposed  that  a  cavity  has 
healed:  but  the  signs  of  excavation  are  notoriously  uncertain,  and  there 
may  be  pectoriloquy  and  caveriu)us  sounds  with  gurgling,  rcM)naiit  rales 
in  an  area  of  consolidation  close  to  a  large  bronchus. 

Jn  the  formation  id'  vomica'  the  blood-vessels  gradually  become  closed 
by  an  obliterating  inilanimation.  They  are  the  last  structures  to  yield 
and  may  be  com])letely  exposed  in  a  cavity,  even  when  the  circulation  is 
still  going  on  in  them,  riifortiiiiately,  the  em-ion  of  a  large  vessel  which 
has  not  yet  been  obliterated  is  by  no  means  iiifrci|iieiit,  and  causes  ju'ofiise 
and  often  laial  ha'inorrhage.  Another  common  event  is  the  develo|uiieiit 
of  aneuri.-ms  on  the  arteries  running  in  the  walls  of  cavities,  'i'hese  may 
be  small,  bunch-like  (dilatations,  or  they  may  foiin  sacs  the  size  of  a  walnut 
or  oven  larger.  l»a-iiiussen,  Douglas  Powell,  and  others  have  called  atten- 
tion to  their  importance  in  ha'iuoptysis,  under  wliiili  section  they  are  dealt 
with  more  fully. 

And  linally,  abmit  cavities  of  all  sorts,  the  connective  tissue  develitjis 
and  tends  to  limit  the  exuiit.  The  thickening  is  particularly  marked  be- 
neath the  pleura,  and  in  chronic  cases  an  entire  apex  may  he  converted  into 
a  mass  of  fibrous  tissue,  enclosing  a  few  small  cavities. 

(c)  J'lcura. — rractically,  in  all  cases  of  chronic  ]ih.tliisis  the  ]ileura  is 
involved.  Adhesions  lake  place  which  may  be  thin  and  readily  torn,  or 
dense  and  firm,  uniting  layers  of  from  '2  to  o  mm.  in  thickness.  This 
pleurisy  may  iie  simple,  but  in  many  cases  it  is  tulicrculous,  and  miliary 
tubercles  or  casemis  masses  are  seen  in  the  tliickcned  membrane.  Klfiision 
is  not  at  all  infrei|uent,  either  serous,  ])urulent.  or  luemorrhagic.  Pneumo- 
thorax  is  a  common  accident. 

(/")  Changes  in  the  siiidllcr  hninrlii  control  the  situation  in  th.e  early 
stages  of  tuberculous  ])lithisis.  and  ])lay  an  important  nVr  throughout  the 
disease.  The  ]irocess  very  often  begins  in  the  walls  of  the  smaller  tul'cs 
and  leads  to  caseation,  dir-tcntiou  with  product-;  of  inflammation,  and 
broncho-)uieumonia  of  the  lobules.  In  many  cases  the  visible  implication 
of  the  bronchus  is  an  extension  njiward  of  a  proces-  which  has  begun  in 
the  smallest  l>rouchiole.  This  involvement  weakens  the  wall,  loading  to 
bronchiectasis,  not  an  uncommon  event  in  iihthisis.  The  mucous  mem- 
brane of  the  larger  l)ronchi,  which  is  usually  involved  in  a  chronic  catarrh, 


^^ 


2,j^  .SI'KCIFIC   INFlXTIOl'S  DISKASKS. 

i.  moiv  (.r  less  swnllcii,  niid  in  s..nir  instaiurs  iilccrat.d.  I'mm^.s  tlics.' 
.MKTilir  Ir.-i.ms.  tl.fv  imiv  !..•  iIh-  s,'at.  ..>|urially  in  il.il.l.vM.  n|  nillaniiMa- 
ti.,M  .luc  t.)  scc.n.lary  iinaMnn.  iMn>l  liv.,urntlv  l.v  the  luHruru.vii^  lati.r,.- 
latus,  Willi  till'  |.nM|ii(ti(iii  of  a  l.n.iu  iin-|m.'iim(piiia. 

(,/)  Till"  hronrhial  ,il<ni<ls,  in  tiu'  mniv  a.iiU'  cases,  aiv  swhIIhi  and 
„.,l,.inat..ii.-.  Miliary  tnLcivlcs  and  .asmiis  lu.i  aiv  n.-ually  |.iVM...t.  in 
cases  (.1'  cl.n.nic  phlliisis  tlic  caM.ins  aivas  aiv  c.ninnni,.  calnlualinu  may 
uccnr,  and  nut  inl'rc(inontly  imrnknl  sultcning.  ,     .     •      ,  , 

il,)  Clnnnirs  in  Ihv  olhrr  Ur;inns.-i)<i  these,  tnheivnlnsis  is  tlie  must 
commu,,.  In  .ny  series  ui'  antupsies  the  l.rain  i-resented  lul..Tculu„>  lesauis 
i„  :n,  the  spleen  in  'M.  the  liver  in  IV,  the  kidneys  in  :J--',  t  a-  inleslincs 
in  (;:.,  and  the  pericardium  in  :.  Other  groups  (d'  lymphatic  -lan.ls  liesides 
liie  lirniicliial  mav  he  alVected. 

(Vnaiii  (h-eneratiniis  arc  cmmun.  Annih>i,l  rh,ni;ii-  is  liv.picnt  in 
the  liver,  spleen,  kidncvs,  and  niiic.ns  mcmhrane  uf  the  intestines.  Ihe 
lircr  is  ..Itcn  the  seat"  .d'  extensive  tatty  inliltratiun,  which  may  caii>e 
marked  ciilar-cnunt.  'i'iie  inlrslinni  luhrtrulosis  occurs  m  advanced  cases 
and  is  respuiiMi.le  in  ^ivrM  part  fur  the  truiihlesumc  diarrlnea. 

J'mhranlills  is  nut  vcrv  iincuinmun.  aii.l  was  i.rcsent  in  VI  ul  my  pusl 
murtenis  ami  in  :.':  ut  I'.mvv  KiddV  ;.(.(.  cas..s.  Tnhcrclc  l.acilli  have  i.cen 
I'.nind  in  the  vcfrctaliuns.  The  siihjc  t  has  heen  considered  in  an  impor- 
tant monu^M-apli  I'V  Tci.-sier  (Paris.  ISIH).  Tnlicrchs  may  i^e  presen  on 
the  cnducardinm.  particularly  .d'  the  ri-ht  veiitri.'le.  As  pointed  out  hy 
Xurman  I'hcvers.  and  cunlirincd  hy  siihse.pient  writers,  the  suhjec  s  ul 
con-cnital  stenusis  (d'  the  pulmonary  (H'ilice  very  Ire.picntly  have  phthisis. 
The  hiniii.r  is  rrc(piently  involved,  and  iilccratiun  of  the  vocal  cords 
and  d(-triictiun  of  the  e|)i-lullis  are  nut  at  all  uncumm.in.  _ 

Modes  of  Onset.— We  have  already  seen  thai  tidierculosis  ut  the 
linifis  mav  uccur  as  the  child'  part  uf  a  '^vnvvA  infectiuii.  ur  may  set  in 
with  sym'ptuius  which  closely  simulate  acute  pneumonia.  In  the  ordinary 
type  o"f  pulmonary  tuberculosis  tlu'  invasion  is  <,n'adual  and  less  stnkiiijr, 
but  presents  an  extraordinarily  diverse  picture,  so  that  the  practitioner  is 
often  led  into  error.     Aniuntr  the  most  characleristie  (d'  these  tyi.es  of  onset 

are  the  foUowit  ,::  ,  •  ,    ,,      v 

((()  There  is  a  small  but  important  fjcroup  of  cases  in  which  the  (lisease 
makes  considerable  pro-ress  bid'ore  there  arc  serious  symptoms  to  arouse 
the  attcntiun  of  the  patient.  This  lalcul  farm  of  the  disease  is  seen  most 
frecpientlv  in  workin^mien.  and  the  disease  may  even  advanc.-  to  excava- 
tion of  an  ai.ex  before  they  seek  advice,  in  some  .d'  these  cases  it  is  not  a 
little  remarkalde  how  slight  the  lung  symi)t<nns  have  been. 

A  ddVerent  tvi-e  (d'  latent  ].uInionary  tuberculosis  is  the  form  in  which 
the  symptoms  aiv  masked  by  the  existence  of  serious  disease  in  other  organs, 
as  in"  the  peritunauini.  intestines,  or  bones. 

(h)  Willi  Sinuplomx  of  Di/.'^prpsia  (unl  .burwrn.— The  gastric  mode  ut 
onset  is  yery  ccimmon,  and  the  early  manifestations  may  be  great  irritability 
of  the  stoiiiach  with  vomiting  or  a  tyj.e  of  acid  dyspepsia  with  eructa- 
tions In  young  girls  (and  in  children)  with  this  dyspo])sia  there  is  very 
frequently  a  jirononncod  cliloro-ana'mia,  and  the  patient  complains  of  pal- 


TinKUCl'LoSIS. 


'Jit'J 


I,  III'  iiilliiiiiMia- 

UlllCCllS    llllU'l'll- 

rc  >ui>llcii  iiiitl 
ly  |in'M'iil.  Ill 
ilciliciitmii  iiiiiy 

siri  is  tlu'  most 
ciciildiis  Ifsioiis 
!,  the  iiitcsliiK'S 
(■  ;:liinils  liL'sides 

is    ri'i'(HK'iit    ill 
illti'slillt'S.      The 

licli    limy  caiiM; 

ailvaiici'd  uisfs 
a. 

1  I'.'  of  my  jiosl 
lacilli  liavi'  l)i'rn 
:'(1  ill  an  iiiipur- 
V  III'  present  on 

[K  lint  I'll  out  l)y 

tiic  sulijccts  of 
iy  iiavc  piitliisis. 

the  vofal  cords 

icrciiliisis  of  the 
I.  or  may  set  in 
In  liic  ordinary 
nd  li'ss  strii<in^'', 
10  pi'actitioncr  is 
'SO  typos  uf  onsot 

vliioh  the  disease 
iptoms  to  arouse 
.'aso  is  seen  most 
vanco  to  oxcava- 
>  oases  it  is  not  a 
1. 

10  form  in  wliioli 
I'  in  otlior  ori,'ans, 

«:asiric  mode  of 
'  ^H'oat  iri'italiility 
psia  witli  enicfa- 
j)sia  there  is  very 
complains  of  jial- 


pilation  (if  tlie  lioarl,  iiioroasiii;,'  weaivuoss,  slij;lit  iifterniH>n  lever,  and 
aitioiioi'i'liioa. 

((■)  In  a  oonsiileralile  numlier  of  oases  the  onset  of  pulmonary  tnlier- 
(  iilosis  is  with  symptoms  which  siiir^icst  imiliirinl  fmr.  The  patient  lias 
rc|ieated  parn\y>nis  of  chills,  fevers,  and  fwoals,  which  may  recur  with 
;:rcat  re^iiilarity.  In  di>tricts  in  which  intoniiittoiits  prevail  there  is  no 
more  coiiiinoii  mistake  than  to  confound  the  initial  ri;;ors  of  pulmonary 
luiicrciiln-if,  with  malaria. 

((/)  Ihisit  irilli  I'lnirisi/. — The  lirst  symptoms  may  ho  a  dry  pleurisy 
over  an  apex,  with  persistent  friction  murmur.  In  other  iii>laiices  the 
pulmonary  symptoms  have  followed  an  attack  of  pleurisy  with  olVusion. 
'I'lie  oMidato  j^radiially  di.sappears,  luit  llio  cou^di  persists  and  the  pa- 
lieiit  liocomos  feverish,  and  gradually  sij^ns  of  disease  at  one  apex  hecoiiie 
manifest.  Of  !•(»  oa.sos  of  pleurisy  with  oll'nsion,  the  history  of  uliicli 
was  followed  hy  11.  I.  I'xiwditcli,  one  third  dovelopod  pulmomiry  liihor- 
oulosis. 

{(■)  Willi  Liiri/iijii'itl  Sijiiiiilniiis. — The  primary  localization  may  lie  in 
the  larynx,  though  in  a  majority  of  the  instances  in  which  hiiskinoss  and 
laryngeal  sym|itonis  are  the  first  noticeahlo  features  of  the  disease  tlii'ro 
are  doiilitless  foci  already  existing  in  the  lung.  The  group  of  I'asos  in 
which  for  many  months  throat  and  larynx  symptoms  jireccdo  the  graver 
manifestations  of  |mliiionary  phthisis  is  a  very  im[)ortaiit  one. 

(/')  Onset  villi  Jliniiojih/Kis. —  Freipiontly  the  very  (irst  sym|itom  (d' 
the  disease  is  a  hrisk  ha'morrhago  from  the  lungs,  following  which  the  jtiil- 
nionary  symptoms  may  develop  with  groat  ra|)idity.  Jn  other  oases  the 
lia'mo]itysis  recurs,  and  it  may  lie  months  heforo  the  symptoms  liooome 
well  estahlishod.  In  a  majority  of  the.se  oases  the  local  tuhorciilous  lesion 
exists  at  the  date  of  the  luomoiitysis. 

(ll)  Willi  'riilwrciiliisis  itf  llii'  ('rrvi(i)-(i.rilhirj/ .  flldiiih. — I'roccding  the 
onset  of  pulmonary  jihthisis  for  months,  or  oven  i'or  years,  the  lymph- 
glands  of  the  nock  or  of  the  nock  and  axilla  of  one  side  may  lie  I'lilarged. 
These  oases  are  liy  no  means  infroiinent,  and  they  arc  of  im|iortanoo  ho- 
oause  of  the  latency  of  the  |iulmoiiary  lesions.  Nowadays,  when  operative 
interference  is  so  common,  it  is  well  to  hear  in  mind  that  in  such  patients 
the  ooi'ros|iondiiig  ajiox  of  the  lung  may  ho  extensively  involved. 

(//)  And,  lastly,  in  hy  far  the  hirgost  numhor  of  all  eases  the  onset  is 
with  a  bniiiiliills,  or,  as  the  patient  ex])ropsos  it,  a  noglcetod  cold.  There 
has  heen,  jiorhajis,  a  lial)ility  to  oatoli  oold  easily  or  the  ])ationt  has  heen 
suhjoot  to  naso-])haryngoal  catarrh;  then,  following  some  unusual  cx]iosuro, 
a  hronoliial  cougli  devolo])s,  which  may  he  frecpicnt  and  very  irritating. 
The  oxanunation  of  the  lungs  may  reveal  hicalixod  Tuoist  sounds  at  one 
t\])o\  and  perhaps  wheezing  hronohitic  nllos  in  other  parts.  In  a  few  cases 
the  early  symptoms  are  often  suggestive  of  asthma  with  marked  wheezing 
and  diffuse  piping  rfdcs. 

Symptoms. ^ — Tn  discussing  the  symptoms  it  is  usual   to  divide  tlic 

disease  into  tliree  ])eriods:  the  first  emhracing  the  time  of  the  growth  and 

development  of  the  tuherclos;  the  second,  in  whieh  they  soften;  and  the 

tliird,  in  whicli  there  is  a  formation  of  cavities.    Unfortunately,  these  ana- 

19 


f 


SPECIFIC  INFECTIOUS   DISEASES. 


300 

tluT^iun.  lK.tt.v  perhaps  to  .lisrogard  t'-'m  «ltc,gother  ^^^^,,1,,^,,,,,, 

1.  Local  Symptoms.-/'.*.  ...  the  ohc.t  i.iay  '•  ^'-  ^    '"^       \  ;   1,^. 

„r  al..c..,t  th.'u„,rhont.     Jt  is  usually  assonatod  m.  h  plrm        •      /  ^   ^^ 

:r;;-:i:::;;;;;;;;;;;=;.^':-;t- 

develops  in  tl.e  course  of  ordinary  phthisis.  „viioritv 

rJ«v/'  i^  -no  of  the  earliest  symptoms,  and  is  presen    '"  '  '^^^ "  ;^^^^.    .^ 

of  ....e/ from  he-^inni.."  to  end.     There  is  nothing  peculiar  or  d  stin    ne 

L  un  1     rlrv  and  haekm,,  and  perhaps  scarcely  exe.tin,  t^lie  at  en- 

■         of  the  patient'  it   suhsequeutlv  becomes  looser,  niore  constant    and 

;;.;:;ed';-ilh:     lairy....uc.ipur..h.ntexpectorat.m.     In^ 
n(  11„.  di.eM.e  the  con-di  is  hroiichial  in  its  orijim.     ^^hen  cnitus  n,n. 
n      1        t:om;t  mo^  paroxysmal  and  is  most  marked  ,n  ^^^  -^^^ 
o    '  ter  a  ^leep.    Congh  is  not  a  constant  symptom,  however,  and  a  pat  c 

av    .  e  e,      hiniself  with   well-marked  excavation  at  one  apex  ^vho  ^^    1 
di  dar    t  has  had  litele  or  ..0  cough.     So,  too,  there  may  be  well- 

^m  rl  Jd  <i  1  .i-nis.  dulness  and  moist  sounds,  witliont  either  expeotora- 
h  n  or  c  md  IiAve  l-estaldished  cases  the  nocturnal  paroxysms  are  mos 
d  "r".h^  and  prevent  sleep.  The  cough  may  be  of  such  pe,-sistenee  and 
':  !,  iv  ^  to  cluse  vomitiilg.  and  the  V^^tient  becom^  ..pnHy  cnnaei^ed 
from  lo-  of  fo.,d-Morton-s  cough  (Phthis.ologia,  lOSD,  p.  101).  Ihe 
:.'  1  explications  give  a  peculiarly  hn.d.y  .piality  to  the  cm^i  ^ 
M-lK.n  erosion  and  nlceration  have  pro<.eedcd  far  ni  the  vocal  coids  th. 

^'1:l:^hS  "^ie^tallv  in  — t  and  character  at  the  dilTeront 
sta^  0  o  aii.rv  phthisi^  There  are  cases  with  well-marked  oc.  sign, 
at  one  apex,  witii  slight  cough  and  moderately  high  fever  ^vithout  from 
dn  to  cliv  a  trace  of  expectoration.  80,  also,  there  are  instances  with  the 
t  t  cxttms'^.  ('onsolidition  (caseous  pneumonia),  and  high  ever  but,  as 
n  Vre  instance  nnder  obscrvaticn.  for  several  months,  without  e-io^igl 

xl  .n  to  enable  an  examination  for  bacilli  to  be  made,     in  the 

..n  V  »ta.n>  of  p.,ln.onarv  tuberculosis  the  sputum  is  chiefly  catarrhal  and 
ns\      arv,  sa.o-like  appearance,  due  to  the  presence  of  alveolar  cells 
dd.di  1     ^nn.^-rgone  the  n.velin  degeneration.     There  is  nothing  dis- 
ve  m-  pecnlia^  in  this  form  of  expectoration,  which  may  j.ersist  for 
Z   h        it.  ut  indicating  serious  troul>le.     The  earliest  trace  of  diarac- 
"        c  sputum  mav  show  the  presence  of  small  grayish  or  ^-enish-g  <  y 
undent  masses.     These,  when  coughed  up,  are  always  suggestne  and 
r  Id   be  the    portions   picked   out   for  microscopical   examination.      As 
'tnin     comes  on,  the  expectoration  becomes  more  profuse   and   puru- 
Wbu^may  still    o.dain  a  considerable  quantity  of  alve.>  ar  ep.lhel.um 
SlwS  cavities  exist,  the  sputa  as.ume  the   so-called  nummular 


TUBERCULOSIS. 


301 


refspondlng  clinical 
1  stage  with  well- 
cr  prospects  of  rc- 
)nsolitliition.     It  is 

Iv  and  troublesome 
■urisy,  and  may  'le 
)!•  i'eit  tnly  during 
ower  tlioracic  zone, 
.k'.-red  to  tlie  apex, 
uralgia  occasionally 

.'lit  in  the  majority 
?idiar  or  distinctive 
,•  exciting  the  atten- 
more  constant,  ami 

In  the  early  stages 
^Vhen  cavities  have 
lu'd  in  the  morning 
wever,  and  a  i)atient 

one  apex  who  will 

there  nuiy  be  well- 
nit  either  expectora- 

paroxysms  are  most 
such  persistence  and 
es  rapidly  emaciated 
lf.S<),  p.  101).  The 
;y  to  the  cough,  and 

the  vocal  cords  the 

acter  at  the  difCerent 
11-marked  local  signs 

fever,  without  from 
re  instances  with  the 
id  high  fever,  but,  as 
nths,  without  enough 
to  be  made,     in  the 

chiefly  catarrhal  and 
rnce  of  alveolar  cells 
riiere  is  nothing  dis- 
vhich  may  persist  for 
rliest  trace  of  charac- 
lyisli  or  greenish-gray 
liwavs  suggestive  and 
cal  examination.  As 
ire  ])rofuse  and  i)uru- 
li  alveolar  epithelium, 
c   so-called  nummular 


form;  each  mass  is  isolated,  llatteiied,  grcenisli-gray  in  color,  (piite  airless, 
and  siidss  to  the  l)ottom  when  spat  into  water. 

By  tiie  microsc()j)ifal  examination  of  the  sputum  we  determine  whether 
the  process  is  tuberculous,  and  whether  softening  has  occurred.  For  tubercle 
luteilli  the  Khrlich-Weigert  method  is  the  l)est.  I-",leven  centimetres  of  a 
.'■atiirated  solution  of  fnchsin  in  ahsolute  alcohol  is  added  to  100  I'ni.  of 
the  satui'ated  solution  of  commercial  aniline  oil  (made  l)y  shaking  up  the 
oil  in  water  and  then  liltering).  This  shoidd  be  made  fresh  every  third 
or  fourth  day.  A  small  liit  of  the  s|)iitum  is  picked  out  on  a  needle  or 
])latinuni  wire  and  spread  thin  on  the  top-cover  so  as  to  nuike  a  uniformly 
thin  layer.  'I'lie  to|i-cover  is  slowly  dried  about  a  foot  above  a  lUinsen 
burner.  Sullicient  of  the  staining  fluid  is  then  dropped  upon  the  top- 
cover,  which  is  held  at  a  little  distaiu'c  above  the  Ihune  until  the  iUiid 
lioils.  'i'lie  staining  lliiid  is  then  washed  off  in  distilled  water  or  put  under 
the  tap.  deeolorizeil  in  ,'5()  per  cent  nitric-acid  iluid,  again  washed  off  in 
water,  and  mounted  on  the  slide.  In  doubtful  cases  the  long  process  is 
used,  the  cover-sliiJS  remaining  twenty-four  hoiu's  in  the  stain.  The  bacilli 
are  seen  as  elongated,  slightly  curvd,  red  rods,  sometimes  presenting  a 
headed  appearance.  They  are  fre((uently  in  groups  of  three  or  four,  but 
the  number  varies  considerably.  Only  one  or  two  may  be  found  in  a  ])rep- 
aration,  or,  in  some  instajues,  they  are  so  abundant  that  the  entire  Held  is 
occupied. 

The  iirese)ice  of  these  haciUi  in  the  sputum  is  an  infaUihk  indication  of 
the  c.vistencc  nf  tuheirulosis. 

Hometinu'S  they  are  found  otdy  after  repeated  examination.  They  may 
be  abundant  early  in  the  disease  and  are  usually  numerous  in  the  num- 
mular sputum  of  the  later  stages. 

Elastic  tissue  nuiy  be  derived  from  the  bronchi,  the  alveoli,  or  from 
the  arterial  coats;  and  naturally  the  a|ii)earance  of  the  tissue  will  vary  with 
the  locality  from  which  it  comes.  In  the  examination  for  this  it  is  not 
necessary  to  boil  the  sjuitum  with  caustic  potash.  For  years  I  have  used 
a  simple  ])lan  which  was  shown  to  me  at  the  London  Hospital  by  Sir 
Andrew  Clark.  This  method  depends  upon  the  fact  that  in  almost  all 
instaiu'cs  if  the  si)utum  is  spread  in  a  sulliciently  thin  layer  the  fragments 
of  elastic  tissue  can  be  seen  with  the  naked  eye.  The  thick,  ])urulent  por- 
tions are  placed  upon  a  glass  plate  15  X  l-">  cm.  and  llattened  into  a  thin 
layer  by  a  second  glass  plate  10  X  10  cm.  In  this  compressed  grayish  layer 
between  the  glass  slips  any  fragments  of  elastic  tissue  show  on  a  black 
backgrouiul  as  grayish-yellow  s])ots  ami  can  either  be  examined  at  once 
under  a  low  power  or  the  uppermost  ])iece  of  glass  is  slid  along  until  the 
fragment  is  ex])Osed,  when  it  is  picked  out  and  placed  upon  the  ordinary 
microscopic  slide.  Fragments  of  bread  and  collections  of  milk-globules 
nuiy  also  i)resent  an  opa([ue  white  a])i)ea ranee,  but  with  a  little  practice  they 
can  readily  be  recognized.  Fragments  of  eiutheliunr  from  the  tongue, 
infiltrated  with  micrococci,  are  still  more  deceptive,  but  the  microscope  at 
once  shows  the  dilference. 

The  bronchial  elastic  tissue  forms  an  elongated  network,  or  two  or 
three  long,  narrow  fibres  are  found  close  together.    From  the  blood-vessels 


302 


SPECIFIC   INFECTIOUS  DISEASES. 


n  somowluit  similar  form  iiiav  be  seen  and  occasionally  a  .lisd.u^t  Hhcotrn- 
iri  Inimd  as  if  it  had  conic  troni  tlic  intima  of  a  go.ul-sizod  artery,  llio 
elastic  tissnc  oi:  the  alveolar  wall  is  (,uitc  distinctive;  the  lil.rcs  arc  .ranchcl 
and  often  show  the  ontlinc  id  the  arran>;enient  of  the  air-cclls._  liie  clastic 
tissnc  from  bronchus  or  alveoli  indicates  extensive  erosion  oi  a  t.ibe  and 
sol'tenin<:  of  the  liinf,'-tissuc. 

Another  occasional  constituent  of  the  spntuui  is  blood,  winch  ma}  bt 
present  as  the  chief  characteristic  of  the  expectoration  in  lucmopiysis  or 
inav  Mmplv  tinge  the  sputum.  In  chronic  cases  ^vith  large  cavities  in 
addition  to  bacteria,  various  forms  <d'  fungi  may  develop,  oi  which  the 
as!)er'nllns  is  the  most  important.     Sarcime  may  also  occur. 

(■alcareovs  Fro^imenh.—FormvyU  a  good  deal  of  stress  was  laid  ni)on 
their  presence  in  the  sputum,  an.l  Morton  described  a  phthisis  a  rnruh,  in 
nuhuunilms  ,,n,n-a{is.  J^avle  also  d.-scribc/l  a  sci-arate  form  n\  phlhisic  cat- 
rukuse  Th'e  size  of  the  fragments  varies  from  a  small  j.ca  to  a  large  cherry 
As  a  rule,  a  single  one  is  ejected;  sometimes  large  numi)crs  are  conglie.l 
up  in.  the  course  of  the  disease.  They  are  lormed  in  the  lung  by  tiic  calci- 
lication  of  caseous  masses,  and  it  is  said  also  occasionally  m  ol.strncte.l 
bronchi.  Thev  mav  come  from  the  bronchial  glands  by  ulceration  into 
the  bronchi,  and  th'cro  is  a  case  on  record  of  suHocation  m  a  clald  from 

this  cause.  ^  ■  n       i         ■ 

The  daily  amount  of  expectoration  varies.  In  rai.idly  advancing  ca>es, 
with  mucii  (■ough,  it  mav  reach  as  high  as  rm  cc.  in  the  day.  Jn  cases  with 
lai-e  cavities  the  chief"  amount  is  brought  up  in  the  morning.  Ihe  ex- 
].ertoration  of  tuberculous  patients  usually  has  a  heavy,  sweetish  odor,  an.l 
occasi(mallv  it  is  fetid,  owing  to  decomi>osition  in  the  cavities. 

Hrembptysis.— One  of  the  most  famous  of  the  llij.pocratic  axioms 
«av«    "  From  a  spitting  of  blood  there  is  a  spitting  of  pus."     The  older 
writers  thou-dit  that  the  jdithisis  was  directly  due  to  the  intlammatory 
or  putrefactive  changes  caused  l)y  the  ha-morrhagc  into  the  lung.     Morton 
however,  in  his  interesting  section,  Phthisis  ab  na'nioi)toe,  rather  doul)tcd 
this  sequence.     Laennee  and  Louis,  and  later  in  the  century  Traube,  re- 
garded the  ha>moi)tvsis  as  an  evidence  of  existing  disease  of  the  lung.    1-  rom 
the  accurate  views"  of  Lacnnec  and  Louis  the  ])rofession  was  led  away  by 
Graves,  and  i)articularlv  by  Niemeycr,  who  held  that  the  blood  in  the  air- 
cells  set  up  an  inflammatorv  process,  a  common  termination  of  which  was 
easeation.     Since  Koclfs  discovery  we  have  learned  that  many  cases  in 
which  the  physical  examination  is  negative  show,  either  during  the  period 
of  ha-morrhage  or  immediately  after  it,  tubercle  bacilli  in  the  siuita,  so  thal^ 
oi.inion  has  veered  to  the  (dder  view,  and  we  now  regard  the  appearance  of 
Inemoptysis  as  an   indication  of  existing  disease.     In  young,  apimrently 
healthy "iiersous.  cases  of  luemoptysis  may  be  divided  into  three  groups,     in 
the  fir'^t   the  blecdimi  has  come  on   without   premonition,  without  over- 
exertion or  injury,  and  there  is  no  family  history  of  tnberculosis.     The 
physical  examination  is  negative,  and  the  examination  of  the  expectoration 
at  "the  time  of  the  ha-morrhage  and  snhsc.piently  shows  no  tubercle  bacilli. 
Such  instances  are  not  uncommon,  and,  though  one  may  susju'ct  strongly 
the  presence  of  some  focus  of  tuberculosis,  yet  the  individuals  may  retain 


TrRERCTLOSIS. 


•M) 


(iiict  sliootiii!; 
lutcry.  Tlu' 
i  are  bniiiclu'd 
;.  Tlic  I'lastic 
1)1'  a  tiilif  and 

wliicli  may  be 

lui'inoi'ivsis  (ir 

ife  cavitios!,  in 

oi  wliic-h  tlu' 

was  laid  upon 
is  a  a(/c(//i',s'  in 
ol'  jililhisic  cal- 
a  large  cherry. 
•s  arc  coiigheil 
g  \>y  tiie  ealei- 
in  ()l)strueted 
ulceratii)n  into 
II  a  eliild  I'roni 

dvancing  eases, 
Jn  eases  witli 
iiinfT.  Tlie  e\- 
etish  odor,  and 
es. 

[locraiie  axioms 
IS."     The  older 
e  inlUuiiniatory 
lung.     Morton, 
rather  doubted 
iry  Traube,  re- 
he  lung.    From 
•as  led  away  by 
iood  in  the  air- 
n  of  whieh  was 
many  eases  in 
iring  the  ])eriod 
le  siuita,  so  that 
le  appearance  of 
ung,  api>arently 
'iree  groups.     In 
.  without  ovor- 
!)erculosis.     The 
he  expectoration 
tubercle  bacilli. 
sus])ect  strongly 
luals  may  retain 


good  health  for  many  years,  ami  have  no  further  trouble.  Of  tlu>  DSC  cases 
of  luenioptysis  noted  by  Ware  in  piivale  juactice,  (iv'  recovered,  and  pul- 
monary disease  did  not  sulisc()uentiy  develop. 

In  a  sccoml  group  individuals  in  apjiareutly  ]ierfect  heahh  are  sud- 
deidy  attacked,  perhaps  after  a  slight  exertion  or  during  some  athletic 
exercises.  The  physical  examination  is  also  negative,  but  tubercle  bacilli 
are  found  s.uuetimcs  in  the  bloody  sputa,  more  freiiuently  a  lew  days  later. 

In  a  third  set  of  cases  the  individuals  have  been  in  failing  health  for 
a  month  or  two.  but  the  symptoms  have  not  been  urgent  and  peihaps  not 
noticed  by  the  patients.  The  jihysieal  examinalion  shows  the  presenee  of 
well-niarke<l  tubereidous  disea.<e,  and  there  are  both  tubercle  bacilli  and 
elastic  tissue  in  the  sputa. 

A  very  interesting  systematic  study  of  the  subject  of  Inrinoptysis,  par- 
ticularly in  its  relation  to  the  (luestion  of  tuberculosis,  has  been  coni|)lcted 
in  the  Prussian  army  by  Franz  Strieker.  During  the  live  years  ]S!tO-"i)r, 
there  were  !l(l()  eases  admitted  to  the  hospitals,  whieh  is  a"  percentage  of 
n.Ol.-)  of  the  strength  (l.:-.',s,,-,o.-,).  Of  (he  cases,  in  ISO  the  ha-morrhaire 
came  on  without  recognizable  cause.  Of  these  li:  eases,  HIi  per  cent  wi're 
certainly  or  jn'obably  tidiercidous.  In  only  •.'•.'!,  however,  was  the  evidenco 
conclusive. 

In  a  second  grouj)  of  •.>!;',  eases  the  luemorrhage  came  on  <luriiiir  the 
nulitary  e.xereise,  and  of  these  T.'i  ])atients  were  shown  to  be  tuberenlo'iis. 

In  IKS  cases  the  haMuorrhage  followed  certain  special  exercises,  as  in 
the  gymnasium  or  in  riding  or  in  conscipience  of  swimming.  In  •■>[  cases 
it  developi'd  during  the  exercise  of  the  voice  in  singing  or  in  irivinij  com- 
mand or  in  the  use  of  wind  instruments.  .\  verv  interestiiiir  aroup  is  re- 
jwrted  of  -il  cases  in  which  the  lueuiorrhage  followed  trauma,  either  a  fall 
or  a  blow  u|)()n  the  tliorax.  In  7  of  these  tubercurosis  was  jiositively  pres- 
ent, and  in  (i  other  cases  there  was  a  str()ng  jirobability  of  its  existeiice. 

Among  the  conclusi(Uis  which  Strieker  draws  the  following  are  the 
most  important:  namely,  that  soldiers  attacked  with  luemoptysis  without 
special  cause  are  in  at  least  SC.S  jier  cent  tubercadous.  In  the  cases  in 
which  the  luenioptysis  follows  the  special  exerci.<es,  etc.,  of  military  serv- 
ice, at  least  T  l.l  jier  cent  are  tuberculous.  In  the  eases  which  come  on 
during  swinmnng  or  as  a  consecpience  of  direct  injury  to  the  thorax  about 
one  half  inc  not  associated  with  tuberculosis. 

Iliemoptysis  occurs  in  from  (K)  to  SO  ]ier  cent  of  all  cases  of  pulmonary 
tidtercnlosis.     It  is  more  freipient  in  males  than  in  females. 

In  a  majority  of  all  cases  the  bleeding  rectu's.  Sonu'tinu's  it  is  a  special 
feature  tliroughout  the  disease,  so  that  a  liaMuori'liagic  or  lurmopt vsical 
form  has  been  recognized.  The  amount  of  blood  brought  up  varies  from 
a  couple  of  drachms  to  a  pint  or  more.  In  (i!»  per  cent  of  1,1"^"")  ea.<es  of 
ha'inoptysis  at  the  Broiuiiton  Hospital  the  amount  brought  up  was  under 
half  an  ounce. 

A  distinction  may  lie  dnwn  between  the  luvmoptysis  early  in  the  dis- 
ease and  that  which  occurs  in  the  later  jieriods.  In  the  former  the  bleed- 
ing is  usually  slight,  is  ai)t  to  recur,  and  fatal  hamiorrhagc  is  very  rare.  In 
these  instances  the  bleeding  is  usually  from  small  areas  of  softeninfr  or 


30-t 


SPECIFIC  INFECTIOUS  DISEASES. 


frum  early  erosions  in  tlie  l.roiicliial  imicosa.  In  the  later  i.eriuds,  after 
cavities  have  formed,  the  bleeding  is,  as  a  rule,  more  profuse  and  is  mure 
apt  to  he  fatal.  Sin-le  lar-e  ha-morrha-es,  proving  quickly  fatal  are  very 
rare,  except  in  the  advanced  stages  of  tlie  disease.  In  these  cases  the  bleed- 
ing comes  either  from  an  erosion  of  a  good-sized  vessel  in  the  wall  ol  a 
cavitv  or  from  tlie  rupture  of  an  aneurism  of  the  ])ulmonary  artery. 

The  bleeding,  as  a  rule,  sets  in  suddenly.  Witiu.ut  any  \vanimg  the 
patient  may  notice  a  warm  salt  taste  and  the  mouth  tills  wilii  l.i  )od.  It 
niav  come  n))  witii  a  slight  eougli.  Tiie  total  amount  may  not  Ik>  more 
than  a  few  drachms,  and  for  a  day  or  two  the  patient  may  L-pit  up  small 
quantities.  When  a  large  vessel  is  eroded  or  an  aneurism  bursts,  the  amount 
of  blood  brought  up  is  large,  and  in  the  course  of  a  short  time  a  pint  or 
two  mav  be  exi.eetorated.  Fatal  Invniorrhage  may  occur  into  a  very  largo 
cavitv  without  any  blood  being  coughed  up.  The  character  of  the  blood  is 
as  a  rule,  distinctive.  It  is  frotiiy,  mixed  with  mucus,  generally  !)nght  red 
in  color,  except  when  large  amounts  are  expectorated,  and  then  it  may  be 
dark  The  s}.uta  mav  remain  blood-tinged  for  some  days  or  there  are 
brownish-black  streaks  in  the  sputa,  or  "  friable  nodules  c(msisting  entirely 
of  blo.)d-corpuscles  "  may  be  coughed  up.  Blood  moulds  of  the  smaller 
bronciii  are  sometimes  expectorated. 

The  microscopical  examination  of  the  simtum  in  tnhercnlous  cases 
is  most  important.  If  carefully  sprea '  out,  there  may  bo  noted,  even  m  an 
apparently  pure  luemorrhagic  mass,  little  portions  of  mucus  from  which 
liacilli  or  elastic  tissue  may  be  obtaimd.  ••mi 

Dijspmra  is  not  a  common  acenuipjiniment  of  ordinary  phthisis,  llie 
greater  iiart  of  one  lung  may  he  diseased  and  local  trouble  exist  at  the 
other  apex  without  any  shortness  of  breath.  Even  in  tlie  paroxysms  of 
very  high  fever  the  respirations  may  not  he  much  increased.  l?apid  ad- 
vance oi  a  broncho-]meumonia,  or  the  development  of  miliary  tul)ercles 
thrmighout  the  lung,  causes  great  increase  in  the  number  of  respirations. 
A  degree  of  dyspntra  leading  to  cyanosis  is  almost  unknown,  apart  from 
extensive  invasion  of  the  sound  ])ortions  by  miliary  tubercles. 

In  long  standing  cases,  with  contracted  apices  or  great  thickening  of 
the  ])leurarthe  right  heart  is  enlarged,  and  the  dyspnoni  may  he  cardiac. 

2.  General  Symptoms.— Fnrr.— To  get  a  correct  idea  of  the  temiiera- 
ture  range  in  pulmonary  tuberculosis  it  is  necessary,  as  Kinger  pointed 
out.  to  imike  tolerahlv  frequent  observations.  The  usual  8  a.  m.  and  8  p.  m. 
record  is.  in  a  inajcirity  of  the  cases,  very  deceptive,  giving  neither  the 
miniiniim  nor  maximum.  The  former  usually  occurs  between  2  and  li  a.  m. 
and  tlie  latter  between  2  and  fi  v.  M. 

A  recognition  of  various  forms  of  fever,  viz.,  of  tuberculization,  of 
ulceration. ^md  of  ahsorjition.  cmiihasizes  the  anat(uiiical  stages  of  growth, 
softening  and  cavity  formation;  hut  practically  such  a  division  is  of  little 
use,  as  in  a  majority  of  cases  these  jirocesses  are  going  on  together. 

Fever  is  the  most  important  initial  symptom  and  throughout  the  entire 
cimrse  the  thermometer  is  the  most  trustworthy  guide  as  to  the  progress 
of  the  affection.  With  pyrexia  a  ]iatient  loses  in  weight  and  strength, 
and  the  local  disease  usually  progresses.    The  periods  of  apyrexia  are  those 


■IriMM 


•  iteriud?,  after 
se  and  irf  more 

fatal,  arc  very 
.'a!^es  the  bleed- 
i  tlio  wall  of  a 
{  artery, 
ly  wariiiiijj;  the 
kvith  1)1  )()(!.  It 
ly  not  be  inort! 
y  L.i)it  up  small 
'sts,  the  amount 

time  a  pint  or 
ito  a  very  largo 
of  the  blood  is, 
rally  bright  red 
then  it  may  be 
^•s  or  there  are 
iisistin.ii:  entirely 

of  the  smaller 

berculous  cases 
jted,  even  in  an 
3US  from  which 

■  phthisis.  The 
ble  exist  at  the 
le  ])aroxysms  of 
sed.  l\apid  ad- 
iiiliary  tubercles 

of  respirations. 
)\vn,  apart  from 
■cles. 

it  thickening  of 
ay  be  cardiac, 
of  the  tem])era- 

Kinger  ])ointed 
A.  M.  and  8  p.  m. 
•ing  neither  the 
'cn  2  and  G  A.  M. 

berculization.  of 
tages  of  growth, 
,ision  is  of  little 
together, 
ighout  the  entire 
i  to  the  progress 
it  and  strength, 
pyrexia  are  those 


TUBERCL'LOSIS, 


3t»5 


of  gain  in  weight  and  strength  and  of  limilation  of  the  local  lesion.  It  l)y 
no  means  necessarily  follows  that  a  patient  with  tiiliercnlosis  has  pyrexia. 
There  Jiiay  lie  (piite  extensive  disease  without  coexisting  fever.  At  one  time, 
I  have  had  IS  iii-tances  of  chronic  phthisis  under  observation,  of  whom 
10  were  practically  free  from  fever.  Jiut  in  the  early  stage,  when  tulicnlcs 
are  devclii|iing  and  caseous  areas  are  in  ])rocess  of  formation  and  when 
softening  is  in  ]irogress,  fever  is  a  constant  symptom.  It  was  present  in 
100  consecutive  cases  in  my  disi-ensary  service. 

Two  types  of  fever  are  seen — the  remittent  and  the  intermittent.    These 
may  occur  indill'crcntly  in  the  early  or  in  the  late  stages  of  the  disease 


/■ — 

Jan.  n 


~>^ 


~\r- 


Tenip. 

lO'.i 


Kcsji 


.  i    i   i   u    ^ 
.  :^  .  a;    a.'   a.'   6. 

.  S     n  .  «    «  :  <n 


a    >i   Ji     i      .  a    ai    a    ;*     •    a    a    a'    ■    "    I    a    a    a    a   J    j   ■    si 
<    <  ,  <  . »  Sa  o;   a;  «. 'J  2  ■  "    •«  ■  •<    ■<   J  ''•■."«•'  o.'   »•'  «:  t'  !•«■■■«" 


CuART  XII.    Three  davs.    Chronic  tuberculosis. 


or  may  alternate  with  each  other,  a  variability  which  de])cnds  upon  the 
fact  that  phthisis  is  a  progressive  disease  ami  that  all  stages  of  lesions  may 
be  found  in  a  single  lung.  Special  stress  should  be  laid  upon  the  fact, 
particularly  in  malarial  regions,  that  tuberculosis  may  set  in  with  a  fever 
typically  intermittent  in  cliaracter — a  daily  chill,  with  subsequent  fever 
and  sweat.  In  ^Montreal,  where  malaria  is  jiractically  unknown,  this  was 
always  regarded  as  a  suggestive  symptom;  but  in  riiiladelphia  and  Ealti- 


it. 


2,^g  SPECIFIC  INFECTIOUS  DISEASES. 

S^ul-ns  p.eunu,nia  are 'usually  ..11  ..ark.,!.     A  cont.nuea  i^-  ;  j" '^ 
„'  i'Ton  in  tho  iirst  week  of  lyplmid,  or  in  .ou>o  ..ases  ot  inllanuuation  ol 

n    1^     V  whon  the  patient  sleep.    Tl.ey  n,ay  eon,e  on  early  ,n    he  d.K^e^ 
;;;.t  are  n.ore  persistent  and  fre.iuent  ailer  cav.t.es  have  founed.     home 

'-'^  ;:r  i:S::d  in  fre,neney.  cspeeially  ^vl..:n  U.eJ^'ver  i.  In^. 
It  i!  t  n  ren>arkahly  full,  tln,n,h  .oft  and  eonipressd-le.  ^^^^^^^^^ 
L.etinu-s  be  seen  in  the  capillaries  and  in  tho  veins  on  the  back  of  the 

^'""F,„.na//..  is  a  prononneed  feature,  from  whieh  the  two  eonnnon  names 
.,  th: dCie  have  been  deri     d.    The  loss  of  weight  is  ^-^^^^^^^^ 
-. .  •  TI...  c/.'iliii  (Vive  one  ol   tne    le^l  uuueii 

disease  is  extending,  progressive,     the  scale.  j-i\t  one 

'•"1   m^i^rSSsl-'n;:^/^^^^^  ^1-pe  of  the  ehestis_  often 

.u.';sU ve     l'  u'  f!t   s  to  be  renienibered  that  pulmonary  tubereidos.s  may 
Ke    wit     hi  ehests  of  any  build,     rraetically,  however,  ,n  a  consider- 


TUnERCrLOSIS. 


307 


ni  yearly  scores 
lire  often  eases 
zatioii — may  lu' 
uiy  tinii'  (lurinfj; 
.  the  remissions 

ly  iiliove  normal 
u'oniMi'.n  in  the 
icniii^'  or  exten- 
iiivf  I'cirister  may 
T.  \Vith  l)reak- 
soeiated  as  tliese 
L'ss  sy>temie  eon- 
littent  or  hectic 

at'ehrile,  but  tlie 
\ai-t,  I'rom  a  ease 

i'rom  10  1'.  M.  to 
it  as  low  as  I).")'', 
il  early  afternoon 

As  shown  in  the 
rs  of  pyrexia  and 
mju'rature  in  the 
,     This  iieetie.  as 
is  met  with  when 
1  and  extendin<r. 
a  dejiree,  develop- 
ve  of  acute  pneu- 
')ns  even  in  acute 
tinned  fever,  sucli 
)i  inilammation  of 

phtliisis  and  con- 
.  They  occur  usn- 
irs,  or  at  any  time 
arly  in  the  disease, 
ve  "formed.     Some 

the  fever  is  high, 
ilo.  Pulsation  may 
[)n  the  back  of  the 

two  common  names 
gradual  but,  if  the 
of  the  liest  indica- 

the  chest  is  often 
iry  tuberculosis  may 
ever,  in  a  consider- 


able proportion  of  cases  tlie  tliorax  is  lung  and  narrow,  witli  very  wide 
intercostal  spaces,  the  rilis  nu)re  viTtical  in  dirrctioii  and  the  costal  angle 
very  narrow.  Tiu'  scapuhe  are  •'winged,""  a  jioint  Udtcd  liy  liippucratcri. 
Another  type  of  chest  which  is  very  eoniiiKHi  is  lliat  wliieli  is  llalteiied  in 
tlie  aiitero-posterior  diameter.  The  costal  cartilages  may  be  iironiineiit 
and  tiie  sternum  depressed.  Occasionally  the  lower  steniiim  forms  a  deep 
concavity,  the  so-called  funnel  breast  (Trirhler-linisl).  Iiispeeliiui  gives 
valuable  information  in  all  stages  of  the  disease.  S|)ecial  examination 
slnnild  be  made  of  the  clavicular  regions  to  see  if  one  clavi'le  stands  out 
more  distinctly  than  the  otiier,  or  if  the  spaces  above  or  below  it  are  more 
marked.  Defective  expansion  at  one  'ipex  is  an  eaiiy  and  important  sign. 
The  condition  of  expansion  of  the  iowi'r  zone  of  the  tliora.x  may  bc  well 
estimated  by  inspection.  The  condition  of  the  pra-cordia  should  also  bo 
noted,  as  a  widt'  area  of  impulse,  particularly  in  the  second,  third,  and 
fourth  intei'.-paces,  often  results  from  disease  of  the  left  apex.  From  a  point 
behind  tin'  patient,  looking  over  the  shoulders,  one  can  often  lu'ltcr  esti- 
mate the  relative  expansion  of  the  a|>ices. 

(/;)  I'dljiiilliin. — Delicieiicy  in  expansion  at  the  apices  or  bases  is  ])er- 
haps  best  gaugt'd  by  jilaciiig  the  hands  in  the  subclavicular  spaces  and  then 
in  the  lateral  regions  of  the  chest  and  asking  the  patient  to  draw  slowly  a 
full  breath.  Standing  behind  the  jiatient  and  placing  the  tlimnbs  in  the 
supraclavicular  and  the  lingers  in  t'le  intraclavicular  spaces  one  can  judge 
accurately  as  to  the  relative  mobility  of  the  two  sides.  Disease  at  an  apex, 
though  early  and  before  dulness  is  at  all  marked,  may  be  indicated  by 
deficient  expansion.  On  asking  tlie  ]mtient  to  count,  the  tactile  fremitus 
is  increased  wherever  there  is  local  growth  of  tuliercle  or  extensive  casea- 
tion. In  comparing  the  apices  it  is  im])orlant  to  bear  in  mind  that  normally 
the  fremitus  is  stnmger  over  the  right  than  the  left.  So  too  at  the  base, 
when  there  is  consolidation  of  the  lung,  the  fremitus  is  increased;  whereas, 
if  there  is  pleural  effusion,  it  is  diminished  or  al)sent.  lu  the  later  stages, 
when  cavities  form,  the  tactile  fremitus  is  usually  much  exaggerated  over 
them.  When  the  ])leura  is  greatly  thickened  the  fremitus  may  be  somewhat 
diminished. 

(r)  Pfirussifiii. — Tubercles,  inflammatory  ])roducts,  fibroid  changes, 
and  cavities  ])roduce  important  changes  in  the  jjulmonary  resonance. 
There  may  be  localized  disease,  even  of  some  extent,  without  inducing 
much  alteration;  as  when  the  tuhereles  are  scattered  and  have  air-contain- 
ing tissue  between  them.  One  of  the  earliest  and  most  valuai)le  signs  is 
defective  resonance  uiion  ami  above  a  clavicle.  In  a  considerable  propor- 
tion of  all  cases  of  jditbisis  the  dulness  is  first  noted  in  these  regions.  The 
comparison  between  the  two  sides  should  be  made  also  when  the  breath 
is  held  after  a  full  insjiiration,  as  the  defective  resonance  may  then  be 
more  clearly  marked.  In  the  early  stages  the  ]iercussion  note  is  usually 
higher  in  i)itch,  and  may  reciuire  an  experienced  cjir  to  detect  the  differ- 
ence. In  recent  consolidation  from  caseous  pneumonia  the  jiercnssion  note 
often  has  a  tubular  or  tym])anitic  (jnality.  A  wooden  dulness  is  rarely 
heard  except  in  old  cases  witli  extensive  fibroid  change  at  the  apex  or  base. 
Over  larue,  thin-walled  cavities  at  the  apex  the  so-called  cracked-pot  sound 


308 


SPECIFIC  IXFECTIOUS  DISEASES. 


may  be  olitainod.  In  thin  sul)jc'fts  the  percussion  sliouM  lie  mrcrully  prnc- 
tisud  in  (he  supraspinous  lossie  and  the  intt'rscapiilar  space,  as  they  cor- 
respond to  very  important  areas  early  involved  in  the  disease,  in  cases 
with  munerous' isolated  cavities  at  the  apex,  without  luudi  llliniid  tissue 
or  thickeniufx  oi'  the  pleura,  the  percussion  note  may  show  little  chan<:e, 
and  the  contrast  lietweeii  the  si^qis  ohtaineil  on  auscultation  am!  percussimi 
is  most  marked.  In  the  direct  percussion  oi  the  chest,  particularly  in  thin 
patients  over  the  i)Cctorals,  one  frequently  sees  tiie  phenomenon  known 
as  iiniiiiilciiHi,  a  local  contraction  oi'  tiu'  muscle  causin;,'  liul-iuj:.  which  jter- 
sists  for  a  varialile  iieriod  and  gradually  sultsides.    It  has  no  special  Mgnill- 

cancc. 

((/)  Aiisnilhilioii.—Vrr^Ai'  hreatli-sounds  are  amon<,'   the   mo>t   eharae- 
teristic  early  sij.qis,  since  not  as  much  air  enters  the  tubes  and  vesicles  of 
the  airected  area,     it  is  well  at  first  always  to  compare  carefully  the  cor- 
respondin-r  ]>oints  on  the  two  sides  of  the  chest  without  askin;:-  liie  patient 
cither  to  draw  a  dee]i  hreath  or  to  coujih.     With  early  apical  disease  the 
insjiiration   on   i[v\v\    i)reaihin<i;  may   he  scarcely  audililc.      Kxpiration   is 
usually  i)roloii,<:ed.    On  the  other  hand,  there  are  cases  in  which  the  earliest 
gifzu  is  a  harsh,  rude,  respiratory  murmur.     On  dee])  hreathinir  it  is  fre- 
quently to  he  noted  that  inspiration  is  jerkinf,'  or  wavy,  tiie  so-called  "  coi;- 
vvheel  "  rhythm:  which,  howevt'r,  is  by  no  means  confined  to  tuherculosis. 
With  extension  of  the  disi'ase  the  inspiratory  murmur  is  harsh,  aiul,  when 
consolidation  occurs,  whiflin.-r  and  bronchial.     With  these  chaufxes  in  the 
character  of  the  murmur  there  are  rfdes,  due  to  the  accompanying  bron- 
chitis.    They  may  he  lu'ard  only  on  ileep  insjiiration  or  on  c(Ui<rhin<r,  and 
early  in   the  disease  are  often   crackliujf   in   character.      When   sid'teniug 
occurs  they  are  louder  and   have  a  hidihlinjr,  sometimes  a   characteristic 
clickin<:  (piality.     'I'hese  "moist  sounds,"  as  they  are  called,  when  asso- 
ciated with  clian<ze  in  the  percussion  resonance  are  extremely  su^irgestive. 
AVlien  cavities  form,  the  rfdes  are  louder,  more  gurgling,  and  resonant  in 
quality.     When  there  is  consolidation  of  any  extent  the  bri'ath-^ounds  are 
tubular,  and  in  the  large  excavations  loud  and  cavernous,  or  have  an  am- 
])horic  (piality.     In  thi'  nmUl'ected  ])ortions  of  the  lobe  and  in  the  o])positc 
hmg  the  breath-sounds  may  he  harsh  and  even  ])uerile.     The  vocal  reso- 
nance is  usually  iiu-reased  in  all  stages  of  the  jiroccss,  and  bronchophony 
and  pcctoril(Mpiy  are  met  with  in  the  regions  of  consolidation  and  over 
cavities.     I'leuritic  friction  may  be  present  at  any  stage  and,  as  mentioned 
before,  occin-s  very  early.    There  are  cases  in  which  it  is  a  marked  feature 
throughout.     When  the  ]ap])et  of  lung  over  the  heart  is  involved  there 
may  lie  a  pleuro-iicricardial  friction,  and  when  this  area  is  consolidated 
there  may  be  curious  clicking  n'des  synchronous  with  the  heart-beat,  due 
to  the  conqiression  by  the  heart  of,  ami   the  exjudsion  of  air  from,  this 
liortion.    An  interesting  auscidtatory  sign,  ne      .lost  commoidy  in  iihtbisis, 
is  the  so-called   cardio-respiratory  murmur,       whitVmg  systolic  bruit  due 
to  the  projiulsion   of  air  out  (d'  the  tubes  by  the   impulse  of  the  heart. 
It  is  liest  beard  during  insjiiration  aiul  in  the  antero-latc     •  regions  of  the 

diest. 

A  systolic  nuirniur  is  frecpiently  hcaid  in  the  subclavian  artery  on  either 


en  re  fully  prac- 
V,  as  tlicy  for- 
I'asf.  Ill  oases 
1   lilii'iiid  tissiio 

■  liltic  clumjrt', 
ami  iHTciission 
lulaily  in  thin 
)im'n(ii<  known 
iii^f.  wliith  |i(.'i'- 

spi'cial  signill- 

■  iiii>>t  cliarac- 
aiid  vcsii'lcri  of 
■ffiillv  tho  eor- 
iii,::'  ihc  iialieiit 
ical  (li.-t'aso  tlu! 

l'!xpiration   is 

licli  the  oarlii'st 

thin;,'  it  is  frc- 

so-calliHl  "  foi;- 

to  tulici'culosis. 

irsh.  and.  when 

fhanjrc's  in  tho 

iilianyiiiji'  hron- 

(•<nij,diin<r,  and 

Vhcn  .siflfniiig 

a  (haraetcristic 

\vi\,  when  asso- 

iicly  suir^'cstivo. 

Hid  resonant  in 

eatli-^ounds  are 

or  have  an  am- 

in  the  opposite 

Tlie  voe;il  reso- 

1  hrniu'hophony 

hit  ion  ami  over 

d.  as  mentioned 

marked  feature 

involved  there 

is  eonsdlidated 

heart-lieat,  due 

f  air  from,  this 

)nly  in  iihthisis, 

4olic  hruit  due 

;e  of  the  heart. 

:  regions  of  the 

arterv  on  either 


TrnERruLosis. 


3U9 


side,  tho  jiulsation  of  wliich  may  he  very  visihie.  'I'he  murmur  is  in  all 
prohahility  due  to  pressure  on  the  vessels  hy  the  thickeiu'd  pleura. 

The  i^igns  of  cavity  may  he  here  hrielly  enumerated. 

(a)  When  there  is  not  niiieh  thiekeiiing  (d'  the  pleura  or  eiuidcMisation 
nf  the  surrounding  lung-tissue,  the  pereussion  sound  may  he  full  and  clear, 
nseinhiing  the  normal  luite.  .More  eommonly  there  is  defective  re<onunee 
or  a  tynipanitie  tjuality  which  may  at  tiiiu's  lie  purely  amplinric.  The  pitch 
of  the  percussion  note  changes  over  a  cavity  when  the  niMUtli  is  opened  or 
clo.sed  (Wintrich's  sign),  or  it  may  he  hrought  out  more  ( learly  on  cluiiige 
(d'  |>osition.  The  cracked-jiot  sound  is  only  ol)taiuahle  over  lolcraldv  large 
cavities  with  thin  walls.  It  is  hest  elicited  hy  a  firm,  quick  stroke,  the 
patient  at  tho  time  having  the  mouth  open,  in  those  rare  instances  of 
almost  total  excavation  of  oiic  lung  the  percussion  note  may  lie  amphorie 
in  quality,  (h)  On  auscultation  tho  so-called  cavernous  sounds  are  lieard: 
(1)  ^  arious  grades  cd"  niodiiied  hreathing — hlowiug  or  tuhular,  cavernous 
or  amphiuic.  'J'liere  may  he  a  curiously  sharp  hissing  sound,  as  if  tho  air 
was  ])assing  froju  a  narrow  opening  into  a  wide  space.  In  very  largo  cavi- 
ties hoth  inspii'ation  and  expiration  may  he  typically  ami)horic.  (-J)  'I'iiere 
are  coarse  hul)hliug  ri'iles  which  have  a  rcsoiuiut  (piality,  and  on  coughing 
may  have  a  metallic  or  ringing  cliaracter.  On  coughing  they  are  ofteii  loud 
and  gurgling.  In  very  large  thin-walled  cavities,  and  "more  rarely  in 
medium-sized  cavities,  surrounded  hy  recent  cousolididion.  the  rales  may 
have  a  distinctly  amphoric  echo,  simulating  tho.se  of  pneumothorax.  There 
are  dry  cavities  in  which  no  rales  arc  heard.  (;])  The  vocal  resonance  is 
greatly  intensified  and  \vhis])ered  pectorilmpiy  is  clearly  heard.  In  largo 
a])ical  cavities  the  heart-sounds  are  well  heanl,  and  occasionally  there  Viiay 
ho  an  intense  systolic  murmur,  prohahly  always  transmitted  to.  and  tiot 
])roduced  as  has  lieen  sup])osed,  in  tho  cavity  itself.  In  large  excavations 
of  the  left  apex  the  heart  imiuilse  may  cause  gurgling  sounds  or  clicks 
synchronous  with  tlH>  systole.  They  may  even  ho  loud  enough  to  ho  heard 
at  a  little  distance  fnuii  the  chest  wall.  A  large  cavity  with  smooth  walls 
and  thin  tluid  contents  may  give  the  succussion  sound  when  the  trunk  is 
ahru]itly  shaken  (Walslie),  and  even  the  coin  souml  may  he  ohtainod. 

rsciDld-nirrniiiiis  si(/iis  may  ho  caused  hy  an  area  of  consolidation  near 
a  large  hrouchus.  The  condition  may  he  most  deceiitive — the  high-pitched 
or  tymjianitie  ]iercussion  note,  the  tuhular  or  cavernous  hreathing,  and  tho 
resonant  rales,  simulate  closely  those  cd"  eavitv. 

4.  Complications  of  Pulmonary  Tuberculosis.— (i)  In  the 
Respiratory  System. — The  larynx  is  rarely  spared  in  chronic  ludmonary 
tuhereulosis.  The  first  symittom  may  he  huskiness  of  tho  voice.  There 
are  pain,  particularly  in  swallowing,  and  a  cough  wdiich  is  often  wheezing, 
and  in  the  later  stages  very  inefTeetual.  Ajthonia  and  dysphagia  are  the 
two  most  distressing  symptoms  of  the  laryngeal  involvcnu'ut.  Wlu'n  tho 
epiixlottis  is  seriously  diseased  and  tho  ulceration  extends  to  the  lateral 
wall  of  the  pharynx,  tho  ])ain  in  swallowing  may  l)e  very  intense,  or,  owing 
to  the  imiiorfect  closure  of  tho  glottis,  there  may  he  coughing  spells  and 
regurgitation  of  food  through  the  nostrils.  Bronchitis  and  tracheitis  are 
almost  invariahle  accompaniments  of  chronic  pulmonary  tuhereulosis. 


ill 


M 


310 


SPECIFIC   IN'FFlCTlors   DISKASKS. 


„htl,i.i<      It  nwiv  run  a  luM'f.rtlv  nnnual  n.nrso,  xvlnl.  m  n  lu'i   .n>tam. 
i       Hinn      ..V  U.  .l..lav.|  and  on.  is  in  .Inul.t,  in  spit,  nt  tho  ahru,. Uu.. 
,    I     ..  -t.    s  to  tlu.iMvscMu..  of  a  sin,,.l.'  or  a  tMlK.r..nlous  iuu.,nno ma 
I      nisn.a  of  the  uniuvolvo.l  portions  of  th.  Inn,  .s  -— "        " 
,„,,,  ,,;,.:;,  ,„,„uu.in,  any  special  synpton.s.     '"-V'^,  ^'^^  ;  ^^^ 
„l.  ,,,,oui;  t  ,lu.r.nlosis  in  Nvlmli  nnpi.yM'n.a  'l'''-''"'^<^:^ /''M'-^^"  ' '  "'   ' 
„    wl>i..i.   tlH.  condition  .U.v..lops  slowly  dnrin,  a   poru.d  on...       o  - 
((ionoral  Bul..-utaneons  on.pi.yscn.a.  uhuh   has  lu^n  "'^  /  '^  \.  "  ;  ,.^'.  • 
ran.  cases,  is  .hu-  ..itiin-  to  p.^rf-n-ation  ol  tiu-  trachea  or  to  tho  mpUnc 
.1  .■•ivitv  clo-clv  adherent  to  the  ehest  wall.) 

,„.  ,,„.„i„Ms ,■  in  »l.i..sl  «ll  insl»iH-v»  1..  s|.lm™li«  "•  H'^'  »""»  "'  "" 

fivitv    rarelv  in  the  l'.in''-tissne  itself. 

Z       rliou.  in  II.  l'lr,n..-X  dry  pleurisy  is  a  very  oonnnon  ^u.^nv- 
mn  n.ent  of  the  earlv  sta-es  of  tui.erenlosis.     It  is  always  a  consenaluo, 
^  "         oe  .       In  sonu.  eases  it  is  very  extensive,  and  fnet.on  n.urn.nrs 
J      ard  over  the  sides  and  l.aek.     The  eases  with  dry  plenr>sy  and 
n      e<i on    are  of  eonrse  n.neh  less  liahle  to  the  .lanjrers  ot  pneun.othorax. 
;w    h  elLion  n,ore  eonunonly  precedes  than  .levelops  ,n  the  eonrse 
if  .nln.onarv  tul,erenlosis.     Still,  it  is  eonnnon  enon,h  to  "-•       '  ' 
in  Vhioh  a  sero-fihrinons  elTusion  develo,.s  ,n  the  ^■""^.^^^  '  '     ^        " 
lc!,'e     There  are  eases  in  which  it  is  a  special  feature,  and  it  often  I  thn  k 
vors  ch  .nicitv.     A  patient  may  durinjr  a  period  of  four  or  f.vo  years 
ir ^il      o'  lo;.al  discle  at  one  apex  with  recurrin,  elVusu.n  ,n  the  sarne 
Jide     Owin.'  to  adhesions  in  diiferent  parts  of  the  pleura,  the  ellusu.n  ma> 
i      oncapsuCted.      lhvn,orrha,de   c.lTusions.   which   are   not    nnconnuon   m 
cou:;::i^>n  with  tuhercmous  pleurisy,  are  eon.parat.vely  rare   ,n  H.ro   , 
pl,tl,isis.     (•hvlif..rni  or  milky  exudates  are  sometimes   found.     l».ui.    t 
.iru-ion<  are  not  frcMuent  a,.arl  from  pneumothorax.     An  emiwenuu  how- 
ever  n.av  develop  in  the  course  <.f  the  disease  or  as  a  se.,uen<r  ot  a  sero- 
^Irimn,;  exudate.      i'n..un,othorax   is  an  extremely  c.nnn,..n  <-';>i;  ';<";;;;; 
of  chronic  pulnmnarv  tul)ercul.,sis.     It  may  <.ccur  early  in    he  d.>eaK,  1. 
to  frcpentlv  is  late.      It   n,ay   prove   fatal   in   twenty-  our  hours.      I 
oher  instances- a  pvo-pneun,othorax  devel..,.s  and  the  pa  <ent  ln.^-r>  i 
voeks  or  n.onths.     m  a  third  j^roup  of  cases  it  seen.s  to  have  a  heneficnd 
olTect  on  tho  course  of  the  disease.  ,,,,,•  „;,..      tIw 

(2)  Symptoms  referable  to  other  Organs. -(<0   ^;'';'^"':'"":"'"  "T,  ';* 
retrac  ion  o    the  left  upper  lobe  exposes  a  lar,e  area  of  the  heart.      n  tlnn- 
sted  suhiects  there'may  be  pulsation   in  the  second    tlur.l.  and   i.null 
interspaces  close  to  the  sternunu     Sometinu-s  w,th  u.nch  retraction  of  the 
,ft  uppor  lohe  the  heart   is  drawn  up.     A  systolic  nu.rmur  over  the  ,ml- 
„ona  V  area  is  conun-m  in  all  sla,ues  of  phthisis.     Apical  murmurs  are  also 
t    nfrcMueut  and  may  be  extremely  rou.h  and  harsh  wuhou    necessarily 
ndicatiu.  that  endocarditis  is  present.     The  association  o     licart-diseasj. 
th   phthisis  is  not,  however,  very  uncommon.     As  already  mentioned 
e  were   Vi   instances  of  endocarditis  in   2V'.   autopsies.      The  arterial 
ension  is  usuallv  low  in  phthisis  and  the  capillary  resistance  lessened  so 


i 


TrnKRCULOSIS. 


311 


m  of  clirnnic 
otIiiT  iii>tiin<<- 
th.'  ill) nipt IK'J^.- 
<  piu'iminiiia. 
ii  coiniiion  fca- 
liowovor,  I'usos 

10  pifluiv,  iiiul 
of  uiii-.iy  years, 
witli   in  a  low 

i  tlio  rniitiiro  of 

uiic  inihiionary 
ho  walls  of  Iho 

ooiiininii  accom- 
i  a  cunsorvalivo, 
riot  ion  iminnnrs 
Iry  ]il('iirisy  and 
t'  piu'Uinotliorax. 
)ps  in  tho  conrso 
iiu'i't  with  casos 
>  of  the  chronic 
it  often,  I  think, 
iiir  or  five  years 
sion  in  the  same 
tlic  ell'usion  may 
it    uncommon   in 
rare   in   clironie 
ouiid.      I'urulent 
1  cmpyeina.  liow- 
HU'iice  of  a  sero- 
non  complication 
1  the  disease,  hut 
-four  hours.      In 
at  lent  lin<:ers  fnr 
luive  a  henefieial 

liii-rtianihir. — The 
e  heaj't.  In  thin- 
third,  and  fourth 

retraction  of  tlie 
iiur  over  the  ]inl- 

munmirs  are  also 
lithout  necessarily 

11  of  lieart-disease 
Ircady  mentioned. 
;i(s.  Tlie  arterial 
istancc  lessened  so 


tliat  the  piilso  is  often  full  and  solt  even  in  the  later  stajres  of  the  di.sease. 
I'he  capiliiiry  pulse  is  not  infrequently  met  uith.  and  pulsation  of  the 
\cins  ill  the  liack  of  the  hand  is  occasionally  to  he  seen. 

(h)  JUiiikI  (ll(ui(liiliir  Siislciii. — The  early  aiiiiinia  has  alrcaily  Im'ch  noted. 
It  is  often  more  apparent  than  real,  a  chloro-aiia'iniii,  and  the  lilood-rouiil 
rarely  sinks  hclow  two  millions  |icr  cuhic  millimetre. 

Tlio  l)Ioo<l-plat<'S  are,  as  a  rule,  enormously  increased  and  ari'  seen  in  tho 
withdrawn  hlood  as  the  so-called  Schidt/.e's  ^'raniilo  masses.  ^Vitllollt  any 
significance,  they  are  of  interest  chieily  from  the  fact  that  every  few  years 
some  tyro  announces  their  discovery  as  a  new  diajrnostic  sijrn  of  piilhisis. 
'I'lie  leucocytes  are  greatly  increased,  particularly  in  the  later  staj;es. 

{(•)  (Jdslni-inlrsliiKil  Siistciii. — The  toiijiuc  is  usually  furred,  hut  may 
he  clean  and  red.  Small  aphthous  ulcers  are  smuctimes  distrcs-inj,^.  ,\ 
red  lino  on  tho  f,'ums.  a  symptom  to  which  at  one  time  much  attention  was 
paid  as  a  special  feature  of  phthisis,  occurs  in  other  cacheclic  slates.  \]\- 
teiisive  tulierculous  di.-case  <if  the  |ihai'ynx.  as.-ociated  with  a  similar  atl'ec- 
tion  of  the  larynx,  may  interfere  seriously  with  deglutition  and  prove  a 
very  distressin>r  and  intractahle  symptom. 

Of  late,  special  attention  has  heen  paid  to  th.e  gastric  symptoms  (d'  this 
aireclion.  Tuherculosis  of  the  stomach  is  rare,  riceration  may  occur  as  an 
accidental  com|ilication  and  mulli|)le  catarrhal  ulcers  are  not  uncommon. 
Intt'i'stitial  and  parenchymatou,';  changes  in  the  mucosa  are  common  (pos- 
sihly  associated  with  the  venous  stasis)  and  load  to  atrojihy.  hut  these  can- 
not always  he  connoted  with  the  symptoms,  and  they  may  he  found  when 
not  expected.  On  tho  other  hand,  when  the  gastric  .symptoms  have  heen 
most  ])ersistent  tho  mucosa  may  show  very  little  change.  It  is  impossihlo 
always  to  refer  tho  anorexia,  nausea,  and  vomiting  (d'  consumption  to  local 
conditions.  The  hectic  fever  and  the  neurotic;  iniliiences,  upon  which 
Immeriiiann  lays  much  stress,  must  he  taken  into  account,  as  they  play 
an  important  role.  The  organ  is  often  dilated,  and  to  muscular  insidli- 
ciency  alone  may  he  due  some  of  tho  ca.ses  of  dyspepsia.  'J'he  condition  of 
tho  gastric  secretion  is  not  constant,  and  the  reports  are  discordant.  In 
the  early  stages  there  may  he  su)ieracidity;  later,  a  deficiency  of  acid. 

Anorexia  is  often  a  marked  symiitom  at  the  onset;  there  may  lie  positive 
loathing  of  food,  and  even  small  (|uantities  cati.se  nausea.  Sometimes,  with- 
out any  nausea  or  distress  after  eating,  tho  feeding  of  the  patient  is  a  daily 
liattle.  When  practicable,  Dehovo's  forced  alimentation  is  of  great  iienoflt 
in  such  cases.  Xansoa  and  vomiting,  though  occasionally  trouhle.some  at 
an  early  ]ieriod,  are  more  marked  in  the  later  stages.  The  latter  may  lie 
caused  by  tho  severe  attacks  of  coughing.  S.  II.  Ilaliershon  refers  to  four 
different  cau.-'os  the  vomiting  in  jihthisis:  (1)  central,  as  from  ttdioreulous 
meningitis;  {'i)  jirossure  on  the  vagi  by  caseous  glands;  (;?)  stimulation 
fnmi  the  poriplioral  branches  of  tlio  vagus,  either  pulmonary,  pharyngeal, 
or  gastric;  and  (4)  meelianical  causes. 

Of  the  inlrsliiuil  symptoms  diarrluoa  is  the  most  serious.  Tt  may  come 
on  early,  but  is  more  usually  a  sym^'^om  of  the  later  stages,  and  is  associ- 
ated with  ulceration,  particularly  of  tho  large  bowel.  Kxteiisive  ulceration 
of  the  ileum  may  exist  without  any  diarrhoea.     Tho  associated  catarrhal 


;)12 


sPEriric  iN'FKt'Tiors  diskasks. 


con.liti.M,  may  arcnui.t  in  part  fnr  it,  aiul  in  son...  in.tancrs  the  amyloid  do- 
L'cMHTation  of  till'  niii('f)ns  nifinliianc.  ,       ,      ,  *      , 

{,!)   ynrnus   S,istnn.-{\)    VonA   lrsi..ns   .hie    to   tlu'   .lrN..lo,.,n...t   ol 
,.nar<i-  t.ilKTclrs  an'.!  arras  ..f  tnlMTcuLms  nirnin-o-cn.-.r!"'!"'-     Aplnisia. 
lur  in.tan.r.  n.av  ivsnit   from  the  {rrowth  ..f  n...ninj:..al   l..i..T.U.s  M.  t  >.• 
lissuro  of  Sylvius,  or  rvn,  i...n.ii.l..^na  n.ay  .l..v..l.r.    'Ww  solitary  tulu'uK.^ 
an.  nu.iv  .onunon  in  tlu-  .lu-oni..  pl.tinsis  of  .l.il.l.vn      C')  l^asilar  nu.nn.. 
,rili.  i.  an  ......asional  .•..nipli.ati.m.    It  n.ay  l.c.V.n.lin.'.l  t..  ti..'  l.rain.  tl..n.j;l, 

n.orr  c...n..„.H,iv  it  is  a  (M)  ccrcO.ro-siMnal  n...ni..^'itis,  vvl.i.l.  ...ay  .•.mu.  .... 

i„  ,K..-s....s  witl".....t  wll-Iovd..]..".!  Io..al  si^M.s  i.i  ti.,-  rUvA.      Iw.rc  l.a  o  I 

known  stn...-.   .'oiMist    ....'n   l..'..n^'l,t   into  hospital   w.th   s.jxi.s  ot   cmvI..-..- 

spinal  n...ninj:itis.  i..  ^vl......   tl...  oxistonc..  ..f  p..l....ma.'y  <l.s...s.;  was   ,.o 

,lis...v...r.l   n..til  tl...  p.>>t-..io.'t...n.     (1)   I'vnrhrml  nnn;h.<    \vl...l.   .^  n.-t 
,„„„„„„,  „u,y  cans.,  an  ..xt..,s..r  pa-'alysis  oi;  the  a.-..,  ...•  h^    ...o.r  cm- 
,„unlv  tl.o  latter,  with   fo..t-.l.'.M>.     It  is  usnally  a  late  n.an.testatn.n.     (-) 
Mental  sv,..pt..n.s.     It  was  no,...l.  ..v..,.  hy  the  oh  er  wr.t..,..    hat  e.u™p- 
tivos  ha.i  a  pee..lia..lv  l...]...!'..!  t.'n.iH..a>..e..t.  an.l  the  spr.  phllns.ra  iorn.> 
a  enri....s  dlaraeteri^tie  of  tl..-  .lis.'ase.      I'ati....ts   with   ext.ms.ve  eavt.es, 

high  fev....,  an.l  t..o  weak  t..  .....v..  will  oft.'n  n.ake  plans  l..r  the  tntni-e  an.l 

e..iitiilentlv  exi.ect  to  recover.  ■        i        ■ 

\,m.t"f.-oni  tnhe,Tulosis  of  the  hrain,  there  is  somet.mcs  in  chroni.' 
phthisis  a  form  of  insanity  ..ot  nnlike  that  whi.h  .lev..l..ps  in  the  e..n- 
vale^cen.e  from  a.^nt..  aiT..<'ti..ns.  The  whole  .in..stion  of  the  mutual  rela- 
ti.ms  of  insanity  a...l  i-hthisis  is  dealt  with  at  lenfith  in  Mi.kle  s  (.ulst.m.an 

lectures.  ,      ,  •       „i 

(r)  \  ivinarkahle  Iniprrtrnphii  of  the  mniumartj  ;ihni,l  may  ..e.nr  in  mn- 
n.onarv  t..l...|vt.l.'sis,* 'n...st  e.)i..monly  in  males.  It  may  he  ..nly  on  the 
atYected  side.  Tw.>  cases  cnnio  under  my  notice  at  the  I  n.ve.'sity  Hospital, 
l'hihid..lphia,  hoth  in  y..nnjr  nial<>s.  It  is  a  chr..iiic  interstitial,  non-U.l)cr- 
o.il.ms  nian.n.itis  (Allot).  . 

(/•)  (Iniilo-nriixini  Siislrm.—'Vhi.'  nrine  i.resents  no  spec.al  iiecnl.ar.- 
tios  in  ani.mnt  or  c.mstiti.cnts.  Fever,  however,  has  a  niarke.l  influence 
iiiion  it  Alhumin  is  met  with  fre(iueiitly  an.l  may  he  ass..ciated  with  tl..' 
fever  or  is  the  result  of  definite  chanjres  in  the  kid.ieys.  In  the  latter  case 
it  is  more  ahnndant  and  more  cnrd-likc.  Amyl.H.l  disease  of  the  kidneys 
is  not  uncommon.  Its  ].resenee  is  shown  hy  allmmin  and  tube-casts, 
and  sometimes  hv  a  great  increase  in  the  an.onnt  of  urine.  In  other 
instances  there  is"  dropsy,  and  the  patients  have  all  the  characteristic  fea- 
tures of  chronic  ?.ri-rht"s  disease. 

Pu^  in  ihe  uriiir  may  he  due  to  disease  ladd.-r  or  of  the  pelves 

of  the  kidneys.    In  some  instances  the  .ary  tract  is  involved.    In 

inilmoua.-y  phthisis,  however,  extensi  .ulous  disease  .s  rarely  foun.l 

in  the  urinary  organs.  Bacilli  may  ..lonally  he  detected  in  the  ihis. 
ITa^maturia  is  n.it  a  very  common  symiitom.  It  may  occur  .iccas.onally 
as  a  result  of  cmoestion  of  the  kidneys,  and  ].ass  ..tf  l..avin.i:  the  urine 
albuminous      In    other   instances   it   results   from   diseas.>   of   tl...    i.elvis 


*  Allot,  Paris  Thesis,  1887. 


Tl'nRRCrLDSIS. 


<>  I  o 


the  iiniylnid  (lo 

(l('Vt'lii|)iiu'nt  (tl 
ililis.  Apliasiii. 
ulicrclf^  in  tlif 
iililiiry  tll•>t•l•(•k'^ 

I  lliisjliir  mcniii- 
If  Imiiii.  tlii)\ij,'Ii 
■li  may  coiiu'  on 
.  Twici'  liiivo  1 
jirjis  lit'  ctTohro- 
(liscasi'  was  imt 
f.s',  wliicli   is  not 

Ic^',  nil  ire  cnm- 
mii't'statinii.  (">) 
s,  tliat  I'oiisiuuii- 
!  phlhisica  forms 
xti'nsivc  favitic<, 
ir  tlu'  I'utnro  nnil 

tiinos  in  clironio 
lops  in  tbo  cnn- 
tlio  mutual  rela- 
cklo's  (lulstoniau 

lay  occur  in  iiul- 
\,-  1)0  only  on  the 
ivcrsity  Hospital, 
stilial,  iion-uibcr- 

p]K'cial  iiccnliari- 
markcil  intlucnco 
isociatcd  with  tiic 
In  the  latter  case 
PC  of  the  kidneys 

II  and   tuhe-casts, 
urine.     In   other 

characteristic  fea- 

■r  or  of  the  pelves 
ct  is  involved.  In 
ise  is  rarely  found 
tected  in  tlie  ]nis. 
occur  occasionally 
leavinj:  the  urine 
■ase    of    the    ])elvis 


or  of  the  I'laddiT.  and  is  associated  either  with  eai'ly  tuhinulosis  of  the 
iiiiicous  nil  nihiaiiis  or  nmre  (omiiioidy  with  uheratinii.  In  any  tnediial 
rlinic  till'  routine  in>peclinii  of  the  te.-tes  lor  tulieiile  will  save  two  or  Ihrei' 
mistakes  a  year. 

((/)  ('iihiiicniis  Si/sh'in. — The  t-kin  is  often  dry  and  harsh.  Lmal  tidier- 
( les  o(  ca>ii)nally  develop  on  tiie  hands,  'riiere  may  he  piL'meiitary  slainiiij,', 
the  rlilniisiiKt  iilillii.siidnnii,  which  is  mure  common  when  the  peritonivtim 
is  iiivohed.  I'pon  the  chest  and  liaek  the  hmwii  stains  o|'  tiie  iiiliirinsis 
rrrslciihir  are  very  freijuent.  The  hair  of  tjie  liead  and  i)eard  may  hecomo 
dry  and  hiid<y.  The  ternnnal  plialan<,'es.  in  ciinnuc  cases,  hocoine  ciulihed 
and  tlie  nails  incurvated — the  Ilippocratic  limrers.  A  remarkalde  and  un- 
usual cnmplicatioii  is  ^'eneral  emiihysema.  which  may  result  fmni  ulcera- 
tion id'  an  adherent  Innj,'  or  perl'oiation  of  the  larynx. 

Diagnosis. — ^^'hen  well  advanced  there  is  rarely  any  douht  as  to  tlie 
cxisti'ncc  of  tulierculous  phthisis,  for  the  sputum  ^dvcs  positive  informa- 
tion, and  the  physical  sijxns  of  local  disease  are  well  marked.  'I'lie  hacilli 
<:ive  an  infallihle  indication  «d'  tiie  existence  of  tuliereiilosis  and  may  lie 
found  in  the  s|)utuni  hel'iire  the  jihysical  siuMis  are  at  all  definite.  On  the 
oilier  hand,  it  must  lie  rememhered  that  there  are  cases  in  which,  even 
with  tojerahly  well-defined  physical  sii,'ns,  the  s|iiilum  is  extremely  scanty 
and  many  examinations  may  he  reipiired  to  detect  tuliercle  hacilli.  80 
c>sential  is  tiie  examination  of  the  s|iutuiti  in  the  early  diaj,niiisis  of  phthisis 
tliat  1  would  earnestly  insist  u|ion  the  more  freijueiit  employment  of  this 
method.  Tlieic  is  no  excuse  now  fur  its  omission,  since,  if  the  |iractitioner 
iias  not  couimand  of  the  necessary  teclinii|ue,  tiiere  are  lahoratories  in 
many  parts  of  the  country  at  which  the  examination  can  he  made.  Karlij 
(li'Ifclidii  ix  iif  riliil  Inijinrhiiire,  as  siiccrssfiil  lirnliiicnl  cli'pcnds  uihin  the 
vu'dsitn'f  hilriii  bcfun'  Ihr  Iiukjh  are  c.iicnsirvh/  ittvolml. 

'i'he  |iri'sence  of  elastic  lihres  in  the  simtum  is  an  indication  of  destruc- 
tion of  the  limj:-t issue.  In  a  lar^n'  proportion  of  cases  it  is  indicative,  too, 
of  tuherculous  disease.  Jt  also  may  he  found  early,  before  the  physical 
si<rns  arc  well  marked.  Its  detection  is  easy  hy  the  aliovo-mentiojied  method, 
not  re(|uirinj:  liif,di  powers  of  the  microscope.  In  cases  of  early  lui'inoptysis, 
hefore  there  is  marked  constitutional  disturhance.  or  even  local  si^ns,  it  is 
very  important  to  make  a  thorou<fh  examination  of  tlie  sputum,  from 
which  mucoid  and  ]iurulent  portions  may  he  ]iicked  out  for  exaiidnation. 
With  localized  and  |iersistent  sii.nis  in  one  luiij:.  couudi,  fever,  and  loss  of 
flesh,  the  dia;;nosis  is  rarely  duhious.  It  is  remarkalile,  however,  to  what 
an  extent  the  lmal  ]iroccss  may  sometimes  ])i'occed  without  disturhance 
of  healtli  suHlcicnt  to  excite  tlie  alarm  of  the  ]iliysician  or  friends.  There 
are  ]iuz/.lin^;'  cases  with  localized  ]diysical  si^nis  at  one  a]iex,  chieily  moist 
rrdes,  rarely  any  percussion  changes,  perha])s  sli^dit  fever,  and  a  ulairy 
expcctoi'iition  coiitaininix  numerous  alveolar  cells.  I  have  seen  several 
cases  of  this  kind  which  have  heen  for  a  time  very  ob.ecure,  and  in  which 
rc]icated  examinations  failed  to  detect  either  liacilli  or  elastic  tissue.  They 
seem  to  lie  instances  of  local  catarrlial  trouble  in  the  smaller  tubes,  some 
of  which  clear  in  a  few  weeks. 


M 


314 


SPECIFIC  INFECTIOUS  DISEASES. 


3.  Fibroid  Phthisis. 

In  their  monograph   on   iMl.roi.l   Diseases  of  llio  Lung   (^^^^'^   <^'''"'J' 
lladley   and   Chajdin   nu.ke  the   following:   elassilication:   l"  ^'^^j^*;;"!;  " 
lil.roi.l  ,,hti.isis-a  eon.lition  in  whieh  there  ,s  no  tu herele      .'.   ^'1'^''     '' ' 
,i,,,oid  disease-a  eon.lition  primarily  tuhereulous    hut  ^^''.•^^  '^^J"   .^ 
lil,n,id  course.     13.  riljn.-tuherenh.us  disease-a  eon.htion  prnnai.l>  ii  .loid, 
l,ut  whieh  luis  heeon.e  tuhereulous.     Tiu.  tuhereulo-lii.roi.l  huiu  may  eonie 
on  ura.h.allv  as  a  sequenee  of  a  ehn.nie  luhereuh.us  hroneho-i.ne.unonui, 
or  t;.Uow  a\-hronie  tuhereulous  pleurisy.     I.i  other  mstanees  the  proee.. 
su,.ervenes   upon  an  ordinary   uleerative   phth.s.s.     li>e   d.sea.e   h ec  on.  . 
1    .ited  to  one  ap..x,  the  eavity  is  surrounded  hy  layers  oL  dense    d.ou. 
issue.  t]>e  pleura  is  thickened,  and  the  lower  loin,  .s  gradual  y  muued    0 
the  selerotie  ehange.    fltin.ately  a  pieture  is  produeed  h.tle  >l  at  all   lie  - 
out  from  the  eondition  kn.nvn  as  eirrh.>sis  ol  the  lungs.     It  ma>  even     t 
.lillicult  to  sav  that  tlie  process  is  tuhereulous,  hut  in  advanced  ease,  t  u 
,      illi  nre  usually  present  in  the  walls  of  the  eavUy  at  the  apex,  or  old 
0  eapsulated  easJs  areas  exist  in  the  lung,  or  ^ --  ""^>\.^Vr    "     tl 
the  apex  of  the  other  lung  and  in  the  hr.melnal  glands     1).  a ta  -on  e 

bronchi  is  present;  the  right  ventricle,  souiet.mes  the  entire  lieait,  i.  hjpa- 

^'"'Thfdisease  is  ehronie,  lasting  from  tc.^  -i  twenty  or  more  years,  dur- 
in"  whieh  time  the  patient  may  have  fair  healtli. 

"^The  ehief  symptoms  are  cough,  whieh  is  often  paroxysmal  in  eharacte 
and  most  marked  in  the  morning.     The  expeetoration  is  pundent,  and 
in  some  instances,  when  the  hronchiectasis  is  extensive,  fetid.      Iheit   is 
dvsnmea  on  exertion,  hut  little  or  no  fever. 

■  The  i.hvsical  signs  are  yery  eharaeteristie.  The  ehest  .s  sunken  and 
the  shouldcA-  lower  on  the  affected  side;  the  heart  is  often  drawn  over  and 
di^i.laeed  If  the  left  lung  is  involved  there  may  he  an  unusually  large 
arelv  of  cardiac  pulsation  in  the  thinh  fourth,  ^-'l^^^'']J'fV'^'r':J^'^ 
murmurs  are  common.  There  is  dulness  over  the  allected  sule  and  dch- 
cient  tactile  fremitus.  At  the  apex  there  may  he  well-marked  cavernous 
rounds;  at  the  hase,  distant  hronchial  hreathing.  The  condition  may  per- 
sist indermitelv.  In  some  eases  the  other  lung  becomes  involved  or  the 
patient  has  rejieated  attacks  of  Inemoptysis,  in  one  of  which  lif  "^'^•.  ^^^ 
n  result  of  the  chronic  sui)i)uration,  amyloid  degeneration  of  the  liver, 

spleen,  and  intestines  may  take  place;  dropsy  frequently  supervenes  from 

'"TmorelStV^I^^nnt  is  found  under  Cirrhosis  of  the  Lung,  with 
which  this  f(nni  is  clinically  identical. 

Concurrent  Infections  in  Pulmonary  Tuberculosis. -Tt  has 

huic^  been  known  that  in  pulmonary  tuberculosis  organisms  other  than  he 
speHfic  bacilli  are  present,  particularly  the  micrococcus  lanceolatus,  the 
sireptococcus  pyogenes,  and  the  staphylococcus  aureus;  less  freciiiently  the 

bacillus  pyocyaneus.  .  ,  •     t  •  r 

\  majority  of  all  cases  of  pulmonary  tuberculosis  are  combined  infec- 
tions; streptococci  and  pneumococci  may  be  found  in  the  sputa,  and  the 


J 


■^v 


TUBEUCULOyiS. 


315 


(1S91)  Clark 
i'uro  libi'oiil; 
2.  Tiil)orciiln- 
■li  hiis  vim  a 
iiarily  ii^ruiil, 
nil  may  come 
i(i-i)nL'iiiuonia, 

'S    tlu'    ])rOL•l•^^S 

-case    het'omt'S 
(Iciisc  lil)n)iis 
ly  invadi'il  l)y 
it"  at  all  (lillVr- 
iiiay  I'VL'ii  be 
11(0(1  cai^es  the 
;  apex,  or  old, 
je  tubercles  at 
lata! ion  of  the 
leart,  is  hyper- 
ore  years,  d or- 
al in  character 
purulent,  and 
>tid.     There  is 

is  sunken  and 
Irawn  over  and 
.musually  large 
spaces.  Ileart- 
.  side  and  deli- 
rked  cavernous 
liticm  may  I'cr- 
nvolved,  or  the 
:'li  he  dies.  As 
n  of  the  liver, 
npervenes  from 

the  Lunp,  with 

llosis.— It  has 

!  other  than  the 
knc(M)latus,  the 
s  fre(piently  the 

combined  infec- 
;  sputa,  and  the 


former  have  been  isolated  from  the  blood.  Pnidden,  who  has  very  carc- 
liilly  studied  this  (lue^tion,  arrives  at  the  following  conclusions:  The  pul- 
iiioiiary  lesions  of  tuberculosis  are  subject  to  variations  (le])ending  largely 
on  the  dill'erent  modes  of  distril)Ution  of  the  bacilli,  whether  by  the  blood- 
\(ssels  or  through  the  bronchi,  and  also  whether  a  concurrent  infection 
uith  other  organisms  has  taken  |ilaie.  The  pneumonia  complicating  tuber- 
<  ulosis  may  Ik;  the  direct  result  of  the  tubercle  bacillus  or  its  lo.xines,  or  it 
may  follow  secondary  infection  with  other  germs,  })articularly  the  stropto- 
niccus  pyogenes,  the  micrococcus  lanceolatus,  and  the  stajibylococcus 
pyogenes.  The  fre(iuency  of  this  secondary  infection  and  the  relative  sig- 
iiilicance  of  these  germs  are  not  yet  fully  decided.  The  introduction  of  the 
luiiercle  bacilli  into  the  lungs  of  a  rabbit  through  the  trachea  induces  the 
various  phases  of  pulmonary  tuberculosis,  but  cavity  formation  is  rare.  If, 
(HI  the  other  hand,  into  the  lungs  of  a  rabbit  which  are  the  seat  of  extensive 
consolidation  the  streptococcus  jiyogenes  is  introduced,  tlien  cavities  form 
rapidly,  and  the  anatomical  picture  is  very  similar  to  that  of  chronic  ulcer- 
alive  tiil)erculosis  in  man.  It  is  very  ])robable  that  in  man,  too,  the  elfect 
(if  contamination  with  these  ])us  organisms  is  a  very  important  one  in 
liastening  necrosis  and  softening,  and  also  in  the  chronic  cases  they  doubt- 
less jiroduce  in  large  amounts  the  toxines  which  are  responsible  for  many 
of  the  symptoms  of  the  disease. 

Diseases  associated  with  Pulmonary  Tuberculosis.— io/>(!r 
jDiruiiuinid  is  a  not  uncommon  cause  of  death.  It  is  met  with,  most  fre- 
(]uently  indeed,  as  a  terminal  event  in  the  chronic  cases.  It  may,  however, 
occur  early,  and  be  diilicult  to  distinguish  from  an  acute  caseous  pneu- 
monia. The  sputa  in  the  latter  are  rarely  rusty,  while  the  fever  in  the 
former  is  more  continuous  and  higher,  but  in  many  cases  it  is  impossible 
to  diU'erentiate  between  the  two  conditions. 

Tijiihoid  fever  occasionally  occurs  in  jiersons  the  subjects  of  ]tulmonary 
tuberculosis.  In  4  cases  of  80  autoi)sies  in  typhoid  fever  tubercidous  lesions 
were  present.  There  are  cases  on  record  also  of  acute  miliary  tuberculosis 
and  typhoid  fever  ]iresent  in  the  same  subject.  There  is  a  widespread 
opinion  that  typhoid  fever  i)redisj»(»ses  to  tubercidosis,  and  Wilson  Fox 
in  liis  treatise  on  diseases  of  the  lungs  gives  references  to  a  number  of 
cases.  In  my  exjierience  it  has  been  very  rare.  I  have  no  recollection  of 
an  instance  in  which  tuberculosis  has  develoi)ed  either  during  convalescence, 
or  immediately  after  recovery,  from  typhoid  fever. 

Eri/sipclds  not  infrc(piently  attacks  old  poilrinaires  in  hospital  wards 
and  almshouses.  There  are  instances  in  which  the  attack  seems  to  be  bene- 
ficial, as  the  cough  lessens  and  the  symptoms  ameliorate.  It  may,  however, 
prove  fatal. 

The  eruptive  fevers,  particularly  measles,  frecjuently  precede,  but  rarely 
develop  in  the  course  of  pulmonary  tuberculosis.  In  the  revaccination  of 
a  tuberculous  subject  the  vesicles  run  a  normal  course. 

F'lsUila  in  ono  is  associated  M-ith  ])lithisis  in  an  interesting  manner. 
In  a  majority  of  such  cases  it  is  a  tuberculous  process.     The  general  affec- 
tion may  progress  rai)idly  after  an  operation.     The  question  is  considered 
in  tuberculosis  of  the  alimentary  canal. 
20 


m^ 


310 


SPECIFIC  INFECTIOUS  DISEASES. 


post-iiioi-toms.  ,;n,  /.;m-,.iuV  rtW/in7i.s,  iil'tm  which  cor- 

Tho  association  of  tuhorcn,  os,s  w  tli     ''''/;';,,, J.i  ,.,,i,taucc  of 

;£eT;l;™.^^,:^«:Sj^sS;rx«^n :,,....,.: ..i- 

„l,i,l,  '"?■'">,:'''';:''''",;;,„„.„  Tuberculosis  at  the  Extremes 

of  Life.— UO  yi"  •>!/^-  .  '    '•  ,  ,  ,„,|,|.,,,  ,^,,to(l  1-1'>  cases  in  which 

thoagc.l,pariieuhirlyini..staul.on.    ^^   -'      ^  ;f.„  ,.,,i,,.  Hospital. 

tubeivulosis  was  l.o  -"^^^^^f '^I^,  '^^  ^  ..,  ,t  the  SalpOtrierc  is  th. 
AH  wc.  over  ^-27;  hrS" in  person  over  ninoly-ninc  years  of  a,.>. 
same.    Laeimeo  met  \Mtli  a  c.isi  in  a  persons  sent  over 

,,„„,,,  latent  .,,.n,,.  a  slow  c-^^^  ,,„„,„,., 

„a.,y  ,,o™  Xr;  *,;t,       vt      la';;  ot  rrorch  wntc    have  *ow,. 
„„.  ..alv.on  .1.0  .ta.,*c.  ot  tho    ,0        r  P..    .   .     ;;  -„„^>„    .  ,„  „„„, 

'■"■"T  oT  fro  ■''.,:  ,0  «U  m r.l-'  1'.;  fro>.  -v  to  ..olvo  mo„«,j, 
montl  »,  f  ■/""',,,,,,.  ,,,„,),  „,„,  r„„„  01,0  to  ll,r«  years,  103.  I'.il- 
53  (a  total  o  111  ""''''''']"'■,  „f  jhc  cafos,  a.i.l  in  only  50  waa  ti.e 
moiiary  cavities  »oro  pro^'iit  ill  ,.<  "t  '"'  "  '  ,,„t„,|„,V„  Foioi.llini-' 
,„,,„,„nary  lesion  the  sole  "'^':>**>*"' ,,^^„'  J  /  ,  ,  ^;  i,  „n„,,ere«losis 

^'^':;:':;^^:::zi''r^:'z:^'^:s  n:;^,™,,,  at  .i,e  Ne„  .•„* 

r       iw  1  o    i  al'  arc  of  special  interest  in  connection  .,11.  tl,e  niocle 
Fom..ll.nK  llo., .  al   arc         ^  ^^  „,^  ^„„„,,,  „,  „,,,  ,„st,t»t,.,n 

t,  mTi  ™ava    s'cre  oxlnsivc,  tl.c  scat  of  tl.e  „vin,ary  altcct.on  was  no. 


TUBEHCULOSIS. 


317 


Mirroiicc  ril 

[.  Stenosis 
to  tubcrc'u- 
sor  circula- 
?nt,  in  9  of 
ho  other  of 
ardio-vascu- 

;oasc  in  100 

1  which  cor- 
rosistauce  of 
slilutions  in 

Extremes 

rculosis  is  in 
iscs  in  which 
■;ca  Hospital. 
iC'trioro  is  tlu' 
years  of  aii'e. 
ans  sent  over 
old  or  recent 
jhty-two  with 
,1  the  aged  is 
often  masked 
The  diagnosis 
clastic  tissue. 
L'reulosis  is  by 
•uses  of  tuber- 
lay  have  dated 

lildrcn  has  al- 
ls occasionally 
5,  have  shown 
f  ago.    Leronx 
ig  219  cases  in 
e  day  to  three 
;welvo  months, 
}ars,  108.    Tul- 
nly  50  was  the 
:)urg  Foundling 
of  t\d)ercnlosis 
the  New  York 
with  the  mode 
this  iTistitution. 
ITcctiou  was  not 


clear,  and  the  Itroncliial  glands  were  large  and  chee.-^y.  In  20  ca.-es  of 
general  tuberculosis  there  were  chee.<y  nui.<ses  in  thi'  bronchial  glaiuls  and 
in  the  lungs.  In  42  cases  of  general  tuberculosis  liie  (inly  cheesy  masses 
were  in  the  lironchial  lymph-glands.  In  !•  cases  the  tuliereles  were  limited 
to  the  broiuhial  nodes  and  the  lungs;  the  latter  containing  only  discrete 
miliary  bodii^s,  while  the  bronchial  glands  showi'd  advaneed  caseation.  Jn 
13  cases  there  was  tuberculosis  of  the  bronchial  nodes  (udy.  In  most  of 
these  cases  the  patients  died  of  infectious  diseases.  Tliese  ligurcs  are  very 
suggestive,  ami  jioint,  as  already  noted,  to  infection  through  the  bronchial 
])assages  as  the  mn.-;(  eoiumon  metlmd,  even  in  children.  Of  'tW  autopsies 
in  children  at  the  ^lunicli  Pathological  Institute,  in  150  (;}0  per  cent)  tuber- 
culosis was  present  and  in  over  t)2  i)er  cent  the  lungs  were  involved 
(Midler). 

Modes  of  Death  in  Pulmonary  Tuberculosis. — (a)  Ih/aslhenia, 
a  gradual  failure  of  the  strength.  The  end  is  usually  peaceable  and  (juiet, 
occasionally  disturbed  by  paro.xysms  of  cough.  Consciousness  is  often  re- 
tained until  lU'ar  the  close. 

{!))  I'll  iisjiln/.ri(t,  as  in  some  cases  of  iicute  miliary  tuberculosis  and  in 
acute  pneumonic  jihthisis.  In  chronic  iihthisis  it  is  rarely  seen,  even  when 
luieumot  borax  develops. 

{(■)  ]li/  si/iiro/ii'.  '^riiis  is  not  common.  1  have  known  it  to  hap|)en  onco 
or  twice  in  patients  who  insisted  u|)oii  going  aliiuit  when  in  the  advanced 
stages  of  the  disease.  Tlu're  may  be,  but  not  necessarily,  fatty  degeneration 
of  the  lu'art.  A  rapidly  developing  syneope  may  follow  luvmoirhago  or 
may  be  due  to  thrombosis  or  embolism  of  the  pulmonary  artery,  or  to  pneu- 
mothorax. 

((I)  Froiii  JidDKirrliaiic.  'Vhv  fatal  bleeiliug  in  chronic  phthisis  is  duo 
to  erosion  of  a  large  vessel  or  ru|)tnre  of  an  aneurism  in  a  pulmonary 
cavity,  most  commonly  the  latter.  Of  2(i  cases  analyzed  by  S.  West,  in  11 
the  fatal  ha'mo])tysis  was  due  to  aneurism,  and  of  o5  cases  collected  by 
Percy  Kidd,  aneurism  was  present  in  .30.  In  a  case  of  Curtin's,  at  the 
Philadeliiliia  iros]iital,  the  bleeding  proved  fatal  before  luemoptysis  oc- 
curred, as  the  eroded  vessel  opened  into  a  capacious  cavity. 

(r)  ]Villi  rcrclirol  si/mptoni.^.  Conni  may  be  due  to  meningitis,  less  often 
to  nrmnia.  Death  in  convulsions  is  rare.  The  luvmorrhagic  jiachy-menin- 
gitis  which  develo]is  in  sonu^  rases  of  phthisis  occasionally  causes  loss  of 
consciousiu'ss,  but  is  rarely  a  direct  cause  of  death.  In  one  of  my  cases, 
death  resulted  from  throndjosis  of  the  ccreljral  sinuses  with  symptoms  of 
meningitis. 

\.    Tl'DERCULOSIS   OF   THE   AT-IMIC \TAI?Y   C.VXAL. 

(n)  Lijix. — Tuberculosis  of  the  li])  is  very  rare.  It  occurs  occasionally 
in  the  form  of  an  ulcer,  either  alone  or  more  commonly  in  association  with 
laryngeal  or  jndmonary  disease.  Two  cases  arc  reported  and  the  literature 
is  analyzed  in  Ycrnenil's  Etudes.*  The  ulcer  is  usually  very  sensitive  and 
may  be  mistaken  for  a  chancre  or  an  epithelioma.     The  diagnosis  may  be 

♦  Tome  ill,  Fnsc.  I. 


SPECIFIC  INFECTIOUS  DISEASES. 

..ado  in  ca.c.  of  d..ul,t  l.y  inoculation  or  the  examination  of  a  portion  for 
tulicrele  bacilli.  ,      .       ,  ,„,r«.,T.iii<>n  of  «mall  granular 

Horc  vitl.  a  di:.tii"t  l..rt  in,cv,.n  mars..,  a.,<l  a    ""=)'•   ",„„,,,„  ,;,,, 

i    r  1...  rarely  met  uiU.  .xco^t  ,1.™  "'  '"-f"™:,  Jit     't  ,T  1,1 
plan*  or  tl.c  angle  ..f  tl,e  ja;r  a.-e  n..l  ';"'"  f-"' »    ' ''    ^2>^J„  ,„■  l.'.l.or- 

L  i,„,i„o  .;<  i;-«^-.^  "^-'^  ';;;"u.;;  1^^:.;:": ,„u„n  te. 

an  immunity,  however,  winch  in  then  ta.t  k 

cases  have  been  reported.  ^  ^^^^^^.  ^tension 

((/)  Tubercles  of  the  hard  or  soft  palate  nearly  ai^\d> 
of  the  disease  from  "oi|:hboring  parts  ^     ^,^^^^,^,,  f,„„a  the  tonsil. 

(,)  7-.^.,r./.s,..f  //..  ':":;'^^utoni/    l)n"  Ix.-ki  dcn.oustrated 

HiSiiiii 
iiiiiiii 

;^  0  is  ;S;;;t;;;;;'of  tl.  .u^H  Jltl,  nnHa,,  tuben.les.  wl...  .  F^-s 

a  greater  or  less  hvportrophy  which  it  is  practically  imposMbl    to  dm 
.^Sh  frou.  an  ordinary  enlarged  tonsil  without  a  nneroseop.cal  examma- 
'^i,^r^      ("•i«eou«  foci  occasionallv  devclo]).  e      ■^■, 

(f)rMZ    -In  extensive  laryngeal  tuberculosis  an  eruption  of  m,h- 

,harvnx  mav  bo  tuberculous,  as  shown  by  T.ermoye=c.    Mac  ,oko  k  lUj,  tuty 
her,  1897). 


'^■ 


TUBERCULOSIS. 


319 


irtion  for 

granular 

irrcguliir 
pons  base, 
raltle  size. 

to  be  cx- 
ved.  Tlio 
;  not  yield 
the  tuber- 
liition  test 
ion. 

ans  of  the 
nfection — 
ale;  a  few 

,•  extension 

the  tonsils 
monst  rated 
ho  eervieal 
'ft ion  ■with 
es  of  tuber- 
K'illi  which 
OS  of  tviber- 
Y  and  asso- 
l  ])\dinonary 
tidiorculons 
the  circula- 
0  commonly 
loh  prodnces 
k>  to  distin- 
.al  examina- 
tion of  mili- 
nncomnion. 
n  of  the  dis- 
sing  of  com- 
of  the  naso- 
iiliically,  they 
ition. 

iilosis  of  the 
in  tlie  slight 
a  case  in  my 
)nrnlent  plon- 
'ono.  who  has 
doliu,  Xuveiu- 


(/()  F!lomacli. — !Many  cases  are  reported  which  nro  donbtful.  Primary 
disease  is  unknown.  .Miiri'an  was  al)lo  to  collect  only  abont  a  dozen  authentic 
cases.  IVrforation  of  the  stomach  occurred  six  times,  thrice  by  a  tuberculous 
gland.  In  Opjxdzer's  case  an  ulcer  of  the  colon  perforated  the  organ.  lu 
.Musser's  case  there  was  a  largo  tuln'rcnloiis  idcer  3  X  H  inches  in  extent. 
Three  cases  liave  been  described  from  jny  wards  by  Alice  Hamilton  (J.  II. 
II.  Bulletin,  April,  IsyT). 

(i)  Inleslines. — 'J'he  tubercles  may  be  (1)  prinuiry  in  the  mucous  mem- 
brane, or  more  commonly  {■■!)  secondary  to  disease  of  the  hings,  or  in  rare 
cases  the  all'ection  may  (ii)  i)ass  from  the  iieritomeum. 

(1)  Primary  intestinal  tubercid(j.>is  occurs  most  frociuently  in  children, 
in  whom  it  may  ije  associated  with  enlargement  and  caseation  of  the  mesen- 
teric glands,  or  with  jjeritonitis.  It  may  be  dillicult  to  say  at  the  time  of 
the  autopsy  whetlier  the  jirimary  lesi(jn  has  been  intestinal  or  peritoneal. 
I  have  already  referred  to  Woodhead's  statistics  showing  the  remarkable 
frequency  of  infection  through  the  bowel.  In  adults  ])rimary  intestinal 
tuberculosis  is  rare,  occurring  in  but  1  instance  in  1,0U0  autopsies  upon 
tuberculous  adults  at  the  Munich  Pathological  Institute;  but  now  and  then 
cases  occur  in  which  the  disease  sets  in  with  irregular  diarrluea,  moderate 
fever,  and  colicky  pains.  In  a  few  cases  luemorrhage  has  been  the  initial 
symptom.  Eegarded  at  first  as  a  chronic  catarrh,  it  is  not  until  the  emacia- 
tion becomes  marked  or  the  signs  of  disease  appear  in  the  lungs  that  the 
true  nature  is  apparent.  Still  more  deceptive  are  the  cases  in  which  the 
tuberculosis  begins  in  the  ctecum  and  there  are  symptoms  of  a])pendicitis — 
tenderness  in  the  right  iliac  fossa,  constipation,  or  an  irregular  diarrhoea 
and  fever.  Tliese  signs  may  gradually  disapjioar,  to  recur  again  in  a  few 
weeks  ami  still  further  complicate  the  diagnosis.  Fatal  luvmorrhage  has 
occurred  in  several  ui  my  cases.  Perforation  may  occur  with  the  fornui- 
tion  of  a  perica^cal  abscess,  or  ])erforation  into  the  peritonieum  may  take 
place,  or  in  very  rare  instances  there  is  partial  healing  with  great  thicken- 
ing of  the  Malls  and  narrowing  of  the  lumen. 

(■J)  Secondary  involvement  of  the  liowels  is  very  common  in  chronic 
])ulnionary  tuberculosis,  o.  g.,  in  .")(!(!  of  the  l.OUO  Jlunich  auto]>sies  in  tuber- 
culosis just  referred  to.  In  only  three  of  these  cases  were  the  lungs  not  in- 
volved. The  lesions  are  chiefly  in  the  ileum,  c;ecum,  and  colon.  The 
allection  boirins  in  the  scditary  and  agminated  glands  or  on  the  surface 
of  or  within  the  mucosa.  The  caseation  and  necrosis  lead  to  ulceration, 
which  may  be  very  extensive  and  inv(dve  the  greater  portion  of  the  mucosa 
of  the  large  and  snuill  boMcls.  In  the  ileum  the  Peyer's  patches  are  chiefly 
involved  and  the  ulcers  may  be  ovoid,  but  in  the  jejunum  and  colon  they 
are  usually  round  or  transverse  to  the  long  axis.  The  tulierculous  uleer 
has  the  following  characters:  (n)  It  is  irregular,  rarely  ovoid  or  in  the 
long  axis,  more  fre(picntly  girdling  the  bowel;  (/*)  the  edges  and  Ijase  arc 
inliltratcd,  often  caseous;  (c)  the  sid)mncosa  and  muscularis  are  usually 
involved;  and  (d)  on  the  serosa  may  bo  seen  colonies  of  young  tul)crcles  or 
a  well-marked  tid)oroulous  lymphangitis.  Perforation  and  peritonitis  are 
not  uncommon  events  in  the  secondary  ulceration.  Stenosis  of  tlie  bowel 
from  cicatrization  may  occur;  the  strictures  may  bo  multiple. 


^^k 


820 


SPECIFIC  INFECTIOUS  DISEASES. 


Localize.,!  dn-oni.  tuLcvulnsis  of  the   Um-nrad  rcjion  i.  (.f  groat  im- 
,,r»a„ct.d  by  a  rocn-Mjf  "I'l"' f  •■■■';,,',;,  V,,c.  AiA\«gM:.i  In.... 

?;i';;:;.,:™ :;  .'■ .:  .0 .  .-"i"-.  i' « v..,,-  n,.,.iy  ,..-n„...y,  b,.t  n  .■... 

™ri.,l.lv  r,..„„l  I,.  1,0  i..v..lvo,l.    11  i*  a  cm,,.......  ol....;"..  I  .at  t  "^ 

"  ^';i::S":io;;-fro.  H.  pc.,-ito„..nn  ,nay  oxcito  tuberculous  disoa^  in 
the  1    w  K     The  atroctiou  n,ay  bo  priu.ary  in  tho  porrtomuuni  or  oxb^ 

uAho  tubes  in  women  or  the  mesenteric  glands  hi  cluhlren.  T  u  co .h, 
of  int  tines  beeon>e  nu.tte.l  together,  caseous  and  supj.urafngoc  de- 
velop blveen  the  f.dds,  and  perforation  n,ay  take  place  between  the  coils. 

YT.   Tl'RERCULOSIS   OF   TIIK   LiVKR. 

Thi.  or<^an  is  verv  constantly  involved  in  (a)  general  tuberculosis.  The 
miliary  grlmdation  may  be  very  s,nall  and  in  acute  cases  scarcely  percepti- 
ble     The  liver  is  pale  and  often  tatty.  i  ,      .i      i      i„,. 

(h)  \  remarkable  condition  of  the  organ  is  produced  by  the  develop- 
men  of  th  ubercles  in  the  finer  bile-vessels.  They  n,ay  atta.n  a  con- 
^d^^lde  e  and  are  ahnost  always  softened  in  the  centre,  rcsen.bhng 
.lllall  ab«ce<.es     The  contents  are  always  bilo-stained.     Tlie  organ  may  be 

assol^h^thm^ith  perihepatitis  or  tuberculous  peritonitis.    They  may  attain 
+ho  «i7P  of  an  oranjxe  or  mav  oven  be  larger. 

S   Tui™loTit  cirrhosis.    With  the  eruption  of  mibary  tubercles  ijiere 
may  lie  sligM  increase  in  the  eonncctive  tissue,  which  is  overshadowed  by 


TUBERCULOSIS. 


321 


groat  im- 
111    of  tlu' 
,'11(1  ix.    As 
is  dc'voloiiri 
rated    in   a 
lesions  ami 
i  closely  a 
mdition  is 
■1,  periodic 
.     In  a  few 
■  sueeessful 
ifiitly  than 
'lal  indura- 
•al  changes 
discharging 
lishcd  from 
1  the  stools 

ection  with 
rs  in  ahout 
'S  the  lesion 
,  hut  if  the 
are  almost 
Kit  the  pul- 
.  This  may 
)en,  and  not 

IS  disease  in 
in  or  extend 
1.  The  coils 
ing  foei  dc- 
.'cn  the  coils. 


cidosis.    The 
L'cly  pcrcepti- 

the  develo])- 
attain  a  con- 
c,  resemhling 
organ  may  be 

sometimes  in 
ey  may  attain 

uherclos  there 
jrshadowed  by 


the  fatty  cliangc.  In  all  the  chronic  forms  of  tubercle  in  tiiis  organ  there 
may  be  (ihrous  overgrowth,  llanot,  who  has  described  .several  varieties, 
states  tinit  the  condition  may  be  [triniary.  Tract ieally  it  is  very  rare,  exi'cpt 
in  connection  with  chronic  tnhcrcidoiis  peritonitis  and  perihepatitis,  wiieii 
the  organ  may  be  much  deformed  by  a  sclerosis  involving  the  portal  canals. 
In  this  last  group  there  may  bo  symptoms  of  ascites;  as  a  rule,  tuberculosis 
of  the  liver  has  a  purely  anatomical  interest. 

^'I1.  TunEiicrLosis  oi'  riii-:  1>i{ai\  and  Coitn. 

Tidierculosis  of  the  hnilti  (tccnrs  as  (n)  an  acute  miliary  ii;feetion  caus- 
ing meningitis  and  acute  hydrocephalus;  [h)  as  a  chronic  meningo-en- 
ccphalitis,  usually  localized,  and  containing  small  noilular  tnliercK's;  and 
(r)  iis  the  so-cali'ed  solitary  tubercle,  i'lctwt'cn  the  last  two  forms  there 
are  all  gradations,  and  it  is  rare  to  sec  the  meninges  uninvolvcd.  The 
acute  variety  has  already  l>cen  ((Uisidercd.  I  shall  here  consider  the  chronic 
form,  which  develoiis  slowly  and  has  the  clinical  characters  of  a  t\imor. 

It  is  most  common  in  the  young.  Of  1  IS  cases  c(tllected  by  Pribram 
118  were  uiuler  lifteen  years  of  age.  Other  organs  are  usually  involved, 
particularly  the  lungs,  the  bronchial  glands,  or  the  Ixuies.  In  rare  in- 
stances no  tubercles  are  found  elsewhere.  They  occur  nu)st  frequently  in 
the  cerebellum;  next  in  the  cerebrum  ami  then  in  the  pons.  The  growths 
are  often  nndtiple,  in  100  out  of  is;i  cases  (( lowers).  They  range  in  size 
from  a  pea  to  a  walnut;  larger  tumors  occasionally  occur,  and  .sometimes 
an  entire  lobe  of  the  cerebellum  is  affected.  On  section  the  tubercle  i)re- 
sents  a  grayish-yellow,  caseous  aiipearance,  usually  firm  and  hard,  and  en- 
circled by  a  translucent,  softer  tissue.  The  centre  of  the  growth  may  bo 
somi-diflluent.  As  in  other  localities  the  tubercle  may  calcify.  Tho 
tumors  are  as  a  rule  attached  to  the  meninges,  often  to  the  i)ia  at  tho 
bottom  of  a  sulcus  so  that  they  look  imbedded  in  the  brain-substance. 
About  the  longitudinal  fissure  there  may  be  an  aggregation  of  the  growths, 
with  compression  of  the  sinus,  and  the  formation  of  a  thrombus.  The 
tuberculous  tumor  not  iiifre(iuent]y  excites  acute  meningitis.  In  localized 
mcningo-encephalitis  the  pia  is  thickened,  tubercles  arc  adherent  to  the 
under  surface  and  grow  about  the  arteries.  It  is  often  combined  with 
cerebral  softening  from  interference  with  the  circulation.  Several  of  tho 
most  characteristic  instances  which  I  have  seen  were  on  the  meniuges 
covering  the  insula.  This  form  may  develop  in  pulmonary  tuberculosis, 
causing  hemiiilegia  or  .  /hasia  which  may  persist  for  months. 

The  symptoms  of  tuberculous  growths  in  the  brain  are  those  of  tumor, 
and  will  be  considered  in  the  section  on  the  bi'ain. 

In  tho  sjiiiuil  cord  the  same  forms  are  found.  The  acute  tuberculous 
meningitis  has  been  considered  and  is  almost  always  ccrebro-spinal.  The 
solitary  tubercle  of  the  cord  is  rare.  Ilerter  has  reported  3  cases  and  col- 
lectcdSl  from  the  literature.  It  was  secondary  in  all  save  one  case.  Tho 
symptoms  are  those  of  spinal  tumor  or  meningitis. 


«■* 


822 


SPKCIFir   iNFKrTlOrS  DISKASKS. 

VIII.  TrnKUOuLosis  ok  thk  (Iknito-i-uinauy  System. 


:il;;:;':^;u;t,;":i:'fv>. ^  r::l<'ti!z  J::z.::^^<^ 

„t  iho  g>.m,o-mi,«,ry  syslcu  one  uhv  3;.  1'-'°  ',';,:        I,  ,„,,,,;.|o  hacilii 

''  ^Inflition  of  the  gonito-urinary  tract  occur,  in  vanm^^ jvay>: 

1  7i,;  nemlilani  Tm„smission.—\i  has  been  mot  \\  th  in  the  latu... 
The  cc^^pa  U  r  cuKMU.y  of  tuberculosis  of  the  testicle  in  very  young 
?1  d  r  'tt^  ver/ strongly  that  the  uro-genilal  organs  n.ay  be  unuhed 
n.  ;  re  ul    of'lirect  Lnsm^sion  of  the  disease  from  the  parents^ 

o"     /  ,•  I  (0    /™,H  nre.s  of  tuhenulosis  already  cMno^nhe  jmUct 

?;,//»  //n-o«.'.  //'''  niood.-m  many  eases  nro-gen>tal  tubercn  o.,. 

i.  f!:ldt  l;i  Jy  aLeiated  .ith  disease  of  sojue  disUmt  o|^--  1^- 

birlv  the  lun.'s,  and  it  would  appear  most  probable  that  in  them  inlctt  on 

ns  b  en  t^omdi  the  blood-vessels.    Jani's  observations,  .h-ch  wei.  pul^ 

h  d^  Wei^rt  after  the  author's  death,  strongly  supi-ort    \u.    heo  >. 

In      ndving  secth.ns  of  the  genital  organs  of  r='t-"ts  uho  d,e     o    pu  1- 

tnmda  tn  o!i;  If  the  seminal  tulmles,  while  in  the  prostate  they  were 
^h"  V    .ituated  in  the  neighborhood  of  the  glandular  op.tlu'l.um.    _ 

)     n^rtion  from  ^  Peritoncvnm.-Thl.  source  of  infectu.n,  in  bo 
,nen    nd  women,  is  much  more  frequent  than  is  commonly  supposed     Ihe 
X    e    cM^nship  between  the  peritonaeum  and  bladder  m  both  snl.ec^ 
and  w  th  the  vesicu  a>  seminales  and  vasa  deferent.a  in    he  male.  alio.,  ol 
Tre  dv  wnv  of  invasion  of  these  organs  by  direct  extension  ot  tne  d  >- 
a^  Tin  pe  iton:vnm  is  a  frequent  source  of  gc^iita^  \f^'^''^;rZ£l 
male     No  doubt  many  cases  of  tuberculosis  of    he  Fallopian  t;  l'^-  iig  - 
nT  from  this  soiirce.     The  fact  that  the  fimbriated  extremity   o     the 
"ule       often  most  seriouslv  involved  points  rather  strongly  in  this  direc- 
on.   Ithov  gh  the  fact  might  be  taken  as  a  point  in  favor  of  blood  infection, 


TUBEIirULOSIS. 


32:? 


r. 

i-k  of  pur- 
1"  tul)crc'ii- 
('  inviidi'tl. 
unless  tin' 

degree  ol' 
re  may  be 
uhere'.iiosis 

possibility 
role  bacilli 
ut  lu'oiluo- 
■liial  gland. 
I'velopnioiit 
y  enter  the 
nd  produce 
vhicli  these 
con  for  one 
•ulous  focus 


the  fcetus. 
very  young 
he  involved 
its. 

//((•  jniticiit. 
tuberculosis 
;;an,  particu- 
.'in  infection 
h  were  pub- 

this  theory, 
died  of  piil- 

eases  in  the 
any  instance 

the  bacilli 

cellular  and 
te  they  were 
uni. 

tion,  in  both 
pposed.  The 
both  subjects, 
ale.  allows  of 
11  of  the  dis- 
.•iilosis  in  the 
n  tubes  origi- 
vuiity  of  the 
in  this  direc- 
[ood  infection, 


favored  by  its  greater  vascidarity.  Various  observations  go  to  show  that  the 
action  of  tiie  cilia  lining  tiie  luniiiui  of  the  Fallopian  tid)es  tend.s  to  at- 
tract j)articles  iiitroduced  i:,to  the  peritoiund  cavity,  dani's  observation 
is  very  interesting  in  tin's  connection,  as  showing  tiie  |)ossihiiity  of  tuherele 
bacilli  entering  the  tul)es  from  the  peritoneal  cavity  without  there  being 
any  tubcrcuhius  jieritonitis.  lie  found  tyjtical  tidiercle  bacilli  in  the  lumen, 
in  sections  of  a  normal  I'alloiiian  tube,  in  a  woman  who  tlied  of  judmoiiary 
and  intestinal  tui)erculosis.  The  explanation  advanced  was  that  the  liacilli 
made  their  way  through  the  thin  peritoneal  coat  from  one  of  the  intestinal 
ulcers,  thus  reaching  the  peritoneal  cavity,  and  thence  were  attracted  into 
the  l-'alloitian  tube  by  the  current  ])roduced  by  the  action  of  th(>  cilia  lining 
the  lumen.  The  intimate  relation.ship  between  tul)erculous  peritonitis  and 
tuberculosis  of  the  Fallojiian  tubes  is  shown  in  the  fact  that  the  latter  are 
atl'ected  in  from  iU)  to  40  ])er  cent  of  the  cases. 

{(•)  Lifcrtion  from  other  On/aus  hy  Direct  E.vtnisinn. — Tli(>  occurrence 
of  direct  extension  from  the  jieritonaMim  has  already  been  mentioned.  In 
tuberculous  ulceration  of  the  intestine  or  rectum  adhesions  to  the  bladder 
in  the  male  or  to  the  uterus  and  vagina  in  the  female  may  occur,  with 
resulting  listuku  and  a  direct  extension  of  the  disease.  Perirtrtal  tuber- 
cuhnis  abscesses  may  lead  to  secondary  involveuicnt  of  some  portion  of  the 
genito-nrinary  tract.  It  must  not  be  forgotten  that  tul)erculosis  of  the 
vertebra}  may  he  fcdlowed  by  tuberculosis  of  the  kidney  as  a  result  of  direct 
extension  of  the  disease. 

3.  Ih/  Infection  from  ]yilJioiif. — Whether  uro-genital  tuberculosis  may 
occur  as  a  result  of  the  entrance  of  tubercle  bacilli  into  the  urethra  or 
vagina  is  still  a  disputed  question.  That  bacilli  gain  ailmission  to  these 
jiassages  during  coitus  with  a  person  the  subject  of  uro-genital  tuberculosis, 
or  by  the  use  of  foul  instruments  or  syringes,  seems  quite  proliable.  The 
Iiossibility  of  genital  tuberculosis  occurring  in  the  female  as  a  result  of 
coitus  with  a  male  the  subject  of  tuberculosis  in  some  portion  of  the  genito- 
Tirinary  system  was  first  suggested  by  Cohnheim,  who  stated,  however,  that 
it  rarely,  if  over,  occurred.     Oiirtner's  experiments  have  been  referred  to. 

In  a  patient  with  intestinal  tuberculosis  the  tubercle  bacilli  might  acci- 
dentally reach  the  urethra  or  vagina  from  the  rectum. 

Uro-genital  tuberculosis  is  commonest  between  the  ages  of  twenty 
and  forty  years — that  is,  during  the  period  of  greatest  sexual  activity. 
I\Iales  are  "afTccted  much  more  frecpicntly  than  females,  the  proportion 
being  3  to  1.  This  great  ditference  is  no  doubt  jiartly  due  to  the  more 
intimate  relationship  between  the  urinary  and  genital  systems  in  the  former 
than  in  the  latter.  In  the  male  the  nrcthra  forms  the  common  outlet  for 
the  two  systems,  while  in  the  female  there  is  a  separate  outlet  for  each. 

Once  the  nro-genilnl  tract  has  been  invaded,  the  disease  is  likely  to 
spread  rapidly,  and  the  method  of  extension  is  an  important  one.  Quite 
fre(|ucntly  there  is  direct  extension,  as  when  the  bladder  is  involved  sec- 
ondarily to  the  kidney  by  passage  of  the  disease  along  the  ureter,  or  where 
the  tuberculous  process  extends  along  the  vas  deferens  to  the  vcsicula; 
spuiinales.  Xo  doubt  surface  inoculation  occurs  in  some  instances,  and  to 
this  cause  may  be  attributed  a  certain  percentage  of  cases  of  vesiciJ  and 


SPECIFIC  INFECTIOUS  DISEASES. 
,,,.tatie  ni.o„.e  following  tul.rculo.i.  of  th.  ki-hu,-    Although  thU^pn.. 

^hcLcct  ,a..agc  of  th.  l.a.UU  up  the  l"-"^  ,^  "^^X  tho  law. 
eaa.  .0  have  to  .upi-ose  that  a  -'';-";;;^^       ^        ,,;    ..f  ......o  ,lowin,  in 

,,  ,n.vity.  asc.n.ls  a,an.t  -  •;  "j;;;^^:  '^^  ^^v    Id  ,  n.cans  for  the  sprea.!- 
tlu'  opiu.site  ihreetu.n.     Hie  l}nipliatu>  nia>  .renerally  sup- 

ing  of  the  disease,  but  in  a  greater  nun.hc    o     .-»  '^!^  J^        J,,^,,. 
y:..A  it  takes  place  hy  way  ..f      ^      ^i;;^ pj;;,,,     Anbc'rele.  heneath 

{ion.  of  the  hhuhler  ->\'f -l'';;':  ^.  '^ "  ^    .,^  ,.    of  sup.rlieial  uUevation 
the  m.uous  n.end.nu.e  before  theie   >  anj  t     u. 

_a  faet  suggesting  ^..ngly  a  1  ;;;;;••; -^^  ,„,  ,,e  obtaining  of 

The  discovery  ot  tubcc  e  ''>^ '";  '\\  .  i,,„,„,,tion  with  tl>e  urinary 
tulu.rculous  lesions  in  annuals  ^^^J^^^l^^^^  „f  ^,,„ito-urinary  tubercu- 
.ediment  alTord  us  the  only  I'''- '  ^^  of  tubercle  bacilli  having 

l.,i.  So  far  there  are  -  ""^^^  \,;  !  ^i,  of  the  testicle  or  vesicuhe 
been  found  in  the  senu-n  'f  ^  ^^  ^  -nna  bacillus  has  the  same  sta.n- 
seminales.    Owing  to  the  fact  tha       t      u  .^.^^^      ;,  practically 

in,  reaction  as  tl>e  ^"''^'''^''^^ ''''^;  ;4'';\;,rn  ust  be  used  in  obtaining 
indistinguishable  from  it,  ^''^  ^''^^^^^^^.^  [',  J  ,te  if  possible,  all  chances 
the  specimen  of  urine  for  exa.nination,  t(.    '  "      'j;  .atlieterizcd  speci- 

of  colitatnination.    Tims  the  unne  ^-'^^'^   ^   J   .^k  jnto  the  bl^lder 
,nen,  and  even  then  ..ne  ^•"" ^        u  im    vl    "   nuv  be  washed  out  in  the 
on  the  end  of  the  catheter  a  ^^'^^"^      '     .     'i^!Jiii  in  the  sedinuMit. 
.trean,  of  urine  and  1h«  nnstaken  ^J^;  V"  -^'^       ,  „)  _]n  general  tuber- 

(.)  Tuberculosis  of  the  Sidneys  (/^^^,  J:^,,^,^  j,^  ,^. 
eulosis  the  kidneys  frequently  presen  -  '^^  ^^ ^ i,  ^^^  j,  ,,,  .nbstance 
n,onary  tt.berculosis  it  is  connuon  o  ^'  '.J/  .^^^J^^^.^^^,!,,,;,  .f  ^he  kidneys 
of  the  organ,  or  tliere  -^^y}^^.^^^^  ^..'L  process  inv<.lves  the  pelvis 

is  not  very  rare.  In  a  ^^i^^^J  ^  .hide  and  prostate.  In  only  1  of 
and  the  ureter  as  well   sonu^tnu  s  tl  c     ladd  r  i  .^^  ^^^^^^^^^^^,^^ 

S  eases  was  t^-  F-^; --^  ^  ^^^  \-;>;\,:;^^  p^ostaie,  or  v^icles, 
cases  whether  tlie  dl^ia^c  nas  .u.  ^^.viod  in  the  kidneys  and  pro- 

,na  crept  up  the  ureters,  -  -^,^"  ^^J J/f ^  I  the  latter  is  true,  and 
eeeded  downwan  .  I"  «  ^  ^^^  ''Z^nly  alone  may  be  involved,  and 
tlie  infection  is  through  ibe  blood.    ^    «  ^        >  ■,      f^,,,  nullimetres 

the  ^i-se  crc.i,s  down  tl.un.er  ^^^^\^,,,,,^^  ,-,0  had  no 
on  the  vesical  mucosa.     A  man  au  '  .    ^^  ^,,^,  ^.j^^ney. 

Unions  in  the  1-'^- P-J-^^^^^  ^  1  -^^  "m  Jlil  bladder  and  at  its 
inv.dving  a  P>ratii"l.  while  tlo^nr  ^^^^^^^^  ^^^  ^^^^  ^^ 

orifice,  was  thickened  and  tnbe  ;  j„^     ,    ^^dlo  period  of  life,  but  it 

caseation.    The  process  is  mos    commm  m   ^^  ^^  .     ,^^^^,  ^^,,^  ;„ 

,nay  occur  at  the  extremes  of  ag  •    J/  ;    "  -  .ecidentally,  the  dis- 

women.  In  the  earliest  f^^'^^^^^lZo..  Necrosis  and  caseation 
ease  is  seen  to  begin  m  the  1^ ^^l'^^  ,;;"*'  ^f.'^  tlirouHiout  the  pyramids 
proceed  rapidly,  and  the  colonies  o  "^f  ^  ^/  ^  ^'^^^^^^^^^^^^^  „  ,nle,  from  the 
lind  extend  npon  the  -"^"^  "-^^^^r  iVc  is'ase  may  be  confined  to  one 
outset  it  is  a  tuberculous  pyo-nephrosi..     1  uc  i 


I 


TUnEUCULOSIS, 


thi^  prob- 

jKis^ibility 
|)roi-tatc  by 
I-  in  such  a 
[(»  the  laws 

llow'mj;  in 
the  Hitmnl- 
lorally  sup- 
ic  exaiuina- 
clcr  beneath 
il  iilccratiiin 

)l)taining  of 

llie  urinary 
iry  tul)i'rcu- 
icilli  havinf,' 
e  or  vesiculii' 
}  i^amo  stain- 
.8  practically 
in  obtaining 
.',  all  chances 
terizod  speci- 
,  the  bhulilcr 
>d  out  in  the 
iment. 

;cnoral  tuber- 
cles. In  i>ul- 
tlie  substance 
,[  tiie  kidneys 
,ves  the  pelvis 

In  only  1  of 
y  in  ailvanced 
te,  or  vesicles, 
neys  and  pro- 
er  is  true,  and 
!  involved,  and 
e\v  millimetres 
.   who  had  no 

of  the  kidney, 
Ider  and  at  its 
\ed  an  area  of 
d  of  life,  but  it 
n  men  than  in 
entally,  the  dis- 
s  and  caseation 
ut  the  pyramids 
:i  rule,  from  the 

confined  to  one 


kidney,  or  ])rn<rress  more  extensively  in  one  than  in  the  other.  At  autopsy 
lioth  organs  aie  ii>ii;illy  foiiiui  ciiliiigiMl.  Oiu'  ividnry  may  lie  (Mniiijctely 
destroyed  and  converted  iriln  a  scries  of  cysts  containing  cheesy  sulistaiur — 
il  form  of  kidney  wliich  the  older  writers  called  scrofulous.  In  the  putty- 
like contents  of  tlicse  cysts  lime  salts  may  be  dc]iosited.  In  other  instances 
tiu'  walls  of  the  jieivis  arc  thickened  and  cheesy,  the  pyramiils  eroded, 
and  caseous  ?'o(hdes  are  scattered  thnnigh  the  organ,  even  to  the  capsule, 
which  may  be  thickened  and  adherent.  'J'lie  other  organ  is  usually  less 
alFected,  and  shows  only  ))velitis  or  a  suiterticial  necrosis  of  one  or  two  jiyra- 
niids.  The  ureters  are  usually  thitkcncd  and  the  mucous  mendirane  idcer- 
ated  and  caseous.  Invotvenu'nt  of  the  hladdcr,  vi'si(  nla*  seiiiinalcs,  and 
testes  is  not  uncommon  in  nudes. 

'Pile  si/ni plains  are  those  of  jjyclitis.  The  uriiu'  nuiy  be  purulent  for 
vears,  ami  there  may  lie  little  or  no  distress,  i'lvcn  before  the  hlailder  be- 
comes involved  micturition  is  fre(pu'nt,  and  many  instances  are  mistaken 
for  cystitis.  'Phe  condition  is  for  many  years  compatible  with  fair  health. 
The  curaliility  is  sliown  by  the  accidental  discovery  of  the  so-called  scrofu- 
lous kidney,  converted  into  cysts  containing  a  putty-like  sulistance.  In 
cases  in  which  the  disease  becomes  advanced  and  both  organs  are  alVeeted, 
constitutional  symptom-f  are  more  marked.  Tliere  is  irregular  U'wr,  with 
ciiills.  and  loss  of  weight  and  strength,  (leiu'ral  tiilierculosis  is  cominon. 
In  only  one  of  my  cases  wt're  the  lungs  iininvolved.  In  a  case  at  t 
^lontrcal  (ieneral  Hospital  a  cyst  perforate(l  and  caused  fatal  ])eritiiniti 

Physical  examination  may  detect  sjucial  tenderness  on  one  side,  or  t..v- 
kidney  may  bo  jialpable  in  front  on  deep  pressure;  but  tulierculous  pyelo- 
neiihritis  seldom  causes  a  large  tumor.  Occasionally  the  ])elvis  lie- 
comes  enormously  distended;  but  this  is  rare  in  comjiarison  with  its 
frequency  in  calculous  ]iyelitis.  The  urine  presents  changes  similar  to 
those  of  ordinary  calc\Uous  iiyelitis — pus-ci'lls,  ciiithclinm,  and  occasionally 
definite  casetuis  masses.  Albumin  is,  of  course,  present.  Tubercle  liacilli 
may  be  denumstrated  by  the  ordinary  methods.  Tube-casts  are  not  often 
seen. 

To  distinguish  the  condition  from  calculous  ]iyelitis  is  often  dilTicult. 


le 


ic 


TTa^nutrrhage  may  be  jiresent  in  both,  though  not  nearly  so  fre(iuently  in 
the  tuberoilous  disease.  The  diagnosis  rests  on  three  points:  (1)  The  de- 
tection of  some  focus  of  tuberculosis,  as  in  the  testes;  ("i)  the  jiresenco  of 
tubercle  bacilli  in  the  sedinuMii;  and  ('■'>)  the  use  of  tuberculin.  Tn  woman 
the  kidney  involved  is  now  easily  dctermiiu'd  by  catheterlzing  the  ureters 
after  the  plan  of  my  colleague  Kelly. 

The  incidence  of  renal  implicati(Ui  in  urn-genital  tuberculosis  may  lie 
gathered  from  Orth's  Ciittingen  material,  analyzed  by  Oppenheim.  Of  GO 
cases  there  were  31  in  which  the  kidneys  were  involved. 

Tuberculosis  of  the  suprarenal  capsules  will  be  considered  under  Ad- 
dison's Disease. 

{/>)  Tuberculosis  of  the  Ureter  and  Bladder. — This  rarely  occurs  as 
a  primary  affection,  but  is  nearly  always  secondary  to  involvement  of  other 
]iarts,  ]i,  I  ticnlarly  the  ])elvis  of  tlic  kidney.  In  the  case  of  nro-genital 
tuberculosis,  above  mentioned,  in  a  patient  who  died  of  heart-disease,  tl 


10 


8PF.CIF1C  ISFKCTlOfS   IIISEASKS. 
„"„,„.,  just  »l,..ro  it  >.nU.rs  tl,.  M.I.W,  .howcl  «  fro*  ,.»..l.  "'  '"'- 

^""£,™e,...  optiu,.  ..,i,.i,  ,„. ......-;  »*;;:  *-;:;:,' :;;?.,;: 

y,.lw  *m.l.l  bo  ...nnin-l  will,  '■"'■^;  >  ^  „  ,,„  ,,;,,;,.  ,,.,„u,„l,s. 

k;;:r::;:;::'i':-;:j  ;!="-■ '--'--^^^^^^ -^ •- 

^^""*^'-  ,    .      !•  +!,»  Prnatatn  and  VesiculjD  Seminales— The  pros- 

(.)  Tuberculosis  of  the  Prostate  ana  vest  j    ^  t^iKf     1" 

Kuyincki.  ca...  ..  1.  -;^«,    j;.;;  i:^:^;     .i;;'  ;.  inv..lv.l  in  IS 
,f  tho  :n  casos  in  males      l'>         ;'  ^j     jj^^^,,     y.,,  ,,,/</m   tl.e  rro.tatu. 

wlueli  inay Jinn.lato  ^♦r'''!;7-T..,,g  _.nns    somewhat    e.uninon    atreetion 
(,/)  Tuberculosis  of  the  Testes      ^  "^  mhoirulou.  disease 

:nay  he  vrin.ary.  or,  nmre  1'-  "^  y'  f/^  '  ,,„,  ,„.i  it  is  state.l  to 
elsewhere.  ^''>ny  ease«  ocenr  helme  ^  ^  '  [  ^^„.i;,^,,  ,,,  ,,,,„y  asso- 
have  heen  met  with  m  the  f.etus.  1" '"'•'";  ^  j  ,  ^,^,,,  r,j,„,ted  hv 
dated  with  tuhenulous  d>sease  ^^ ^^^^^^^  !^jj,^  alTedh.n.  In 
llutinel  and  Deschanq-s.  ,n  every  one  ^'^  _^  ^  ^  J  ;^',        ^,  i,^.^,,.,,.„  ,,„, 

^^r  XoM '^in t':; t,: :z ;;::;!:vxij:w;rlcted.  kopuu 
;inh.n;::'l\hcin;t::o.onhis.ind^ 

sense.    In  the  adult  the  ^''^--l^^^-^'"  ^\  ^'\  1    ^  a      T       tuhercle  docs 

;:;i;^':;ix:i:rtii;:::;rr::J^^ 

"'Vr^Vv 'iTJhrnesi^  most  likeW  to  he  eonfonnded  with  syphUis 
:.    Ue^htMl'^hod'of  the  or,u.  i— J  «.- (f  :•^^^,:^:::ia:!  t 
,„i„  and  the  m.tlines  of  the  gnuvth  are  -^^  ^    "  j  \;\^,    "^ ,  ,„t  in- 

Lbseure  peritoneal  disease  Jl-/^^'*-!;--;?  J^  ^  e  t  on  of  the  two  eondi- 
frecp,ently  led  to  a  -wee.  dn^m..  1  la  ^^^^^^^  ^^,  ,,,,,,,  ,, 
tions  is  not  nncommon.    The  l.Mon    n  t  u 

tr!^::zr:z:z:^:rt  ,1;:;  ™'r  ;,n,.o*...  ^ .  ..n,. 

«,l,.i„filiJ.  1.1  Mliiili  t  »'  t"'"'       ,      "i,";,,  Uk  lilaoc  brtivoon  tl.c  liiiil.ri»' 

'";'';\r"':;;;""  ."-t  s\,i;n:"i;r;itL  'tuo  c,„„r,n,n,  i.  i..aiiy 

?";  ,11'm  '  1     iviv  Hiir  ,1  vmiTii:  VliiMmi.    Alllioiigli,  as  »  niK-.  "Ty  "..; 
!;;lrS  .110  nS  ;c,  moi-o  are'^pocimo,.  resembling  orJiiiary  salping,,., 


J. 


Tunp:ucuLosis. 


327 


h  of  tu1)or- 

iit  cuvi^c,  is 
tori,  ami  till' 
•lo-iU'i>liritis, 
iu  seiiiinaU'.-i. 
my  tiiiniilato 

.—The  pros- 
Ill  tract.  In 
11  and  thi' 
iviilvid  in  l'^ 
ntly  involvi.l 
tlic  prot'tiitic 
I'roni  a  pfU  U> 
lizinf,'  pain  in 
1  tul)erculosi!', 

nou    airoctioM 
c'lilous  (lisoasr 
it  is  stated  to 
1  usually  asso- 
;s  reported  l>y 
affection.     In 
(i  between  one 
octed.    Koplik 
I  Baum<;artenV 
,.  of  the  gland, 
?  tubercle  docs 
r  of  enibryonie 

1  with  syphilis. 
(1,  there  is  less 
1  irregular.  In 
stis  has  not  in- 

the  two  eondi- 
l  completely,  or 

followed  opera- 
cc  of  a  routine 

d  Uterus.— The 
ital  tuberculosis, 
■teristic  form  of 
•kened  and  infil- 
vccn  the  fimbria: 
diiion  is  usually 
a  rule,  very  evi- 
inary  salpingitis, 


which  sliow  on  micro..ieopi(iil  examination  nniniTous  miliary  tul)ercled 
(Welch  and  Williams).  Tulierculous  salpingitis  may  cause  serious  local 
di.-ease  with  abscess  formation,  and  it  may  ho  the  starting-point  of  peri- 
tonitis. 

Tiilx'rciMohis  of  the  (niiri/  is  always  sccomlaty.  'riicre  may  be  an  erup- 
tion of  tubercles  over  the  surface  in  an  extensive  involvement  of  the  stroma 
with  abscess  formation. 

Tiilicrcidosis  of  the  ulcriis  is  very  rare.  Only  three  examples  have  come 
under  my  observation,  all  in  connection  with  pidmonary  phthisis.  Jt  may 
lie  primary.  The  mucosa  of  the  fundus  is  thicki'iied  and  caseous,  and  tuher- 
t  les  may  lie  seen  in  tlu'  muscidar  tissue.  <)eca>ioiuilly  the  jirocess  extends 
to  the  vagina. 

IX.    TfltKltCCI.OSIS    Ol'    Tin:    ^IaMMAKY    Cil.AND. 

Mandry  (I'runs's  lieitriige,  viii)  has  collected  -lO  cases.  1  of  whidi  was 
in  a  male.  The  disease  is  most  cdinmon  between  the  fortieth  and  sixtieth 
years.  'I'he  breast  is  frequently  listujous,  unevenly  indurated,  and  the 
nipjde  is  retracted.  The  iistulic  and  ulcers  present  a  characteristic  tuber- 
cidous  a>pect.  There  is  also  a  cold  tuberculous  abscess  of  the  lireast.  The 
axillary  glands  are  alVecteil  in  about  two  tiiirds  of  the  cases.  The  disease 
runs  a  chronic  course  of  nuniths  or  years.  The  diagiuisis  can  l)e  nuide  by 
the  geiuTal  appearance  of  the  tistula'  and  ulcers,  and  by  the  existeiue  of 
tubercle  liacilli.  The  prognosis  is  not  bad,  if  total  cra<lication  of  the  dis- 
ease be  possible. 

In  1S;?()  l?edor  described  an  hypertrophy  of  tlie  lircast  in  the  sulijects 
of  pulmonary  tuberculosis.  As  a  ride,  if  one  gland  is  involved,  usually  on 
the  <i(le  of  the  all'ected  lung,  as  already  mentioned,  the  condition  is  one  of 
chronic  interstitial  mammitis,  aiul  is  not  tuberculous. 

X.  Tt'ni:ncri.osis  of  Tine  Ciitri'i.ATouY  System. 

(a)  M ijiWdrdlnm . — Scattered  miliary  tubercles  are  soiuetimcs  nu^t  with 
in  the  acute  disease.  Larger  casecuis  tubercles  are  excessively  rare.  Alfred 
Hand,  dr.,  has  reporteil  'i  cases  and  reviewed  .">!>  instaiucs  in  the  litera- 
ture. 

(/*)  Eudtirnriliinn. — In  210  autnjisies  in  cases  of  chronic  ])hthisjs  I  found 
endocarditis  in  1'3.  As  a  ride,  it  is  a  secondary  form,  the  result  <d'  a  mixed 
infection,  so  common  in  ]iiilmonary  tuberculosis.  A  true  tulierculous  en- 
docarditis does,  however,  occur,  directly  dependent  ujion  infection  with 
the  bacillus  of  Koch.  As  a  rule,  it  is  a  vegetative  endocarditis,  not  to  bo 
distinguished  from  that  caused  by  the  streptococcus  or  staphylococcus.  In 
rare  case;,  however,  caseous  tubercles  develop. 

(r)  Arleriea. — Primary  tuberculosis  of  the  larger  blood-vessels  is  un- 
known. The  disease  may,  however,  occur  in  a  largo  artery  and  not  result 
from  external  invasion.  In  a  case  of  chronic  tuberculosis  Fhwnor  found  a 
fresh  tuberculous  growth  in  the  aorta,  which  had  no  connection  with  cheesy 
masses  outside  the  vessel. 


«■* 


328 


SPECIFIC  INFECTIOUS  DISEASES. 


1„  tin.  lungs  ana  oilu.r  ..r.ans  !'^  ^  ^  ,  ^j  ^j,  ,.,  thro.nbu.is,  or  tubev- 
i,volv.l  in  an  acute  ^'f  ^^^r'^^a  ^  J^il  o  cLoalion  and  .ottoning  hv- 
el.s  n.ay  develop  m  the  ^vall.  '^"^  P  ^^^^^^.  ,,,^,,,,1,,,,  int..  vessels,  V'^^^;-^' 

of  L  arledes  plays  an  important  rok. 

XI.  Diagnosis  oi'  TrnKUCfLOSis.  _^  ^^ 

The  recognition  of  the  <^'^7^^;';;::;;;;,!;;:a  the  F^^^"^"^^ 
«.a  .iero^eopij.!  appeara,u.e.  o    Uk  1.^^   ^^^^^^^^^^  .^  ^^ 

aeleristic   l.aeilli.      <       l.>^        „     Koch's  tul.ereulin.     For  ^'>'»e  jeu»   iiu 
been  introdncea  n,  the  lorn    «     ^^    ,  ;,,^  5^,  ,,,  m  the  diagnosis  ol  oh- 
aean  has  in^sted  upon  t'-    >^'-^;  ]  ,.    \    ,,,  ,een  en.ployed  extensively 
Bcnre  cases.     Dnrn.g  ^'^^^ /'"^  ,  \^\;   \n  the  nunlieal  and  surgical  sule., 
at  the  Johns  llopk.ns  llo  P   al    h    U  on  ^  ^^^^^^^^  ^^.^^^^^^^  ^,^^.  ^,^, 

v^iththeniostsat.sla.toryr  s  lt.,^M,   0  ^^  ^^^  ^^^^^^  ^^^^  .^^  ^^^^^  ^^^  ^  ^ 

ful  eireets.  In  ol.eure  -;t-  \^';  ^-j,  tibereulin  gives  n.ost  va  ua  de 
tuberculosis  of  the  kulue>.  ' ^ ^^ ^^^,  ,„  i,,tance  of  Addison  s  di.- 
inforniation.     I  may  mention,  ^''^  ^^J  "  ^^,,^.  ,;    ,  .vhatover  of       ceral 

,,.e  in  a  v-ning,  very  nuiscular  "^'^'V.  1    i^^d      bave  been  expected)  ^as 
ubercnloiis.     The  r.,ction   i^i;f^'^;:^L  Uindly  furnished  from 
v.rv  eharaeteristie.     \\  e  ha  e  n>ed      >^    \     ^^  .^  ^^iginal  plan.     In  adults 
tu/saranac  Laboratory,  ^^  -;  ;  ^  ;>        C^r;:action  a  larger  dose  of  Uvo 

^"  ^'^^°"  XII    Tur.  rnoGNOSis  ix  Trnr.iKTi.osis. 

..tallpors:ns;n.dio.l^^^;.ol,.nU..^^^^^ 

,ot  necessarily  mean  the  -  ^^^^ ,[  ;  ...U.^vy  phthisis,  7.5  per  cent 
Tn  my  autopsies,  excluding  asc.  ^fX__^  j,^,,.  ^,er,entage  in  compan- 
p,..onted  tuberculous  l--"^;/^^{    ^^  I  ^Uided  the  simple  libroid  pucker- 

b  :VX^'^^  ^--^^  --'^-  ^""^^ '-''-'''''" "' ' 

^n:^;r^Ss  a  n.nral  o^^^P- ^di^^  ::":t  "^^t^^^ 

tions  favorable  to  the  ^^^  3!^     ."^^  l^^' from  this  group   a  majority  of 

.vords,  the  tissno-soil    >    "^;:':     l'  ,,,,  ^f  aisease,  there  may  be  spontaneo  . 

^vhich  proln.bly  do  "'^^  slu^^  ai^^    ■  .  ^^         ^.,,,,  ,00  Hint 

an-ost  after  the  ^y";i;**^"^i/  '-.t    ion  and  intrinsic  tendency  to  recovery 

called  aitenthm  to  the  ^f "    ^^^^^^^^^^^^^         of  his  (uO  cases.  U  recovered, 

in  weU-n^avked  pulniona^       b    -^  .^  ,3  ,f  the  lirst  group 

and  in  31  the  disease  m^:^  arrcsieu,  q 


I 


i 


~^• 


TUBERCULOSIS. 


829 


arteries  are 
IS,  or  tubev- 
[tening  ii'o- 
cls,  jiurtiiu- 
tuberculosi? 


lacroscopical 
of  tlie  c4iar- 
ic  agont  has 
,e  years  Tru- 
irnosis  of  ob- 
(1  extensively 
urgieal  sides, 
mt  any  barin- 
in  suspeetetl 
most  valuable 
Addison's  dis- 
ver  ot       ceral 
expeeted)   was 
uniisbed  from 
Ian.     In  adults 
rer  dose  oi  two 
'I'liere  is  often 
n  ten  to  twelve 
to  from  10-2° 


oollicdd  present 
xt  section,  loeal 
Til  feet  ion  docs 
lid  fatal  disease, 
sis,  7.5  per  cent 
ape  in  compari- 
>  lil)roid  pucker- 
ronnded  by  colo- 

d,  for  the  condi- 
iresent— in  other 
up,  a  majority  of 
ly  be  spontaneous 
'"  years  ago  IHint 
leiicy  to  recovery 
ses.  "'It  recovered, 
of  the  first  group 


and  in  15  of  the  second.    Tliis  natural  tendency  to  cure  is  still  more  strik- 
ingly shown  in  lympluitic  and  bone  tuberculosis. 

The  following  may  be  considered  i'avorabU'  circumstances  in  the  iiro;_'- 
nosis  of  pulmonary  tuberculosis:  A  good  family  history,  i)rcvious  good 
health,  a  strong  digestion,  a  suitable  cnvironnu'nt,  and  an  insidious  onset, 
without  liigh  fever,  and  witiu)Ut  extensive  pneumonic  consolidation.  Cases 
beginning  with  pleurisy  seem  to  run  a  more  jirotracted  and  more  favorable 
course.  l{e]icated  attacks  of  lucmoptysis  are  unfavorable.  When  well  estab- 
lished the  course  of  tul)crcuh)sis  in  any  organ  is  marked  by  intervals  of 
weeks  or  months  in  which  tiie  fever  lessens,  tlie  symptoms  subside,  and 
there  is  improvement  in  the  general  bealtii. 

In  jiulmonary  cases  the  duration  is  extremely  varialile.  Laennec  jilaced 
the  average  duration  at  two  years,  and  for  the  majoiity  of  cases  this  is 
perha]>s  a  correct  estimate.  Pollock's  large  statistics  of  over  :!.:)»)()  cases 
si'iows  a  mean  duration  of  the  disease  of  over  two  years  and  a  half.  A\  il- 
liams's  analysis  of  l.OdO  cases  in  ]irivate  ])raetiee  shows  a  mneh  n.iore  pro- 
tractcil  course,  as  the  average  duration  was  over  seven  years. 

Tnder  the  subject  of  i)rognosis  comes  the  (luestion  of  the  marriage  of 
]iersons  who  have  had  tul)erculosis,  or  in  whose  family  the  disease  prevails. 
The  following  brief  statements  nuiy  be  made  with  reference  to  it:      . 

(a)  Sul)jects  witli  healed  lymithatic  or  bone  tulierculosis  marry  with 
]iersonal  impunity  and  may  beget  healthy  cliildren.  It  is  undeniable,  how- 
ever, that  in  such  families,  scrofida,  caries  of  the  bom\  arthritis,  cerel)ral 
and  ]nilmonary  tuberculosis  are  more  common.  Which  is  it,  "  lieredite 
do  graine  ou  hercdite  de  terrain,"  as  the  Fremh  have  it,  the  seed  or  the 
soil,  or  both:-'  We  cannot  yet  say.  'I'lie  risks,  Jiowever,  are  such  as  may 
properly  be  taken. 

(h)  Tlie  (piestion  of  marriage  of  a  ]ierson  who  lias  arrested  or  cured 
lung  trd)erculosis  is  more  ditlicult  to  decide.  In  a  nude,  the  personal  risk 
is  not  so  great;  and  when  the  health  and  strengtli  are  good,  the  external 
environment  favorable,  and  the  family  history  iu)t  extremely  bad  the  ex- 
periment— for  it  is  such — is  often  successful,  and  many  lu-althy  and  hajipy 
families  are  begotten  under  these  circumstances.  In  women  the  (pu^stion 
is  complicated  with  that  of  child-bearing,  which  increases  the  risks  enor- 
mously. With  a  localized  lesion,  absence  of  hereditary  taint,  good  ])hy- 
pi(iue,  and  favorable  environment,  marriage  might  be  ]iermitted.  When 
tulierculosis  lias  existed,  however,  in  a  girl  whose  family  history  is  bad, 
whose  chest  expansion  is  slight,  and  whose  ])hysi(pie  is  below  the  standard, 
the  ])hysician  should,  if  possible,  place  liis  veto  upon  marriage. 

((■)  With  existing  disease,  fever,  bacilli,  etc.,  marriage  sluiuld  be  pro- 
hibited. Pregnancy  usually  hastens  the  ])rocess,  tlunigh  it  may  be  held 
in  abeyance.  After  parturition  the  disease  advances  ra])idly.  There  is 
mucli  truth,  indeed,  in  the  remark  of  Duljois:  "  If  a  woman  tlireatened  with 
])hthisis  marries,  she  may  bear  tlu'  first  accouchement  well;  a  second,  with 
ditTiculty;  a  third,  never."  Conception  nuiy  occur  in  an  advanced  stage 
of  the  disease. 


«■* 


330 


SPFX'IFIC  INFECTIOUS  DISEASES. 
XIII.    rHOl'llYLAXlS    IN-    TlBERCULOSIS. 


.,s  General -'rho  sputa  of  phthisical  patients  should  be  carefully  col- 
lect^ m^Ist  roved,     ratienti  should  be  urged  not  to  sp.t  about  oa    - 
ly,  but  ahvavs'to  use  a  spit-cup  and  never  to  swallow  the  sput        Sc 

r  3cal  V  ™  tv,.n.  tl.is  K.iircc..  The  d.ancos  of  i„t,,-t,<.naro  greatest 
slisht  i-i*ks  imlee.1  if  l.n.l.er  |.m-,u.tK.lH  arc  taken,  li.e  pat.mt  Mioiuu 
""T.'.ntltm'tn.rt  general  pr„,,l,,laetlc  ,„e„...re  relates  to  the  in.poe- 

interest  of  public  health  the  state  should  take  measure    ^o  ^tanip  o      t     cr 

Xi    in  cattle     Svsteniatic  veterinary  inspection  ol  dairies,  particularly 

n  ^e  1^.4  d  L^s  should  be  nuide,  and  full  ,K.wer  granted  to  ccmhscnite  and 

1      u  Sc^    u   luals.     The  abattoirs  should  be  under  skilled  veterinary 

e:^t;;;i  -d  the  carcasses  of  animals  .ith  advanced  tuberculosis  confis- 

'''The  advisabilitv  of  placing  pulmonary  tuberculosis  on  the  list  of  dis- 

t;;  e:^,ariin  .-itl,  tl.e  ,.„l.lie  p,o,l  .hiel,  ™,l.l  follow  the  ado|,.,o,>  of 

svslenvitic  measnres  of  insiiectitm  and  disiniection.  ,     .      ,      ,,        . 

^       )  /  <S""/-A   "H'ther  with   pulmonary  tuberculosis  should   not 
suck     h  r      ild.     An  inlant  born  of  tuberculous  parents,  or  of  a  family 
n      hi       consuiuplion  prevails,  should  be  brought  up  with  the  gijeatest 
"r'a^  <™1ed   nost  particularly  against  catarrlial  affections  of  aU  kind. 
Sp^hd  aUention  should  be  given  to  the  throat  and  --^ -^J  ^^^  ^^ 
indic'ition  of  month-breathing,  or  any  obstruction  oi  the  na.o-  liarjiix, 
"r      1  exam  nation  should  be  made  for  adenoid  vegetations.    The  ehikl 
!h     Id    e  cd  d  in  llannel  and  live  in  the  open  air  as  mucli  as  possible  avo.d- 
lo  e  room-     It  is  a  good  practice  to  sponge  the  throat  and  chest  nigh 
3  m  r,  in"  .'it  1  c.dd^water.     Special  attention  should  be  paid  to  die 
n        o         mode  of  feeding.     Tlie  meals  should  be  at  regular  hours  and 
If^od  Pl  in  and  substantial.     From  the  ontset  the  child  should  be  en- 

^^i^^tl:  drink  freely  of  ^^^^-  ^f^^^;^^fyi,^.J^'' ^Z^ 
«eenis  to  be  an  uncontrollable  aversion  to  fats  of  all  kind..     As  the  cliiU 
™  older    systematically  regulated  exercise  or  a  course  of  pulmonary 
glows  oKici,  .yn  occupation   i.reference 

Sd  Wi^  to  ^n  tnd^fior'ife.    Families  .ith  a  marked  predisposi- 

i  no  tuberculosis  should,  if  possible,  reside  in  an  equable  climate.       t 

would  bo  best  for  a  young  man  belonging  to  such  a  laiiuly  to  remove  to 


TUBEHCTLCSIS. 


331 


?fully  col- 
30Ut  care- 
iita.  Sev- 
^iilo.  Tho 
leasurc  in 
iig  it  into 
X'ctions  as 
gi.ing  the 
t  tho  only 
re  greatest 
volve  very 
.'lit  should 

the  inspcc- 
ansmission 
ami  in  the 

out  tuber- 
)articularly 
ifiscate  and 

Yoteriiuiry 
osis  confis- 

list  of  dis- 

sed.     I  am 

are  trifling 

adoi)tion  of 

should   not 
of  a  family 
the  greatest 
of  all  kinds, 
on  the  first 
iso-pharynx, 
The  child 
■siblc,  avoid- 
chest  night 
paid  to  diet 
r  hours  and 
lould  be  en- 
cases there 
As  tlio  child 
f  pulmonary 
n  preference 
d  ])redisposi- 
cliniate.     It 
to  remove  to 


Colorado  or  Southern  California,  or  to  some  other  sui(al)le  cliniale,  before 
I  rouble  begins. 

Tlie  trilling  ailments  of  cliildren  sliould  be  carefully  watched.  In  the 
convalescence  from  the  fevers,  which  so  faHpiently  prove  dangerous,  the 
greatest  caution  slioiild  be  exercised  to  prevent  catcjiing  cold.  Cod-liver 
oil,  tlie  syrup  of  the  iodide  of  iron,  and  arsenic  may  be  given.  As  men- 
tioned, care  of  the  throat  in  these  children  is  very  important.  Enlarged 
tonsils  sliould  be  removed. 

XIV.  Treatment  of  TcnEiicuLosrs. 

I.  The  Natural  or  Spontaneous  Cure.— Tho  spontaneous  healing  of 
local  tuberculosis  is  an  every-day  affair.  Many  cases  of  adenitis  and°dis- 
ease  of  the  bone  or  of  the  joints  terminate  favora1)ly.  Tlie  liealing  of  pul- 
monary tuberculosis  is  shown  clinically  by  the  recovery  of  patients  in  whose 
sputa  elastic  tissue  and  bacilli  have  been  found;  anatomically,  by  the  pres- 
ence of  lesions  in  all  stages  of  rei)air.  In  the  granulation  products  and 
associated  i)neiimonia  a  scar-tissue  is  formed,  while  the  smaller  caseous  areas 
become  impregnated  with  lime  salts.  To  such  conditions  alone  should 
the  term  healing  be  ai)i)lied.  When  the  fibroid  change  encapsulates  but 
does  not  involve  the  entire  tuberculous  tissue,  the  tubercle  may  be  termed 
involuted  or  quiescent,  but  is  not  destroyed.  When  eavities'of  any  size 
liave  formed,  healing,  in  the  proper  sense  of  the  term,  does  not  occur. 
I  have  yet  to  «eo  a  specimen  which  would  indicate  tliat  a  vomica  had  cica- 
trized. Cavities  may  be  greatly  reduced  in  size— indeed,  an  entire  series 
of  them  may  be  so  contracted  by  sclerosis  of  the  tissue  about  them  that 
an  upjier  lolte,  in  whicli  this  ])rocess  most  frecjuently  occurs,  may  l)e  re- 
duced to  a  third  of  its  ordinary  dimensions.  Laennec  understood  thor- 
oughly tiiis  natural  process  of  cure  in  tul)erculosis,  and  recognized  the 
frecpiency  witli  which  old  tuberculous  lesions  occurred  in  the  lungs.  He 
descrilied  ciailnccs  cumplcics  and  cicalriccs  fisliilciises,  the  latter  being  tho 
slirunkcn  cavities  communicating  with  the  bronchi;  and  remarked  that,  as 
tubercles  growing  in  tlie  glands,  whicli  are  called  scrofula,  often  heal,  wliy 
should  not  the  same  take  ])lace  in  the  lungs? 

There  is  an  old  German  axiom,  "Jcilcrmanu  hut  am  Ende  ciit  hiaclipn 
Tnhcmilosc,"  a  statement  partly  borne  out  by  the  statistics  sliowing  the 
pro])ortion  of  cases  in  persons  dying  of  all  diseases  in  wliom  (piiescent  or 
tuberculous  lesions  are  Aiund  in  tho  lungs.  We  find  at  tlie  a])ices  the 
following  conditions,  which  have  boon  held  to  signify  healed  tuberculous 
processes:  (1)  Thickening  of  tho  ])leura,  usually  at  the  jiosterior  surface 
of  the  apex,  with  subadjacent  induration  for  a  distance  of  a  few  milli- 
metres. This  has,  perhaps,  no  greater  siguifieance  than  the  milky  i)ptch 
en  the  pericardium.  (2)  Tuekered  cicatrices  at  the  aju'x,  depressing  the 
ple.'-a,  and  on  section  showing  a  large  pigmented,  fibrous  scar.  Tiie  bron- 
chioles in  the  neighborhood  may  bo  dilated,  liu't  there  are  neither  tuliorcles 
nor  cheesy  masses.  This  may  sfunetimes,  but  not  always,  indicate  a  healed 
tulierculous  lesion.  (3)  Puckered  cicatrices  Avith  ciieesy  or  cretaceous 
nodules,  and  with  scattered  tubercles  .in  the  vicinity,  (i)  The  cicatrices 
21 


' 


332  SPECIFIC  INFECTIOUS  DISEASES. 

fMuscs  of  Laonnoe,  in  .Inch  the  iil.roia  l-l-^'lJ^^-.-tonihi"  "' 
of  ono  or  n,oro  .avitios  ^vlm•h  conununuale  ^^''-^'^^'V  f  y,     i  u  o  won> 

vicinity:  These  59  cases  died  of  vanous  d,seases  ^^^ ^^^f;^^ 
.najority  of  them  wore  '^f^^^^  ';^!\l^^^,^^'^ ^^^"^L-rnori.^ 
,U.ely  with  |'1V'>;^^;;^^:!:^;1  ;^  ^  "  t  :Uh  was  not  diJeetly  cansed 
records,  m  which,  ot  l(),.)b^  cabts  m  ^m"  »  4„i,„r,.l,.— a  Dcrcentatje  ol 

dying  «„l.lc„ly-tl,c  l»«"t«»»    "7V;  '''t  ™rflg,  '      h<^v  the  oxtraor- 

f.it  •iiid  the  local  d  soaso  may  be  leit  to  take  care  oi  u.aii. 
V     Ho  .    Fir.t  to  place  the  patient  in  surroundings  most  favorable  for 

^     T  e  op  n:air  treatment  of  tuberculosis  may  be  carried  out  at  home. 
1.V  rhnmro  of  residence  to  a  suitable  climate,  or  in  a  sanatorium. 
^   r«     f  iL';-!  1  a  majority  of  all  cases  the  patient  has  to  be  cared  for 
(fl)  At  Uome.     uin  i  j  disadvantagcnis  circuin- 

is  fern  he  should  be  at  rest  in  bed,  and  for  the  greater  part  ot  each  da,, 


TUBERCULOSIS. 


333 


100(1  tlio  sizo 
•oiuhi. 
!,  thoro  wero 
IS  losions  in 
litary  chee^y 
L>rek'3  in  the 
;)us  ages.     A 
:icnce  tallies 
post-inortom 
rootly  causoil 
)t'roentagc  of 
ation.     Vari- 
■ntapo  ranges 
oil  this  point 
■\i  there  were 
l)y  Bouchard 
upon  j)ersons 
if  tuberculou:^ 
,v  the  extraor- 
g  fact  that  in 
s  a  process  of 

4ion  of  nutri- 
\  ])atient  grow 
'here  are  three 
:  favorable  for 
,  to  take  sucli 
lous  processes; 

)\it-of-(loor  life 
}d  rabbits  con- 
allowed  to  run 
ame  in  human 
y  in  the  close, 
Lospital  ward — 
a  liutch  in  the 
'  for  the  greater 
t  running  wild. 
1  out  at  home, 
rium. 

to  he  cared  for 
tage(nis  circum- 
omote  arrest  by 
to  attempt  any 
y  cases  in  whieli 
n  cxiilicit  rules. 
10.  "While  there 
lart  of  each  day, 


unless  the  weather  is  bhistering  anil  rainy,  tlie  windows  should  bo  open, 
so  that  the  patient  may  l)e  exposed  freely  to  the  fresh  air.  Low  temi)era- 
turo  is  not  a  contraindication.  Jf  there  is  a  lialcony  or  a  suitable  yard,  on 
the  brighter  days  the  patient  may  be  wrapped  up  and  i)Ut  in  a  reclining 
chair  or  on  a  sofa.  The  important  thing  is  for  the  physician  to  emphasize 
the  fact  that  neither  the  cough,  fever,  night  sweats,  ami  not  even  luemop- 
tysis  coiitraimlicate  a  full  exposure  to  the  fresh  air.  In  /ountry  places 
this  can  be  carried  out  much  more  elVectively.  1  alwa}  dvise  to  give 
the  i)atient  an  almanac,  that  he  can  tick  oil'  the  number  of  hours  of  sun- 
shine. Jn  the  summer  he  shoidd  be  out  of  doors  for  at  least  eleven  or 
twelve  hours,  and  in  winter  six  or  eight  hours.  At  night  the  room  should 
be  cool  and  thoroughly  well  ventilated.  In  the  early  stages  of  the  disease 
with  much  fever,  it  nuiy  re([uire  several  months  of  this  rest  treatment  in 
the  open  air  before  the  temiierature  falls  to  normal. 

(h)  Trealmcnt  in  Sanatoria. — Perhaps  the  most  important  advance  in 
the  treatment  of  tuberculosis  has  l)een  in  the  cstal)lishment  in  favorable 
localities  of  institutions  in  which  patients  are  nuide  to  live  according  to 
strict  rules.  'i\t  Brehmer,  of  Gobersdorf,  we  owe  the  successful  execution  of 
this  i)lan,  which  has  been  followed  in  (iermany  with  nu)st  gratifying  results. 
In  this  couiilry  the  zeal,  energy,  and  scientific  d(!Votion  of  Edward  L. 
Trudeau  have  demonstrated  its  feasibility,  and  the  Saranae  institution 
has  become  ■<•  .nodel  of  its  kind.  We  need  pid)lic  sanatoria  within  easy 
access  of  the  large  cities,  in  which  cases  of  early  tuberculosis  could  be 
treated  at  low  rates  or  at  the  puljlic  cost.  Private  sanatoria  for  the  well- 
to-do  classes  are  urgently  needed.  The  results  at  (iiiiiersdorf,  Falkenstein, 
and  Saranae  denu)nstrate  the  great  imjwrtance  of  system  and  rigid  disci- 
]>line  in  carrying  out  a  successful  treatment  of  tul)erculosis.  The  estab- 
lishment of  National  Sanatoria  in  Canada,  the  Sharon  Sanatorium  near 
Boston,  in  charge  of  Dr.  A'incent  Y.  Bowditch,  the  new  Looniis  Sana- 
torium near  New  York,  and  the  estaltlishments  at  Asheville  and  Aiken  indi- 
cate that  both  the  profession  and  the  public  are  beginning  to  appreciate  the 
supreme  importance  of  this  method  of  treatment.  So  far  as  the  profes- 
sion is  concerned,  they  must  have  im])lieit  confidence  in  tlie  men  in  charge 
of  these  institutions,  in  their  integrity  and  in  tluir  scientific  al)ility.  Burton- 
Fanning  has  recently  ])ul)lished  some  interesting  oliservatious  wliich  show 
that  this  o])en-air  plan  of  treatment  can  be  carried  out  most  effectively  in 
England.  (For  an  interesting  description  of  the  method  of  life  at  Nordrach 
in  "the  Black  Forest  by  a  i)hysician  cured  at  the  sanatorium,  see  pages 
393-39(1  of  Fowler  and  Godlee's  Diseases  of  tlie  Lungs.) 

(r)  Clinwfic  Treatment. — This,  after  all,  is  only  a  modification  of  the 
open-air  method.  The  first  question  to  be  decided  is  whether  the  patient  is 
fit  to  1)0  sent  from  home.  In  many  instances  it  is  a  positive  hardship.  A 
patient  with  well-marked  cavities,  hectic  fever,  night  sweats,  and  emacia- 
tion is  mucli  better  at  home,  and  the  physician  should  not  be  too  much 
influenced  by  the  imiiortunitics  of  the  sick  man  or  of  his  friends.  The 
requirements  of  a  suitable  climate  are  a  pure  atmosphere,  an  equahh  tem- 
perature not  subject  to  rapid  variations,  and  a  ma.rimum  amount  of  sunshine. 
Given  these  three  factors,  and  it  makes  little  difference  ivhere  a  patient 


«■* 


334 


SPECIFIC   INFECTIOUS  DISEASES. 


i 


goes,  so  long  as  he  lives  au  nuUloor  life.  The  imriUj  of  the  atmnsphere  is 
Uie  first  consi.lenilioii,  iuid  it  is  this  re(iuirenient  that  is  met  so  well 
in  the  mountains  a.i.l  forests.  The  .litVerent  eliniates  may  he  groupe.l 
into   tlie   high   altitudes,   the   dry,   warm   eliniates,   and  tiie   moist,   warm 

elimates.  -,  .  .i  * 

In  tliis  country  of  high  altitudes,  the  Colorado  resorts  are  the  nuM 
important.     Of  others,  those  in  Arizona  aud  New  Mexico  have  heen  de- 
veh.ping  rapidlv.    The  rarefaction  of  the  air  in  high  altitudes  is  ot  henelit 
in  increasin.'  the  respiratory  movements  in  pulmonary  disease,  but  brings 
about  in  tiiue  a  condition  of  dilatation  of  tlie  air-vesicles  and  a  permanent 
increase  in  the  size  of  tlie  chest  wliich  is  a  marked  disadvantage  when  sucii 
persons  attempt  suhse(iuently  to  reside  at  the  sea-level.     The  great  advan- 
ta.H'  of  these  western  resorts  is  tliat  tiiey  are  in  i)rogressive,  prosperous 
countries,  in  which  a  man  may  find  means  of  livi'lihood  and  live  m  com- 
fort    Til  Kurope  the  chief  resorts  at  higli  altitudes  are  at  Davos,  Les  Avants, 
and  8t    ^loritz.     Of  resorts  at  a  moderate  altitude,  Asheville  and  the  Adi- 
rondacks  arc  the  best  known  in  this  country.     The  Adirondack  cnre  has 
become  of  late  vears  (piite  famous.     Objections  to  it  are  the  exptmse,  ex- 
cept in  the  case  of  the  sanitorium,  but  for  well-to-do  people  it  is  l)y  lar 
the  most  satisfactory  ])lace.     One  very  decided  advantage  is  that  after 
arrest  of  the  disease  the  patient  can  return  to  the  sea-level  without  any 
special  risk.    The  cases  most  suitable  for  high  altitudes  are  those  m  whicii 
ihc  disease  is  limited,  withont  inncli  cavity  formation,  and  w  ithout  much 
emaciation      The  thin,  irritable  patients  with  chronic  tuberculosis  and  a 
good  deal  of  emphysema  are  better  at  the  sea-level.     The  cold  winter  cli- 
mate seems  to  bo  of  decided  advantage  in  tuberculosis,  and  in  the  Adiron- 
dacks    where  the  tem]ierature  falls  sometimes  to  20°  or  even  more  below 
zero,  the  patients  are  al)le  to  lead  an  out-of-door  life  throughout  the  entire 

winter.  -,    ^     ^^  i 

Of  the  moist,  warm  climates,  in  this  country  Florida  and  the  IJernnuias, 
in  Europe  tlie  :\ladeira  Islands,  and  in  Great  Britain  Torquay  and  Fal- 
mouth are  the  best  known. 

Of  the  dry,  warm  climates,  Southern  California  in  this  country  is  the 
most  satisfactorv.  :Manv  of  the  health  resorts  in  the  Southern  States,  such 
as  Aiken,  Thomasville,'  and  Suuimerville,  are  delightful  winter  climates 
for  tuberculous  cases.  Egv])t,  Algiers,  and  the  Riviera  are  the  most  satis- 
factory resorts  for  patients  from  Europe.  For  additional  information  on 
the  suliject  of  climate,  jmrticularly  in  this  country,  the  reader  is  referred 
to  Sollv's  recent  work  on  the  subject. 

Otlier  considerations  which  should  influence  the  choice  of  a  locality 
are  good  accommodations  and  good  food.  \Qvy  much  is  said  concerning 
the  choice  of  localitv  in  the  different  stages  of  pulmonary  tuberculosis, 
but  wlun  the  disease 'is  limited  to  an  apex,  in  a  man  of  fairly  good  personal 
and  family  liistorv,  the  chances  are  that  he  may  fight  a  winning  battle  if 
he  lives  out  of  doors  in  any  climate,  whether  high,  dry.  and  cold  or  low, 
moist,  and  warm.  With  bilateral  disease  and  cavity  formation  there  is  but 
little 'hope  of  permanent  cure,  and  the  mild  or  warm  climates  are  prefer- 
able. 


TUISKUCL'LOSIS. 


3^5 


iiiospliorc  is 
net  .so  well 
he  [ii'oupiHl 
iioist,   Wiii'iu 

ro  llu'  most 
ve  been  de- 
is  of  beiielit 
,  but  brings 
1  porruauent 
c  wlieii  sueli 
great  advaii- 
,  prosperous 
live  in  coni- 
,  Les  Avants, 
md  the  Adi- 
ick  euro  has 
expense,  ex- 
it is  by  far 
is   that   after 
without  any 
ose  in  which 
ithout  much 
ndosis  and  a 
d  winter  cli- 

I  the  Adiron- 
i  more  below 
)ut  the  entire 

he  Bermudas, 
uay  and  Fal- 

onntry  is  the 

II  States,  such 
ntcr  climates 
lie  most  satis- 
iformation  on 
Icr  is  referred 

of  a  locality 
id  concerning 
r  tuberculosis, 
good  personal 
ining  battle  if 
fl  cold  or  low, 
in  there  is  but 
tes  are  prefer- 


Ill.  Measures  which,  by  their  Local  or  General  Action,  influence  the 
Tuberculous  Process. — I  nder  this  iieiuling  we  may  i(Uisider  the  speuilic, 
iho  dietetic,  ami  the  general  mciiicinal  trcalmciit  ol  tuberculosis. 

(a)  Sj)cci/ic  'J'ri'dhiiciiL—'lhv  use  of  Koch's  original  tuberculin  has  been 
in  great  part  aljandoned.  Some  ol)sei'vi'rs.  as  W  liiltaker,  have  liad  good 
success  witli  it.  Jn  April,  JSDT,  Kocli  announced  the  discovery  of  lu'W 
tuberculins,  the  nu)st  im]iortant  of  wliieli  is  tiie  so-iallcd  tiii)ereuliu  1{.  It 
is  still  under  trial.  TJie  verdict  so  far  has  been  not  at  all  favorable,  ex- 
cept in  lupus. 

A  very  large  number  of  antitoxiiu's  of  various  sorts  have  lieen  intro- 
duced witliin  the  i)ast  few  years.  .Many  of  them  have  iieen  sulimitted  to 
very  searciiing  tests  in  the  Saranac  Lal)oratory  by  Trudean  and  Ualdwin, 
who.'^e  careful  work  has  extended  over  a  i>eriod  of  four  years.  They  state 
brieily  that,  wJiile  one  or  two  of  tiie  serums  have  shown  a  sliglil  degree  of 
antitoxic  ])owcr,  in  all  the  others  the  tests  were  negative.  In  none  could 
any  germicidal  or  curative  inllueiu'c  lie  denu)nstratcd. 

(h)  Dich'tir  Tmiliiicnt. — The  outlook  in  tuberculosis  deiiends  much 
upon  the  digt'stion.  It  is  rare  to  see  recovery  in  a  case  in  wiiieh  there  is 
persistent  gastric  trouble,  and  tiie  pliysieian  sluudd  ever  bear  in  mind  the 
fact  that  in  tliis  disease  the  priituv  vhv  control  the  position.  The  early 
nau.sea  and  loss  of  ajiiietite  in  many  cases  of  |ilitiiisis  arc  serious  obstacles. 
Many  jiatients  loathe  food  of  all  kinds.  A  change  of  air  or  a  sea  voyage 
may  ])romptly  restore  the  a])petitc.  Wiu'ii  eitlu'r  of  tliesc  is  impossil)le, 
and  if,  as  is  aliriost  always  the  case,  fever  is  ])resent,  the  jiatieiit  sliould  l)0 
])laced  at  rest,  kejit  in  the  open  air  nearly  all  day,  and  fed  at  stated  inter- 
vals with  snudl  (piantities  cither  of  milk,  buttermilk,  or  koumyss,  alternat- 
ing if  necessary  with  meat  juice  aiul  egg  albumin.  Some  cases  which  are 
disturbed  by  eggs  and  milk  do  well  on  koumyss.  It  may  bo  necessary  to 
resort  to  Debove's  method  of  over-alimentation  or  forced  feeding.  The 
stomach  is  first  washed  out  with  cold  water,  and  then,  through  the  tube, 
a  mixture  is  given  containing  a  litre  of  milk,  an  egg,  and  100  grammes  of 
very  finely  powdered  meat.  This  is  given  three  times  a  day.  Sometimes 
the  patients  will  take  this  mixture  without  the  unpleasant  necessity  of  the 
stomach-tube,  in  which  case  a  smaller  amount  may  be  given.  1  can  speak 
of  the  advantage  of  this  plan  in  cases  in  which  the  gastric  symptoms  have 
been  obstinate  and  distressing,  and  the  general  expression  of  opinion  is 
very  favorable  to  this  plan  of  treatment  in  sucii  instivnccs.  In  the  (icrman 
sanatoria  a  very  special  feature  is  this  overfeeding,  even  when  fever  is 
present. 

In  many  cases  the  digestion  is  not  at  all  disturbed  and  the  patient  can 
take  an  ordinary  diet.  It  is  remarkable  how  rapidly  the  appetite  and  di- 
gestion improve  on  the  fresh-air  treatment,  even  in  cases  which  have  to 
remain  in  the  city.  Care  should  be  taken  that  the  medicines  do  not  dis- 
turb the  stomach.  Xot  infrequently  the  sweet  .syrups  used  in  the  cough 
mixtures,  cold-liver  oil,  creasote,  and  the  hyiioidiosithitcs  produce  irritation, 
and  by  interfering  with  digestion  do  more  harm  tlian  good.  On  the  other 
hand,  the  bitter  tonics,  with  acids,  and  the  various  malt  preparations  are 
often  in  these  cases  most  satisfactory.    The  indications  for  alcohol  in  tuber- 


in* 


f 


336 


SPECIFIC  INFECTIOUS  DISEASES. 


culosis  arc  onfool.lHl  .lij;estion  uith  fcvor,  a  -.vak  heart,  an.l  rapu  inl.sc. 
\  routine  administration  i.  not  atlvisaLUs  an.l  tluMv  is  no  rvidHuo  that  ts 
l„.r<i-t.'nt  us,,  promotes  fil.roi.l  prorrsscs  in  tlu'  tul.erculuus  ar.as.  In  t ho 
ulvancrd  stage's,  partirulariy  wh.n  tl.o  tnuporaturo  is  low  bc-twoon  eight 
and  t..n  in  the  morning.  Nvi.isUy  and  milk",  or  whisky,  egg.  and  milk  may 
1,0  .riven  with  great  advantage.     The  red  wines  are  also  benelicial  m  mud- 

''''%\^'a!^ncraTMcd!r<,l  Tm,lmn,l.-^o  medieinal  agents  have  any  si.e''ial 
or  neeuliar  action  upon  tulu'ivulons  processes.  The  inlluenee  wh.eh  they 
exert  is  ui.on  the  general  nutrition,  inereasing  the  physiologic'al  nsistance, 
Imd  rendering  th;tissues  less  susceptible  to  invasion.  The  following  are 
the  most  important  remedies  whieh  seem  to  aet  in  this  manner: 

Crensole,  which  mav  be  administered  in  capsules,  m  increasing  doses, 
l,,.n„ning  with  1  minim  three  times  a  day  and,  if  wcdl  borne  increasing 
the  dose  to  8  or  10  minims.  It  may  also  be  given  in  solution  with  tincture 
of  cardamoms  and  alcohol.  It  is  an  old  remedy  strongly  recommended 
bv  Vddi^on,  and  the  rep..rts  of  Jaccond,  Fraent/.el,  and  many  others  sll0^v 
that  it  has  a  positive  value  in  the  disease.  Guaiacol  may  be  given  as  a  sub-- 
Htitute,  eitluT  internally  or  hyp.,dermicany.  In  101  cases  in  which  it  was 
n«ed  at  mv  clini.',  bv  Meredith  Ifeese,  the  chief  action  was  on  he  cough 
and  expectoration,  wiiich  were  much  lessened,  but  the  remedy  had  no  essen- 
tial intluence  on  the  itrogress  of  the  disease. 

Cnd-liirr  0/7.— In  glandular  and  bone  tuberculosis,  tins  remedy  is  un- 
doubtedly beneficial  in  improving  the  nutrition.  In  imlmonary  tuber- 
culosis it's  action  is  less  certain,  and  it  is  scarcely  worthy  of  the  unl)0uiided 
conlidence  which  it  enjoved  f..r  so  many  years.  It  should  be  given  in  small 
.loses,  not  more  than  a  teasi)oonful  three  times  a  day  after  meals.  It  seems 
to'act  better  in  children  than  in  adults.  Fever  and  gastric  irritation  are 
contra-iudications  to  its  use.  ^Vhen  it  i.  not  well  borne,  a  .lesserts,u>..ntul 
of  rich  cream  three  times  a  day  is  an  excellent  substitute.  Ihe  clotted  or 
Devonshire  cream  is  ])referable.  ,  ,  ,     •       ,    .  •, 

The  Hypnplwsphiti's.—'nw^c  in  various  forms  are  useful  tonics,  but  it 
is  doubtful  if  thev  have  any  other  action.  They  certainly  exercise  no  spe- 
cific influence  upmi  tubercle.  They  may  be  given  in  the  form  of  the  syrup 
of  the  hvpophosphites  of  calcium,  sodium,  and  potassium  of  the  I  .  h.  1  . 

^,.,,f;,,-,.__'n,ore  is  no  general  tonic  more  satisfactf)Ty  in  cases  of  tuber- 
cnlosis  of  all  kinds  than  Fowlers  solution.  It  may  l)e  given  in  o-minim 
doses  three  times  a  day  and  szradually  increased;  stoi)ping  its  use  when- 
over  unideasant  symptoms  arise,  and  in  any  case  intermitting  it  every 

third  or  four  week. 

One  or  two  special  methods  of  dealing  with  pulmonary  tuberculosis 
mav  here  be  mentioned.  The  l<ical  treatment,  by  direct  injection  into  the 
luii"^  has  been  practised  since  its  strong  advocacy  by  Pepper.  It  has, 
hovxTver.  not  gained  the  general  support  of  the  profession,  and  is  occa- 
sionally followed  bv  serious  results.  As  a  rule,  it  may  be  practised  with 
imDunitv,  and  the  injections  may  be  made  with  a  long  hypodermic  needle 
into  any  portion  of  the  lung  which  is  diseased.  Iodine,  carbolic  tK'id 
creasote  (S-por-cent  solution  in  almond  oil),  and  iodoform  have  been  used 


TUBEUCl'LOSIS. 


ou  i 


\\\'u\  pulsp. 
(.•e  that  its 
IS.  In  the 
,vcon  eiglit 
milk  may 
al  ill  iiioil- 

iiny  spo'-ial 

kvhich  tlioy 

n^ii^tance, 

llowiiig  are 

ising  doses, 
,  inereasiiig 
ith  tincture 
L'ommendeA 
others  show 
Ml  as  a  sill)- 
hich  it  was 
I  tlic  cough 
i\d  no  ossen- 

incdy  is  un- 
navy  tuher- 
unliounded 
von  in  small 
Is.  It  seems 
rritation  are 
serts]K)onful 
ic  clotted  or 

anics,  hut  it 
rcise  no  spe- 
of  the  svrup 

le  u.  s."  r. 

ses  of  tuhor- 

in  5-minim 

:s  use  when- 

ing  it  every 

tuherculosis 
tion  into  the 
per.  It  has, 
and  is  oeca- 
ractised  with 
lermic  needle 
i-arhnlic  ;!"id, 
ivc  heen  used 


for  the  jjurpose.  The  reniarkahle  results  which  surgeons  liave  recently 
ohtaiiied  in  the  treatment  of  joint  tuberculosis  by  iujectioiis  of  iodoforu! 
point  to  this  as  a  remedy  which  will  probably  prove  of  service  when  in- 
jected directly  into  the  lungs. 

Treatment  by  com})rcssi'd  air  is  in  many  cases  beneluial,  and  under 
its  use  the  appetite  improves,  there  is  gain  in  weight,  and  reduction  of  the 
fever.    The  air  may  \>v  saturated  with  creasote. 

IV.  Treatment  "of  Special  Symptoms  in  Pulmonary  Tuberculosis.— (^0 
The  Fcnr. — Tlieii'  is  no  more  dillicult  problem  in  practical  therapeutics 
than  the  treatnifiit  of  the  pyrexia  of  tuberculosis.  The  patient  should  bo 
at  rest,  and  in  Ihc  iqien  air  fur  a  dc/iiii(c  number  af  hours  daily.  Fever  does 
not  contra-indicate  an  out-of-docu'  liie,  but  it  is  well  for  patients  with  a 
teniiierature  altove  l(l(i..j''  to  lie  at  rest.  For  the  continuous  pyrexia  or  the 
remittent  tyjie  of  the  early  stages,  tiuininc,  small  doses  of  digitalis,  and 
the  salicylates  m;iy  be  tried;  but  they  are  uncertain  and  rarely  rclialile. 
I'lider  no  eircumstanees  is  that  jiriceless  remedy,  (pdnine,  so  imich  abused 
as  in  the  fever  of  tuberculosis.  In  large  doses  it  has  a  moth'rate  antip\retie 
aition,  but  it  is  just  in  tlic-c  eilicicnt  doses  that  it  is  so  ajit  to  disturb  the 
stomach. 

Autipyrin  and  antifebrin  may  he  used  cautiously;  but  it  is  better, 
when  the  fever  rises  above  10;5°,  to  rely  uixm  cold  sponging  or  the  tepid 
bath,  gradually  cooled.  When  softening  has  taken  place  and  the  fever 
as.snmes  the  characteristic  septic  typo,  the  problem  becomes  still  more  dilli- 
cult.  As  shown  by  Chart  XII  (which  is  not  by  any  means  an  exceptional 
one),  the  pyrexia,  at  this  stage,  lasts  only  for  twelve  or  liftecn  hours.  As 
a  nde  it  is  not  more  than  froni  eight  to  ten  hours  in  which  the  fever  is 
high  enough  to  demand  anti|)yretic  treatment.  Sometimes  antifebrin, 
given  in  "i-grain  doses  every  hour  for  three  or  four  hours  before  the  ri,<e  in 
temperature  takes  jdace,  either  ])revents  entirely  or  limits  the  paroxysm. 
If  the  temperature  begins  to  rise  between  two  and  three  in  the  afternoon, 
the  antifebrin  may  be  given  at  eleven,  twelve,  one,  and,  if  necessary,  at 
two.  It  answers  better  in  tlii.'i  way  than  given  in  the  single  doses.  Careful 
sjionging  of  the  extremities  for  from  half  an  hour  to  an  hour  during  the 
liei'dit  of  the  fever  is  useful.  Quinine  is  of  little  benefit  in  this  Ivpe  of 
fever;  the  salicylates  are  of  still  less  use. 

(h)  Sirealini/. — Atropine,  in  doses  of  gr.  Tiir-T,V>  ii'"l  <'"'  aromatic  siil- 
jilniric  acid  in  large  doses,  are  the  best  remedies.  When  there  are  cough 
and  nocturnal  restlessness,  an  eighth  of  a  grain  of  morphia  may  be  given 
with  the  atropine,  ^fuscarin  {^.v  of  a  1-per-cent  solution),  tincture  of 
mix  vomica  (11  xxx),  picrotoxin  (gr.  -^y)  may  be  tried.  The  patient  should 
use  light  flannel  night-dresses,  as  the  cotton  night-shirts,  when  soaked  with 
pers]iiration,  have  a  very  unpleasant  cold,  clammy  feeling. 

(f)  The  riiufih  is  a  troublesome,  though  necessary,  feature  in  pulmonary 
tuherculosis.  Vnless  very  worrying  and  disturbing  sleep  at  night,  or  so 
severe  as  to  produce  vomiting,  it  is  not  well  to  attempt  to  restrict  it.  When 
irritative  and  bronchial  in  character,  inhalations  are  useful,  particularly  the 
tincture  of  benzoin  or  preparations  of  tar,  creasote.  or  turpentine.  The 
throat  should  he  carefully  examined,  as  some  of  the  most  irritable  and 


Ml* 


333  SPECIFIC  INFRCTlorS  DISRASES. 

.listres*in.'  form*  of  .'..n-l.  in  \>h\h\>\^  vsult  fnun  larynfjoiil  erosions.    Tl.o 
distressii.rr  nuct.irnal  <•ui,^^h.  „ln.l.   L.-ins  just  as  tl...  imtiHit   j:|«ts  into 

oi.iu.n.    ('o.l..ia,  in  .inart.-r  or  l.aii'  urain  .los.s.  or  tlu-  svrupus  r.Avuv     .  ,| 
nav  )..'   -'iv.n.      An   ..N.rlK.nt   con-l-ination   for  tlu-   no.tuvnal   .on,h   ot 
l,,Aisis  ;:  n,or,.l>ia  (,r.  .-J),  'lilnto  hylrocyani.  an.l  (^^'J-'IJ);,*;"^  r^^;;!; 
!,,.  ,,i,,,  ,,u.rry   (  3  j).     Tl..  spirits  of  ,.l.lorolorn>,   U.   I  ..  o.   ti  .     n  I     ■ 
chloroformi,  V.  S.  P.,  or  llotrnuufs  ano.lyn..  j^ivvn  n,  wlusl<>    ;"   '     ^  ^':; 
to  ^krp    aro  Hli-a.-ions.     MiM  .•ount.M-irr.tat.on.  ..r  tl.o  a].   l..at>on   ot  a 
ot  poi.lti..,  will  so,„..ti...c.s  ,.n...M.tly  roliovo  tho  oonoh.     Tl.o  n.orn.n, 
ouu-r h  is  oft.n  n.n.I.  l.n>,not...l  l.y  taki...^  tl.o  first  tl.in,^  u>  tl.o  m„r,....j:  a 
llaJ;  of  Lot  tnilk  or  a  on,,  of  hot  wato,-.  to  xvhioh  15  ,n-a.ns  ol    „oa,'l,on  ,o 
t    soda  l.avo  Loon  a-i.lo.l.     In  tl.o  la.or  sta.os  of  tl.o  .l.soaso.  -i--  ';;   '  - 
have   forn,o.l,   tl.o   aocM„n..lato.i    soonlion    >.,nst    ho   oxpooto.-ato.l   a.  1    tl  . 
,aroxysn.s  of  <.ou,hi.„  aro  now  n.ost  oxhaust.n,.      l''--'"!-;:',;        /^ 
„or,.l.ia  and  ].yd,-o,.yanio  aoi.l,  shonld  ho  ,,vo,.  oant.ousl>.      i^''   •       "'^^^ 
s.irt  of  a.on.onia  in  f..ll  dosos  holps  to  allay  tl.o  paroxysm      ^\  hon  tlu 
e^to  ation  is  pn.fnso,  oroasoto  intornally.  or  i..l,alat,ons  of  t-np.n  -no 
and  iodino,  or  oil  of  ou.alyptns.  aro  „s..fnl.     For  tho  t.-oul.losonK.  ,ly>pha,M, 
a  Itn.ng  s.ilntion  of  ooonino  (,.•.  x)  w.h  horio  aoid  (^r.  v.)  n.  j^lyoorn.o  and 
wntor  (  X  i)  inav  he  \isod  locally.  ,       •  ,     ,v 

Uhvlr  tl.;.  ^Unvrhnn  hn-o  dosos  of  his,n.,tl,,  oun.hin.'d  w.tl.  Dovor 
powdor,  and  small  sta.rh  ono.nata,  with  or  without  opinn.  n.ay  ho  ^n von. 
The  neetato  of  load  and  opi..m  pill  ofton  aots  pron.ptly.  and  tho  ao.d  l.ar- 
rhov.  n.i.Ntur..,  dih.to  aooti<.  aoid  (nix-xv).  n.orphia  (-r.  i).  and  acotato  ol 

load  ("r.  i-ii).  niav  ho  tried.  ,       -,   .       , 

(O  Tho'troatnlont  of  tho  l.a'mo,,ty.sis  will  ho  oonsidorod  in  the  soot.on 
on  haMHorrhajzo  from  tho  Inn-s.  Dyspnoea  is  rarely  a  prominent  symptom 
excoi.t  in  tho  a<lvano.>d  sta-os,  when  it  may  he  vory  tronhlosome  and  d.s- 
tro-in-      \mmonia  and  morphia,  oauti.M.sly  administorod,  may  he  nsod. 

If  ?he  plouritio  ,mins  aro  severe,  tho  side  may  he  stra,.iM-d,  or  painted 
with  tincture  of  iodino.  The  dyspeptic  symptoms  ro.ii.iro  careful  reat- 
ment  as  tho  outlook  in  individual  ca.-^os  depends  n.iuh  i.iion  tho  condition 
of  the  stomach.     Small  doses  of  calomel  and  soda  ofloii  allay  tho  distress- 


ing nan 


sea  of  tho  earlv  stas^o 


XXXV.    LEPROSY. 

Definition.— A  chronic  infectious  disease  caused  hy  tho  hacilhis  Jcpnr, 
characterized  hv  the  presence  of  tubercular  nodules  in  the  ,<kin  and  mucous 
momhranes  (tuhercular  leprosy)  or  hy  changes  in  the  nerves  (aiKosthotio 
lei.ro^v)  \t  first  those  forms  may  he  separate,  hut  ultimately  both  are  com- 
bined: and  in  the  characteristic  tuhercular  form  there  are  disturbances  ot 

sensation.  .,    i   •      ti       4. 

History  —The  disease  a])pears  to  have  prevailed  m  K-iyjit  even  so 
•far  back  as  tlnee  or  four  tbousand  years  before  Christ.  The  n.>brew  writers 
make  many  roforonces  to  it,  but,  as  is  evident  from  the  description  m  Leviti- 
cus  many  ditTorent  forms  of  skin  diseases  were  embraced  under  the  term 


liKI'UOSV. 


3:59 


liorif!.    Till' 

unitinii.-j  <il' 
Kilria'  (  3  j) 

(•oii;,'li    «>l 

and  j^yfup 
lie  ini>Uira 
cfiiri'  <r'>in^' 
lilt  ion  of  ii 
u'  iiKiriiini: 

morning  a 
liicarlxmatc 
hen  ciivitit's 
I'd  ami  the 
vi's,  sni'h  as 
he  aromatic 

WIU'H  tlio 
"  turiH'ntinc 
ic  (lysiilia.iria 
lycerim'  ami 

with  Dover 
uv  he  irivcn. 
ic  aciil  "liar- 
Ill  atotato  of 

1  the  seotion 
'.nt  symptom 
)me  ami  <lis- 
y  1)0  iiseil. 
1,  or  painted 
•arefiil  trcat- 
iie  condition 
the  distress- 


'xirlllus  Icpnv. 
\  and  mtu'ons 
s  (aiKCsthetie 
both  are  com- 
sturbancos  of 

Icrypt  even  so 
fi^brew  writers 
tion  in  Lcviti- 
[ider  the  terra 


leprosy.  Both  in  India  and  in  China  tlie  alTeetion  was  also  known  many 
centnries  before  the  ('liri>tian  eia.  'I'lie  old  (J reek  and  l.'oinan  i)hysieians 
were  perfectly  familiar  with  its  manifestations.  As  evidence  of  a  pre- 
(•oliind)ian  existence  of  leprosy  in  America,  Ashmead  refers  to  the  (dd  pi.ves 
of  ]*eriivian  pottery  representinj,'  deformities  sii«.',i:estivo  of  this  disease, 
'riiroiiirhoiit  the  middle  a^jes  leprosy  ])revaih'd  extensively  in  Knrope,  and 
the  nnmlier  of  leper  asylums  has  been  estimated  at  at  least  -.MKOOO.  During; 
the  sixteenth  century  it  <;radnally  dcidined. 

The  prize  essays  of  the  National  l-eprosy  Committee  and  the  recently 
issued  Transactioiis  of  the  llerlin  Leprosy  Conferi'iice  contain  an  immi'iise 
liody  of  valnalile  information  relating  to  every  possible  aspect  of  the  dis- 
ease. 

Geographical  Distribution.  — In  i'.nrope  leprosy  prevails  in  lee- 
land,  .Norway  and  Sweden,  parts  of  liussia.  particniarly  abont  Dorpat,  Uigi. 
and  the  Caucasus,  and  in  certain  provinces  cd'  Spain  and  rortiigal.  In 
Great  ]5ritain  the  cases  are  now  all  imitorted. 

In  tlie  I'nitcd  States  tliere  are  three  important  foci:  Louisiana,  in  which 
the  disease  has  been  known  since  ITS.1,  and  has  of  late  increased.    'I'he  state- 
ment that   it   was  introduce<l   by  the  .\cadians  (hu's  not  seem   to  me  very 
likely,  since  the  records  of  its  existence  in   Xova  Scotia  and   New  Bruns- 
wick do  not  date  back  to  that  jieriod.     Dr.  Dyer  rejiorts  that  on  January 
V2,  1S!)S,  ho  knew  of  \-i\  iiositive  living  cases,  including  2.")  in  the  Le])er 
Homo  in  Iberville  Tarish.     He  adds  that  it   is  jnsti(ial)lc  to  estimate  the 
number  of  lepers  in  the  State  of  Louisiana  as  between  MOO  and  5(i().     in 
California,  whither  the  di.seaso  has  boon  imported  by  the  Chinese,  cases  art- 
not  very  infre(pient.      \   am  informed  by  D.  W.  :\rontgomcry  that  tliero 
are  (May  1,  ISDS)  IC  cases  in  the  Twenty-sixth  Street  llos|)ital,  San  Fran- 
cisco.   Of  these,  only  '2  are  Americans,  10  are  Chinese.     In  Minnesota  with 
tlie  Norwegian  colonists  aliont  ITO  lepers  are  known  to  have  settled.     The 
disease  lias  steadily  decreased.     Dr.   r>racken,  the  Secretary  of  the  State 
r.oard  of  Health,  writes  that  all  had  contracted  the  disease  before  com- 
ing to  America.     Four  of  those  are  now  known  to  be  dead.     It  is  rei)orted 
that  two  children  of  one  of  the  leprous  women  have  shown  symptoms  of 
leprosy. 

Tlie  few  eases  seen  in  the  large  cities  of  tlH>  Atlantic  coast  are  imported. 
In  the  Dominiim  of  Canada  there  are  foci  of  lejirosy  in  two  or  three 
counties  of  Now  I'.runswick,  settled  by  French  Canadians,  and   in  Cape 
Breton,  Nova  Scotia.     The  disease  ai)pears  to  have  l)een  imported  from 
Normandy  abont  the  end  of  the  last  century.     The  number  of  cases  has 
gradually"  lessened.     Dr.  A.  C.  Smith,  the  ])liysician  in  charge  of  the  laza- 
retto, at  Traeadie,  Now  lirunswick,  reports  under  date  of  January  17,  1898, 
that  there  are  24  lc]iers  at  ])resent  under  his  care — 18  males  and  G  females. 
Of  these.  3  are  immigrant  Icelanders  from  ]\ranitol)a;  1  is  a  negro  from  the 
West  India  Islands.     Dr.  Smith  states  that  segregation  is  gradually  stamp- 
in<r  out  the  disease  in  New  Brunswick.    The  cases  have  dwindled  from  about 
40  to  half  tha+  number.    In  Cape  Breton  it  has  almost  disapi)eared.    A  few 
cases  are  met  with  among  the  Icelandic  settlors  in  ^Manitoba,  and  with  the 
Chinese  the  affection  has  been  introduced  into  British  Columbia.    Dr.  Ilan- 


340 


srKClFIC   INFKCTIOl^S  DISKASKS. 


ni„.tun,  .,f  Vic  tori.,  wifs,  January  20,  18I.S.  tl.at  ihnv  arc  S  caKc.  known 
in  tlii>!  Drovimo.    Tlit-v  arc  K'^rrcgatod  on  Oarcy  l.-land. 
'"  '     ;  ";  scnacnuc-in  .he  {^-o.  In.lia  Man.ls.     It  al;o  ;>^-'rs  u.  Mcx.nj 
a„,l  tlrouirhont  the  S-.uthrrn  States.     In  the  San.hvuh  Ish.n.  .  it  ^ire. 
d      a  ter  lS.iO,  and  strenuous  atte,„,.ts  have  l.een  n.ade  to  sta,,.,.  .    on 
l^"Z:,Li:  ail  lepers  ..n  the  i.land  of  M-lukai.     In  ISL  I  there  were  M- > 

'■^irnn;il'h:;H;raee.n.din,  to  the  Leprosy  Co.nnussion.  t.>ere  are 
l,.,;...  leper.  This  is  prohahly  a  low  estin.ate.  In  Chum  ^'P-^n  - 
.vten^ivh  In  South  Afriea.  it  has  nureased  nip.dlN  n  Ao^^al  , 
N  /  and.  and  the  Australasian  islands  it  also  prevads,  ';•->;--« 
,,.,  chin.-e.  The  essavs  of  Ashhurton  Thun.psnn  and  .hunes  (  autta  d.al 
iullv  with  leiu'osv  in  ("hina,  Au.-tralia.  and  the  rae.lie  ishunls 

Etio  OKV.-'rhe  haeillns  lepnv.  diseovered  l.y  Hansen,  o     1  ergen,  m 
IKM    ISrsdlv  rec.o.M,i/.ed  as  the  cause  of  tin-  disease.     It  has  niany 

:;,;;.;:;::d,huu.e  .rti.  tuherde  ..anuus,  hut  can ';;;  - ''y,;  f  ;; 

■ntiated       It   is  cultivated  with  extren,e  dilhcultv,  and,    n   hut,     lure  .s 
d  Hd.t  as  to  whether  ,t  is  .apahlc  of  jrrowth  on  art.hcal  njed.a. 

M  ics    f  Infection.-(.)  / ././/..".-While  it  .s  n.hly  F;' •;; '  ;^ ^- 

l,prc,sv  n>av  he  cnntra.t.Hl  hy  accidental  inoculatn.n,  the  exF^n  u-nt.  1  e 

,  ee'is  as'vet  inc...n..lnsive.  With  one  possible  except.on  -"^-t.vj;  -  t^ 
have  f(dlow"ed  the  atten.pts  to  rcpn.duce  the  disease  in  num.  He  lla- 
.!^  u  nvut  under  senUMU..  of  .leath,  who  was  inoodated  on  Sep  en. be 
•or  .1  by  Arnin.'.  fcur  weeks  later  had  rheumatoid  pains  and  gradud 
;  in  ;  su  '  lin;  of  tin.  ulnar  and  nu.dian  nerves.  The  neurit^  gradual  y 
d  but  tl^.re  developed  a  s.nall  lepra  tubercle  at  the  site  of  the  niocu- 
on  in  ISSr  the  disease  ^vas  quite  numifest,  and  the  nian  died  ot  it  six 
yl^a^r'aft"  inoculation.  The  case  is  not  regarded  as  conclus.ve,  as  he 
had  leimnis  relatives  and  lived  in  a  leprous  country. 

(1  '//.n./Z/v-Kor  years  it  was  thought  that  the  disease  was  trnnsnu  a 
from  l-arent  to  child,  but  the  general  opinion,  as  expressed  ,n  >^'  "^ 
Tcnro'v  Con-HHss  in  I'.crlin.  uas  decidedly  against  tins  view.  Of  course 
i  po'ssibilitv  of  its  transnus«ion  cannot  be  denied,  and  m  this  respc^c 
^rosv  and  tuberculosis  occupy  very  much  the  same  pos,t,..n,  t^-^-- 
Mith  very  wide  experience  have  never  seen  a  new-born  h^per.  1  ho  }oun„ 
est  cases\ire  rarelv  under  three  or  four  years  of  age. 

0  B,  r../«,/...-The  baeiUi  are  given  olT  from  the  open  sores    they 
are    -uni    in  the  saliva  and  expectoration  in  the  cases  with  leprous  lesion 
Tthe  mouth  and  throat,  an.l  occur  in  very  large  numbers  .n    he  nasal 
oe       o        Sticker  found  in  1^3  le,,ers.  subjects  of  both  forms  of    he  dis- 
^,'o     nH  li  in  the  nasal  secretion  in  1-S.  and  herein,  he  thinks,  lies  the  chief 
n'  o  .or.     SchatTer  was  able  to  collect  h^pra  b^u^illi  on  clean  slides 

1  on    able-  and  floors  near  to  lepers  whom  he  had  caused  to  read 
n    n        The  bacilli  have  also  been  isolated  from  the  urine  and  the  milk  of 
n  tnts      Tt  seems  probable  that  they  may  ent<'r  the  body  in  many  wajs 
:,h  th     mueouJ  nu.nbranes  and  through  the  skin.     Sticker  believes 
.t   h    initial  lesion  is  in  an  ulcer  above  the  cartilaginous  part  of  the  nasa 
ep  urn      One  of  the  most  striking  examples  of   the  contagiousness  of 


LKl'UOSY. 


.141 


PCS  known 

in  Mcxiot 
,  it  fpri'iul 
mill  it  tint 
will'  1,1  ■)» 

ll\('ro  aro 
isy  iiri'vailri 

Australia, 
I'ily  aiiKiiiK 
'iiiittio  (li'al 

r.iTfii'n,  in 
:  lias  many 
(lily  (lilTor- 
it,  tlKTO  is 
iiu'ilia. 
•oliable  that 
niontal  evi- 
itivi'  results 
The  lla- 
i  SeiiteniVier 
11  ml  gradual 
is  gradually 
if  the  inocu- 
lied  of  it  six 
usive,   as  he 

transmitted 
II  the  recent 
Of  course, 
this  respect 
thouiih  men 
The  yonng- 

11  pores;  they 
prous  lesions 

in  the  nasal 
IS  of  the  dis- 

lies  the  chief 
II  clean  slides 
lused  to  read 
1  the  milk  of 
n  many  ways 
icker  believes 
't  of  the  nasal 
agiousness   of 


leprosy  is  (lie  following:  "  In  ISCO,  n  girl  who  liad  hiilicrlo  lived  at  Ilolst- 
fi'rsliof,  where  im  leprosy  existed,  married  and  neiil  to  live  at  Tarwa.-t  with 
her  mother-in-law,  who  was  a  leper.  Siie  reniaiiird  heidtliy,  Imt  her  three 
children  (I,  '.',  I!)  heciime  leprous,  as  also  her  younger  si^ler  (1).  who  cami' 
on  a  visit  to  Tarwast  and  slept  with  the  children.  The  younger  sister  de- 
veloped leprosy  after  returning  to  ll(d>t IVrsliof.  .\t  the  lallir  place  a 
man  (*>),  lil'ty-two  years  old.  who  married  one  of  the  'yiuinger  sister's' 
iliildreii,  actpiired  leprosy;  also  a  relative  ((i),  thirly-.-i\  years  old,  a  tailor 
liy  occupation,  who  frcijiicnti'd  the  house,  and  his  wife  ("!),  who  came  fron> 
a  place  where  no  le|)rosy  existed.  'I'he  two  nun  la.-l  inciitioiicd  are  at 
present  (ISHT)  inmates  of  the  leper  asylum  at  Dorjiat."'  There  is  certain 
evidence  to  show  that  the  disease  may  he  spri'ad  thrnngh  infected  clothing, 
and  the  high  jiercentage  of  wa^herwonicii  among  lepers  is  also  suggestive. 

Conditions  influencing  Infection.— The  disease  atlaiks  persons  (if  all 
ages.  We  do  not  yet  understand  all  the  conditions  necessary.  I\vidently 
tlie  closest  and  most  intimate  contact  is  essential.  The  ddctors,  nurses, 
and  Sisters  of  Charity  who  care  for  the  patients  are  very  rarely  attacked. 
In  the  lazaretto  at  'i'racadie  not  one  of  the  Sisters  who  lur  more  than  forty 
years  have  so  faithfully  nursed  the  lepers  has  ciuitracted  the  disease.  I'ather 
Dainian,  in  the  Sandwich  Islands,  and  Father  iioglinli,  in  New  Orleans, 
hotli  fell  victims  in  the  discharge  of  their  jiricstly  duties.  There  has  long 
heen  an  idea  that  jiossihly  the  disease  may  he  associated  with  some  special 
kind  of  food,  and  .Tonalhan  Hutchinson  helieves  that  a  llsh  diet  is  the 
fprliiivi  quid,  which  either  renders  the  patient  suseeptihle  or  with  which 
the  poison  may  he  taken. 

Morbid  Anatomy. — The  leprosy  tuhercles  consist  of  granuhima- 
toiis  tissue  made  up  of  cells  of  various  sizis  in  a  connective-tissue  matrix. 
The  bacilli  in  extraordinary  nninbers  lie  ]iartly  between  and  partly  in  the 
cells.  The  process  gradually  ijivolves  the  skin,  giving  rise  to  tuheroiis  out- 
growths with  intervening  areas  of  nlceration  or  cicatrization,  which  in  the 
face  may  gradually  ]U'odiice  the  so-called  fdcii's  Ironliiid.  '["he  mucous 
membranes,  jiarticularly  the  conjunctiva,  the  cornea,  ami  the  larynx  may 
gradually  be  involved.  In  many  cases  deep  ulcers  form  wiiicli  result  in 
extensive  loss  of  substance  or  loss  of  fingers  or  toes,  the  so-called  Irpra 
7)i}itihii)/i.  In  ana'sthetic  leprosy  there  is  a  ])eripheral  neuritis  due  to  the 
development  of  the  bacilli  in  the  ncrve-filires.  Indeed,  this  involvement 
of  the  nerves  ])lays  a  jn-imary  part  in  the  etiology  of  many  of  (lie  impor- 
tant features,  ])artieularly  (he  trophic  changes  in  the  .«kin  and  the  disturb- 
ances of  sensation. 

Clinical  Forms.— (^0  Tubercular  Leprosy. — Prior  to  (he  appear- 
ance of  the  nodules  there  are  areas  of  cutaneous  erythema  which  may  bo 
shar])ly  defined  and  often  hypera'sthetic.  This  is  sometimes  known  as 
maruhir  leprosy.  The  affected  spots  in  time  become  pigmented.  In  some 
instances  (his  superficial  change  continues  without  the  development  of 
nodules,  the  areas  become  anaesthetic,  the  pigment  gradually  disappears, 
and  the  skin  gets  perfectly  white — (ho  Irprn  aJIm.  Among  (he  jiatients 
at  Tracadie  it  was  particularly  interesting  to  see  three  or  four  in  this  early 
stage  presenting  on  the  face  and  forearms  a  patchy  erythema  with  slight 


342 


SPECIFIC  INFECTIOUS  DISEASES. 


swelling  I'l'  tlif 


in      Tlie  (lia<:nn?is  of  the  condition  is  perfectly  clear, 

Ihou-li  it  niav  ).e  a  lonj;-  time  l)efore  any  otlier  tluui  sensory  changes  de- 

'     r    The  c.  eh,shes  and  evehrows  and  the  hairs  on  Xh.  face    all  out.     ihe 

!;Jn;,.nd,ranes   hnally'  l,econ.e  involved,  particularly  ol   t  u-  n.uh 

Inoat    and  larvnx:  the  voice  heeon.es  luu'sh  and  imally  aphonic.     D  alli 

;;;';  ...  u.riv„uently  fron.  the  laryngeal  --f-tn,:.  and  aspirat^m 

pneumonia.    Ti>e  conjunetiva.  are  frcciuently  attacked,  and  the  sight  i.  lo.t 

bv  a  leormis  keratitis.  „  ,         ■       ^         ,  „;.(;„ 

'  (i)  Anaesthetic  Leprosy.-This  remarkahlc   form  has,  in   ^'l^^lj-tai. 
ca^cs  no  external  reseinhlance  ^vhatever  to  the  other  variety.     Jt  usually 
be-^ins  Nvith  pains  in  the  limbs  and  areas  of  hypenvsthesia  or  of  numbness 
Ym-  earlv  there  mav  l,e  trophic  changes,  seen  in  the  lornuition  ot  small 
bulie  (liiUis).     Maeulie  appear  upon  the  trunk  and  extremities,  and  attei 
persisting  for  a  variable  time  gradually  ^'-M-l-r    leaving  areas  otamrs- 
hesia,  but  the  loss  .„[  sensatiou  may  come  on  iiidependentlN   "i/ '^^  «"  " 
break  of  niaeuhe.     The  nerve-trunks,  where  supcrlicial,  may  be  lelt  to  be 
lar-e  and  imdidar.     The  tn.phic  disturbances  arc  usually  marked.     Um- 
phhnis-like  biilhe  develop   in  the  allected   areas,  Avhicli  break  and  leave 
ulcers \vhu.h  mav  be  very  destructive.     The  fingers  and    oes  are  liable  to 
contractures  and   to  neerosis,  so  that  in  chronic  cases  the  phalanges  are 
l.wt      The  course  of  amvsthetic  lepn>sy  is  extraordinarily  chronic  and  ma\ 
ner^i4  for  years  witli.mt  leading  t-.  much   deformity.     One  ot  the  most 
Lmiinent  clergvmeii  on  this  continent  had  amvsthetic  leprosy  for  more 
Ihan  thirty  yeal^,  which  did  not  seriously  interfere  with  his  usetulness,  and 
not  in  the"  slightest  with  his  career. 

Diaenosis.-l.veu  in  the  earlv  stage  the  dusky  erythematons  miieuhe 
with  InTcra-sthesia  or  areas  of  amcsthesia  are  very  characteristic.  In  an 
advanced  grade  neither  the  tubercular  nor  ana'sthefc  forn.s  could  possibly 
be  mistaken  f(n-  any  other  affection.  In  a  doubtful  case  the  microscopical 
cxaminaticm  of  an  excised  nodule  is  decisive. 

Treatment.— i'h ere  are  no  specific  remedies  in  the  disease,  and  gen- 
oral  touirs  combined  with  local  treatment  meet  the  only  available  iiidica- 
lion<  The  --uriun  and  chauhnoogra  oils  have  been  recommended,  the 
former  in  do^es  of  from  o  to  10  minims,  the  latter  in  2-drachm  doses. 

Tlie  Xorwe-ian  method  of  segregation  should  be  enforced  wherever 
the  di-ea-e  prevails,  as  in  Louisiana  and  California.  It  should  be  eom- 
pnNorv  in  all  ca-es  cxce-pt  where  the  friends  can  show  that  they  have  ami)le 
jtrovision  in  their  own  home  for  the  complete  isolation  and  proper  care 
of  the  jiatient. 

XXXVl.    INFECTIOUS  DISEASES  OF  DOUBTFUL  NATURE. 

(1)  FEBRICUL.V-EPIIEMERAL  FEVER. 
Definition.— Fever  of  slight   duration,  probably  depending  upon   a 

varietv  of  causes. 

V'febrile  paroxvsm  lastins:  for  twenty-fonr  hours  and  disappearing  com- 
pletelv  is  spoken  of  as  ei^bemeral  fever.  If  it  persists  hn-  three,  four,  or 
more  'days  witliout  local  affection  it  is  referred  to  as  febricula. 


INFECTIOUS  DISEASES  OF  DOUBTFUL  NATURE. 


343 


■('(•tly  clear, 
(•liaiigL'iJ  do- 
ll out. 

tllO    lUDlltll, 

uie.  Death 
I  uj^piration 
siglit  is  lorit 

haracterit-tic 
Jt  usually 
i"  nuuibnoss. 
ion  ol;  small 
.'s,  and  al'tor 
uas  of  ana^s- 
of  the  out- 
je  felt  to  be 
rkfd.     Peni- 
k  and   leave 
are  liable  to 
halanges  are 
iiie  and  may 
of  tlie  most 
)sy  for  more 
efulness,  and 

\tons  macula' 
•istic.  In  an 
ould  possibly 
microscoiiical 

ase,  and  pen- 
ilable  indica- 
imended,  the 
lim  doses. 
ccd  Avhcrever 
nnld  be  com- 
>y  have  amjjle 
I  proper  care 


,  NATURE. 


iding  upon  a 

ppenring  com- 
liree,  four,  or 
a. 


Tlie  cases  may  be  divided  into  several  groups: 

{(i)  Those  which  represent  mild  or  abortive  types  of  the  infectious  dis- 
eases. It  i.s  not  very  infre(iuent,  during  an  epiilemie  of  ty[)iioi(l,  t^carlet 
fever,  or  nu-asles,  to  see  cases  with  some  of  the  prodromal  .-ymiitoms  and 
sligiit  fever,  which  persist  for  two  or  tliree  days  without  any  distinctivo 
features.  I  June  already  spoken  of  tliese  in  connection  with  the  abortive 
typo  of  tyi)hoid  fever.  Possibly,  as  Kahlor  suggests,  somo  of  the  cases  of 
transient  fever  are  duo  to  tlie  rheumatic  poison. 

(It)  In  a  larger  and  perha^js  more  important  group  of  cases  the  symp- 
toms develop  with  dyspepsia.  In  children  indigestion  and  gastro-intes- 
tinal  catarrh  are  often  accompanied  by  fever.  Possibly  some  instances  of 
longer  duration  may  bo  due  to  the  absorption  of  certain  toxic  substances. 
Slight  fever  has  been  known  to  follow  the  eating  of  decomposing  sid> 
stanccs  or  the  drinking  of  stale  beer;  but  the  gastric  juice  has  renuirkable 
antiseptic  iirojierties,  and  the  frequency  with  which  persons  take  from 
choice  articles  which  are  "high,"  shows  that  poisoning  is  not  likely  to 
occur  unless  there  is  existing  gastro-intestinal  disturliance. 

{(•)  Cases  which  follow  exposure  to  f(nil  odcn's  or  sewer-gas.  That  a 
febrile  paroxvsm  may  follow  a  i)rolonged  exposure  to  noxicnis  odors  has 
long  been  recognized.  Tlie  cases  which  have  been  described  uiuler  this 
heading  are  of  two  kinds:  an  acute  seve-o  form  with  nausea,  vomiting, 
colic,  and  fever,  followed  perhaps  by  a  condition  of  collapse  or  coma; 
secondly,  a  form  of  low  fever  with  or  without  chills.  A  good  deal  of  doubt 
still  exists  in  the  minds  of  the  profession  about  these  cases  of  so-called 
sewer-gas  })oisoning.  It  is  a  notorious  fact  that  workers  in  sewers  are 
remarkably  free  from  disease,  and  in  many  of  the  cases  which  have 
been  repcn'ted  the  illness  nuty  liave  been  oidy  a  coincidence.  There  are 
instances  in  which  ]iersons  have  been  taken  ill  with  vomiting  and  slight 
fever  after  ex])osure  to  the  odor  of  a  very  oU'ensive  post  mortem. 
Whether  true  or  not,  the  idea  is  firmly  imjilanted  in  the  minds  of  the 
laity  that  very  ])owerful  odors  from  decomposing  matters  may  produce 
sickness. 

((/)  ]Many  cases  doubtless  depend  upon  slight  nnrceognized  lesions,  such 
as  tonsillitis  or  occasionally  an  abortive  or  larval  pneumonia.  Children 
are  much  more  freiincntly  affected  than  adtdts. 

The  si/Dipfums  set  in,  as  a  rule,  abruptly,  though  in  some  instances 
there  may  liave  been  preliminary  malaise  and  indisposition.  Headache, 
loss  of  appetite,  and  furred  tongue  are  present.  The  urine  is  scanty  and 
hisrh -colored,  the  fever  ranges  from  101°  to  103°,  sometimes  in  children  it 
rises  hi<dier.  The  checks  may  be  flushed  and  the  patient  has  the  outward 
manifestations  of  fever.  In  children  there  may  be  bronchial  catarrh  with 
sli>Tht  coush.  Herpes  on  the  lips  is  a  common  symptom.  Occasionally 
in  children  the  cerel)ral  symiitoms  are  marked  at  the  outset,  and  there  may 
be  irritation,  restlessness,  and  nocturnal  delirium.  The  fever  terminates 
abruptly  by  crisis  from  the  second  to  the  fourth  day;  in  some  instances 
it  may  continue  for  a  week. 

Tlie  diagnosis  generally  rests  upon  the  absence  of  local  manifestations, 
particularly  the  characteristic  skin  rashes  of  the  eruptive  fevers,  and  most 


3^^  SPECIFIC  INFECTIOUS  DISEASES. 

in.portant  of  all  the  vapid  rtisappoarance  of  ^}Y\^ai^ZZ'  ""' 
readily  recognized  are  tho.e  with  acute  ^^^^^<-^^^':-''^^.^'^'^'^^  ,,^j  , 

The  Uraln,a,t  is  that  of  nnld  pyrex.a-rest  ,n  ^^^'^^^      ;.^'' 
fever  inixturo  containing  nitrate  of  potassium  and  .^^cct  .pint,  ot  nitic. 

(2)  WEIL'S  DISEASE. 
Amitfl  Febrile  Icterus.-ln  lS8f3  Weil  described  an  acute  infectious  di> 

mmimmm 

tl  e  ^mmer  month.  The  cases  have  occurred  m  ^^-'^^^ -^,;  f  ^"'  ^.  ^^f :;• 
A  few  ca«es  l.ave  been  reported  in  this  country  (Lanpbear)  ^^  ^' ^'"^ 
inort  frequently  alVected.    Many  of  the  cases  Iv.ve  been  xn  butchers.    Ihe 

.itl  ^c  1  There  are  heaiu^ie,  pains  in  the  ba.k,  -^  --;";-  - 
^^^  pains  in  the  legs  and  muscles,  particularly  of  the  chee..     il  e  k  u 

V    pton,s  rW-ely  present.     The  fever  lasts  from  ten  to  fourteen  days; 
o     S  s    here  are  s  ight  recurrences,  but  a  definite  relapse  is  rare. 
iZniin  i^^usually^^resent  in  the  urine;  lurmatuna  has  occurred  m 

'°"cerXal  symptoms,  delirium  and  coma,  may  be  present 

Ii    t   e  few  Lt-mortems  which  have  been  made  nothing  distinct    e 
in  tiie  It      1  :„,.,,,ti<.ations  of  Jaeger  render  it  not  impossible 

«  tf^cpuic  ?„nn  0°  ;;l:.ulico  ac,«Os  ,^.on  infection  .i.h  „  protons 
—haciUus  proteus  fluorescens. 

(3)  MILK-SICKN'ESS, 
This  remarkable  disease  prevails   in   certain  districts  «f  ||^^ J'"^ 
States  west  of  the  Alleghany  Mountains,  and  is  connected  with  the  al  ec- 
tim  i;    at  !e  known  as^the  Urn,hks.    It  prevailed  extensively  in  the  ea 
le  n     c^its  in  certain  of  the  Western  Stat  's  and  proved  very  fat    .     Th 
seitui  cm.  communicated  to  man  only  by  eating  the  lle^h 

s «;,."::;"  i»Vi:r",rin,.i.  t.,c.  ,,„.to;.  »„.,  ..„«.e  „. ..» 

or  diuiKin^  ^^  ^  ^  ^1  (,f  i^nrses  and  sheep  are  most 

i:::S;  ' y r^^^dlh^t  ^ows  giVing^milk  do  not  theniselves  show 
n.  rl  «  vnii.t.nns  unless  driven  rapidly,  and,  according  to  Graff,  the  secie- 
io  1  nm  e  i  ctive  when  the  disease  is  latent.  Wlien  a  cow  is  very  ill 
dies  the  eyes  are  injected,  the  animal  staggers,  tlie  c^iitire  nnis- 
cu  .r  sv^tem  t  emblel  and  death  occurs  in  convulsmns,  sometimes  w,  i 
great  sncldenness.  Xothing  defniife  is  known  as  to  the  cause  of  the  dis- 
ease.   It  is  most  frequent  in  new  settlements. 


INFECTIOUS  DISEASES  OP  DOUBTFUL  XATUIIE. 


345 


a?cs  morit 

ll-O. 

VI',  ami  a 
!  nili'o. 


ctious  dij- 
akon  j^lace 
.  deiinitoly 
vl'ich  may 
rod  during 
iTiit  cities, 
^lales  are 
hers.    The 

and  often 
iiotimes  in- 

The  fever 

Tlie  liver 

lie  jaundice 

of  tlie  oh- 
•o-inlestinal 
irtcen  days; 
!  rare, 
occurred  in 


[  distinctive 
t  impossible 
th  a  proteus 


the  ITnited 
th  the  aifec- 

in  the  early 
■  fatal.  The 
ing  the  flesh 
leese  are  also 
eep  are  most 
nselves  show 
ilT,  the  secre- 
w  is  very  ill, 
e  entire  nius- 
nctimos  witli 
se  of  the  dis- 


In  man  the  symptoms  are  those  of  a  more  or  less  acute  intoxication. 
After  a  few  days  oi  uneasiness  and  distress  the  patient  is  seized  with  pains 
in  the  stomach,  nausea  and  vomiting,  fever  aiul  intense  thirst.  Tiiere  is 
usually  obstinate  constipation.  The  tongue  is  swollen  and  tremulous,  the 
breath  is  extremely  foul  and,  according  to  GratV,  is  as  characteristic  of  the 
disease  as  is  the  odor  in  small-pox.  Cerebral  symi)t()ms— restlessness,  irri- 
tability, coma,  and  convulsions — are  sometimes  nuuked,  and  there  may 
gradually  be  in-oduced  a  typhoid  state  in  which  the  patient  dies. 

The  duration  of  the  disease  is  variable.  In  the  most  acute  forms  deaUi 
occurs  within  two  or  three  days.  It  may  last  for  ten  days,  or  even  for 
three  or  four  weeks.  Grail  states  that  insanity  occurred  in  one  ease.  Tlie 
poisonous  nature  of  tlie  llesli  and  of  the  milk  has  been  demonstrated  ex- 
perimentally. An  ounce  of  butter  or  cheese,  or  four  ounces  of  the  beef, 
raw  or  boiled,  given  three  times  a  day,  will  kill  a  dog  within  six  days.  No 
definite  pathological  lesions  are  known.  Fortunately,  the  disease  has  be- 
come rare,  and  the  observation  of  Drake,  Yandell,  and  others,  that  it 
gradually  disappears  with  the  clearing  of  tlie  forests  and  improved 
tillage,  has  been  amply  substantiated.  It  still  prevails  in  parts  of  North 
Carolina. 

(4)  GLANDULAR  FEVER. 

Definition.— An  infectious  disease  of  children,  developing,  as  a  rule, 
witiiout  premonitory  signs,  and  characterized  by  slight  redness  of  the 
throat,  high  fever,  swelling  and  tenderness  of  the  lymph-glands  of  the  neck, 
particularly  those  behind  the  sterno-cleido-mastoid  muscles.  The  fever  is 
of  short  duration,  but  tlfe  enlargement  of  the  glands  persists  for  from 
ten  days  to  three  weeks. 

In 'children  acute  adenitis  of  the  cervical  and  other  glands  with  fever 
has  been  noted  by  many  observers,  but  I'fciil'er  in  ISS!)  called  special 
attention  to  it  under  the  name  of  Drucsen-Fielwr.  lie  described  it  as  an 
infectious  disease  of  young  children  between  tl  ages  of  five  aiul  eight 
years,  characterized  by  the  above-mentioned  syn.,  toms.  Since  rfcifl'er's 
pa]ier  a  good  deal  of  "work  has  been  done  in  connection  with  the  subject, 
and  in  this  country  West  and  Ilamill,  and  in  England  Dawson  Williams, 
have  more  particularly  emphasized  the  condition. 

Etiology.— It  may  occur  in  epidemic  form.  \Yest,  of  Bellaire,  Ohio, 
describes  an  epidemic  ^of  9G  cases  in  children  between  the  ages  of  seven 
months  and  thirteen  years.  Bilateral  swelling  of  the  carotid  lymph-glands 
M-as  a  most  marked  feature.  In  three  fourths  of  the  cases  the  post-cervical, 
inguinal,  and  axillary  glands  were  involved.  The  mesenteric  glands  were 
feU  in  37  cases,  the"s])leen  was  enlarged  in  37,  and  the  liver  in  87  cases. 
Coryza  was  not  iiresent,  and  there  were  no  bronchial  or  pulmonary  symp- 
toms. Cases  occurred  between  the  months  of  October  and  June.  The 
nature  of  the  infectiim  has  not  been  determined. 

Symptoms.— The  onset  is  sudden  and  the  first  complaint  is  of  pain 
on  moving  the  head  and  neck,  liierc  may  be  nausea  and  vomiting  and 
aljdominafpain.  The  temperature  ranges  from  101°  to  10:3°.  The  tonsils 
may  be  a  little  red  and  the  lymphatic  tissues  swollen,  but  the  throat  symp- 


g^g  SPECIFIC  INFECTIOUS  DISEASES. 

ton.  arc  ,.ito  transient  and  -f  U'oHjU.      On  lljo  sc.o,ul  o^ 

pea  to  a  g•o(.^e-e-K^     1  li  ■}  "re  pa  mm    '>  ^  there  is  some  i.ulliness  of 

mlness  or  swelling  of  the  skin,  though  f  "  ;^^[^/^^'i^,i,  luveullv  in 
the  subeutaneons  tissues  of  the  neck,  ami  ^  -^^^^  J^/^  ,,,,  .i^.^ana 
.^vallo^vin.^  Jn  son.,-  iustanees  there  ha.  ^^  /\'  '^  !;^.^^.^^i  .^^j  ^^onehial 
a  paroxysnud  eough,  i"^^-'^tn>g  un^olveanent  of  th       a^^  ^^^_^_j^^ 

glands.  The  swelling  o  the  ^l-^^l-^  ^^^  ,^^  ^  ^^n^nation  of  the 
An.ong  the  seru.us   i->tures  of   the  ^^^^^^^^^^^,,,  j,,  ,,et  with 

^-Kr::i£ri:IZ^  '^--^S^  U.  use  of  s.an  aoses  of  calo- 
iiH-1  Juiiiig  the  lifiglil  of  tlic  IroiiWc. 

(-„  MOUSTAIS  FEVEll-MOUNTAIS  SICKNESS. 

S.v,.ra.  JWi„ct  .,;.«.«  1.-0  Loon  ;^-*J J S' ^ "«5»'"» " 
i,„,,„,,„„t  gro,,,'.  ll'o  '"»""  ■"";;^"'7;  ■ '!,;Xf  v"  "oml  group  ot  o»«s 
.I'icl,  has  m,t  yet  boc.i  met  >nlh  m  lh,»  o ""      > •    -^  '^«      ^      1 

M„ngs  to  tvphold  fcvor;  ami  '''^'^  ^^^^^^V^  rn<,»nX,An  lov.r. 

S  h;^s  '^57  >i  ^- ;;l  ™*r.s  IZX 

iiarehed,  ami  tncic  was  iuiLu.v,  ,        .„^  ,o      riM,„  =vnuitoms  in  his 

j,;o/    A>r   Whvniwr's  temperature  was  100.1  .     Hie  sympioms 
mahuse.    Mr.  "'^^"'1'"-^  .        ^       a^gravaied  form  such  symp- 

(G)  MILIARY  FEVEU-SWEATING  SICKNESS. 
T,,o  *oa.  .  0,-^0,0*.  %J;..v.o,».^ts  ^^  ;n,  cr,,.ion 

?;«;!;ra:r':!Sce„tl,'o:;?:l^l%>.t   o.  late  y..  it  has  he™  o„n. 


INFECTIOUS  -DISEASES  OF  DOUBTFUL  NATURE. 


347 


tliird  tlay 
iize  from  a 
riiroly  any 
lulliiu'^t'  of 
illk'ulty  in 
■  chest  and 
1  bronchial 
irce  weeks, 
ion  of  the 
IS  mot  ■with 

aiul  retro- 

)sos  of  calo- 


fover.  An 
Hchyhustoina, 
oup  of  cases 
i^f  in  monn- 
mtain  lever, 
idruil  and  of 

p  of  35  cases 
described  as 
idal  reaction 
ond,  too,  re- 
aming among 
It  Avould  be 
icontinucd. 
omena  which 
icciirately  de- 
loy  were  first 
ere  headache, 
le  throat  was 
id  of  general 
iptorns  in  his 
n  such  synip- 
■  ascent  of  the 
■eathing.    The 
.ture.    A  very 


d  an  eruption 
ngland  in  the 
las  been   con- 


fjnetl  entirely  to  certain  districts  in  France  (Ticardy)  and  Italy.  An  epi- 
demic of  some  extent  occurred  in  France  in  1S87.  Hirseh  gives  a  chrono- 
logical accoujit  of  l!>i  epidemics  between  1T18  and  !«?!),  many  of  whuli 
wtTC  limited  to  a  single  village  or  to  a  few  localities.  Occasionally  the  dis- 
ease has  l)ceome  widely  spread.  Slight  ci)idemics  have  occurred  in  (ler- 
iiiany  and  Switzerland.'  Within  the  past  few  years  there  have  been  several 
sinafl  oiitlireai<s  in  Austria.  They  are  usually  of  short  duration,  lasting  only 
for  three  or  four  weeks— sometimes  not  more  than  seven  or  eight  days. 
As  in  inlliiciiza.  a  very  large  number  of  persons  are  attacked  in  rapid  suc- 
cession. In  tiie  mild  "cases  tliere  is  only  sliglit  fever,  with  loss  of  appetite, 
an  erythematous  eruption,  ]>rofuse  perspiration,  and  an  outbreak  of  miliary 
vesiclVs.  Tiie  severe  cas<'s  present  the  symptoms  of  intense  infection— de- 
lirium, high  fever,  profound  i)rostratioii,  and  liaMuorrbage.  The  death- 
rate  at  the  outset  of  the  disease  is  nsual'y  high,  and,  as  is  so  graphically 
described  in  the  account  of  some  of  the  epidemics  of  liie  middle  ages,  death 
may  occur  in  a  few  lion  s.  The  most  recent  and  the  fullest  account  of  the 
disease  is  given  in  Xothnagel's  ITandbuch  by  Immcrmann. 

(7)  FOOT   AND   MOUTH    DISEASE— EPIDEMIO  STOMATITIS- 
APIITIIOUS  FEVEU. 

Font  and  nu)uth  disease  is  an  acute  infectious  disorder  met  with  cliieny 
in  cattle,  sheep,  and  i)igs,  but  attacking  other  domestic  animals.  It  is  of 
extraordinary  activity,  and  spreads  with  "lightning  rapidity"  over  vast 
territories,  causing  very  serious  losses.  In  cattle,  after  a  period  of  incuba- 
tion of  three  or  five  days,  the  animal  gets  feverish,  the  mucous  membrane 
of  the  mouth  swells,  and  little  grayish  vesicles  the  size  of  a  hemp  seed 
bcuin  to  develop  on  the  edges  and  lower  ])ortion  of  the  tongue,  on  the 
gums,  and  on  the  mucous  membrane  of  tlie  lips.  They  contain  at  first  a 
clear 'fiuid,  whicli  becomes  turbid,  and  then  they  enlarge  and  gradually 
become  converted  into  superficial  ulcers.  There  is  ptyalism,  and  the  ani- 
mals lose  ficsh  rapidlv.  In  the  cow  the  disease  is  also  frequently  seen 
about  tlie  udder  and  teals,  and  the  milk  becomes  yellowish-white  in  color 
and  of  a  mucoid  consistency. 

The  transmission  to  man  is  l)y  no  means  uncommon,  and  of  late  sev- 
eral imjiortant  epidemics  have  been  studied  in  the  neighborhood  of  I^erlin. 
Dr.  Salmon  informs  me  that  in  the  "I'nited  States  foot  and  mouth  dis- 
ease has  very  rarely  occurred,  but  in  1870,  as  well  as  in  1841,  it  was 
communicated  in  a  few  instances  to  man.  In  Zuill's  translation  of  Fried- 
berger  and  Frohner's  Pathology  and  Therapeutics  of  Domestic  Animals 
(ririladelphia,  1805)  the  disease  is  thus  described:  "  Transmission  of 
aphthous  fever  to  man  is  not  rare.  The  veterinarian  has  oftener  occasion 
to  observe  it  than  the  physician.  The  use  of  milk  from  aphthous  cows 
contaminates  children  quite  frequently  and  is  fatal  to  them.  This  may 
also  happen  through  ingestion  of  butter  or  cheese  made  of  milk  coming 
from  aphthous  animals,  or  also  directly  through  wounds  of  the  arms,  hands, 
or  by  intermediary  agents.  In  man  the  symptoms  are:  fever,  digestive 
troubles,  and  vesicular  eruption  upon  vhe  lips,  the  buccal  and  pharyngeal 


STECIFIC  INFECTIOUS  DISEASES. 

Several  forms  ol  niiero-orgiuuMii>  na\c   uctii 
with  it.    Weinhasdeseribodainiorococcus^^  ^^^^^^^  ^^^  ^^^^.^^^^, 

■  ...^';:; -^"::;:;M^r;;;;;^^^^^^         -.  a.  eau.  a.. 

the  individuals  who  come  in  contact  with  them. 


ill 


SECTION   II. 
DISEASES  DUE  TO  ANIMAL  PARASITES. 


I.    PSOROSPERMIASIS. 

Fn-dki!  this  term  arc  oiiliriK'cd  scvoral  alfoetioiis  pvddiircd  "hy  tlu'  ^m- 
rozoa.  TIk'sl'  pani.^itos,  Itclonjiiiij:'  to  the  protozoa,  aro  also  known  as  psoro- 
spcrins  and  ^n-('garini(hv.  Tlu'y  arc  extraordinarily  al)nndant  in  the  in- 
vertebrates, and  are  not  iinconunon  in  the  higher  nianunals.  The  entire 
group  (d'  lilood  ])arasites,  luvniatiizoa,  which  live  within  tlie  eorpiiseles,arc 
cdosely  related  to  them.     I'sorospcrins  are,  as  a  rule,  ]>arasites  of  the  cells 

Ci/'lii:iiii.     The  coniinonest  and   most   suital)le  variety  I'or  study  is  the 

Coccidiinii  orifuniie  of  the  rahhit,  which  produces  a  disease  of  the  liver  in 
which  the  organ  is  studded  throughout  with  wliitish  nodules,  ranging  in 
size  from  a  jiin's  head  to  a  split  jiea.  On  section  each  nodule  is  seen  to  he 
a  dilated  portion  of  a  l)ile-duet;  the  walls  are  lined  with  epithelium  in  the 
interior  of  which  are  multitudes  of  ovoid  hodies — the  coecidia.  Another 
very  common  form  occurs  in  the  muscles  of  the  pig,  the  so-called  J'ainey's 
tube,  which  is  an  ovoid  body  within  the  sarcolemma  containing  a  number 
of  small, sickle-shajied, unicellular  (U-ganisms,  the  Siiirnrustis  Micschcri.  An- 
other species,  the  S.  hoiiiinis,  has  been  described  in  man. 

These  bodies  probably  jilay  a  more  imjiortant  nVr  in  human  pathology 
than  has  hitherto  been  thought.  The  cases  reported  may  be  grouped  under 
the  following  divisions:  internal  and  external. 

(1)  Internal  Psorospermiasis.— In  a  majority  of  the  cases  of  this  group 
the  psorosperms  have  Vieen  found  in  the  liver,  ]iroducing  a  disease  similar 
to  that  which  occurs  in  rabbits.  In  Ouehler's  case  there  were  tumors 
which  could  be  felt  in  tlie  liver  during  life,  and  tliey  were  determined  l)y 
Leuckart  to  lie  due  to  coecidia.  In  W.  B.  ITaddon's  case  the  patient  was 
admitted  to  St.  Thomas's  Hospital  with  slight  fever  and  drowsiness;  he 
gradually  became  unconscious;  death  occurred  on  the  fourteenth  day  of 
observation.  Whitish  neoplasms  were  found  uiion  the  peritonaeum,  omen- 
tum, and  on  the  layers  of  the  pericardium;  and  a  few  were  ftnind  in  the 
liver,  spleen,  and  kidneys.  A  somewhat  sinular  case,  though  more  remark- 
ahle,  as  it  ran  a  very  acute  course,  is  reported  hy  Silcott.  A  woman,  ageil 
fifty-three,  adnnttedto  St.  Mary's  lTosi)ital.  was  thought  to  Tie  sulTering  frmu 
tvnhoid  fever.  She  luid  had  a  "chill  six  weeks  Ijcfore  admission.  There  were 
•  '  349 


350 

f 


lUSEASKS  l>li;  TO  AXIMAI.  PAKASITF.S. 

„„a  .,k«.,  »..a » M  •-.sue;  dca.K  »»";-,;;™,t:  ;:!';.  c '  - 

";^'  ^y-^'T  "';"■;:,  ':;:i;";;';v  "■;  J/  ;t  ;.;;:..-•  ti.  ,o.v.  »n.i 

nlacc  on  the  sf\oiitwiitli  <la\.      m-  _    roDortwl  l)y  Joseph 

'ureters  have  been  regarded  as  mueous  ^vy^^;-     ; J  /,;  VJ^^  ^ 

(;,itmhs  the  tinuors  in  tlu-  .reter  ^'^^^I^'^ »   .^T^f  ^^re  of  the  Mosi. 
{-)  Cutaneous  Psorospemiasis.-- 1  0  1"'^'^^^/';,  "'     '  ;\,|,i,u  ...med 
foliirularis  of  ^Vhite,  and  of  Tagefs  d.sease  "^      '-     '1^    ^  ^X^ios  de- 
;„  have  been  established,  has  been  eal  ed  m  .^^^u  ^^^^     ^^'^  , 

seribed  as  psoruspern.s  are  beheved  to  be  ^''^  ;'  f  °  ^^    ,,a    the  nature 
tion.     So,  too,  in  nioUusemn  eontagu.si.m  and  ui  .  P'^ .'""'  j  ^  5^ 

;;,  the  st;netures  .hieh  be  in  and  iK.twe..  ^^^^^^^iS^-^, 

sr^rnsri^-at^iHu;:::  a^  ^-^  ----  --^ 

'^^^^ii:':;;!tv;,:l  ulldlillw'nJia^^es,  however,  of  parasHie  sporo^a 

w      t,.f    ™    1  r     ■    .?1.  -viU,  ,mn,l™t  ex,«„,ralion.     Tl,«  »»to,,.y 

Z,1ni  wl,.,    11  Lonrcd  to  bo  l«l,cr<-.,lo«»  ,.f  tlu.  l..ns»,  a.liTi.nl.,  ami  testis. 

T  ™   t       m    ZI  t,ftcr™lous-lo»ki„s  .-.,,lt,U.s  in  .l,c  «,,,«.„,  on  t  ,c 

™       c      H.C  liver,  »n,l  tl,e  „leu™..    In  all  of  11,0  les„.ns  «"---  ;;"';^  - 

p        1    .o.^nr.inilv  in  ili(i  rji'^eons  masses,     »ueco^^lul  mocu- 
, if  «nnro7oa  were  found,  espcoialiy  m  Hit  t<i.i.Auin  iiKiv. 

:  tkm    wo^  i-do  into  rablnts  and  dogs.    The  second  case  was  sun.  ar^  bu 
mch  nun-o  acute.     There  ^vere  thirty  skin  lesions   d.strd)uted  o^er  the 
I      T  e  m   ont  died  within  three  months  after  the  appearance  of  the 
body.     riH  pat    nt  mea  j^^,^^^  enormous  numbers  of  sporozoa 

"  nnd     The  ^ck^'dev    "loi^t  was  readily  followed.    These  bodies 

Shu  rJl  po^^?t^those  described  as  protozoa  in  cancer  and  in  n.ol- 

^"X"f  IT  molt  important  protozoon  diseases-namdy,  amebic  dys- 
entery and  malaria— have  been  described. 


DISTOMIASIS. 


351 


noss  over  tlio 
-I'ailuro.  The 
ere  wore  car-o- 
Tho  sploon 
prc^i'iitcd  six 
,  on  exaiuiiia- 

Casos  of  this 

In  KvL'"!-  I'ase' 

lul  dratli  took 

he  ])t'lviri  and 

rk'd  hy  Joseph 

f  the  keratosis 
whii'h  s-eenu'll 
the  bodies  dc- 
lelial  (U'gonera- 
nia,  tlie  nature 
ells,  and  whieh 
some  claiming 
re  nothing  but 

rasitic  sporozoa 
e  (from  JUienos 
eft  thigh.  The 
esions,  and  als) 

ns  IIos]iital  IJe- 
jereulosis  of  the 
ymphatie  glands 
he  nose,  cheeks, 
the  left  testicle. 
1  sym])toms,  l)Ut 
veloped.     In  the 
1.     The  autopsy 
■onals,  and  testis, 
c  sjileen,  on  the 
lormons  numbers 
Successful  inocii- 
'  was  similar,  1)nt 
ribiited  over  the 
]ipearance  of  the 
libers  of  sporozoa 
ed.    These  bodies 
iiu'or  and  in  nu)l- 

icly,  amabic  dys- 


II.    PARASITIC    INFUSORIA. 

Several  flagellates  have  been  found  jiarasitic  in  man.  Anmng  the  most 
common  arc  tlie  Trichuuinnas  rai/iiialis,  wliicli  measures  1.5  to  )i'>  ft-  in 
length,  and  has  I'onr  llagella,  wiiicli  are  as  long  jjs  or  longer  than  the  body. 
It  is  by  no  uu'ans  an  uuciuumon  parasite  in  the  acid  vaginal  mucus. 

The  TrirltdiiKiiias  or  CciroiiioiKtft  limuiiiis  lives  in  the  intestines,  and 
is  met  with  in  the  stools  under  all  sorts  of  conditions.  It  is  ))rol)al>ly  not 
|»athogenic.  1  have  seen  it  also  in  the  vomit  in  a  case  of  chronic  gastric 
catarrh.  Triciuunonads  iuive  hccn  met  with  also  in  the  urine  in  .several 
cases,  and  may  he  truly  palhogcnic.  Ju  Hock's*  ca.se  the  parasite.^  were 
associated  witli  a  Inemorrhagie  cystitis  without  bacteria. 

The  Lanihlia  inlcstinalis  is  another  intestinal  moiuid,  larger  than  the 
common  TfifJiomnnas.  Flagellates  have  also  been  found  in  the  expec- 
toration in  cases  of  gangrene  of  the  lung  and  of  l)ronchiectasis,  and  in 
pleurisy. 

Among  the  parasitic  Cillala  nuiy  be  mentioned  the  li/danlidium  nili, 
which  has  been  found  occasionally  in  the  large  intestine  in  forms  of  dys- 
entery. The  parasite  is  oval  in  form.  TO  to  IUO/a  long  and  50  to  TO/*  broad. 
it  is  doubtful  whether  it  is  pathogenic. 


III.    DISTOMIASIS. 

Several  forms  of  trematodcs  or  flukes  are  parasitic  in  man,  and  when 
in  numbers  nuiy  cause  serious  disease. 

(1)  Liver  Flukes. — The  following  species  of  flukes  have  been  found: 
The  FascioJn  hepafira,  a  very  common  ])arasite  in  ruminants,  which  has  a. 
length  of  from  28  to  33  mm.  The  Distdunnn  hutreolniiim,  a  much  smaller 
form,  from  8  to  10  mm.  in  length,  which  is  also  very  common  in  sheep  and 
cattle.  The  Disloma  hiiski,  the  largest  form,  measuring  from  4  to  8  cm. 
in  length.  One  or  two  other  less  im])ortant  fonns  Inive  occasionally  been 
met  with.  Tlie  studies  of  the  Ja])anese  i)hysicians  have  brought  to  light 
the  interesting  fact  that  there  is  a  distoma  widely  endemic  in  certain  prov- 
inces in  that  country.  The  two  forms  described  as  Disfoma  endeminum  and 
Dtstonm  pernirinsitm  are  identical,  and  are  known  now  as  Distoma  sivense. 
According  to  Baelz,  fnlly  20  per  cent  of  the  inhabitants  of  certain  provinces 
are  affected.  The  Di.ihimn  felliirvm,  which  has  been  found  recently  in  this 
country  by  Ward,  of  Nebraska,  in  cats,  is  a  common  human  parasite  in 
Siberia. 

The  flukes  occnpy  the  bile-passages  and  ihe  npper  ])or1ion  of  the  small 
intestine.  "When  in  large  nnmbers  they  may  canse  serious  and  fatal  dis- 
ease of  the  liver,  nsuallv  with  ascites  and  jaundice.  The  liver  may  l)e  enor- 
mously enlarged;  in  Kichner's  case  it  weighed  11  pounds.  The  flukes  may 
cause  a  chronic  cholangitis,  lending  to  great  thickening  or  even  calcifica- 
tion of  the  walls  of  the  l)ile-duct.  The  ova  have  ])een  found  in  the  stoolb. 
Occasionally  the  distomes  are  found  under  the  skin. 


*  American  Journal  of  the  Medical  Sciences,  January,  1896. 


;'.r)2 


DI 


SKASKS   hVK  TO  ANIMAL   TAHASITES. 


Tho  ..n,lnni..  link-  .li..-.  of  ...,..,  is  ..l.,n.H..m.<l  l.v  .nlnv.  n,.  nt  of 


_Ti;^    n.M>al...U.  is  fnun-l  in  K^y,.!.  sontluT.,  Alr.n.,  ;nul  ;    • ''    ; 

'"•      V     ;         ,   V  .in<  of  tlH.  s,.l..H,.  l.huM.T.  Uidnoyn,  an.l  nu'sn,  .;ry,     Ac- 
^■"";-  Vi     ..         1     ■        ^<    iKT  ...nt  of  llu.  l..w.r  .iMss...  in  K.vpt  an- 

"f  I'Vin  I  It    ^  v,.t  I<nnwn  lunv  tlu-  ,.rasi,.  ,a.n>  unnnu.e    o 


.'Uibrvos. 


liii'  syniptonis  air  iluc  to  chan-cs  ii 


I   the   n\iirniis  iiiciiilirani'  of   tlu' 


.nulually  to  anaa,ua.     'I  u-v  ->  ^'■•"-   ^^l^;  "  ,/'        j^nharxia  a.v  ,va,l,ly 

tho  m'tun.,  in  thr  lunps  an.l  (.l.c.vvhr.v.  ^,,^.,_ 

Thrdi-rasr  is  raivlv  fatal;  a  -ivat  inajon;;,  ot  tU'   ta...   i. 

.In.,!  an    n>o,v  connnonly  atta.k.l  than  grown   prrsons,  an,l  th.  -l.^u.. 


la'nioptysis 
tubes 


IV.    DISEASES    CAUSED    BY   NEMATODES. 


I.    AsiAIUAiSIS. 


parasite,  is  found 


(,A    t.r^n-s'  lumhrirohlrs,  tho  uiost  ominuon  human  parasite,  is  louno 
.hicn    il  d,   ilv   .    Tho  fon>ale  is  from  7  to  1^  iuolu.  in  length    the  ma  e 
^n    !    n  8      <  U.S     Tn  form  it  is  ovlin.lrieal,  heiug  pomted  at  hoth  end^:  - 

i  .If     he   "direct  "-i.e..   M-ithout    intermediate   ho^t.      'Ihe    para~,te 
:  ';'    -es    1,     upp    •  ,11'iion  of  the  small  intestine.     Fsually  no,  more  than 
::rtwo  are  lresl.nt.hnt  oeeaslonally  they  ooeur  ni  enornmus  uumh  .. 


(.lie  or  two  an.  prese 


:;■     „;;,     i«  a,x:peeuliar.     They  may  pass  into  the  stomach,  whenee 

t    :;  rn^ho  oiecedS.v  vunitin..  or  they  may  ..rawl   up  tln^  a..^-l.a,us 

Id  en  or  the   .harvnx.  fnnn  whieh  they  may  he  withdrawn      A  child  nude, 

^^   ^'     n     >       uall-,..x  department  of  tho  General  Hospital,  dnnng  con- 


DISHASKS  CArsHl)    HY    NKMAToDKS. 


0>>'> 


lV_i  Ullllt    of 

hitiiitiliihiii). 
aliiii,  iUiil  i> 
II'  Icinalc  ir^ 
n.  ill  diiUiH'- 

I  tlu'  lM>rt;il 
cut  cry,     Ac- 

II  Ivjypt  ni'*' 
.  I  lUniiice  111 
.iitiiiiiini!;  till' 

ir;mi'  of  ill'' 
iiiil-vt'S>('lri  ol 
ilnlll.   Irailillfi 

irition.  'rin' 
la  lire  rradily 
)iil  ill  shiiiic, 
ly  (listriliiilcil 
irV('sci'iici.'S  in 

(.(•iivcr.  Chii- 
il   llif   (ViHcasc 

'Iiriimphj^ii!^. — 

ic  (li-casf,  (Ic- 

of   vo\\]x\\   iiml 

the  In-oiifliial 


ES. 

a>it(',  i>  found 
nuth.  till'  male 
it  hotli  ends:  it 
nr  lonuitiidinal 
(iva.  wli it'll  aro 
1.  lu'dwnisli-vi'd 

incasiin'  0. ()*.") 

a^■  liccn  dt'iiion- 

Tlu'    iiara-ilc 

not  moiv  111  an 
rniouis  luniilii'T;^. 
loniacli.   wliciHc 

tlic  (<'~o|iliaL';ii^ 

A  child  under 

ital,  during  con- 


valescence, witlidrew  in  tiiis  way  hhmv  than  Ihirly  round  worms  williin  iv 
Uw  weeks.  In  oilier  instances  ihe  worm  readies  the  larynx,  and  lias  heeii 
known  to  iirodnce  fatal  iisjihyxia.  or.  \v.\»\\\\i  into  the  trachea,  to  cause 
i:iin,i.'rene(d'  the  luiiLr.  'I'liey  may  ;:(i  tlirou-h  the  Kii>tachian  (nlic  and  appear 
al  the  external  mealns.  'i'he  most  srrious  migration  is  into  ;he  bile-duct. 
'I'here  is  a  specimen  in  the  Wislar-llorner  Museum  of  the  I'niversity  of 
I'cnn.-ylvania  in  which  nut  only  ihc  common  duel,  but  also  the  main 
hranches  throughout  the  livci',  aic  enorm(Ul^ly  distended  and  packed  with 
numerous  round  w(Uins.  The  iiowcl  may  l>e  blocked,  or  in  rare  instances  an 
ulcer  may  he  pcrforalcd.  l-lvcn  llie  healthy  bowel  wall  may  be  |M'netrjited 
(.\postolides). 

A  peculiarly  irrilaliug  sidistancc,  often  evident  to  the  sense  of  smell  in 
handling  >peeinu  ns.  is  f((rmcd  by  llie  I'oimd  worms.  I'ci|ici'  and  others 
su"gest  that  the  nervous  sympt(uus,  sometimes  roembling  those  of  menin- 
gitis, are  <lue  to  this  jioison.  ChaulVard,  Marie,  and  'rauchon  have  gone  still 
nirther.  ami  report  a  remarkable  condition  (d'  fever,  intestinal  symptoms, 
foul  breath,  and  intermittent  diarrhiea  in  connection  witli  the  prcscni'c  of 
lumhricoides.  They  call  it  tyiilio-lumbricosis.  The  febrile  eomlition  may 
continue  for  a  month  or  moi'e.  The  symptoms  are  supposed  to  he  excited 
rdlexly,  or  to  be  due  to  the  virulence  of  the  ascarides  liiem.selves.  It  does 
not  seem  to  me  a  very  clearly  dclined  eomlition,  and  when  one  considers 
the  extraindinary  fi'e(|Ueiicy  of  lumbricoid  worms  and  the  remarkable  num- 
ber which  mav  lie  harbored  without  causing  any  special  tnuddc.  I  think  we 
rc(|uiie  more  evidence  bid'ore  we  accejit  the  coiiclnsions  of  these  authors. 

The  symptoms  arc  not  delinite.  When  a  few  parasites  are  present  they 
may  he  passed  without  causing  disturbance,  in  (  hildren  theiv  are  irritative 
symiitoms  usually  attribiite.l  to  worms,  such  as  restlessness,  irritability, 
picking  at  the  nose,  grinding  of  the  teeth,  Iwitchings,  or  convulsions.  These 
symptoms  mav  1k'  marked  in  very  nervous  ciiildren. 

Treatment.— Santonin  can  be  given,  mixed  with  sugar,  in  doses  of 
from  one  half  to  one  grain  for  a  child  and  two  to  three  grains  for  an  adult, 
followed  by  a  calomel  (u-  a  saline  purge.  The  dose  may  he  given  for  three 
or  four  days.  An  unpleasant  conse<pience  which  scnnetimcs  follows  the 
admiuistralion  (d'  this  drug  is  xanthopsia  or  yellow  vision. 

(//)  O.n/iirlx  irniiirularls  (TInrad-irorm ;  /'//(-worH/).— This  common 
parasite  occu|Mes  the  rectum  and  colon.  The  male  measures  about  1  mm. 
in  leuirth,  the  female  about  10  mm.  They  produce  great  irritation  and 
ilehinir,  jiarticularlv  at  night,  t^ymptoms  which  become  intensdy  aggravated 
by  the  nocturnal  migration  of  the  (uirasifcs.  Occasionally  peri-rectal  ab- 
scesses are  formed,  containing  numbers  of  the  worms. 

The  i)atients  become  extremely  restless  and  irritable,  the  sleep  is  often 
disturbed,  and  tlieiv  may  be  loss"  of  appetite  and  anu'uiia.  Tlibugh  most 
common  in  children,  the  parasite  occurs  al   all  ages. 

The  worm  is  readily  detected  in  the  fa'ces  Infection  probably  takes 
place  thnmgli  the  wati'r  or  iiossibly  through  salads,  such  as  lettuce  and 
cresses.  A  person  the  subject  of  tlie  worms  passes  ova  in  large  numbers 
in  the  fa'ces,  and  the  possibility  of  reinfection  must  be  serujiulously 
'niarded  against. 


354  DISKASKS  DUE  TO   ANMMAL  PAIlASITRfl. 

.,H„in  any  lu-nHil  from  prolun^'cl  t^'at    ul  by  "^    J  ,,^.  „,.„, 

1  1.-0  n,.orl.l  a  .;a.,  of  -vora    years   dnK     S         n      ^^^^. 
in  sM.all  .loses,  and  nuM   pnrj,..tn.N  P''      ;''''>    ^^    ,„.  ,,,,,,.„i,,o  n.ay 
tions  ...ntaining  carl.ol,..  an.  .  v.ne^a  ,  '1     -;';,-    ,    J,,,^,  ,,u  an.l 

water  is  nsnally  enieaeions.        '"    ^  >"  '    '  ',     .^,  ,,,,  ,,i  ,  ^-.U  eU'vat.Ml. 

In  .Mvinj:  the  inj.-etion  .'are  slu.nl.l  l.o  taken  t.     .        li 
so  ^,at  U.e  lluul  can  be  retaine^  as  l.,n,  a.  po  sH.l        1  -      ]       J^,,,,^^  „,,^. 
ing  ami  irritation  at  ni^l-t  vaseline  n.ay  l-e  t.eel>  n.ul, 

nient. 

II.  TRioinxtAsis. 

tin...    The  .lisoase  is  I-rmlneed  h>  ^'^  \'"^  >;  ^  ;  ",  ,•,,,„,  Unonio  en.ap- 
tin..s  and  reach  the  volnntary  nu.s.|le.      -^/     >„       „;  .,,  „„  ,,„,,,,yos 
Bulatcl  larva-inuscle  trichuue.       t         "  *'       "  ^  ^.      ...        „■  ,,n>,.ton.s 
(possibly  from  poisons  produced  by  tlum)  tiuu  in     ^       i 
known  as  trichinasis  is  i)rodiiced.  ini,.4inal  f.)rm.    The  female 

„„,.r'!S:^i:'^:;rrt'^i:!t^':i;.;::2'^;;:'.»,.mne,,.,je.i,.,. 

and  a  somewhat  rounded  tail.  ^  .^,^i. 

^^:«'ntrHSS2 

have  been  estimate.!  at  several  '"'",;  '^^^j^^^^^;,;"  thousand  em- 
broods  are  developed  in  succession,  ""<^  ^^"^  !^  ";  ,.,,„  t,,,  jn.ostion 
bry..s  may  be  produced  by  a  single  -!™-  ^  ^  "ci !  ,,nient 'of  tlie 
of- the  flesh  containing  the  ^^f'^^Z^Z'^^,   J,   davs.     The 

brood  of  embryos  in  the  "^^^f ';!;;;.;;';/;,  \.nbrv.,s  are-pn>bably 
female  worm  penetrates  the  "^/^'^t  nal     al    an,    t  .^  1^^^^^  ^^^^ 

discharged  directly  ;"^^;/^\V'"  te  n  t.  t  ie^^^^  ^^^^^  which  constitute 
venous  syst.nn  and  by  tbe  blo.^.  ^^/^^^rthe  University  of  Alabama, 
their  seat  of  election.  Di.  .)•  J;  ^'^  "Vnunlo  of  transmission  in  an  .-x- 
has  recently  -viewed  t^^^o.iuct  on  -^^-  .  ^  ^^^.^^  ^^  ^,^  ^^.^„,. 

srt::^r;tu:^fSn^ 


J 


w- 


tl 


^ 


<?>^ 


/Ic* 


<>: 


4^ 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


/ 


0 


fo 


<.y  ^4i6 


C/j 


M 


1.0 


I.I 


1.25 


'-1^ 


112 


150 

I"  IIM 

It  m 


M 

1.8 


1.4 


1.6 


^m 
M 


i 


Photographic 

Sciences 
Corporation 


4 


\ 


S 


\ 


V 


\ 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


^<b 


v 


4 


^ 


6\ 


<"'. 
i.<^ 


'^'- 


W    #j 


^ 


IS 


m 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  canadien  de  microreproductions  historiq 


ues 


i 


-   - 


DISEASES  CAUSED  BY   NEMATODES. 


355 


process  an  interstitial  niyositis  is  excited  ami  gradually  an  ovoid  capsule 
develops  al)out  tiie  j)arasite.     Two,  occasionally  tiiree  or  four,  worms  may 
be  seen  within  a  single  capsule.     This  process  of  encapsulation  has  been 
estimated  to  take  about  six  weeks.     Within  the  muscles  the  parasites  do 
not  undergo  further  devclojiment.     Cradually  the  capsule  becomes  thicker, 
and  ultimately  lime  salts  are  deposited  within  it.     This  change  may  take 
place  in  man  within  four  or  five  months.     In  the  hog  it  may  be  deferred 
for  many  years.     The  calcillcation  renders  the  cyst  visiijle,  and  since  first 
seen  by  Tiedemann,  in  ISv^-.',  and  Hilton,  in  183i3,  these  small,  opaque,  oat- 
shaped  bodies  have  been  familiar  objects  to  demonstrators  of  normal  and 
morbid  anatomy.    The  trichina'  may  live  within  the  muscles  for  an  indefi- 
nite period.    They  have  been  found  alive  and  capable  of  developing  as  late 
as  twenty  or  even  twenty-five  years  after  their  entrance  into  the  system. 
In  many  instances,  however,  the  worms  are  comiiletely  calcified.     The 
Irichina  has  ])een  found  or  "  raised  "  in  twenty-six  difl'ercnt  species  of  ani- 
mals (Stiles).     ]\ledical  literature  abounds  in  references  to  its  presence  in 
fish,  earthworms,  etc.,   but   these  parasites  belong  to  other  genera.     In 
fa>cal  examinations  for  the  ])arasite  it  is  well  to  remember  that  the  "cell 
body"  of  the  anterior  ])ortioii  of  the  intestine  is  a  diagnostic  criterion  of 
thcT'.  spiralis.     It  was  first  found  in  the  hog  by  the  late  Joseph  Leidy. 
Experimentally,  guinea-i)igs  and   ralibiis  are  readily  infected  by  feeding 
them  with  nuisclc  containing  the  larval  form.     Dogs  are  infected  with 
ditTiculty;  cats  more  reailily.     Experimentally,  animals  sometimes  die  of 
the  disease  if  large  numbers  of  the  parasites  have  been  eaten.    In  the  hog 
the  trichina^  like  the  cysticerci,  cause  few  if  any  symptoms.     An  animal 
the  muscles  of  which  are  swarming  with  living  trichina^  may  be  well  nour- 
ished and  healthy-looking.     An  imiiortant  point  also  is  the  fact  that  in 
the  hog  the  capsule  does  not  readily  become  calcified,  so  that  the  parasites 
are  not  visible  as  in  the  human  muscles.    For  a  long  time  the  trichina  was 
looked  upon  as  a  pathological  curiosity,  but  in  IStiO  Zenker  discovered  in 
a  girl  in  the  Dresden  Ilosjiital,  who  had  sYni]itoms  of  typhoid  fever,  both 
the  intestinal  and  the  muscle  forms  of  the  trichinav,  since  which  time  the 
disease  has  been  thoroughly  studied. 

^fan  is  infected  by  eating  the  flesh  of  trichinous  hogs.  The  incidence 
of  the  disease  in  swine  varies  much  in  dilferent  countries.  In  (iermany, 
where  a  thorough  and  systematic  micro.scopic  examination  of  all  swine 
flesh  is  made,  the  pro])ortion  of  trichinous  hogs  is  about  1  in  1,853.  At 
the  Berlin  abattoir,  where  the  microsco])ic  examination  is  conducted  by  a 
staff  of  over  eighty  men  and  women,  two  portions  are  taken  from  the  ab- 
dominal muscles,  from  the  dia]ihrngm,  and  from  the  intercostal  muscles, 
and  one  piece  from  the  muscles  of  the  larvnx  and  tongue.  A  special  com- 
pressor is  used  to  flatten  the  fragments  of  the  nuisclc,  and  the  examination 
is  made  with  a  magnifying  power  of  from  70  to  100  diameters.  During 
the  three  years  ending  in  1SS-")  there  were  fi03  trichinous  bogs  detected,  a 
ratio  of  1  to  1:2\)2.  Statistics  are  not  availalile  in  England.  In  the  United 
States  systematic  inspection  is  unknown,  and  the  statistics  are  by  no  means 
extensive  enough.  ''Taking  all  the  examinations  of  American  pork  thus 
far  made,  both  at  home  and  abroad,  and  we  have  a  total  of  298,783,  in  which 


I 


:u 


'}l 


350  DISEASES  DUE  TO  ANIMAL  PARASITES. 

tricliina.  were  lound  (;;.>.S0  ti.nc-s,  licing  'iA  V^v  cent,  or  1  to  -18"  (Siilmon, 

^'"'In  188;l,  in  conjunction  witi.  A.  W.  Clenu.nt,  I  oxununcHl  1,000  hogs 
at  lliu  .AlontroiU  aimltoir,  and  I'ouiul  only   I  iuIocUhI 

J/.<fe  0/  /»Ar/,-.».-'nu.  danger  of  i.Uecl.ou  .  e,.end.  enU  el      M    » 
tl,e  n,ode  oi  preparation  of  the  lle.h.    Thorough  eook,ng.o  tha  . 

of  the  nieat  reach  the  boiliug  point,  destroys  the  parasdes;  hut   .u  la  g 
joints  the  central  portions  are  often  not  raised  to  ^'"^^^I'^'-lf  I'"  J,    '^ 
freouency  of  the  disease  in  dill'erent  countries  depends  largel)    apon  tiic 
?U  Vthe  people  in  the  preparation  of  pork.     In  North    ier.uany,  where 
raw  Inun  and' ,■»'./  are  freely  eaten,  the  greatest  .uutiber  ol  n.stanc  .  ha  e 
occurred.     In  South  (iernuuiy,  France,  and   Kng  and  cases  aie    a.c^   In 
this  country  the  greatest  nund.er  of  persons  attacked  have  been  Geinians 
Saltin.r  and  smoking  the  llesh  are  not  always  sullicient,  and  the  IlaMC 
^^c^dments  showed'that  anin.als  are  readily  infcct..d  w h-  1;;^  -ith  por- 
tions of  the  pickled  or  the  smoked  n>eat  as  prepared  m  this  countiy.     C.a 
Fnu.nkel,  however,  states  that  the  experiments  on  this  point  have  been 
1   iitive/and  that  it  is  very  doubtful  if  any  cases  of  trichiiuasis  m  l.erma.  y 
have  bec'ii  caused  by  American  pork,     (iennany  has  yet  to  show  a  single 
case  cd'  trichiniasis  due  to  pork  of  unquestioned  American  origin. 

Fmiuencu  of  lnfcclion.-Th(i  dissecting-room  and  post-mortem  statis- 
tic- slu/w  that  from  one  half  to  two  per  cent  of  all  bodies  contain  trichin.-u 
Ori  000  consecutive  autopsies,  of  which  I  have  notes,  trichina"  were  present 
in  (i 'instances.    1  have,  in  addition,  seen  them  in  two  dissecting-room  cases 
imd  in  two  bodies  at  the  Philadelphia  Hospital. 

The  disease  often  occurs  in  epidemics,  a  large  number  of  persons  being 
infected  from  a  single  source.    Among  the  best  known  ot' these,  one  occurm 
.,t  lledersleben,  in  which  there  were  ;?a7  persons  allected,  and  anothei  at 
].:mersleben,  in  which  there  Mere  '.>50  persons  attacked.    The  extensive  out- 
breaks of  this  sort  have  been,  with  few  exceptions,  in  North  Germany,  and 
thev  are  a  comment  on  the  inemciency  of  the  inspection.     1  he  statistics  on 
the%ubject  in  this  country  have  been  collected  fo"  me  by  Alfred  Mann, 
bv  F  A   Packard,  of  Philadelphia,  and  more  exhaustively  by  C.  W    b  Ues, 
who  states  that  up  to  181)3  there  was  a  total  of  70'J  cases,  since  which  he 
c,.,vs  ^in  a  lett(>r  of  February  T,  18!l8,  there  have  been  40  or  50  cases  re- 
n.u^ted      lie  thinks  that  900  would  cover  the  total  number  thus    ar  re- 
ported' for  this  country.     According  to  States.  New  York  l^^^;  J  the    .j^ 
with  r'<)  cases:  Illinois  shows  11!);  Massachusetts,  11-.;  Iowa,  ]0,s.     Only 
rarelv  are  cases  diagnosed  in  hospital  practice.     With  the  exception  of  a 
tvnical  case  in  one  of  Traube's  wards,  I  never  recognized  an  instance  ot  the 
(ii'ea-e  until  the  iiast  eighteen  months,  during  which  time  3  cases  have 
occurred  in  my  service  at  the  Johns  Hopkins  Uosi.ital. 

Svmptoms.-Tho  ingestion  of  trichinous  llesh  is  not  necessarily  iol- 
lowcd  by  the  disease.  When  a  limited  number  arc  oaten  only  a  few  em- 
bryos pass  to  the  muscles  and  may  cause  no  symptoms.  AVell-eharacten/.ed 
cases  present  a  gastro-intestinal  period  and  a  period  cd  general  >''1;;<'';;;"; 

In  the  course  of  a  few  davs  after  eaiing  the  inlected  meat  theie  arc 
signs  of  .^astro-intestinal  disturbance— pain  in  the  abdomen,  loss  ot  appe- 


DISEASES  CAUSED  BY  NEMATODES. 


357 


"  (Salmon, 

1,000  hogs 

jrcly  iiiioii 
at  all  parts 
ut  in  'argo 
it  live.     The 
y  Lipon  the 
\any,  where 
laiiees  have 
e  rare.     In 
n  Germans, 
the  Havre 
d  with  ]Jor- 
intvy.    Carl 
;  have  been 
in  Germany 
low  a  single 
gin. 

)rtem  statis- 
lin  Irichinaj. 
were  ])rescnt 
g-room  cases 

icrsons  being 
one  oceiirred 
d  another  at 
xtensive  ont- 
iermany,  and 
'  statistics  on 
Ufred  :\lann, 
C.  W.  Stiles, 
nee  which  he 
•  50  cases  re- 

thus  far  re- 
leads  the  list 
I,  ]0S.  Only 
xception  of  a 
istance  of  tlie 

3  cases  have 

lecessarily  fol- 
ily  a  few  eni- 
l-characteri/.ed 
il  inl'eclion. 
neat  there  are 
,  loss  of  appe- 


tite, vomiling,  and  sonu'tinies  diarrhd'ii.  The  iireliniinary  symptoms,  how- 
ever, are  by  no  ineans  constant,  and  in  some  of  the  large  epidt'inics  cases 
jiave  been  obsci'vcd  in  which  they  iiavi'  been  alisent.  in  other  instances 
the  gastro-inteslinai  features  liave  been  marked  from  tlie  outset,  and  t!ie 
attack  has  resembled  cholera  nostras.  I'ain  in  diiVercnt  parts  of  the 
body,  general  debility,  and  weakness  have  been  noted  in  some  of  the 
epidemics. 

The  invasion  symptoms  develop  between  the  seventh  and  the  tenth  day, 
sometimes  not  until  the  end  of  the  second  week.  There  is  fever,  except  in 
very  mild  cases.  t'liilN  are  not  common.  Tlu'  thermometer  may  register 
102°  or  101°,  and  the  fever  is  usually  remittent  or  intermittent.  The  mi- 
gration of  the  parasites  into  the  mus(des  excites  a  more  or  less  intense  myo- 
sitis, which  is  characterized  by  |>ain  on  pressure  and  movement,  and  by 
swelling  and  tension  of  the  muscles,  owr  which  the  skin  may  be  cedema- 
tous.  The  limbs  are  placed  in  the  ]iositions  in  which  the  muscles  are  in 
least  tension.  The  involvement  of  the  nuisclos  of  mastication  and  of  the 
larynx  may  cause  dillicnlty  in  chewing  and  swallowing.  Tn  severe  cases 
the  involvement  of  the  dia])hragm  and  intercostal  nuiseles  may  lead  to 
intense  dysjiiuea,  which  sometimes  i)roves  fatal.  (Mdema,  a  feature  of  great 
imjiortance.  may  bo  early  in  the  face,  particularly  about  the  eyes.  Later 
it  develojis  in  tlie  extremities  when  the  swelling  and  stilVness  of  the  mus- 
cles are  at  their  height.  Profuse  sweats,  tingling  and  itching  of  the  skin, 
and  in  some  instances  urticaria,  have  been  descrilti'd. 

Bhwd. — A  marked  leucocytosis,  which  may  reach  above  ;50,000,  is  pres- 
ent. A  s])Ocial  feature  is  the  extraordinary  increase  in  the  nnndier  of 
eosinojihilie  cells,  which  may  comjjrise  more  than  50  ])er  cent  of  all  the 
lencocytes.  I'liere  have  been  in  my  wards  within  the  jiast  two  years  3 
cases  in  which  tliis  eosinophilia  was  most  ])rononnced.  in  2  of  the  cases 
the  diagnosis  was  actually  suggested  by  the  great  increase  in  the  eosino- 
pliiles;  in  1  case  they  reached  (!8  ])er  cent  of  the  total  numl)cr  of  leuco- 
cytes. 

The  genoTiil  nutrition  is  much  disturbed  and  the  patient  becomes 
emaciat(>d  and  often  ana'inic,  particularly  in  the  prrotracted  cases.  The 
])atcllar  tendon  rellex  may  be  abst'iit.  The  patients  are  nsually  conscious, 
except  in  cases  of  very  intense  infection,  in  which  the  delirium,  dry  tongue, 
and  tremor  give  a  i)ictnre  ."'.uggesting  typhoid  fever.  Jn  addition  to  the 
dvspncea,  i)resent  in  the  severer  infections,  there  may  l)e  bronchitis,  and  in 
the  fatal  cases  pneinnonia  or  pleurisy.  In  some  epidemics  polyuria  has  been 
a  common  symptom.     Albuunnuria  is  fre(pu'id. 

'I'he  intensity  and  duration  of  the  symptoms  depend  entirely  ni)on  uic 
orade  of  infection.  In  the  mild  cases  recoverv  is  complete  in  from  ten  to 
fonrtecji  davs.  In  the  severe  forms  convalescence  is  not  establi,-;lied  for 
six  or  eight  weeks,  and  it  may  be  months  before  the  patient  recovers  the 
mnscnlar  strength.  One  case  in  the  Iledersleben  epidemic  was  weak  eight 
years  after  the  attack. 

Of  72  fatal  cases  in  the  ITcdersleben  epidemic,  the  greatest  mortality 
occurred  in  the  fonrth  and  fifth  and  sixth  weeks;  namely,  52  cases.  Two 
died  in  the  second  week  with  severe  choleraic  symptoms. 


*   V 


.,  * 


358 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


The  n.ortality  has  ranged  in  ailTe..ent  -f -^^  J-;^  ^  ^1:^:^ 
in  30  per  eent.     In  the  lledersleben  ei.ulenue  ^''J  l^V     \^'" 
t::^L..  repvted  .n  tins  country  t^.c..  ^   ^^^^'^,,,,,,     The 

The  anatomical  cha,u,es  are  c  uellj  ^  l\^ Znd:^r^,o  granular  de- 
tnchin:e  enter  tl>e  prinutive  mnsele  !;"  l^^j/ 'l^^^^,  ^  local  myositis, 
gonerati.>n  with  nuu-ked  nnelear  P^'^^l^  ^'  ^^  "'  ;  /.  ^^^^  r^^,,,,  ,i,a„goB,  as 
and  gradually  about  the  paras.te  a  ^y^  ^^  U  -  "^IJ^,,,,^,,^  m  xuU 

intestines.  ,     mnntitv  of  infected  meat  which 

The  prognosis  depends  ";-  -/i;-,      ^^hi     'n"  t.n-e  in  the  intestines. 

has  been  eaten  and  the  nnnd.er  of    Y;;  u  ^    Fa.ly  diarrhcea  and  nioder- 

':j:^^:^:.:::^:£^^:;^X::^^  ^-  --^  -- '--''-  "- 

^°"S:^sis.-The  disease  f^^J^^^^^j:!^;'!:'':^^^ 
birthday  party  or  Fest  among  ^'^'""^"r^  ^  .^"  f  ^^^^  .'l.ants  of  the  ham 
typhoid  fever.  The  parasites  may  1-  fo^^^^^^^  ^^yb"  discovered  in  the 
or  sansages  nsed  on  the  occasion,  l'^;^  "^^  ^  ^,  |,i,,k  backgronnd 
stools.    Tlie  stools  should  be  spread  on  a  gl         la      or         ^^^^^  ^. ^^^^ 

and  examined  with  a  1<>-P«7'\?^','^^;i^\  diagnosis  may  be  made 
glistening,  silvery  threads  In  '1<^^'  f  "I  ^^^^  ;'  ^^  I  -.^i  harpoon  has 
by  tlie  removal  of  a  small  fragment  of  mn.c    .     A  1  ^^^^ 

been  devised  for  this  pnrpose  by  means  <^^-^^;^  ^,,1,,  ..^aine 
biceps  or  of  the  1-toral  mn.de  y  ^^'^;^^^^^^,  ,,„,oved.  The 
^.stbesia  -;-;^;- -^^^\^;^^Xnmatism,  particularly  as  thepains 
disease  may  be  "^'^^'^^\  "  ;;\  "'/W'^.e  is  no  special  swelling  of  the  joints, 
are  so  severe  on  movement,  bnt        re       n      i  ^.^ntioned  above, 

The  great  increase  -  the --^^  -^^^  telXn^ss  is  in  the  mnscles 
a  most  suggestive  point  m  ^"«-"«-'-  intensity  of  the  gastro-intestinal 
both  on  pressure  and  on  f"^\^^"7^^-,J^' ;.;;,";,  ^f  eholenf.  Many  of  the 
symptoms  in  some  cases  ]-^^^ ^^^^^'^ ^^^  fever,  which  the 
former  ^1-^^"-^  J^  tt  X^^t^er,  the  sleats,  the  delirium,  dry 
severer  cases,  «\'";,  *  ;'  ^^  .^^.toms,  somewhat  resemble.     Tlie  pains 

tongue,  and  i^^'^'^^Tl"^^  ,nd  swelling,  anlema,  particularly  about  the 
in  the  muscles   wthtoi-^^^^^^^  ,-^      .^^  ^^^1^^^  ^.^^^^^^.^  ^^.^,^_ 

eyes,  and  f-^"-^,f,  .Ta/alreadv  been  made  to  the  eases  which 

Under  '^^^^^^^^^f ^f.''^!;"  qn,.  enidem ie  in  1870  on  board  the  training 
t%'Z^'J:::^tJ^^^^r  to  those  of  trichiniasis.     One 
X:tS^^C;.nthsaJ.bu.al.^^^^ 

t  Sin^;:;^  Slbil^^^T:; V-^  1.01.1,.  not  parasitic,  but  en- 
tered  the  body  of  the  cadet  after  burial.         ^ 


*  Journal  of  Experimental  Medicine,  vol. 


iii. 


DISEASES  CAUSED  BY  NEMATODES. 


359 


2  per  cent 
1.     Among 

clos.  The 
ranular  dc- 
il  myositis, 
■liaiigos,  as 
ibed  in  lull 
cgcnoration 
me  of  death 
ound  in  the 

meat  which 
e  intestines, 
and  modcr- 
v-orable  than 

hen  a  large 
of  ajiitarent 
of  the  ham 
vered  in  the 
;  background 
een  as  small, 
nay  he  made 
harpoon  has 
nrtion  of  the 
'nder  cocaine 
jmovcd.     Tlie 
as  the  pains 
of  the  joints, 
itioncd  above, 
1  the  mnsclos 
stro-intestinal 
Many  of  tlie 
er,  which  the 
delirinm,  dry 
[>.     The  pains 
arly  about  the 
ixnostic  points, 
he  cases  M-hich 
•d  the  training 
diiniasis.     One 
iicd.  and  living 
owed,  were  not 
rasitic,  but  en- 


Prophylaxis.— It  is  not  definitely  known  lu.w  swine  bcr-omc  dis- 
eased, it  has  been  tliuiight  that  they  are  iiilected  trmn  vats  about  shuigli- 
ter-house,s,  but  it  is  just  as  reas()nai)l"e  to  believe  that  tlie  rats  are  inl'eeled 
by  eating  portions  of  the  triehinous  ilesli  of  swine.  The  swine  should,  as 
far  as  jjossible,  be  grain-l'eil,  and  not,  as  is  so  eonimon,  allowed  to  eat  olVai. 
The  most  satisfactory  propiiylaxis  is  the  complete  cooking  of  p<n'k  aiul 
sausages,  and  to  thi.s  custom  in  Kngland,  I'rance,  South  tJermany,  and 
particularly  in  ihis  country,  immunity  is  largely  due. 

Treatment.— If  it  has  been  discovered  witliin  twenty-four  or  thirty- 
six  hours  that  a  large  number  of  persons  have  eaten  infected  meat,  the 
indications  aie  to  tiioroughly  evacuate  the  gastro-intestinal  canal.  Purga- 
tives of  rhubarb  and  senna  may  he  given,  or  an  occasional  dose  of  calomel, 
(jlycerin  lias  been  recommended  in  large  doses  in  order  that  by  passing 
into  the  intestines  it  may  by  its  hygroscopic  iJrojH'rties  destroy  the  worm. 
Male-fern,  kanuda,  santonin,  and  thynud  have  all  been  recommended  in 
this  stage.  Turpentine  may  be  tried  in  full  doses,  'i'here  is  no  doubt  that 
diarrhcea  in  the  first  weekV.r  ten  days  of  the  infection  is  distinctly  favor- 
able. The  indications  in  the  stage  of  invasion  are  to  relieve  the  pains, 
to  secure  sleep,  and  to  sui)])ort  the  patient's  strength.  There  are  no  nu'di- 
eines  which  have  any  iniluence  upon  the  embryos  in  their  migration 
through  the  muscles. 

III.    AxCIIYI.OSTmilASIS. 

The  Unciiiana  {Dochmins,  Slmif/nUifi)  ihiodcuaUs,  also  known  as  the 
Scler(ii<((:)innii  or  Anchijhshmum  dimdcnab,  is  the  oidy  strongyle  harmful  to 
man.  It  belongs  to  the  same  family  as  the  Sdcroslnmum  cquinum,  which 
causes  the  verminous  aneurism  in  the  liorse.  The  ]parasites  live  in  the 
npi)er  portion  of  the  snudl  intestine,  chiefly  in  the  jejunum.  They  are 
easily  seen,  the  male  being  from  ('.  to  1<)  mm.  long,  and  the  female  from 
10  to  18  mm.  The  mouth  is  ])rovided  with  a  series  of  tooth-like  hooks, 
l)y  means  of  which  the  i)arasite  attaches  itself  to  the  mucous  membrane. 
The  male  has  a  ])rominent  exiiansion  or  1)ur,-a  at  the  tail  end.  The  exist- 
ence of  the  parasite  has  long  been  known,  but  it  was  not  thought  to  be 
pathogenic  until  (Jriesmger  demonstrated  its  association  with  the  Egyp- 
tion  dilorosis.  It  has  also  been  shown  to  be  the  cause  of  the  ana-mia 
to  which  miners  and  brick-makers  are  subject.  Throughout  Euro]K>  the 
disease  has  been  widely  spread  by  the  employment  of  Italian  and  Polish 
laborers.  In  certain  Italian  ])rovinces  it  is  extremely  prevalent  and  serious. 
It  occurs  in  the  Indies,  in  Brazil,  and  the  West  Indies,  and  has  b-on  de- 
scribed in  Jamaica  (Strachan).  Dobson  has  shown  that  there  is  an  extraor- 
dinary jirevalence  of  the  worm  even  among  healthy  coolies  in  India  and 
Assam,  amounting  to  SO  per  cent  Policy  states  that  the  parasite  was 
described  many  years  ago  by  physicians  in  the  Southern  States,  l)ut  no 
recent  obsc-vatioiis  upon  the  disease  have  been  made  in  this  country. 

Symptoms. — The  iiarasites  withdrnw  blood  by  suction,  and  the  symp- 
toms result  from  this  slow  de]iletion.  That  the  parasites  produce  a  toxic 
substance  has  also  been  sngirested.  In  the  early  stage  there  may  only  be 
gastric  or  gastro-intestinal  disturbance,  but  if  the  parasites  are  present  in 


I; 


DISEASES  DUE  TO   ANIMAL   PARASITES. 


;300 

tins  -use.    The  clini.al  ;-'-  ■-;;-!;,,;';,.;:  U,...,  .ausin.  ..vat 
i.  the  pallur  and  the  a^.u-iatod  l-:onu.na  nl     J  '       ;^'      '^,  ,„„,  ,,,,,,,?, 

s:,:;;;'":;;;:--rr.';::inr;M^;:";:;n,,.,.-™....i..>.i. 

whicli  inlVction  occurs.  Imilin"-  of  all  water 

sary,  the  treatment  may  be  repealed  m  a  week. 


IV.    Flt-AKIASIS. 


:Man- 


Zoiilogicallv  tlu.  Filnria  snnjuiuis  hnuini.  is  as  yet  suh  jv.Urc. 
''''l^:;::Z^^lr.n   F..W«   .../"-^   ^"--^   three   species   of 
nematodes  arc  included:  ordinary  hlood  iilaria. 

1.  ri,.n.,  l.nrn4U  {^^^^''^-^J^.^.Z.u  only  during  sleep  or 
'?^-^';  '"''n'm^  o  s  he^^ltlrn^ediate  lu>st.  The  eml.vos  measure 
at  night.     1 IH-  "'7'1"^';   '  ,     ^  ^^.  t,,ii  pointed.    The  adult  male  meas- 

0,0  to  340  ^   ong  by  .    0  11/^   ';.:i./         ail  forms  two  t.rus  of  a  spiral. 
„res  83  mm.  long  b>  0.407  mm       "«^  '  i,,,,,,,,-,.  ,,^,1,.^  2M 

t!^-„r  .'l,™  Z  ;;;,tio„t  ..up  a,„l<o.    Man»„  su.pcct,  .l,at  il.c  /■„..-,■.«  I*. 


DISEASES  CAUSED  HY  NEMATODES. 


301 


the  cli.irnr- 
luakcr':'  aiui'- 
;i  ani  duo  to 
;  Ihf  iina'inia 
causing  jlivat 

of  nutrition, 
cud  symptoni 

witli  (k'l)ility 
;'()iiic  catavrli, 

I'ound  within 
iiiUM)<a.    l'>ila- 

cascs.  Santl- 
.nts  who  work 

ludant  in  the 
a  thin,  trans- 
e  oxyuris,  and 
n.  The  hirva; 
vatcr,  ttirou.Lih 

K  of  all  water 
ctic  mcasuns. 
!d  he  given  in 
nes  at  10  a.  m. 
lours  after  the 
iveii.    11'  ncccs- 


h  judicc.     Man- 

liree   species   of 

ry  hlood  hlaria. 
during  sleep  or 
nihryos  measure 
idult  male  meas- 
lurns  of  a  s])iral. 
road;  vulva  2,50 
is  the  species  to 

Ih  the  preceding, 
.  the  axis  of  the 
only  dnring  the 
at  tire  Fihiria  ha 

lie  known.  These 


are  mucli  smaller  than  tlie  preceding— '.'(M*  /^  long,  posterior  cxireniity  oh- 
tuse,  anterior  extremity  with  a  sort  of  nlracliie  rosiclluin. 

Tliis  is  the  sjiccies  to  wliicli  Manson  \v(udil  attrilnite  the  sU'cping- 
sickness  of  tlie  negroes.  He  is  also  inclined  to  regard  the  Fihiria  jirrxlaii'i 
as  the  cause  of  craw-rrair,  a  ])apillo-liustular  skin  eruption  of  the  west 
coast  of  Africa,  which  is  proi)ahly  the  same  as  ^'iclly's  (In-niatose  parasitain; 
the  ]iarasite  of  which  was  called  hy  JUanchard  L'hahilili.s  Xivlhii.  ^lanson 
has  shown  that  in  the  hlood  of  the  ahorigiual  Indians  in  British  (luiana 
tiiere  are  two  forms  of  iilarial  eml)ryos,  which  dill'cr  somewhat  from  the 
(udinary  types.  Daniels  and  O/.zard  have  shown  the  extraordinary  preva- 
lence of  these  jiarasitcs  in  the  ahoriginals— fully  ns  per  cent.  Recently 
Daniels  has  found  the  niatiire  lilaria'  in  two  snhjects  in  the  upper  part  of 
the  mesentery,  near  the  pancreas  and  in  the  suhpericardial  fat. 

The  most  important  of  these  is  the  Filaria  bancmj'li,  which  produces 
the  luvmatochyluria  and  the  lymph-scrotum. 

The  female  produces  an  extraoidinary  numlxM-  of  cmhryos,  which  enter 
the  l)lood  current  through  the  lyni];hclics.  Kach  enihryo  is  within  its 
shell,  which  is  elongated,  scarcely  ])eri'ei)tihle,  and  in  no  way  impedes  tlie 
movements.  'J'liey  are  aliout  the  ninetieth  part  of  an  inch  in  length  and 
the  dianietcr  of  a  red  hlood-corpTiscle  in  tliicknes^,  so  that  they  readily 
]>ass  through  the  capillaries.  They  n^ovo  with  the  greatest  activity,  and 
form  very  striking  and  readily  recognized  objects  in  a  hlood-drop  nnder 
the  mieroscoiic.  A  remarkiille  feature  is  the  jieriodicity  in  the  occurrence 
of  the  emliryos  in  the  hlood.  In  the  daytime  they  are  almost  or  entirely 
ahsent,  whereas  at  night,  in  typical  cases,  they  are  ])resent  in  large  num- 
hers.  If,  however,  as  Stejjhen  :Mackenzie  has  shown,  the  jiatient,  reversing 
his  hahits,  sleeps  during  the  day,  the  periodicity  is  reversed.  The  further 
devt'lo])nient  of  the  emltryos  ajipears  to  he  associated  with  the  mosquito, 
which  at  night  sncks  the  iilood  and  in  this  way  frees  them  from  the  body. 
Some  slight  develoimicr.t  takes  ])lace  within  the  hody  of  the  mosquito, 
and  it  is  ])rohahle  that  the  enii)ryos  are  set  free  in  the  water  after  the  death 
of  the  host.  The  further  development  is  net  known,  l)ut  it  prohaMy  occurs 
in  drinking-water.  The  filariu'  may  l)e  present  in  the  l)ody  without  causing 
any  symjjtoms.  In  animals  hlood  iilariie  are  very  common  and  rarely  canso 
inconvenience.  It  is  only  when  tiie  adult  worms  or  the  ova  hlock  the  lymph 
channels  that  certain  definite  symptoms  occur.  :Manson  snggests  that  it 
is  the  ova  (prematurely  discharged),  which  are  considcrahly  shorter  and 
thicker  than  the  fnll-grown  einhryos.  which  hlock  the  lympii  channels  ami 
])roduee    the    conditions    of    Invmatochyluria,    elephantiasis,    and    lympli- 

scrotnm. 

The  iiarasite  is  widely  distributed,  particularly  in  tropical  and  snh- 
tro])ical  countries,  fhiiteras  has  shown  that  the  disease  prevails  extensively 
in  the  Southern  States,  and  since  hi;  pajier  appeared  contributions  have 
been  made  hy  :\[atas,  of  New  Orleans,  :Mastin.  of  ]\fohilc,  and  De  Saussure, 
of  Charleston. 

The  cITects  iirodu(>ed  may  he  described  nnder  the  following  conditions: 
{a)   L'wmniorlnjlurin.—WW^wwi   any   external   manifestations,    and    in 
many  cases  without  special  disturbance  of  health,  the  subject  from  time 


;  : 


■;  ^. 


3(52  DISEASES  DUE  TO  ANIMAL  PARASITES. 

to  ti.uo  i.assc.«  urine  of  an  opa.iuo  white,  n.ilky  aproaranco,  or  ]^-^y^^ 
a  cl.yious  lluid  which  on  .dtlinK  .hows  a  .hjilitly  rcMish  dot.     1  he  u mu 
„,„y  he  normal  in  quantity  or  inerease.l.     The  eon.hUon  .s  .i-ually  niter- 
nuttent.  and  the  patient  may  pass  normal  urine  tor  weeks  or  '";•"    '^j'    'J 
time      Mieroseopieallv,  the  ehylous  urine  contains  minute   iiioheula     lat 
.rranules,  usually  red'hlood-eorpuseles  in  various  amounts      J  he  emluios 
tore  first  discovered  hy  DemarHuay,  at  Paris  (USO^i),  and  m  the  unne  hy 
Wucherer,  at  Uahia,  in  ISdG.     It  is  remarkable  for  how  long  the  cond.  u.n 
may  persist  without  serious  impairment  of  the  health.     A  patient,  sent  to 
mc  hy  Dawson,  of  Charleston,  has  had  luemalociiyluria  mlernutlently  for 
eighteen  years.     The  onlv  inconvenience  has  been  m  the  passage  ol  the 
bbocl-clots  which  collect  i^i  the  bladder.    At  times  he  has  also  uneasy  ^n^i- 
tions  in  the  lumbar  region.    The  embryos  are  present  in  his  blood  at  n  g  it 
i„  hu-e  numbers.     Chvluria  is  not  always  due  to  the  lilaria.     Hie  non- 
parasitic form  of  the  disease  has  alrea.ly  been  considered. 

Opportunities  for  studying  the  anatomical  ccnidiuon  oi  these  cases 
rarelv  occur.  In  the  case  described  by  Stephen  Mackenzie  the  renal  and 
peritoneal  lymph  plexuses  were  eno-iously  enlarged,  extending  from  the 
diaphragm  to  the  pelvis.    The  thoracic  duct  above  the  diai)hragm  was  im- 

^''''\)TLinnph.scrotum  and  certain  forms  of  ,'!cpha„tiasi>^  are  also  caused 
hv  the  filaria.  Tn  the  former  the  tissues  of  the  scrotum  are  enormously 
thickened  and  the  diMended  lymph-vessels  may  he  plainly  seen.  A  clear, 
so,  ■  '.mes  a  turbid,  tluid  follows  puncture  of  the  skin,  i  he  parasites  are 
not  alwavs  to  he  found.  I  have  exauiined  two  typical  cases  without  lind- 
hv  filaria  in  tlie  exuded  (luids  or  in  the  blood  at  night.  So  also  the  major- 
ity of  cases  of  cle])hantiasis  which  occur  in  this  country  are  non-parasitic. 
In  China  it  is  stated  that  the  parasites  occur  in  all  these  cases  * 

Treatment.— So  far  as  I  know,  no  drug  destroys  the  embryos  m  the 
blood  In  infected  districts  the  drinking-water  should  be  boded  or  fil- 
tered In  cases  of  chvluria  the  i>atients  should  use  a  dry  diet  and  avoid 
all  excess  of  fat.  The  chyle  may  disai)pear  (luite  rapidly  fr.)m  the  urine 
under  these  measures,  but  it  docs  not  necessarib-  indicate  that  the  case  is 
cured  So  long  as  clots  and  all)umin  are  present  the  leak  in  the  lymphoid 
variv  is  uot  healed,  although  the  fat,  not  being  sui)plied  to  the  chyle,  may 
not  be  present.  A  single  tumlilerful  of  milk  will  at  once  give  ocular  proot 
of  the  patency  or  otherwise  of  the  rupture  in  the  varix  (^lanson). 

The  «urcrical  treatment  of  some  of  these  cases  is  most  successful,  par- 
ticularlv  in  the  removal  of  the  adult  filaria^  from  the  enlarged  lymph-glands, 
especially  in  the  groin.  l\raitland  states  that  during  the  past  seven  years 
24  operations  of  this  kind  have  been  performed  without  serious  symptoms. 

V.  Dracontiasis  {Gmiiea-trorm  Disease). 
The  Filaria  or  Draninrnhti^  medinrnsi^  is  a  widely  spread  parasite  in 
parts  of  Africa  and  the  East  Indies.  Jn  tiie  Ignited  Statj^tanccs  ocea- 

^^FV^fuF7onTid^atUin~(^^       subioot  of  onnsonital  occlusion    nM    diliitation  ol 
lymph  channels,  see  the  work  on  this  subject  by  Samuel  C.  Busey,  New  York,  1878. 


DISKASKS  (.'AUSKD   BY   NEMATODKS. 


3(>;i 


liloody,  or 
Tlio  iiiiiie 
iially  iiitor- 
iioiiths  at  a 
)k'fular  I'iit 
111-  nuliryos 
le  uriiio  l)y 
0  coiulitidU 

L'llt,   K'Ut   to 

itt'jiUly  for 
tfiige  ol'  tho 
neasy  s^ciisa- 
)oil  at  night 
Tlie  noii- 

thc'se  cases 
0  ronal  and 
Iff  from  tlio 
igni  was  ini- 

also  caused 

enormously 

u.     A  clear, 

parasites  are 

without  find- 

0  the  major- 
lon-parasitic. 

1  * 

ibryos  in  the 
)oiled  or  fil- 
et and  avoid 
(in  the  urine 
it  the  case  is 
he  lymphoid 
,e  chyle,  may 
ocular  proof 

ccespful,  par- 
ymph-glands, 
t  seven  years 
us  symptoms. 


id  parasite  in 
istances  occa- 

nl   (lilntiition  of 
'ork,  1878. 


sionally  occur.  .larvis  rcporls  a  ('a.-^e  in  a  post  chaplain  who  had  lived  at 
Fortress  .Monroe,  \'a.,  Tor  thirty  years.  \'an  Ilarlingen's  patient,  a  man 
aged  I'orty-seveii,  had  never  lived  out  of  I'hiladelphia,  so  (luit  tiie  worm 
niii.-l  lie  included  among  the  parasites  of  this  country.  A  majority  of  the 
cases  reported  in  American  journals  have  been  imported. 

Oidy  the  female  is  known,  it  (icvclo|is  in  the  subcutaneous  and  inter- 
nuiscular  connective  tissues  and  produces  vesicles  and  abscesses.  In  the 
large  majority  of  the  cases  the  jiarasite  is  found  in  the  leg.  Of  iSj  cases, 
in  1"J  1  the  worm  was  found  in  the  b'ct,  I!;}  times  in  the  leg,  and  I  1  tinu's  in 
the  thigh,  it  is  usually  solitary,  though  there  are  cases  on  record  in  which 
six  or  more  have  been  pri'sent.  it  is  cylindrical  in  form,  about  :;.'  mm.  in 
diameter,  and  from  ."iO  to  HO  em.  in  length. 

'i'he  worm  gains  entrance  to  the  system  througli  the  stomach,  not 
through  the  >kin,  as  was  formerly  su|)posed.  It  is  probable  that  both  male 
and  female  are  ingested;  but  the  foriuer  dies  and  is  diseiiargi^d,  while  the 
latter  aller  impregnation  penetrates  the  intestine  and  attains  its  full  de- 
velopment ill  the  siihciitaneoiis  tissues,  v  hen;  it  may  remain  (luieseeiit  for 
a  long  time  and  can  he  felt  beneath  the  skin  like  a  bundle  of  string,  'i'he 
worm  contains  an  enormous  number  of  living  embryos,  and  to  enable  them 
to  e.-^cajie  she  travels  sh-.i-ly  downward  head  first,  and,  as  mentioned,  usually 
reaches  the  foot  or  ankle.  The  head  then  penetrates  the  skin  and  the  epi- 
dermis forms  a  little  vesicle,  which  ruptures,  and  a  small  ulcer  is  left,  at  the 
bottom  of  wlii(!h  the  head  often  protrudes.  The  distended  uterus  ruptures 
and  the  embryos  are  di.^charged  in  a  whitisli  fluid.  After  getting  rid  of 
them  the  worm  will  spontaneously  leave  her  host.  In  the  water  the  em- 
bryos develop  in  the  cyclop.'^ — a  small  ernsfaeean — and  it  seems  likely  that 
man  is  inrected  I)y  drinking  the  water  containing  these  developed  larva". 

When  the  worm  first  ajipears  it  shouhl  not  he  disturhed,  as  after  ]iar- 
turition  she  may  leave  spontaneou.sly.  When  the  worm  hegins  to  come 
out  a  comiiKUi  procedure  is  to  roll  it  round  a  portion  of  smooth  wood  and 
in  this  way  juevent  the  retraction,  and  each  day  wind  a  little  more  until 
the  entire  worm  is  withdrawn.  It  is  stated  that  special  care  must  be  taken 
to  prevent  fearing  of  the  worm,  as  disastrtnis  conse((uences  scnnetimes  fol- 
low, proliably  from  the  irritation  caused  by  the  migration  of  the  embryos. 

The  parasite  may  be  excised  entire,  or  killed  by  injections  of  hiehhnide 
of  mercury  (1  to  1,(100).  It  is  stated  that  the  leaves  of  the  plant  called 
aiixtrpallce  are  almost  a  specific  in  the  disease.  Asafcvtida  in  full  doses  is 
said  to  kill  the  worm. 

In  East  Africa  Kolb  states  that  lie  found  in  the  abdominal  cavity  of 
a  recently  killed  native  ^fassai  several  large  nematode  worms  believed  to 
be  allied  to  the  fllaria  mediiieiisis.  Tie  thinks  this  parasite  is  fiossihly  asso- 
ciated witli  what  is  known  as  the  Afassai  disease,  characterized  by  attacks  of 
fever  lastii'LT  some  three  days,  with  tenderness  of  the  abdomcm  and  vomit- 
ing. KoU)  thinks  that  in  these  cases  the  fllaria'  which  have  become  en- 
cysted about  the  liver  "as  a  normal  event  in  their  life  iiistory  burst  their 
cysts,  the  contents  escaping  into  the  peritoneal  cavity,  thereby  giving  rise 
to  the  symiitoms."     The  subject  is  one  which  requires  further  in\'estiga- 

tion. 

23 


?A'A 


DISKASES  DUE  TO  ANIMAL  TAUASlTES. 


VI.    UrilKU   XKMATOUliS. 

(„)   Anion-  loss  inipcrtunt  filarian  Avorm.  parns^itio  in  man  tlio  follou- 
in./  Ly  h     ;;..Mlion.d:  Fil.na  loa,  which  i.  a  cylindrical  worm  oi  ahuu 
Ten      n  l.M,.nii  and  whose  hahitat  is  honcath  the  conjunet    a      It  ha> 
i.      iu  n     on    1.0  West  AlTican  coast,  in  IWa/il,  and  in  the  West  Ind.e. 
/  r  s  \vlnch  has  heon  found  in  a  cataract.    Three  specnnen«  luue 

,e  n  foun     t;'e  her.     FUuria  labialis,  which  has  been  found  ma  pustule 
i     the  "per  lip.     fUaria  kou,inis  oris,  which  was  descnhed  by  Leu    , 
f  on    th      uoutl    of  a  child.     FUaria  bronchiaUx,  winch  has  been  found 
K      ion  llv         ho  trachea  and  bronchi.    This  parasite  has  been  seen  in  a 
w    ;"    hi    he  bronchioles  and  in  the  lungs.    There  -  -  -ueijce  tha 
t  over  nroduccs  an  extensive  verminous  bronchitis  similar  to  that  whuh 
'Z^^^^  in  dogs.    FUaria  i..nitis-il.  common  ^ '^"•' ;;-;(;';,;- 
'  f  tl,e  do.^-of  which  Uowlby  has  described  two  cases  m  man.    In  one  ca. 
;'ui  liannaturia  female  worms  were  found  in  th-.  portal  vein   and  the  ou. 
wore  im-ent  in  the  thickened  bladder  wall  and  in  the  uiete,. 

M  rW /<  n.M"/».s  dispar  {mip-icorm).-T\m  parasite  is  not  infre- 
quent yf.nd  i  r  the  ca-cuiu  and  large  intestine  of  man.  t  measures  rom 
Tto  5  c™  in  len.^tli,  the  male  being  somewhat  shorter  than  the  fema  o. 
The  ^-orn  i  riadUy  'recognized  by  the  remarkable  dilTorence  between  the 
antork  r  and  posterior  portions.  The  former,  which  form,  at  least  e 
fi  1  s  of  ho  b  .dy,  is  extremely  thin  and  hair-like  m  contras  to  th.  th  ck 
h  l^er  portion  of  the  body,  which  in  the  female  is  --noa Und^^nU^  and 
in  the  male  more  obtuse  and  usually  rolled  like  a  spring  lie  egg.  t 
oval,  lemon-shaped,  O.cr,  mm.  in  length,  and  each  is  provided  with  a  button- 

'"'l^r^mil^r  of  the  worms  found  is  variable,  as  many  as  a  tliou^ 
havin.^  been  counted.  It  is  a  widely  s,.read  parasite  In  parts  o  Lu  ope 
to  cur  in  from  10  to  30  per  cent  of  all  bodies  exanuned,  but  in  this  coun- 
ry  t  i  not  so  commom  The  trichocephalus  rarely  causes  symptoms^ 
It^las  been  thought  bv  certain  physicians  in  the  Eastto  be  the  cause  o 
bedlri.  Sever.;i  cases  have  been  reported  recently  m  which  prof.umd 
an"n  ia  has  occurred  in  connection  with  this  parasite,  usually  ^^ith  dm  - 
Jh^    l-:normous  numbers  may  be  present,  as  in  IMdolphi's  case,  without 

^™Ti;:ii:^Jor;r;X;ny  made  by  the  examination  of  the  f.ces,  wliieh 
contain,  soiiietimes  in  great  abundance,  the  characteristic  lemon-shaped, 

the  male  of   vhieli  measures  about  a  foot  in  length  and    he  female  a 
lee  feet,  occurs  in  verv  many  animals  and  has  occasionally  been  met       h 
il!  man.    It  is  usually  found  in  the  renal  region  and  mny  entirely  dcstro> 

'^'' !^)lLwil''^<^<-  intr.li,>al!...-V^v^^v  this  name  are  now  inclu<Ted  the 
fmal    nematoco  worms  found   in  the   faeces   rnd   formerly  described   a 
^Zi^Xllcrroralis.  AnnnilMa  infr.tinali.,  and  /7/,«?.  oh.h^  _.:../a.,^ 
Th  s  parasite  occurs  abundantly  in  the  stools  of  the  endemic  diarrluca  of 


DISKASKS  C'ALSKI)   UV   CKSTODKS. 


the  follow - 
rm  oi'  al)oiit 
iva.  It  has 
West  Indit's. 
icimons  luivc 
in  a  pustule 
■d  hy  Lt'idy, 

beoii  found 
]vn  scon  in  a 
nidcucc  that 
[)  that  which 
rid  siniijuim>< 

In  one  case 
,  and  the  ova 

is  not  inlrc- 
acasures  from 
II  the  female. 
}  between  the 
at  least  three 
t  to  thj  thick 
I  pointed,  and 
The  ejigs  are 
rt-ith  a  button- 
as  a  thousand 
irts  of  Europe 
t  in  this  coun- 
ses  syni[)tonis. 
0  the  cause  of 
hich  profound 
illy  with  diar- 
?  case,  without 

e  faices,  which 
lemon-shaped, 

lous  nematode, 

c  female  about 

been  met  with 

'Utirely  destroy 

w  included  the 
V  described  as 
ma  Ir.'i'i^tinale. 
liic  diarrluca  of 


hot  ronntries,  and  has  l)ecn  specially  dcscril)ed  by  th(>  Krendi  in  the  diar- 
rh(ea  of  {.'ochin-l'iiina.  It  occurs  also  in  I>razil,  and  has  been  found  in 
Italy  in  connection  with  the  anchylostoma  in  cases  of  miners'  ninvmia.  It 
is  slated  that  tlie  worms  oceu[iy  all  parts  of  the  intestines,  and  luive  even 
been  i'ouiul  in  the  biliary  and  pancreatic  ducts.  It  is  oidy  when  they  are 
in  very  laryc  numi)ers  that  they  jirodnce  severe  diarrluea  and  ana'inia. 

Ac'ANTJi()ti;riiAi-A  {Thnrit-ltcailcil  Womix). 

The  Gii/ontorhijnclius  or  l^clniiorhynchus  (ji'jds  is  a  common  para-^ite  in 
the  intestine  of  the  ho<:  and  attains  a  large  size.  The  larvie  develop  in 
(ockcliafer  j,a'ui)s.  The  American  intt'rmediate  liost  is  the  June  bug 
(Stiles).  Lambl  found  a  small  Eihiiiorliijnchus  in  the  intestine  of  a  boy. 
Welch's  specimen,  which  was  found  encysted  in  the  intestine  of  a  soldier 
ai  Xetley,  is  stated  by  Col)l)old  ])robably  not  to  have  been  an  Kcliinnrlnin- 
chiis.  Recently  a  case  of  Ecli'uwrhijnchus  iiionUifiirniis  has  iieen  described 
in  Italv  by  (Irassi  and  Calandruccio. 


V.    DISEASES   CAUSED    BY  CESTODES 

(Tape-worms ;  Hydatid  Disease). 

ilan  harbors  the  adult  parasites  in  the  small  intestine,  the  larval  forms 
in  the  muscles  and  solid  organs. 


I.  IxTESTiXAL  Cestodes;  T  vrE-WoRMS. 

(fl)  Tcvnia  solium,  or  pork  tape-worm.  This  is  not  a  conniion  form  in 
this  country.  It  is  much  more  frequent  in  parts  of  Kuropo  and  Asia. 
When  mature  it  is  from  H  to  Vi  feet  in  length.  The  head  is  small,  round, 
not  so  large  as  the  head  of  a  pin,  and  provided  with  four  sucking  disks  and 
a  double  row  of  booklets;  hence  it  is  called,  in  contradistinction  to  the 
other  form  in  man,  the  armed  tape-worm.  To  the  head  succeeds  a  narrow, 
thread-like  neck,  then  the  segments,  or  jtroglottidcs,  as  they  are  called. 
The  segments  possess  both  male  and  female  generative  organs,  and  about 
every  four  hundred  and  fiftieth  becomes  nuUure  and  contains  ripe  ova.  Thfi 
worm  attainy  its  full  growth  in  from  three  to  three  and  a  half  months, 
after  which  time  the  segments  are  continuously  shed  and  appear  in  the 
stools.  The  segments  are  about  1  cm.  in  length  and  from  7  to  8  mm.  in 
breadth.  Pressed  between  glass  ])lates  the  uterus  is  seen  as  a  median  stem 
with  about  eight  to  fourteen  lateral  branches.  There  are  many  thousands  of 
ova  in  each  ripe  segment,  and  each  ovum  consists  of  a  firm  shell,  inside  of 
which  is  a  little  embryo,  provided  with  six  booklets.  The  segments  are 
continuously  passed,  and  if  the  ova  arc  to  attain  further  develo])mcnt  they 
must  be  taken  into  the  stomach,  cither  of  a  pig,  or  of  man  himself.  The 
(.fjir-plu'lls  are  digested,  the  six-hooked  embryos  become  free,  and  jiassing 
fnmi  the  stomach  reach  various  ]iarts  of  the  body  (the  liver,  muscles,  brain, 
or  eve),  where  they  develop  into  the  larviV  or  cysticerci.    A  hog  under  these 


DISEASES  DUE  TC  ANIMM'  PARASITES. 


300  ,  ... 

incaslcs  or  Madder  wonns.  ,^^  ^,^,,    ,,,t  <„  ,,x,st  a~ 

Tin.  is  a  l..,„o>-  and  1-g..  P-.^o  -  tl>c  i -^^^^^  ^^^  ^^^^^.^^^^„^  ,,,,  , 
the  c.n.un.ni  tapc-NVonu  ol  Un-  '  ;"'  '.■^\.,^,,i,t..  A,e<.rdhi-  to  l',6r.n-er- 
l,,vo  exa.uincd  almost  all  were  of  ^1^^     •^;  .         ,,uMy  io  th. 

leTand  U  has  spread  ™l'!^^>^,-;7;;'ll^3iterran;;n  basin.  It  n,ay 
i,       ,tatiun  of  beef  and  live-stodv      om  the  ^       .^^  ,,o,npar.son 

,„;,,„  ,  u„,th  of  15  or  ^'/^^''^^^,,,,,IZ^,  .nn.  in  breadth.  It  is 
,,t!v  that  of  the  Tanu,  :7'V''''.;  "  ,  ^  e  suekinj^  disks,  bnt  tlieve  are  no 
,^,„,e.shaved  ami  V--'^-^^^'  ^  „  "^^o  18  mm.  in  length,  and  iron. 
hLklels.     The  ripe  segments  aio  ^  "'      '  ^.  ^^  j,,,,,;,,,  „,,»  Nvith  iron, 

S  to  10  nun.  in  breadth,    'l.e  ^'^^'    -  ^  ;      .J     •,,,,  „„•  ,uor.  diehoto- 

liftecn  to  thirty-live  at..al  l;™;-!'^:, ^^^^^  \  .^.n^vhat  larger,  and  the 
,„ou.ly  than  in  the  T.nnn  ^Uum  ^  ^  ,  ;^.  ,ii,tin,n.ished  by  thoir  ova. 
,U.ll  is  thiekor.  bnt  the  two  hn.n>  '^^  ;,„,,„,„  ^..l  .re  ingest.,  by 
The  ripe  segnnetUs  are  passed  a.  m    h     Mn,  ^^  .^^^^^  ^,^^,  ,^^^  ,^,i    . 

iril^bit^a-Wjuvn  reported  in  .mm. 

'^»;  .Iher  forn.s  of  tape-.orm  ^^l^;;ZXtur.,>.n,,a).     A  small 

J,,  in  the  i..testine  of  a  ch.ld  ...    -^on^and  ha^_  .^^  /,,,;,/.,/.. 

one  or  two  cases.    It  is  con.mo..  m  iat>.      1  l.c 

and  in  beetles.  ,  ,j  infr.Minently  in  Italy; 

tho  /^«'v,u,m  3/«r7<'.'/r'.''™'-"'"^^'''^-  ({""  "     /iH  bv  Ward 

(/)  ^>'-'.  -"('7''    M::  'T::^uZt^'^  o.,lv  m  eertai..  dis- 
(n)  lionn-wrrphihi><  hhi^.     A  c^/"^  Switzerland,  and  in  dapan. 

Hc!fno,,,n-i„.  »";';;.,■■-,;;:;;      ,       'i,:n:i:;'.m,.r,  ,...,,„  in  .  IW 
So  far  as  1  know,    t  ha>  not  i    c  ,„,a,„ring  from  •-•■.  to  •>(• 

i,nported  eases.     The  parasde  .^  ^'^^  '    '     l^^'   ^  <i„  ta..ia.  a<  it  possesses 
J,  or  more.     Its  head  .s  ^^^^-^' ^Z^^.    The  larva^  develop  in  the 
t.vo  lateral  grooves  ^>^  l"*^"^;^^.^"^^        ,'  Mu  a,.d  it  has  been  shown 
,,ito..an„..  and  ...nseles  of  ^1-\1  ^^^  ^^^^  ,   ^  ,,,,,,„  ,,i„n  eaten  by  man. 
xperin,e..tally  that  they  grow  ..to  the  a  ,|,^^^      ^^,,^,  ,^„^ 

'  SymTJtomS.-These  pa.'as.te.  '^  ':',,,,!   ■,,  ,,„.ui„.s.     \V.  T. 

-^---"   in  -I'i^-^-.;:;    ,--:;;!:  ,[;;^;.r  two  yea..  a,.d  tbe,v  i^ 

^"  "Ti;:';rl!u:;nu;ta..e  no  distnrba..ce  and  are  rarely  da,.gerous.     A 


DISEASES  CAUSED  BY  CESTODES. 


out 


-pokfU  of  a> 

it  to  oxi'^t  i>~ 
e  woniif^  luay 

A  lii|)i'-worin. 
It  is  certainly 
nciir'  vh it'll   1 

to  l')6ronger- 
ol'al)lY  to  tlu' 
)asin.  It  may 
in  comparison 
liivatllh.  It  i^ 
it  tlievc  arc  no 
,o;tli,  and  i'l'fni 
tcni  Willi  I'i'oin 

luori'  iliclioto- 
larii'cr,  ami  the 
,.,1  hy  their  ova. 
irc  in,i;'cstc(l  liy 
Uo  the  l)la(l(lcr 

{(milt  ti(i(jiiuitii 


',-iii(t).    A  pmall 
man;  the  larva' 

mall  coslodo  was 
,(.(■11  met  with  in 
|,  in  J^rpiilnplcrii 

picntly  in  Italy; 
)  is  a  rare  form. 

ly  in  certain  (Vis- 
,1.  anil  in  .lapaii. 
■  (iNc('i>t    in  a  few 
iir  |'v(>iii  •-'■■'>  to  -W 
lia.  a-  it   ]»ossesses 
Viv  develop  in  the 
it  has  been  shown 
1  eaten  hy  man. 
,s.     They  are  not 
sii<-l<lin,-s.     AV.  T. 
vears.  and  there  is 
L'-worm  was  found 


cly  dangerous. 


knowled-c  of  the  existence  of  tlie  worm  is  jrcnerally  a  source  ot  w..rry  and 
Miixietv;  the  patient  may  have  coiK-iderahle  distress  and  complain  ot  a  .- 
dominal  pains,  nausea,  diarriuea,  and  sometimes  amemia.  Occasionally  the 
appetite  is  ravenous:  In  w..nien  and  in  nervous  patients  the  constilutu.na 
,li<turhaiice  mav  he  coiisiderahle,  and  we  not  infrciueiitiy  see  groat  mental 
.Ic.pression  and'even  iivpochondria.  Various  nervous  piienoiueiia,  such  as 
..l,un.a,  convulsions,  .,r' epilepsy,  are  lielieved  to  he  caused  hy  the  parasites. 
Such  <.irec-ts,  however,  are  very  rare.  The  J'.ulhriocphalns  may  cause  a 
severe  and  even  fatal  form  of  amvmia,  which  has  hcen  described  luily  m 
a  recent  monograi>h  hv  Schaumann,  of  Jlelsingfors. 

The  dunpwsis  is  never  d.uihtful.  Tlie  presence  o^'  the  segments  is  dis- 
tinctive. The  ova,  too,  may  he  recognized  in  tiie  stools.  It  makes  hut  little 
.liiference  as  to  the  form  of  tape-worm,  hut  the  rii)e  segments  of  tlie  hnna 
,,ujiHala  are  hirger  and  broader,  and  show  dillerences  in  the  generative 
system  as  already  mentioned. 

The  prnpln/liu-is  is  most  imiu.rtant.  Careful  attention  .should  be  given 
t„  three  points.  First,  all  tai.e-worni  segments  should  he  burned,  ihey 
should  never  be  tlirown  into  the  water-.doset  or  outside;  secondly,  carelul 
inspection  of  meat  at  the  aliattoirs;  and  thirdly,  cooking  tiie  meat  sulli- 
cicntiy  to  kill  the  parasites. 

In'  the  case  of  the  lurf  measles,  the  distribution  of  tlie  ].arasites  as 
o-iven  by  Osterta-',  shows  that  the  muscles  of  the  jaw  are  much  more  fro- 
■  qucntlv  atlVctcd'than  other  parts-:!(;o  times,  while  other  organs  were 
infected  hut  oo  times.  Sometimes  there  are  instances  o  gem^a  m  ec- 
ti„n  Stiles  states  tliat  no  exact  statistics  have  been  imhhshed  lor  tlii:^ 
,„Hntry.  in  i'.erlin  the  proporth.n  of  cattle  infected  in  1S!.--!):5  was  about 
1  to  (;:•-'.  Cold  storage  kills  the  cysticercus  usually  withm  three  weeks. 
The  measles  are  more  readily  overlooked  in  beef  than  m  pork,  as  they  do 
not  i)rescnt  such  an  opaipie  wiiite  cohir.  ,      n, 

In  the  examination  of  hogs  for  cysticerci  "particular  stress  should  h.. 
laid  upon  tlu.  tonuue.  the  mnsch-s  of  mastication,  and  t  le  Miuscles  of  the 
shoulder,  neck,  and  diaphragm  "  (Stiles).  According  to  Stiles,  statis  ics  lor 
the  Cnited  States  are  not  available.  American  hogs  are  comparatively  tree. 
In  Pru-ia  one  ho^  is  infected  in  aliout  every  (V.17.  Specimens  have  been 
found  aliv  twcntv-nine  davs  after  slanglitering.  In  the  examination  ot 
1  m)  liooc  in  Montreal,  Dr.  Clement  and  1  f.mnd  TO  instances  of  cys  icerei. 
For  fuirdetails  with  reference  to  the  inspection  of  meat  for  animal  pivra- 
sites,  the  practitioner  is  referred  to  the  work  of  Dr.  Stiles  in  l.ulletin  No. 
1<)   T'nited  States  Deiiartment  of  Agriculture,  lSi)8. 

'Treatment.— For  two  days  prior  to  the  administration  of  the  reme- 
dies (lie  i.atieiit  should  take  a  very  li-ht  di.>t  and  hav.'  the  howels  moved 
occasionally  by  a  saline  cathartic.  The  practitioner  has  the  choice  of  a 
la,-e  number  of  dru-s.  As  a  rule,  the  male  fern  ads  promptly  and  well. 
The  ethereal  extract,  in  '?-drachm  doses,  may  be  given  fasting,  and  fol- 
lowed in  til.-  course  of  a  couple  of  hours  by  a  brisk  purgative.  This  usually 
succeeds  in  brin-in-  awav  a  large  i.ortion,  hut  not  always  the  entire  worm. 
\  combination  of  the  remedies  is  sometimes  very  elTectivo.  Ati  in- 
fusion is  made  of  pomegranate  root,  half  an   ounce;  pumpkin  seeds,   1 


3(53  DISEASES  DUE  TO  ANIMAL  PARASITES. 

ounce;  powacred  .,ot,  a  dnu-ln.  -^  ^;;;^;^^  ::Str-^rSthIca::: 
,,,a.ic.n  of  the  n>alo  fern  (a  ^'^  -\;;;,^  ^^^i^^l  ie,!;  should  have  had 
po^vder,  2  minhns  of  croton  oi      ^^  '^    *-;';   /    ,^;  ^^  ,,its  in  the  evening. 

""^  T;;?pon.,rana.e  root  is  a  ve-T  e,.eient  ^n^y,^n^  -ay^b^ 

on  infusion  of  the  bark,  3  ounees  o    .  n.      -  J^-^;        ^,^^  ^,,,i,,,  ,„„, 

of  .ater  and  tl>en  reduced  ^  T^^'^l^l^Z^^Wo^i.c.^  -1>'-  ^'"^  " 
tity  is  then  taken  in  ^vuled  cl      .  o      -  ^^^  J^l  ^^^^^^^  ^,^^^^,.,,,,,    ;, 

a  very  elTectue  renunlj      ^^^^^^^^  J  «  to  8  or  even  10  gra.ns,  w.th 
now  much  cnii.h.yed.    It  is  gi  "    »  ^^j^^^^^.^.,^  ^^^  ^^^^  j^^ur  by  a 

a  little  tannin  (grs.  v)  m  sweetened  Nsatci, 


purge. 


ge.  .  ,(r,r.i..nt-     Three  or  -4  ounees  s^hould 

^"I'mnpkin  seeds  are  scmjetnnes  v^-Y  *  ''^        ''^  f^^^,,,  Uours  and 

be  carefully  ^'^^f -:^,f -^^1  in  an  W  by  a  purge.     Of  other 

!;:;SS^r";  Uiijenl^r  u/'.nce  doses  in  honey,  and  ka.ala  may  be 

"•tn;;:^-the  head  is  bjought  a.^;,  tlu>  i;an;;i^^ -^-j^-  t.>  |.-  -J 

.vithin  a   f<.v  "'-^^-/^^^Sr^S^v^Vung  depends  upon  th^ 
extraordinarily  ^^^^tinate.     l)ox  b  Ic        1" «      c      J       ^^^^,,.^,     .,,,     j„,t,eted 

exposure  of  the  ^vorm.    The  ^;^';>'\  '  ";^    .    ^^^^  \^,,  ,,nuHlies  may  not  act. 

l.l,eath  the  valvule  ^Xt  /:/-^  ^    ^  -«-  ^^'"^"^^  ^^'  ^'^l'"^"     '5  " 
Owing  to  its  arnuvture  the  '         '^^^,^^  ^.^,^^,  the  head,  and  unless 

probable  that  no  degree  of  pcuis  al   s  ^^^  .   ^^^    ^,,.,^,  j.^ia  on  the 

ke  worm  is  killed  ^t  ^oe^ nc^.  1^^   t^-^;;^^^  ^^^,,  ,,,  ,,,„.  is  less 
luucous  membrane.    It  \\aim  ^\alLl        i 
likely  to  contract  and  lie  l)rokin. 

II.   YlSCKKAL   C'EiSTODES. 

•  ...  vico  +n  little  or  no  disturbance,  and  rarely, 
W„oro».  -I'l"  <;™-;:f ,,       ;  a  o  ,    ™.-^  l.y  *o  Inrv.  or  i„„„n.nvo 
if  ever,  prove  directlj  latal,  tnt  a  ill  •  „„„,.t,„,f     Tlicrc  are  two  chief 

i;,„ns  in  the  solid  organs  are  ^^^^'^%('::^,s  crUul..,  the 
cestode  larvae  known  to  ^-> '  ^^^  ^^r  I r  rr„.,'the  larva  of  the  Tcenia 
larva  of  the  Ta'nm  ^>hnm,  and  ^)J^'^^^^^^^^  ^^.^^  i„,„  found  only  two  or 

three  times  in  man.  .icoidentallv  takes  into  his  stom- 

I.  Cysticercus  C9lM0Sffi.-^  beu  "':"\f;,X"  become  the  intermediate 

ach  the  ripe  ova  of  Tama  sohnm  ho  is  ^^^^^f  \"   'Jf  " ,';     t,,-,  ,,,iaent 

tt,  a  pait  usually  pl^o-l  |or  ^X;^Z^,^nr^X  ^vl-h  case  the 
„,av  occur  in  an  md.v.dual   he  subjut  ol     rr,  ^^^^^^^^^^^^  ^^^  ^^.^^^^^ 

mature  proglottides  ether  ^^^^^^^^^f  ,^  ^'^f.^ttaX  of  ,.rolonged  vomiting, 
is  more  likely,  are_  forced  •"  «.,  -^^^  if^,.  of  a  fe.-  ova  is  quite 
;!^.Sn:S^hri- dnlt'oitS  a-ys  be  borne  in  mind  in 

handling  the  segments  of  the  worm. 


tmtam 


DISEASES  CAUSED  BY  CESTODES. 


309 


COS.  To  an 
>  with  acatiti 
lid  have  had 
the  evening, 
nine  in  the 

•  be  given  a- 
iii  10  ouniT- 
entire  (iiuui- 
.  eulie,  hut  is 
leUetiei'ine,  is 
)  grains,  witli 
an  liour  Ijy  n 


ounces-  Miould 
>eu  hours  and 
•ge.  Of  other 
amala  may  Ije 

to  grow,  and 
instances  are 
ends  upon  tlie 
ghly  protected 
s  may  not  act. 
o  expeh  It  is 
]ad,  and  unh'ss 
m  hold  on  tlie 
he  worm  is  less 


mce,  and  rarely, 
viv  or  immatui'o 
re  are  two  chief 
(s  cclhihsd',  the 
vii  of  the  T(cnia 
.ind  only  two  or 

s  into  liis  stom- 
thc  intermediate 
;.  This  accident 
n  whieh  case  the 
tomach  or,  what 
longed  vomiting, 
few  ova  is  quite 
iorne  in  mind  in 


The  symi)toms  depend  entirely  u]ion  the  number  of  ova  ingested  and 
the  localities  reached.  Ju  the  hog  the  eysticerci  produce  very  Utile  dis- 
turbance. The  muscles,  the  connective  tissue,  anil  the  brain  nuiy  be  swarm- 
ing with  the  measles,  as  they  are  called,  and  yet  the  nutrition  is  nuiintained 
and  the  aninml  does  not  appear  to  he  seriously  incommoded.  Jn  the  in- 
vasion })eriod,  if  large  numbers  of  the  parasites  are  taken,  tiu<re  is,  in  all 
probability,  constitutional  disturbance;  certaiidy  tliis  is  seen  in  the  call', 
when  fed  with  the  ri[)e  segments  of  Tccnia  sai/inahi. 

In  man  a  few  eysticerci  lodged  beneath  the  skin  or  in  tlie  muscles  may 
cause  no  danuige,  ami  in  time  the  larva-  die  and  become  calcitied.  Tiiey 
are  occasionally  found  in  dissection  subjects  or  in  post  mortems  as  ovoiil 
white  bodies  in  the  muscles  or  subcutaneous  tissue.  In  this  country  they 
are  very  rare.  I  have  .seen  but  one  instance  in  my  post-uu)rteui  experience. 
Depending  on  the  number  and  the  locality  specially  affected,  the  symptoms 
may  be  grouped  into  general,  cerel)ro-si)inal,  and  ocular.  In  IT).")  cases  com- 
piled by  Stiles,  the  parasite  in  117  was  found  in  the  brain,  in  :i-i  in  the 
muscles,  in  S)  in  the  heart,  in  3  in  the  lungs,  suhcutaneously  in  5,  in  tlie  liver 
in  'i. 

(1)  (leitcral. — As  a  rule  the  invasion  of  tlie  larviv  in  man,  unless  in  very 
large  nund)ers,  does  not  catise  very  definite  symptoms.  It  occasionally 
happens,  however,  that  a  striking  picture  is  produced.  For  instar 
a  patient  was  adniitt-d  to  my  wards  very  stilf  and  iieipiess,  so  much  ^o 
that  he  had  to  be  assisted  upstairs  and  into  bed.  lie  complained  of  numb- 
ness and  tingling  in  the  extremities  and  general  weakness,  so  that  at  first 
he  was  thought  to  have  a  jieripheral  neuritis.  At  the  examination,  how- 
ever, a  numlier  of  painful  subcutaneous  nodules  were  discovered,  which 
proved  on  excision  to  he  the  eysticerci.  Altogether  75  could  be  felt  sub- 
cutaneously,  and  from  the  soreness  and  stilfness  they  probalily  existed  in 
large  numbers  in  the  muscles.  There  were  none  in  his  eyes,  and  he  had 
no  symjitoms  pointing  to  brain  lesions. 

(?)  Ccrchro-spiiKil. — IJemarkable  sym])toms  may  result  from  the  pres- 
ence of  the  eysticerci  in  the  brain  and  cord.  In  the  silent  region  they  may 
be  abundant  without  jiroducing  any  symptoms.  I  have  in  my  possession 
the  brain  of  a  pig  containing  scores  of  "measles,"  yet  the  animal  in  the 
few  moments  in  which  1  saw  it  just  prior  to  death  did  not  iiresent  any 
symiitoms  to  attract  attention.  In  the  ventricles  of  the  brain  the  eysti- 
cerci may  attain  a  considerable  size,  owing  to  the  fact  that  in  regions  in 
which  they  are  unrestrained  in  their  growtli,  as  in  the  peritona'um,  the 
bladder-like  body  grows  freely.  When  in  the  fourth  ventricle,  remarkable 
irritative  sym])toms  may  be  produced.  In  1881  I  saw  witn  Friedliinder  in 
Berlin  a  case  from  l^iess's  wards  in  which  during  life  there  had  been  symp- 
toms of  diabetes  and  anomalous  nervous  symptoms.  Post  mortem,  the 
cysticercus  was  found  beneath  the  valve  of  Yieussens,  pressing  upon  the 
floor  of  the  fourth  ventricle. 

(;>)  Ocnhir. — Since  von  Graefe  demonstrated  the  ]iresence  of  the  cysti- 
cercus in  the  vitreous  humor  many  cases  have  been  jilaced  on  record,  and 
it  is  a  condition  easily  recognized  by  oculists. 

Except  in  the  eye,  the  diagnosis  can  rarely  he  made;  when  the  cysti- 


370 


DISF^ASES  DUE  TO   ANIMAI.   PAKASITRS. 


ccrci  arc  sulu'iitniicoiis,  one  may  ))0  excised.  It  is  possible  that  when 
miiiierous  throiijrhoul  the  imiseles  tliey  may  he  seen  iiiuler  the  loii-riie,  in 
which  situation  tlicy  may  exist  in  the  ])is  in  numl)ers. 

II.  EchinoCOCCUS  Disease.— Tiie  liychitid  woims  or  eehinoeoeci  are  tlie 
hirva'  of  the  Twiiia  (rliiminxrus  ol  tiie  (h)-'-  'I'his  is  a  tiny  cestodi'  not 
more  than  4  or  5  mm.  in  U'n<;tli,  consisting  of  only  lliree  or  four  se,iiinents, 
of  wliieli  tiie  terminal  one  alone  is  mature,  and  has  a  len.uth  of  about  2  mm. 
and  a  breadth  of  O.C  mm.  'I'he  head  is  small  and  provided  with  four  suck- 
ing disks  and  a  rostellum  witii  a  double  row  of  booklets.  This  :-  -'  exceed- 
ingly rare  parasite  in  Iho  dog.  Cobliold  states  that  he  has  never  met  with 
a  natural  specimen  in  Knglaud.  l>eidy  had  not  one  in  iiis  large  ndleetion. 
I  have  not  met  with  an  instaiice  in  this  country,  nor  do  1  know  of  its  ever 
luiving  been  descril)ed.  The  only  sjiecinu'ns  in  my  cabinet  1  i)r()cured 
exiierimentally  by  feeding  a  dog  witli  echinococcus  cysts  from  an  ox.  Tlie 
worms  are  so" small  that  they  may  be  readily  overlooked,  since  they  form 
small  white,  thread-like  l)odics  closely  adherent  among  the  villi  of  the 
small  intestines.  The  ri])e  segment  contains  about  5,01)0  eggs,  which  at- 
tain their  development  in  the  solid  organs  of  various  animals,  inirticularly 
the  hog  and  ox,  more  rarely  the  horse  and  the  sheep.  In  some  countries 
man  is'^a  common  intermediate  h()>t,  owing  to  the  accidental  ingestion  of 

the  ova. 

Dt'irloimioil.—'Vha  little  six-hooked   emliryo,  freed   from  the  eggshell 
by  digestion,  burrows  through  the  intestinal  wall  and  reaches  the  perito- 
neal t'i^ivity  or  the  nniscles;  it  may  enter  tiie  portal  vessels  and  be  carried  to 
the  liver.     It  may  enter  the  systemic  vessels,  and,  iiassiii :  tlu    iiulnionary 
caiuUaries,  as  it  is  ])rotoi)lasmic  and  elastic,  may  reach  t  c  brain  or  other 
parts.     Once  having  reached   its  destination,   it  undergo,      the   following 
changes:  The  booklets  disajijiear  and  the  little  embryo  is        idually  eon- 
verted  into  a  small  cyst  which  presents  two  distinct  layers — an  externnl. 
laminated,  culicular  mendmine  or  capsule,  and  an  internal,  granular,  ])ar- 
enchymatous  layer,  the  cndocyst.     The   little   cyst  or  vesicle   contains   a 
clear"  tluid.     There  is  more  or  less  reaction  in  the  neighl)oring  tissues,  and 
the  cyst   in  time  has  a  fibrous  investment.     \Vhen  this  jtrimary  cyst   or 
vesicle  has  attained  a  certain  size,  ])uds  develop  from  the  parenchymatous 
layer,  which  arc  gradually  converted  into  cysts,  presenting  a  structure  iden- 
tical with  that  of  the  original  cyst,  namely,  an  elastic  chitinous  membrane 
lined  with  a  granular  i)arenchyuiatous  layer.     Tiiese  secondary  or  daughter 
cysts  are  at  first  connected  with   the  lining  membrane  of  the  primary 
cyst,  but  are  soon  set  free.     In  this  way  the  ])arent  cyst  as  it  grows  may 
contain  a  dozen  or  more  daughter  cysts.     Inside  these  daughter  cysts  a  simi- 
lar process  may  occur,  and  from  buds  in  the  walls  granddaugliter  cysts  are 
develojied.    From  the  granular  layer  of  the  jiarent  and  daughter  cysts  buds 
arise  which  develop  into  brood  capsules.     From  the  lining  membrane  the 
little  outgrowths  arise  and  gradually  develop  into  bodies  known  as  scolices, 
which  represent  in  reality  the  head  of  the  To'tiia  erhinornrrus  and  present 
four  sucking  disks  and  a  circle  of  booklets.     Each  scolex  is  cai)al)le  when 
transferred  to  the  intestines  of  a  dog  of  develoi)ing  into  an  adult  ta]ie-worm. 
The  ditferenco  between  the  ovum  of  an  ordinary  tape-worm,  such  as  the 


DISEASES  CAUSHI)   HY  CESTODES. 


371 


If  that  when 
lie  lon^'uc,  ill 

)cofci  art'  tlic 
y  t'ostodi'  mil 
four  segments. 


ahoiit 


nun. 


itli  lour  sui'k- 
s  is  ii'-  oxcood- 
ovcr  nu't  with 
,rj;T  t'ollcction. 
low  ol'  its  over 
et  1  jiroeureil 
n  an  ox.  Tlu' 
nee  lliey  form 
le  villi  of  the 
figs,  which  al- 
ls, ])artieularly 
sonic  countries 
al  ingestion  of 

n  (he  eggsliell 
hcs  the  pcrito- 
(1  he  carried  to 
the  ])iilmoiiary 
brain  or  other 

IJie  following 
^ladiially  con- 
•! — an  external. 

granular,  jiar- 
iclc  contains  a 
ng  tissues,  and 
iriniary  cyst  or 
)arenchyniatous 
structure  ideii- 
nous  nienilirane 
iry  or  daughter 
)f  the  primary 
s  it  grows  may 
ter  cysts  a  siini- 
iglitcr  cy.sts  are 
rhter  cy.sts  buds 

membrane  the 
own  as  scolices, 
rus  and  present 
is  cajiable  when 
dult  ta])0-worm. 
rm.  such  as  the 


Twinn  snhiim,  and  the  T,rni,!  rvhiunmrrus  is  in  this  wav  very  striking  In 
the  lorniercaso  the  ovum  (],.\vh.ps  into  a  single  larva— the  c'.i.limrns  irlln- 
/,,v,p_w],orcas  tlic  egg  of  (he  Tivnla  rrhinnmrntx  (h'velops  in(o  a  cy.st  wiiich 
i.s  capable  of  nuiKiplying  ..normously  nud  from  (iie  lining  meuihran..  of 
winch  nnlhens  of  larval  lap.-worms  dev..|op.  Ordinarilv  in  man  the  de- 
velojnnent  of  the  echino.o.ms  takes  pla.e  as  above  nientioned  and  by 
an  endogenous  b.rm  in  which  (he  s.rondarv  and  (ertiary  cysts  are  con- 
tained within  the  primary:  but  in  animals  the  formation  may  be  dillVrent, 
as  (be  buds  from  the  primary  cyst  penetrate  between  (he  lavers  and  develoi, 
cxtenially,  lormiiig  the  exogenous  variety.  A  (hin)  form  is"(he  multiloeiilar 
ecbnuH.o.ciis,  ui  which  from  the  primary  cysts  buds  .levelop  which  are  cut 
oil  cmpletciy  and  are  surrounded  by  thick  capsules  of  a  coimeetive  tissue 
which  join  together  and  ultimately  fon.i  a  hard  mass  repr.seiited  by 
strands  of  connective  ti.-^sue  enclosing  alveolar  spaces  about  the  size  of 
peas  or  a  little  larger.  In  these  spaces  are  found  the  irmnants  of  (ho 
echinococciis  cyst,  occasionally  the  scolices  or  booklets,  but  tliev  are  often 
sterile. 

The  lluid  of  the  ecliinococ-us  cysts  is  clear  and  limpid,  and  has  a  m)c- 
citic  gravity  from  1.005  to  1.00!).  It  does  not  cntaiu  albiimiu,  but  niay 
contain  traces  of  stigar.  As  a  rnle,  the  cysts,  when  not  deov.u.ratcd,  con'- 
(am  (he  hydadd  heads  or  scolices  or  (he  characteristic  booklets 

Chain/es  in  Ihe  Ci/st.—  U  is  not  known  delinitelv  how  Ion--  the  echino- 
coccus  remains  alive,  bu(  i(  probably  lives  many  vJar.s— acconling  (o  some 
andiors  as  long  as  (weiily  years.  Th.'  uiost  common  change  is  dea(h  and 
(ho  gradual  ins|)issa(ion  of  (he  cimtents  and  coiiversi(m  of' (ho  cys(  in(o  'i 
mass  containing  imity-like  or  granular  material  whieh  may  he  jiartially 
caleilied.  IJ.'mnants  of  the  ehitiiious  cyst  wall  or  booklets  may  bo  found. 
These  obsolete  hydatid  cysts  are  not  infre(iuentlv  bmnd  in  tlic  liver.  A 
more  serious  terniination  is  ru|)ture,  which  may" take  place  into  a  serous 
sac.  or  ])erforation  may  take  place  externally,  when  the  cysts  are  discharged, 
as  into  the  bronchi  or  alimentary  canal  or  urinary  passages.  More  "un- 
favorable are  the  instances  in  which  rupture  occur.-"  into  (bo  bile-passages 
or  into  the  inferior  cava.  Recovery  may  b)llow  (ho  rupdiro  and  dischar"-o 
of  the  hydatids  externally.  Sudden  death  has  been  known  to  follow  the 
riiiitnro.  A  third  and  very  serious  mode  of  (orminadon  is  sup])uration, 
which  niay  occur  spontaneously  or  follow  riipdire  and  is  found  most  fre- 
qiiendy  in  the  liver.  T,.,rge  ab.sco.-sos  may  bo  formed  which  contain  the 
hydatid  membranes. 

drut/ivphira}  Dislrihiitioii  „f  ihe  Erhinornrnis.— The  di.sea.so  i)revails 
most  extensively  in  those  countries  in  which  uian  is  brought  into  close 
contact  with  the  dog,  ])ar(i(ularly  when,  as  in  Aus(ralia,  (ho  dogs  are  useil 
extensively  for  herding  sheep,  the  animal  in  wliicli  (he  larval  form  of  the 
T(ruia  frJiliinrnrnt.^  is  most  freipiently  found.  Tn  Iceland  the  cases  are 
very  numerous.  In  Kurojio  the  disease  is  not  uncommon.  Tn  this  country 
it  is  extremely  rare  and  a  groat  majority  of  all  eases  are  in  forei-'nors 
T^p  to  .luly,  ISni,  T  have  boon  able  (o  find  in  (he  IKoradire  (and  in  the 
museums)  only  85  cases  in  (he  T'niud  S(a(os  and  Canada.  In  (he  Ice- 
landic se(deinents  of  ]\Ianitoba  many  instances  occur.    A.  II.  Ferguson,  wlio 


«■* 


372 


DISEASES  DUE  TO  ANIMAL  PARASITES. 


lias  opiTiUi'd  oil  a  ininihcr  of  ratted  at  the  Winnipog  ticneral  Hospital,  status 
that  IjL'twui'U  I'oi'ty-livo  and  lii'ty  persons  with  ecliinococcus  diseaso  have 
l)L'i'ii  tivatud  ill  Winnipog  since  IS?  1,  the  date  of  the  Icelandic  iinniigra- 
tiou. 

Distrihiiliiin  in  llic  lii.dij.—Oi  the  l,8(;iJ  cases  comprised  in  the  statis- 
tics of  Davaine,  Cohhohl,  Finsen,  and  Neisser,  tlie  parasites  existed  in  tlie 
liver  in  {)■)'?,,  in  tiie  intestinal  eaiuil  in  IGO,  in  the  lung  or  i)leura  in  ir»;5,  in 
the  kidneys,  hjadder,  and  genitals  in  180,  in  the  brain  and  si)inal  car  4  in 
l-v'7,  hone  (i1,  heart  and  blood-vessels  (Jl,  other  organs  158.  Of  the  85 
cases  in  tliis  co.mtry,  tlie  liver  "was  tlie  seat  of  the  disease  in  5i).  Of  50 
consecutive  cases  treated  hy  Mosler  at  the  (Ireii'swald  clinic,  3(j  involved 
the  liver,  10  the  lungs,  '?,  the  right  kidney,  and  1  the  spleen. 

Symptoms.— («)  Ili/dotids  of  the  Z/cer.— Small  cysts  may  cause  no 
disturbance;  large  and  growing  cysts  iiroduco  signs  of  tumor  of  the  liver 
with  great  increase  in  the  size  of  the  organ.  Xaturally  the  physical  signs 
depend  much  upon  the  situation  of  the  growth.  Xear  the  anterior  sur- 
face in  the  epigastric  region  the  tumor  may  form  a  distinct  prominenco 
and  have  a  tense,  llrm  feeling,  sometimes  with  fluctuation.  A  not  infre- 
quent situation  is  to  the  left  of  the  suspensory  ligament,  forming  a  tumor 
which  pushes  up  the  heart  and  causes  an  extensive  area  of  dulness  in  the 
lower  sternal  and  left  hypochondriac  regions.  In  the  right  lobe,  if  the 
tumor  is  on  the  posterior  surface,  the  enlargement  of  the  organ  is  cliieily 
upward  into  the  iilcura  and  the  vertical  area  of  dulness  in  the  posterior 
axillary  line  is  increased.  Superficial  cysts  may  give  what  is  known  as  the 
hydatid  fremitus.  If  the  tumor  is  palpated  lightly  with  the  fingers  of  the 
left  hand  and  percussed  at  the  same  time  with  those  of  the  right,  there  is 
felt  a  vibration  or  trembling  movement  which  persists  for  a  certain  time. 
It  is  not  always  present,  and  it  is  doulttful  whether  it  is  peculiar  to  the 
hydatid  tumors  or  is  due,  as  Briangon  held,  to  the  collision  of  the  daugh- 
ter cysts.  Very  large  cysts  are  accomi)anied  by  feelings  of  pressure  or 
dragging  in  the  hepatic  region,  sometimes  actual  pain.  The  general  con- 
dition of  the  patient  is  at  first  good  and  the  nutrition  little,  if  at  all,  in- 
terfered with.  I^nless  some  of  the  accidents  already  referred  to  occur,  the 
symptoms  indeed  may  be  trilling  and  due  only  to  the  jiressure  or  weight 
of  the  tumor. 

Suppuration  of  the  cyst  changes  the  clinical  jiicture  into  one  of  pyirmia. 
There  are  rigors,  sweats,  more  or  less  jaundice,  and  rapid  loss  of  weight. 
Perforation  may  occur  into  the  stomach,  colon,  pleura,  bronchi,  or  exter- 
nally, and  in  some  instances  recovery  has  taken  place.  Perforation  into 
the  pericardium  and  inferior  vena  cava  is  fatal.  In  the  latter  case  the 
daughter  cysts  have  been  found  in  the  heart,  ])lugging  the  tricusjiid  ori- 
fice and  the  ]nilmonary  artery.  Perforation  of  the  bile-passages  causes 
intense  jaundice,  and  may  lead  to  suppurative  cholangitis. 

An  interesting  sym])tom  connected  with  the  rupture  of  hydatid  cysts 
is  the  development  of  urticaria,  wliicli  may  also  follow  as]iiration  of  the 
cvsts.  Erieger  has  separated  a  highly  toxic  material  from  the  fluid,  and  to 
it  the  symptoms  of  poisoning  may  lie  due. 

Diagnosis. — Cysts  of  moderate  size  may  exist  without  iiroducing  symp- 


[lospital,  stiitus 
s  diseaso  have 
ludic  immigia- 

1  in  llio  statis- 
cxistt'd  in  the 

eiira  in  Ib'o,  in 
s})iiial  oar  "1  in 
8.  Of  the  85 
in  51).  Of  50 
.c,  3(j  iuvolved 

may  cause  no 
or  of  the  liver 

physical  signs 
e  anterior  siir- 
ict  prominence 
A  not  infre- 
rming  a  tumor 
dulness  in  the 
lit  loho,  if  tlie 
jrgan  is  chielly 
11  the  posterior 
s  known  as  the 

2  fingers  of  the 
right,  there  is 

a  certain  time, 
peculiar  to  the 
L  of  the  daugh- 
of  pressure  or 
ic  general  con- 
ic, if  at  all,  in- 
d  to  occur,  the 
isure  or  weight 

one  of  i)yaMnia. 
loss  of  weight, 
mchi,  or  exter- 
'orforation  into 
latter  case  the 
e  tricuspid  ori- 
passagcd  causes 

f  hydatid  cysts 
piration  of  the 
he  fluid,  and  to 

roducing  symp- 


DISEASES  CAUSED  BY  t'ESTODES. 


373 


toms.      Large    multiple    cchinm'occi    may    cau.<e   great    enlargement    with 
irregularity  of  the  outline,  and  such  a  condition  persisting  .for  any  time 
with  retention  of  tlie  healtli  and  strength  suggests  hydatid  disease.     An 
iiiegula,",  jiaiidess  enlargement,  particularly  in  the  left  lol)e,  or  the  pres- 
ence of  a  large,  smooth,  fluctuating  tumor  of  the  epigastric  region  is  also 
very  suggestive,  and   in   (his  situation,   wlien   aeoessihle   to   palpation,   it 
gives  a  sensation  of  a  smooth  elastic  growth  and  possibly  also  the  hydatid 
tremor.     When  su])puration  occurs  the  clinical  picture  is  really  that  of 
ahscess,  and  only  the  existence  of  previous  enlargement  of  the  liver  with 
good  health  would  point  to  the  fact  that  the  suppuration  was  associated 
with  hydatids.     Sypliilis  may  produce  irregular  enlargement  without  much 
(listur])ance  in  the  health,  sometimes  also  a  very  definite  tumor  in  the 
epigastric  region,  hut  this  is  ustially  firm  and  not  fiuctuating.    The  clinical 
features  may  simulate  cancer  very  closely.    In  a  case  which  I  reported  the 
liver  was  greatly  enlarged  and  there  were  many  nodular  tumors  in  the 
abdomen.     The  post  mortem  showed  enormous  suppurating  hydatid  cysts 
in  the  left  lobe  of  the  liver  whieh  had  perforated  the  stomach  in  two 
places  and  also  the  duodenum.     The  omentum,  mesentery,  and  pelvis  also 
contained  numerous  cyst-;.     As  a  rule,  the  clinical  course  of  the  disease 
would  sulfice  to  separate  it  clearly  from  cancer.     Dilatation  of  the  gall- 
l)laddor  and  liydrone])hrosis  have  both  been  mistaken  for  liydatid  disease. 
In  the  former  the  mo])ility  of  the  tumor,  its  sliape,  and  the  mucoid  char- 
acter of  the  contents  sulTice  for  the  diagnosis.    In  some  instances  of  hydro- 
nephrosis only  the  exploratory  puncture  could  distinguish  between   the 
conditions.     :\rorc  frequent  is  the  mistake  of  confounding  a  hydatid  cyst 
of  the  right  lobe  pushing  uj)  the  pleura  with  pleural  elfusion  of  the  right 
side.    The  heart  may  be  dislocated,  the  liver  depressed,  and  dulness,  fet^jle 
breathing,  and  diminished  fremitus  are  present  in  l)oth  conditions.     Fre- 
richs  lays  stress  upon  the  dilferent  character  of  the  line  of  dulness;  in  the 
echinococcus  cyst  the  upjier  limit  presents  a  curved  line,  the  maximum 
of  which  is  usually  in  the  scapular  region.     Suppurative  pleurisy  may  be 
caused  by  the  perforation  of  the  cyst.    If  adhesions  result,  the  ])erforation 
tidvcs  place  into  the  lung,  and  fragments  of  the  cysts  or  small  daughter 
cysts  may  be  coughed  uj).    Vot  diagnostic  i)urposcs  the  exploratory  punc- 
ture should  be  used.    As  stated,  the  lliud  is  usually  perfectly  clear  or  slightly 
opalescent,  the  reaction  is  neutral,  and  tlie  specific  gravity  varies  from  1.005 
to  1.000.    It  is  non-albuminous,  but  contains  chlorides  and  sometimes  traces 
of  sugar.     Ilooklets  may  be  found  either  in  the  clear  fluid  or  in  t'le  suj)- 
purating  cysts.     They  are  sometimes  absent,  however,  as  the  cyst  may  be 
sterile. 

(h)  Erlihwcnccus  of  ihr  T!c:<pirator!j  Stjsicm.~Ol  809  cases  of  single 
hydatid  cyst  collected  by  Thonuis  in  Australia,  the  lung  was  aA'ccted^'in 
134  cases.  The  larvfc  may  develop  primarily  in  the  pleura  and  attain  a 
large  size.  The  symptoms  are  at  first  those  of  compression  of  the  lung 
and  dislocation  of  the  heart.  The  physical  signs  are  tliose  of  fluid  in  the 
jdeura  and  the  condition  could  scarcely  be  distinguished  from  ordinary 
effusion.  The  line  of  dulnos;  may  be  quite  irregular.  As  in  the  echino- 
coccus of  the  liver,  the  general  condition  of  the  patient  may  be  excellent 


.-* 


374 


DISEASES  DUK  TO   ANIMAL   PARASITES. 


I 


in  ^nW  ..[  thf  exislcncr  ..1'  .■xtcnsiv  .lis.as.".  I'U'Uiisy  is  nuvly  (vxcitod. 
Till'  cvsts  iiiiiy  Itofoiiiu  inllunu'd  iin.l  iHTlurati'  tlir  v\ivA  unll.  In  a  ease 
or  1)  r  Siiiilirs,  of  WalkcHown,  Oulario,  a  j;irl.  ajzf.l  twenty,  lia.l  a  run- 
u\u"  ...re  in  tl.o  ei-l.tli  U'l'l  intercostal  space.  This  was  freely  opened, 
aiufin  the  pus  wliieh  llowed  out  were  a  nuud-er  of  well-eharaetenxed  e.Iunu- 
eoceus  evsts  of  various  r-i/.es.     'I'lie  pi'tient  recovered. 

K,.l,in(. cocci  occur  more  fre(iueutly  in  tlic  lung  than  m  the  pleura.  II 
small  thev  may  exist  for  some  time  without  causing  serious  symptoms. 
In  their  growl li  they  compress  the  lung  and  sooner  or  later  l.'ad  to  ml  am- 
n.atorv  in'ocesses,  oiteii  to  gangrene,  and  the  formation  of  cavities  which 
connect  witli  the  bronchi,  i'ragments  of  meml)rane  or  small  cysts  may  he 
exi.ectoratc.1.  Ihvmorrhagc  is  not  infreipient.  Perforation  into  tlic  pleura 
with  empvema  is  common.  A  majority  of  tiie  cases  are  regarde.  during 
life  as  either  i-hthisis  or  gangrene,  and  it  is  only  the  detection  ol  the  char- 
acteristic meiid.ranes  or  the  h.uddets  whicli  leads  to  the  diagm.sis.  i  he 
ccmdition  is  uMiallv  fatal;  only  a  few  cases  have  recovered.  Oi  tiie  h.j 
American  cases,  in  (i  the  cy.sts  occurred  in  the  lung  or  pleura. 

(r)  Echinoroccm  of  tlir  Kiihic!is.-\n  the  c.dlected  statistics  relerre. 
to  ahove  the  genito-urinary  system  comes  se.'ond  as  the  seat  ol  liydat>d 
disease,  though  here  the  atlection  is  rare  in  compari.son  with  t  lat  o  the 
liver  Of  the  cSr,  American  cases,  there  were  only  3  m  whicli  tiie  kidneys 
or  bladder  were  involved.  The  kidney  may  be  c.nivorted  into  an  enormous 
cvst  resembling  a  hydronephrosis. 

'  The  dia-uosis  is  only  p-ossible  by  ].iincture  and  examination  oL  the 
fluid  The 'cvst  mav  perforate  into  the  pelvis  of  the  kulney,  and  p-u'tions 
of  the  memlirane  oV  cvsts  may  bo  discharged  with  the  urine,  sometimes 
producing  renal  colic.  ^I  have  rejiorted  a  case  in  wliicli  f..r  many  nu)nt  is 
the  imtient  passed  at  intervals  numbers  of  small  cysts  with  tiic  urine.  J  he 
general  health  was  little  if  at  all  disturbed,  cxcei.t  by  the  attacks  ol  colic 
during  the  passage  of  the  ])arasites. 

(d)  Eihinunnru:<  of  llir  Xcrmus  >>/*■;».— In  this  country  very  iew  in- 
stances liave  occurred  in  the  brain.  One  or  two  reports  indicate  clearly 
that  the  common  cvstic  disease  of  the  choroidal  plexuses  lias  been  mistaken 
for  hvdatids.  Davies  Thomas,  of  Australia,  has  tabulated  1)7  eases,  mclud- 
in<^  some  of  the  Cy><lir('rnis  rrl],nns(V.  Acc.n-ding  to  his  statistics,  the  cyst 
is  more  common  on  the  right  than  on  the  left  side,  and  is  most  frequent 

in  the  cerebrum.  ,      ,    .        ,,  e  > 

The  svmi.tonis  arc  very  indefmile.  as  a  rule,  being  those  of  Imnm. 
I'ersistent'  headache,  convulsions,  cither  limited  or  general,  and  gradually 
developin--  blindness  have  boon  prominent   featiuvs  in  many  cases. 

Multilocular  EchinocOCCUS.-^riiis  form  merits  a  brief  separate  descrip- 
tion as  it  dilVers  so  remarkably  from  the  usual  type  of  the  disease.  7t  has 
been  met  with  only  in  T.avaria,  Wiirtemberg,  the  adjacent  districts  of 
Switzerland,  and  in  th.^  ^Fyrol.  Possett  has  reported  ]:]  cases  from  von 
l^okitanskv's  clinic  at  Innsbruck.  Tn  the  Ignited  .States  cases  are  occasion- 
ally seen.  "  The  ])atient  of  Delafield  and  Prudden  was  a  C.M-man.  who  had 
been  in  tln^  country  live  years.  For  a  year  previous  to  his  death  he  was 
out  of  health,  jaundiced,  and  somewhat  emaciated.     A  lluctuating  tumor 


■■ 


in 


I'AUASITIC   AUACIINIDA. 


375 


•lUfly  ('xciti'd. 
11.  In  ii  ciiSL' 
y.  luul  a  nin- 
frccly  npt-MKMl. 

Cl'i/A'il  ctllilln- 

lu'  |>i('ui'ii.    ir 

ms  sytuptoni.--. 
cad  to  inllain- 
cavitics  which 
1  cysts  may  he 
iito  thv  |ilcura 
uanlcd  duriiiji 
111  of  the  char- 
iagiuisis.  The 
d.'  or  liie  s.-) 
■a. 

tistics  rererred 
eat  of  hydatid 
th  tliat  of  tlie 
ch  the  kidneys 
()  an  I'Horinous 

illation  of  the 
\\  and  portions 
iiie,  soiiietiines 
•  many  moiitlis 
he  lu'ine.  The 
iitlacks  of  colic 

ry  very  few  in- 
indicate  clearly 
;  hecn  mistaken 
7  cases,  incUid- 
tistics,  tlie  cyst 
■■  most  frecjuent 

hose  of  tumor. 
,  and  gradually 
iiy  cases. 
:'parate  descrip- 
(iisease.  Tt  has 
eiit  districts  of 
eases  from  vou 
;es  are  oeeasion- 
■rnian,  who  had 
is  death  he  was 
ictuating  tumor 


was  found  in  the  righl  Inndiar  and  iiinliilieal  regions,  apparently  connected 
with  the  liver.  This  was  o|iened.  and  (h'ath  followed  fioiii  hiemorrhage. 
Ahout  a  foiirlh  of  the  right  hilie  of  the  liver  was  occupied  iiy  an  irregular 
cavity  with  rough,  ragged  wails,  which  in  places  were  from  one  to  two 
inches  in  thickness  and  ciicloseil  irregular  small  cavities.  'I'lie  laiiiclhited 
ciiticiila  (  haracteristic  of  the  ecliiiiococeiis  cyst  was  found  lining  these  cavi- 
ties. In  some  instances  the  tiiiiior  hears  a  striking  likeness  to  colloid  can- 
cer, as  on  section  it  presents  a  lihroiis  stroma  with  cavities  containing 
gelatinous  material.  They  are  often  sterih — that  is.  without  the  hyilatid 
heads  or  larva\  'I'his  form  is  almost  exclusively  confined  to  the  liver,  and 
the  .<yinptoiiis  rcsemhle  more  those  of  tumor  or  cirrhosis.  The  liver  is,  as 
a  rule,  enlarged  and  smooth,  not  irregular  as  in  preseiico  of  the  ordinary 
echiiiococciis.  .laiindice  is  a  common  symptom.  The  spleen  is  nsnallv  en- 
larged, there  is  progressive  emaciation,  and  towani  the  close  ha'niorrhagos 
are  conimoii. 

Treatment  of  Echinococcus  Disease.— ^fedicines  nro  of  no 
avail.  J'ost-mortem  reports  show  that  in  a  considerahle  nuniher  of  cases 
the  parasite  dies  and  the  cyst  hecomes  harmless.  ( (perative  measures  should 
he  resorted  to  when  the  cyst  is  large  or  troulilesome.  The  simjile  aspira- 
tion of  the  contents  has  heeii  successfid  in  a  large  nnmher  of  cases,  and  as 
it  is  not  in  any  way  dangerous,  it  may  l)e  tried  hefore  the  more  radical 
procedure  of  incision  and  evacuation  of  the  cysts.  Suppuration  has  oc- 
casionally followed  the  puncture.  Injections  into  the  sac  should  not  he 
practised.  With  modern  methods  surgeons  now  open  and  evacuate  the 
echinococcus  cysts  with  great  holdness,  and  the  Australian  records,  which 
are  the  most  numerous  and  iin])ortaiit  on  this  suhjeet,  show  tiiat  recovery 
is  the  rule  in  a  large  projiortion  (d'  the  cases.  Suppurative  cysts  in  the 
liver  sliould  he  treated  as  ahseess.  \afurally  the  outlook  is  less  favorahle. 
The  ])ractical  treatnu'iit  of  hydatid  diseas(^  has  heen  gr(>atly  advanced 
hy  Australian  surgeons.  The  works  of  the  Australian  physicians  James 
(fraliam  and  Thomas  may  l)e  consulted  for  interesting  details  in  diagnosis 
and  treatment. 


VI.    PARASITIC    ARACHNIDA. 

(1)  Pentastomes. — (n)  Liiif/nahila  rltiimria  (Ppufaslomn  hviiiniih'x)  lias 
a  somewhat  lancet-shaped  liody.  the  female  heiiig  from  '.^  to  4  inches  in 
length,  the  male  ahoiit  an  inch  in  length.  The  I)ody  is  tapi-ring  and  marked 
iiy  iiiimerous  rings.  The  adult  worm  infests  the  frontal  sinuses  and  nostrils 
(d'  the  dog.  iiKU-e  rarely  of  the  horse.  The  larval  form,  which  is  known  as 
tlie  Limimilithi  .ii'rnifn  (Pi'iifftsloiinnii  ilciifinihifiini),  is  seen  in  the  internal 
organs,  particularly  the  liver,  hut  has  also  Iieen  found  in  the  kidney.  Tlu' 
adult  worm  has  Ikhui  found  in  the  nostril  of  man,  hut  is  very  rare  and 
seldom  occasicnis  any  inconvenience.  The  larva-"  are  hy  no  means  uncom- 
mon, particularly  in  parts  of  riermany. 

(h)  The  PnrorrphaJiis  roiislrirtiis  (Pcnfa.ifonnim  ronsfrirliim),  which  is 
ahout  the  length  of  half  an  inch,  with  twenty-throe  rings  on  the  ahdomen. 


370 


DISEASES  DUE  TO  ANIMAI.   PARASITES. 


was  foiina  by  Aitken  in  the  liver  iin<l  Imi-s  of  a  soldier  of  a  West  Tiiclian 

regiment. 

The  parasite  is  very  rare  in  this  eouutry.  Flint  refers  to  a  Missouri 
case  in  wliieli  from  T.')  to  100  of  the  jiara-ites  were  expectoratoil.  Tlu' 
liver  was  enlarged  niul  the  parasites  prohahly  oeeiipied  this  region.  In 
ISd!)  I  saw  a  sjieeimen  wliieli  had  Ixen  passed  with  the  uriiu.-  by  a  patient 
of  .hunes  II.  Iiiehardson,  of  Toronto. 

{•i)  Demodex  (Acarus)  folliculorum  (var.  hominis).— A  niinnt.>  pani- 
gite,  from  U.;5  nun.  to  O.i  nun.  in  length,  whieh  lives  in  the  sehaeeous  folli- 
cles, particularly  of  the  face.  It  is  doubtful  whether  it  produces  any  symp- 
toius.  Possibly  when  in  large  numbers  they  may  excite  inilammation  ol 
the  follicles,  leading  to  acne. 

(3)  Sarcoptes  (Acarus)  scabiei  (Tlch  7«,sct7).— This  is  iiu'  most  impor- 
tant, of  the  arachnid  jiarasites,  as  it  produces  troublesome  and  distressing 
Fkin  crui.tions.  The  male  is  0.3.1  mm.  in  length  and  0.10  mm.  in  breadth; 
the  female  is  0.1.")  mm.  in  length  and  O.3.")  mm.  in  width.  The  female  can 
be  seen  readily  with  the  naked  eye  and  has  a  pearly-whito  color.  It  is  not 
60  common  a  i)arasite  in  the  Tnited  States  and  Canada  as  in  Europe. 

The  insect  lives  in  a  small  burrow,  about  1  cm.  in  length,  wliicli  it  makes 
for  itself  in  the  epidermis.  At  the  end  of  this  burrow  the  female  lives. 
The  male  is  seldom  found.  The  chief  scat  of  the  parasite  is  in  the  fold.s 
where  the  skin  is  most  delicate,  as  in  the  web  between  the  fingers  and  toes, 
the  backs  of  the  hands,  the  axilla,  and  the  front  of  the  abdomen.  The  head 
and  face  are  rarely  involved.  The  lesions  which  result  from  the  presence 
of  the  itch  insect  are  very  numerous  and  result  largely  from  the  irritation 
of  the  scratching.  The  commonest  is  a  papular  and  vesicular  rash,  or,  in 
children,  an  ecthymatous  eruption.  The  irritation  and  pustulation  which 
follow  the  scratching  may  completely  destroy  the  burrows,  l)ut  in  tyi)ical 
cases  there  is  rarely  doubt  as  to  the  diagnosis. 

The  treatment  is  simple.  It  should  consist  of  warm  baths  with  a  thor- 
ono-h  use  of  a  soft  soap,  after  whieh  the  skin  should  lie  anointed  with  sul- 
phur ointment,  which  in  the  case  of  children  should  be  diluted.  An  oint- 
ment of  nai)hthol  (drachm  to  the  ounce)  is  very  cflicacious. 

(4)  Leptus  autumnalis  (Harvest  7?(/ry).— This  reddish-colored  ])arasite, 
about  half  a  millimetre  in  size,  is  often  found  in  large  numbers  in  fields 
and  in  gardens.  They  attach  themselves  to  animals  and  man  with  their 
sharp  proboscides,  and  the  iiooklets  of  their  legs  produce  a  great  deal  of 
irritation.  They  are  most  frequently  found  on  the  legs.  They  are  readily 
destroyed  by  suiphur  ointment  or  corrosive-sublimate  lotions. 

Several  varieties  of  ticks  are  occasionally  found  on  man — the  Txoilrs 
riritiui^  and  the  Dcrmaccnfor  a)ncricauu><,  which  are  met  with  in  horses 
and  oxen. 


VII.    PARASITIC    INSECTS. 

(1)  Pediculi  (PhUiiriasIf! :  re(licuhsis).—ThQYO  are  tliroe  varieties  of  the 
l)ody  loTise,  which  are  found  only  in  persons  of  uncleanly  habits. 

rcdinihis  capitis.— Tlnj  male  is  from  1  to  l.o  mm.  in  length  and  the 


West  Indian 

()  a  Missouri 

oratoil.     Tlu' 

i  region.     In 

by  a  patient 

niiiiuti'  pani- 
'Imoeous  ioili- 
?cs  any  pynip- 
laniniation  of 

'  most  inipor- 
11(1  distressing 
n.  in  breadth; 
he  I'enude  can 
b)r.  It  is  nut 
''urope. 

rhieli  it  makes 
!  female  lives. 
s  in  the  folds 
igers  and  toes, 
en.  The  head 
1  the  jiresence 
tlie  irritation 
ar  rash,  or,  in 
ulation  whieh 
l)ut  in  typieal 

IS  with  a  thor- 
nted  with  sui- 
ted.   An  oint- 

iiored  ])arasite, 
libers  in  fields 
lan  with  tlieir 
I  great  deal  of 
ley  are  readily 

111 — llie  Lrodrs 
ivith  in  horses 


varieties  of  the 

bits. 

length  and  the 


I'.MlASITir   IN.SKCT.S. 


U  t 


female  nearly  2  mm.  The  eolor  varies  somewhat  with  the  dilTerert  races 
of  men.  It  is  liglit  pray  with  a  liiaek  margin  in  the  iuiropeiin,  and  very 
iiiiieh  darker  in  the  negro  and  Chinese.  They  are  oviparous,  and  tiie  female 
lays  about  si.xty  eggs,  which  mature  in  a  week.  Tiie  ova  are  attached  to 
the  hairs,  and  can  be  readily  seen  as  wiiitt'  spi'cks,  known  popularly  as  nits. 
The  symptoms  are  irritation  and  itching  of  the  scalp.  When  numerous 
the  insects  niny  e.xeite  an  eczema  or  a  pustular  dermatitis,  which  causes 
crusts  and  scabs,  jwirticularly  at  the  back  of  the  bead.  In  the  most  cxtrenu; 
cases  the  hair  becomes  tangled  in  these  crusts  and  matted  togi'ther,  form- 
ing at  the  occiput  a  firm  mass  which  is  known  as  plint  jiohiiiiai,  as  it  was 
not  infreipieiit  among  the  Jewish  inhabitants  of  I'oland. 

I'viliniliis  corpiiris  {rcsliiiicnlnnnii). — This  is  considerably  larger  than 
the  iiead  louse.  Jt  lives  on  the  clothing,  and  in  sucking  the  blood  causes 
minute  luemorrhagic  specks,  which  are  very  common  about  the  neck,  back, 
and  abdomen.  The  irritation  of  the  bites  may  cause  urticaria,  and  tiie 
scratching  is  usually  in  linear  lines.  In  hmg-standing  cases,  ])artieidiirly 
ill  old  dissii)ated  characters,  the  skin  becomes  rough  and  greatly  pigmented", 
a  condition  which  has  been  termed  the  vagabond's  disease — iii'irhiis  crrorniu 
—and  which  may  be  mistaken  for  the  bronzing  of  Adilison's  disease. 

PJiiliifiiis  /nthis  dill'ers  somewhat  from  the  other  forms,  and  is  found 
in  tlie  parts  of  the  body  covered  with  short  hairs,  as  the  pubes;  more  rarely 
the  axilla  and  eyelirows. 

The  laches  bJfU(itre>i  are  stated  liy  I'reneh  wiitcrs  to  be  excited  by  the 
irritation  of  p(-diciili. 

Treatment.— I'or  the  Polirulus  capitis,  when  the  condition  is  very 
had,  the  hair  should  be  cut  short,  as  it  is  very  diiVicult  to  destroy  tlior- 
ougldy  all  the  nits.  I?(>peated  .saturations  of  the  hair  in  coal-oil  or  in  tur- 
pentine are  usually  ellicacious,  or  witii  lotions  of  carliolie  acid,  1  to  o<». 
Scrupulous  cleanliness  and  care  are  sutricient  to  prevent  reciirience.  In 
the  case  of  the  I'ciliciiliis  corporis  the  clothing  should  be  placed  for  sev- 
eral hours  in  a  disinfecting  oven.  To  allay  the  itching  a  warm  bath  con- 
taining 4  or  5  ounces  of  bicarlionato  of  soda  is  useful.  The  skin  may  be 
nibbed  with  a  lotion  of  carbolic  acid,  2  drachms  to  the  pint,  with  'i  ounces 
of  glycerin.  For  the  Phlliiriiis  piihis  white  precipitate  or  ordinary  mer- 
curial ointment  should  be  used,  and  the  ]iarts  should  be  thoroughly  wa.slied 
two  or  tliree  times  a  day  with  soft  soap  and  water. 

(2)  Cimex  lectularius  (row?)/*)/;  7?^J-&,„/)._This  parasite  is  from  3  to 
1  mm.  in  length  and  has  a  reddish-brown  color.  It  lives  in  the  crevices  of 
tiie  bedstead  and  in  the  cracks  in  the  floor  and  in  the  walls.  It  is  noc- 
turnal in  its  habits.  The  ]ieculiar  odor  of  the  insect  is  caused  by  the  secre- 
tion of  a  s])eeial  gland.  Th(>  parasite  possesses  a  long  proboscis,  with  wliicli 
it  sucks  the  lilood.  Individuals  differ  remarkably  in  the  reaction  to  the 
bite  0^  this  insect;  some  are  not  disturlied  in  the  slightest  liy  them,  in 
others  the  irritation  causes  hyjierannia  and  often  intense  nrticaria.  Fumi- 
gation with  sulphur  or  scouring  with  corrosive-sublimate  solution  or  kero- 
sene destroys  them.     Iron  bedsteads  should  be  used. 

(3)  Pulex  irritans  (The  Connnon  Fka).— The  male  is  from  2  to  2.5 
mm.  in  length,  the  female  from  3  to  4  mm.    The  flea  is  a  transient  para- 


378 


DISEASES  DUE  TO  ANIMAL   IWUASITES. 


Bite  on  num.  Tlif  hiti"  causes  a  (iniilar  n<l  spct  ..f  liyporiiMnia  in  tin'  (riitic 
(.r  \vlii<'li  iH  a  liltli-  speck  wliciv  tlic  l.orin-,'  apimraUis  has  cnl.'iv.l.  'I'lic 
iUiK.nnl  nf  irritation  canscd  hy  llu-  l.itc  is  varial.k'.  Many  i-crsons  sull.r 
intensely  and  a  ditViise  erytiienia  or  an  irritai)le  urticaria  develnps;  olliers 
snil'er  no  inconvenience  whatever. 

Tlie  I'lilr.r  iinwlniiis  {sdiid-flra :  jiijijn-)  is  tonnd  in  tropical  countries. 
].articniarly  in  the  West  Indies  and  Soiitii  America.  It  is  luiidi  smaller 
than  tiie  common  Ilea,  and  n..t  only  peiietnitt's  the  skin.  Inil  Imrn.ws  and 
produces  an  iidlammation  witli  puMidar  or  vesicular  swellinj:.  It  mosl 
lre(iuently  attacks  the  IVet.  It  is  readily  removed  witii  a  needle.  Where 
they  exist  in  large  nund)ers  the  ess(ntial  oils  aie  used  on  \\n'  ieet  as  a 
])reveiitive. 


VIII.    MYIASIS. 

or  tiiese,  the  most  important  are  the  larva'  of  c(Mliiin  diptera.  particu- 
larly the  flesh  Hies— ('mv///i/r'.     The  condition  is  called   myiasis. 

The  most  common  form  is  that  in  which  an  e.\ternal  wound  l.ecomos 
hvinij,  as  it  is  called.  This  myiasis  vulnerum  is  caused  hy  the  larva-  of 
either  the  hlue-hottle  or  the  common  ilesh  lly.  The  larva-  of  the  LunUa 
marclhinn,  the  so-called  screw-worm,  have  heen  found  in  the  nose,  m 
wounds,  and  in  the  va<rina  after  di'livcry.  They  can  he  removed  readily 
with  the  forceps;  if  there  is  any  dillicidty,  thoroufrh  cleansin;,'  and  the 
apjdication  of  an  antiseptic  handa^'c  is  snilicient  to  kill  them.  The  ova 
of  these  Hies  may  he  deposited  in  the  nostrils,  the  ears,  or  the  conjunctiva— 
the  myiasis  mirium,  aurium,  conjuiutiva-.  This  invasion  rarely  takes  jdace 
unless  these  regions  are  the  seat  of  disease.  In  the  nose  and  in  the  ear  the 
larva'  may  cause  seri(Uis  inllammation. 

The  cutaneous  myiasis  may  he  caused  hy  the  larvic  of  the  Mitsra  vmni- 
turia,  but  more  commonly  by  the  bot-flies  of  the  ox  and  sheep,  which 
occasionally  attack  man.  This  condition  is  rare  in  teini)erate  climates. 
:\latas  has  "described  a  case  in  which  (cstrus  larvie  were  found  in  the  glu- 
teal region.  In  parts  of  Central  America  the  eggs  of  another  bot-fly,  the 
Derwatohia,  are  not  infreciueiitly  deposited  in  the  skin  and  ])roduce  a 
swelling  very  like  the  ordinary  boil. 

A  specimen  of  the  JlomaloDiyia  sralaris.  oiu-  of  the  ])rivy  flies,  was  sent 
to  me  by  Dr.  TIartin,  of  Kaslo  ('ity.  IWitish  ("olund)ia.  the  larva'  of  whuh 
were  passed  in  large  numbers  in  the  stools  of  a  man  aged  twenty-four, 
a  native  of  Louisiana.     Tiiey  were  present  in  the  stools  from  May  1  to  -Tuly 

15.  1S!)7.  " 

]\fyiasis  interna  may  result  from  the  swallowing  of  the  larvie  of  the 
common  house  fly  or  of  species  of  the  genus  Antlwmyia.  There  are  many 
cases  on  record  in  which  the  larvsr  of  the  Mni<rn  dnmeslicn  have  been  dis- 
charLH'd  by  vomiting.  Instances  in  which  dipterous  larv.T  have  been  passed 
in  the  fa-ces  are  less  common.  Finlavson,  of  Cilasgow.  has  recently  re- 
ported an  interesting  case  in  a  ]ihvsician.  who,  after  protracted  constipa- 
tion and  pain  in  the  back  and  sides,  piissed  large  numbers  of  the  larv%T 
of  the  flower  fly — Anthomyia  canicuhiris.     Among  other  forms  of  larva) 


in  tlic  cciiin' 
U..1V.1.  'PI... 
crsoiis  siill't  r 
I'lopji;  ollii'is 

•al  (•(luiitrics, 
micli  siiiiilliT 
liiirrows  anil 

11},'.        It     IlUIHl 

(.(lie.  Wliorc 
I  lie   t'ct't   as  a 


it  era,  particii- 

iifis. 

niiid  l)iM'omrs 

the  larva'  ol' 
if  the  Lnrilln 

tlu'  i\i)s(',  ill 
iidvcd  readily 
isinj^  and  the 
'in.  Tlic  ova 
coiijuiu'liva — 
'ly  takes  jdace 
in  the  ear  the 

'  Musra  vami- 
shee]),  whieli 
•rate  eliiiuites. 
id  ill  the  gln- 
er  bot-fly,  the 
ud   ])roduee   a 

flies,  was  scut 
arviP  ol'  which 
1  tweiitv-fniir, 
May  1  to  ,1  Illy 

'  larva^  of  tlie 
here  are  many 
have  boon  dis- 
vo  boon  passed 
IS  ropontly  to- 
lotod  oonstipa- 
R  of  the  larva? 
'ornis  of  larvaj 


MYIASIS. 


3711 


"I-  Uni/lrs,  as  (hry  are  snin.(ini..s  ealj..!.  uhirli  have  been  found  in  tho 
lares,  are   llmse   ul    the   .■.„,„„.„,    hun>e    lly,   the    hjiie-hottlo   ily,  und   the 

stated  that  the  eaterpiiiar  of  th,.  lahby  inulli  has  been  foi.n.l  in  the  fioces 
"'■'V  iMiiy  he  nieiitin,„.d  aninn-  the  ..ir.vls  of  Jnseets  the  n'lnarkable 

"'•'""•;''  ri.uln.na    uhieii   i.  ,,nised   in  some  <listriets  by  tho  proeossiou 

'■i"<--l'i  h.rs.  parlie.ilarlv  tlie  speeies  Cnrlhonunpn.  Tlietr  are  distriets  in 
he  Kahlher^vr  .Selnve.x  wimh  have  heeti  ren.lered  almost  uninhabilablo 
'      '"■  ■mia  ,ve  skin  eruptions  ..aused  by  the  presenee  of  tlu.so  insects,  tho 

"'^•'•|"  "'   "lii'l.   IS  not  i,cees.s.rily  in  eunsoquenco  of  aet.ial  eo.ita..t  with 

In  Af.i.ea  the  Iarva>  of  the  Cayor  lly  t    >  not  uneonunonly  found  bo- 
noatii  tlie  skin,  in  little  boils. 


24 


d^ 


SECTION   III. 
TnE  INTOXICATIONS 

AND  SUN-STROKE. 


1.   ALCOHOLISM. 

(1)  Acute  Alcoholism.— Wlien  a  lar<ie  quantity  of  alcohol  is  taken  it^ 
inllucnco  on  tlie  nervous  system  is  nianifested  in  muscular  mcooriUna- 
tion,  mental  disturbance,  and,  finally,  narcosis.  The  individual  presen  < 
a  Hushed,  sometimes  slightly  cyanosed  face,  a  full  pulse,  with  deep  l>nt  rarely 
stertorous  respirations.  Tiie  pupils  "ve  dilated.  The  temperature  is  fre- 
quently below  normal,  particnlarly  if  the  patient  has  been  exposed  to  cold. 
Perhaps  the  lowest  rej.orted  temperatures  have  been  m  cases  oi  this  sort 
An  instance  is  on  record  in  which  the  patient  on  admission  to  hosi)ital  had 
a  temperature  of  24°  C.  (ca.  To°  F.),  and  ten  honrs  later  the  temi)erature 
had  not  risen  to  91°.  The  nneonsciousness  is  rarely  so  deep  that  the  pa- 
tient cannot  be  roused  to  some  extent,  and  in  reply  to  tiuestions  he  mutters 
incoherently.  :Muscular  twitchings  nuiy  occnr,  but  rarely  convulsions. 
The  breath  has  a  heavy  alcoholic  odor. 

The  diagnosis  is  not  diilicult,  yet  mistakes  are  frecpiently  made.  1  er- 
gons are  sonu'times  bromrht  to  hospital  by  tlie  police  su].posed  to  be  drunk 
when  in  reality  tliev  are  dying  from  apoplexy.  Too  great  care  cannot  be 
exercised  and"  tiie  ].atieiit  should  receive  the  benefit  of  the  douljt.  In 
«ome  instances  the  mistake  has  arisen  from  the  fact  that  a  person  who  has 
licen  drinking  heavily  has  Ijeen  stricken  witli  apoidexy.  In  this  condition 
the  coma  is  usually  deeiuM-,  stcrtor  is  piescni,  and  tliere  may  be  evidence  ot 
hemiplegia  in  the"gi'eater  flaccidity  of  the  limlis  on  one  side.  Tlie  subject 
will  be  considered  in  the  section  ujion  urannic  coma. 

Dlp.'^oinania  is  a  form  of  acute  alcoholism  seen  in  persons  with  a  strong- 
hereditary  tendency  to  drink.  Periodically  tlie  victims  go  "on  a  spree,' 
but  in  tlie  intervals  they  are  entirely  free  from  any  craving  for  alcohol. 

(2)  Chronic  Alcoholism.— In  moderation,  wine,  beer,  and  spirits  may 
be  taken  tiirougliout  a  long  life  witliout  iiiii)airing  the  general  health. 

Accordins;  to  Tavne,  the  ])oisonons  effects  of  alcoliol  are  manifested  (1) 
as  a  functional  poison,  as  in  acute  narcosis;  (2)  as  a  tissue  jmison.  in  which 
its  effects  are  seen  on  the  parenchymatous  elements,  jiarticularly  epitho- 
380 


ALCOHOLISM. 


381 


)1  is  taken,  its 
u'  incoijrdiua- 
idual  prcso!)!-: 
let'])  l>ut  rarely 
erature  is  I're- 
qiosed  to  cold. 
\s  of  this  sort. 
0  hosi)ital  had 
le  teiuiJeratiire 
|)  that  the  pa- 
nns  he  mutters 
y   convulsions. 

ly  made.  Per- 
L'd  to  be  drunk 
care  cannot  be 
he  doubt.  In 
person  wlio  has 
this  condition 
lie  evidence  of 
.'.     The  subject 

s  with  a  stron<i- 
"  on  a  spree,'' 
for  alcohol, 
nd  spirits  may 
•al  heallh. 
■  manifested  (1) 
loison,  in  which 
icularly  epithc- 


hum  and  nerve,  producing  a  .slow  degeneration,  and  on  the  blood-vessel.s, 
causing  thickening  and  ultimately  tibroid  changes;  and  (3)  as  a  checker 
ol  tissue  oxidation,  siiico  the  alcohol  is  consumed  in  place  of  the  fat.  Thi.s 
leads  to  fatty  ciianges  and  soniftimes  to  a  condition  of  general  steatosis. 

riie  cliiof  cll'ects  of  chronic  alcohol  ])oisoning  may  bo  thus  summa- 
rized. 

Nervovs  <S>/effl.— Functional   disturbance  is   common.      Unsteadiness 
of  the  muscles  in  performing  any  action  is  a  constant  feature.    The  tremor 
IS  best  seen  in  the  hands  and  in  the  tongue.     The  mental  processes  may 
be  dull,  ])articularly  in  the  early  morning  hour,*,  and  the  i)atient  is  unable 
to  transact  any  business  until  he  has  had  his  accustomed  stimulant.     Irri- 
tability of  teiiii)er,  forgetfulness,  and  a  change  in  the  moral  character  of 
tlie  individual  gradually  come  on.     The  judgment  is  seriouslv  impaired, 
the  will  enfoelded,  and  in  the  final  stages  dementia  may  supervene.     Tlu' 
relation  of  chronic  alcoholism  to  insanity  has  been  much  discussed       Vc- 
cordmg  to  Savage,  of  4,000  i)atients  admitted  to  the  Bethlehem  Hospital 
i;i3  gave  drink  as  the  cause  <>i  their  insanity.     Chronic  alcoholism  is  be- 
lieved by  many  to  be  one  of  the  special  causes  of  dementia  paralvtica,  but 
the  opinions  of  experts  on  this  ([uestion  are  still  discordant.    Savlnro  states 
that  not  more  that  7  per  cent  are  caused  by  alcohol  alone.     In  many  cases 
it  IS  certainly  one  of  the  important  elements  in  the  strain  which  leads  to 
this  l)reakdown.     P:pik>psy  may  result  directly  from  chronic  drinkiiii:.     It 
IS  a  hopeful  form,  and  may  disappear  entirely  with  a  return  to  habUs  of 
temperance. 

Xo  characteristic  changes  are  f(nind  in  the  nervous  system.  Ilffmor- 
rhagic  ])achymeningitis  is  not  very  uncommon.  Opacity' and  tliickenimr 
of  the  pia-arachnoid  membranes,  with  more  or  less  wasting  of  the  convo- 
lutions, generally  occur.  These  are  in  no  way  peculiar  to  chronic  alcohol- 
ism, but  are  found  in  old  persons  and  in  chronic  wasting  diseases.  In  the 
very  protracted  cases  there  may  be  chronic  encephalo-nreningitis  with  ad- 
hesions of  the  membranes.  Finer  changes  in  the  nerve-ccHs.  their  iiro- 
cesses,  and  the  neuroglia  have  been  descri'bed  by  Berklev,  iroch.and  others. 
By  far  the  most  striking  ell'ect  of  alcohol  on  the  nervous  svstem  is  the  pro- 
duction of  the  alcoholic  neuritis,  which  will  be  con.sidered  later. 

D!r/r.xlirr  .^/hh.— Catarrh  of  the  stomach  is  the  most  comiiion  symp- 
tom. The  toper  has  a  furred  tongue,  heavy  breath,  and  in  ;he  mornin-r  a 
sensation  of  sinking  at  the  stomach  until  he  has  had  his  dram.  The  appe- 
tite is  usually  impaired  and  the  l)owels  are  constipated.  In  beer-drinkers 
dilatation  of  the  stomach  is  common. 

Alcohol  ].roduces  definite  changes  in  the  liver,  leading  ultimately  to 
the  various  b.rms  of  cirrhosis,  to  be  described.  In  Welch's  laboratory  J. 
Friedenwald  has  can.«ed  ty])ical  cirrhosis  in  rabbits  by  the  administration 
of  alcohol.  The  effect  is  probal)ly  a  primary  degenerative  change  in  the 
liver-cells,  although  many  good  observers  still  hold  that  the  ])olson  acts 
first  nj.on  the  connective-tissue  elements.  It  is  probable  that  a  special 
vulnerability  of  the  liver-cells  is  necessary  in  the  etiology  of  alcoholic 
cirrhosis.  There  are  cases  in  which  comparatively  moderate  drinkino-  for 
a  few  years  has  been  followed  by  cirrhosis;  or  the  other  hand,  the  fivers 


3g2  THE  INTOXICATIONS  AND  SUN-STKOKK. 

of  „e>-..n<  wl.o  have  hv,n  stea.ly  drinkcM's  for  thirty  ov  forty  yoar>  may 
1       nb-  a      .den,,.,  g.ule  of  .irosi.    For  year.  bef<.re  eurl...    p e  o  . 
u^v^  IHnkers  .nav   Resent   an  enhu-ecl  and  tender  hver,  .Uh  . 

te  1  n       !•  the  .pRrn.     With  the  i^a.in.  and  hej.at.e  disorders    l.e  hu 
;;::;",^eon.es  vety  eharaeter.stie.     The  vennles  ^^^^^^^^^^  ^^  ^Z 
<li|..te,l-  the  hitler  heeoines  eidar-:ed,  reo.  and   ni.i\    jtiiMM 

"'lS;il-The   inlluetK.e  of  ehn.nie  aleoholism  .,.on   tlu.e  organs   is 

.    'fa      t  nt  in  a  lar-n-  proportion  of  ehroiue  aleolndus  the  k.dne>s  a.e 

:    in  le      'n  e Cm-     Hospital  statisties  su,.port  this  sta  e.nent, 

^^^^Z::L  il':.  v.:  eent  of'the  hodies  of  hard  aji^-^  ^^^^^-^^ 

«■,.,-..  hvnertrol.iiied  witliout  showing  iiiorhid  eliange.      I  lu   M  uai  ^ran 

;;rk!;in:^t!.>i^  to   result   mdireetly  fron,   alcohol  through   the  artenal 

'^"if  W.S  fonnerlv  thought  that  aleohol  was  in  some  way  antagonistic  to 

.  1        V  „«         i.e   hut  the  ohservations  .d'  late  years  indieale  elearly  that 
ub.n.nlou    d.    a^c    hut     u  ^^_^^^.  ^^^^  ^^^^^^^^  ^^^^^^.^  ,.  ^,,,^  ^^ 

■  p  ison  on  the  hrnin.     The  eoudition  was  iirst  aecurately  described 

:  r      in        s  eenturv  by  Sutton,  of  (ireenwieh.  who  had  n.nnerous  opiKji^ 

um,i  s  tor  studying  the  different   forms  among  the  sailors.       »-.;;/ 

„u.st  thorough  an.l  careful  studies  of  the  disease  was  made  Uy   \\,m,  <\ 

to        A  s^ree  in  n  temperate  ju-rson.  no  matter  how  prolonged,  is  rarel. 

o^r   followed    bv   delirium   trenu>ns;  but    in   the   ease   ot    an    halutua 

^•iZ  a  temporal,  excess  is  apt   to  bring  on  an  ,..ack.      "   --  -- 

evelops  in  conscpience  .d'  the  sudden  withdrawal  ot  the  aleoh  d.      I 
.re  oicnmstances  which    in   a  heavy  drinker  dCerniine,  sonuimes  wi  1 
Xt,     nc        bo  onset  of  d-lirium.     Such  are  an  acc.ident,  a  sudden  iright 
;i!"       k;;ind   an   acute   inflammation     partieularly   1--'--;';,,,:^  ,,    !" 
outlet  of  the  attack  the  patient  is  restless  and  depivssed  and  sleep,    ad 
7m%.^^  wliicb  cause  bim  to  take  alcohol  more  freely      After  a  da> 
vTtbo  characteristic  d.dirium  sets  in.     The  patient     alks  ^""^tantl.N   a 
col  crcntlv;  ho  is  incessantly  in  motion,  and  desires  to  go  on,  and  attend 
o    or^niinarv  business.     lialUieinations  ot  sight  and  hearing  develop. 


„1,io,.|s  in  tlie  room,  m,-h  a>  rals.  ioi<-<'.  "i-  simkos  niul  f«n<-io»  that 


;;:;"v;'ru,;g  „;;;  i;;-  i.o.iy.  ti.  ...,.,w  i,.,iv,.,i  i.  <>...  i„u.inary 


ALCOnOLISM. 


3S3 


■  yeiivs  may 
isis  (k'VL'loiis 
ih  iit  times 
•s  tho  I'acios 

llltl  Hd.-C  iU'C 
If  foinlilinll 
.'  liypenvmic 

(Ir^fciicnitivo 

qi.Ji    ilVtflio- 

lilatiition   in 

■so  organs  is 
renal  disL-aso 
■ct  of  alcohol 
tod  attention 
J  kidneys  arc 
is  statement, 
•^  the  kidneys 
ypical  },n'aini- 
.  the  arterial 

iitajronistic  to 
e  clearly  that 
nore  liat)le  to 
ret  her  a  qiies- 
l  enahling  tho 

icideiit  in  the 
itinued  action 
tely  descritu'd 
inerous  oi)por- 
.     One  of  the 

■  l)y  Ware,  of 
iiLred,  is  rarely 
f   an    haliitual 

It  siiinetimes 
Icoiiol.  There 
iinietinies  with 

sndilen  fright 
lonia.  At  the 
(I  sleeps  badly, 
After  a  day  or 
constantly  and 
ont  and  attend 
earing  develop, 
nd  fancies  that 
these  imairinary 


objects  is  great,  and  lias  given  the  popular  name  "horrors"  to  the  disease. 
'I'lie  patients  need  to  he  watched  constantly,  for  in  their  delusions  they 
may  jump  out  of  the  window  or  escape.  Auditory  hallucinations  are  not 
so  commiui,  hut  the  patient  may  complain  of  hearing  the  roar  of  animals 
or  the  threats  of  imaginary  enemies.  There  is  much  muscidar  tremor; 
tile  tongue  is  covered  with  a  tliick  white  fur,  an.d  when  protruded  is  tremu- 
lous. The  pulse  is  .^oft,  rajiid,  and  readily  compressed.  There  is  usually 
fever,  hut  the  temperature  rarely  registers  aiiovo  l(tv'°  or  103°.  Jii  fatal 
cases  it  may  he  higher.  In.somnia  is  a  constant  feature.  On  the  third  or 
fourth  liay  in  fav(U'ahle  cases  the  restlessness  aliati's,  the  patient  sleeps, 
and  im|.rovemcnt  gradually  sets  in.  The  tremor  jiersists  for  some  days, 
the  hallucinations  gradually  disappear,  and  the  appetite  returns.  Jn  more 
serious  ca.sos  the  insomnia  persists,  tho  delirium  is  incessant,  the  pulse  iie- 
comes  lucn-e  frecpient  and  I'eehle.  the  tongue  dry,  the  prostration  extreme, 
ami  death  takes  place  from  gradual  heart-failure. 

Diagnosis. — 'i'lie  clinical  picture  of  the  disease  can  scarcelv  he  con- 
founded with  any  other.  Cases  with  fever,  however,  may  he  mistaken  for 
meiiingiiis.  iiy  lar  the  most  common  error  is  to  overlook  some  local  dis- 
ease, such  as  pneumonia  or  erysipel;  <  an  accident,  as  a  fractured  rih, 
which  in  a  chronic  drinker  may  ju-ei  le  an  attack  of  delirium  tremens. 

In  every  instance  a  careful  exaniiiiat loa  should  he  made,  particularly  of 
the  lungs.  It  is  to  he  rememhered  that  in  the  severer  forms,  particularly 
the  fehrile  cases,  congestion  of  the  hases  of  the  lungs  is  hy  no  means  un- 
common. Another  jioiiit  to  he  home  in  mind  is  the  fact  that  pneumonia 
of  the  apex  is  a])t  to  he  accompanied  hy  delirium  similar  to  nnniin  a  pain. 
Prognosis.— IJecovery  takes  place  in  a  largo  jiroportion  of  the  eases 
in  ])rivate  practice.  In  hosjiital  practice,  particularly  in  the  largo  city 
hospitals  to  which  the  dehilitatcd  iiatients  are  taken,  the  death-'i-ato  is 
higher.  Oerhard  states  that  of  \:i\\  cases  admitted  to  the  riiilailelphia 
Ilosjiital  \-i\  proved  fatal.  Eecnrrenco  is  fre([uont,  almost  indeed  the  rule, 
if  the  drinking  is  kept  uj). 

Treatment. — Acute  alcoholism  rarely  ro(|nires  any  special  measures, 
as  the  iiatieiit  sleeps  off  the  ellVcts  of  the  deliauch.  In  tlio  case  of  pro- 
found alcoholic  coma  it  may  he  advisahh'  to  wash  out  the  stomach,  and  if 
collnjise  symptoms  occur  the  limhs  should  he  nihhed  and  hot  applications 
made  to  the  hody.  Should  convulsions  supervene,  chloroform  may  ho 
carefully  administered.  In  the  acute,  violent  alcoholic  mania  the  hypo- 
dermic injection  of  apomorjihia,  one  eighth  or  one  sixth  of  a  grain,  is 
usually  very  cn'ectnal,  causing  nausea  and  vomiting,  and  rapid  disappear- 
ance of  the  maniacal  syni]itonis. 

Chronic  alcoholism  is  a  condition  very  dilTlcult  to  treat,  and  once  fully 
estahlished  the  hahit  is  rarely  abandoned.  'Hie  most  obstinate  cases  are 
those  with  marked  heVeditary  tendency.  Withdrawal  of  the  nlcolio]  is  tho 
first  essential.  This  is  most  ofTeetuaily  accomplished  by  ])laciim  the  ita- 
lient  in  an  instifiitirm.  in  which  he  can  bo  carefully  watched  during  tho 
trying  period  of  the  first  week  or  ten  days  of  abstention.  The  abser^ro  of 
temptation  in  institution  life  is  of  special  advantage.  For  the  sleepless- 
ness the  bromides  or  hyoscine  may  be  employed.     Quinine  and  strycliniiie 


^^ 


\ 


\ 


;i 


3g^  THE  INTOXICATIONS  AND  SUN-STROKE. 

i„  tonic  .losos  .nay  l.o  ^ivH'-    Cocaine  or  tlu-  lUn<l  extract  of  coca  l.a.  boon 
recmunendod  as  a  ...l.stitul.  for  al...liol,  Imt  it   i.  not  ol  nnuh  service 
l'rolon.n.d  Hcclusion  in  a  suitaldc  institution  is  in  reality  the  only  elloauai 
means  of  cure.    When  the  hereditary  tendency  is  strongly  deveh.iied  a  ap.t 
into  the  drinkin-r  lial.it  is  almost  inevitable.  ,        ,    i        n 

In  delirium  tremens  the  patient  should  he  confined  to  bed  and  care- 
fnllv  Nvatched  night  and  day.  The  danger  of  escape  in  these  ^^^'J^'^ 
great,  as  the  patient  imagines  himself  pursued  by  eneiii.es  oi  demons. 
Flint  mentions  the  case  of  a  man  who  escaped  in  his  night-clothes  and  ran 
l,avefooted  for  iifti'en  miles  on  the  frozen  ground  before  he  was  ov-er- 
taken  The  patient  should  not  be  strapped  in  bed,  as  this  aggravates  the 
delirium:  sometimes,  however,  it  may  be  necessary,  in  which  case  a  sheet 
tied  across  the  bed  may  be  sntlicient,  and  this  is  certainly  be  ter  than  vio- 
hMit  restraint  by  three  or  four  men.  Alcohol  should  be  withdrawn  at  once 
unless  the  inilse  is  feeble. 

Deliriuln  tremens  is  a  disease  which,  in  a  large  majority  of  cases   runs 
a  course  very  slightly  iniluenced  by  medicine.     The  indications  lor  trea  - 
nent  are  to  procure  sleep  and  to  support  the  strength.    In  mild  cases  halt 
a  drachm  of  bromide  of  potassium  combined  with  tincture  of  capsicum 
may  be  given  every  three  hours.    Chloral  is  often  of  great  service,  and  may 
be  given  without 'hesitation  unless  the  heart's  action  is  feeble.     Good  re- 
sults s<.metinies  lollow  the  hypodermic  use  of  hyoscine,  one  one-hundredth 
of  a  "rain.     Opium  must  be  used  cautiously.     A  special  merit  of  \\  are  s 
work  was  the  demonstration  that  on  a  rational  or  expectant  plan  of  treat- 
ment the  percentage  of  recoveries  was  greater  than  with  the  indiscnminatc 
xwe  of  sedatives,  which  had  been  in  v(^guc  for  many  years.    ^^  lion  opium  is 
indicated  it  should  be  given  as  morjihia,  hypodermically.    The  etfi'ct  should 
be  caretullv  watched,  and  if  after  three  or  four  quarter-gram  doses  have 
been  given' the  i.atient  is  still  restless  and  excited,  it  is  best  not  to  push  it 
farther     When  fever  is  present  the  tranciuillizing  effects  of  a  cold  douche 
or  cold  bath  may  be  tried,  or  the  cold  pack.     The  large  doses  of  digitalis 
formerly  emi.loyed  are  not  advisable.  ,...,,        f  ^f 

Careful  feeding  is  the  most  important  element  m  the  treatment  ot 
the«e'ca«os  :Milk  and  concentrated  broths  should  be  given  at  stated  inter- 
val- If  the  pulse  becomes  rai.id  and  shows  signs  of  flagging  alcohol  may 
be  given  in  combination  with  the  aromatic  spirits  of  ammonia. 


11.    MORPHIA    HABIT    {.Vorphi7wmania ;  Morphinism). 

Thi<  habit  arises  from  the  constant  use  of  morphia— taken  at  first,  as  a 
rule  for  the  purpose  of  allaying  pain.  The  craving  is  gradually  engen- 
dered and  the  habit  in  this  M-ay  acipiired.  The  injurious  effects  vary 
very  inuch.  and  in  the  East,  where  o])ium-smok*ng  is  as  common  as  tobacco- 
smoking  with  us,  the  ill  effects  are,  according  to  good  observers,  not  so 

The  habit  is  particularlv  prevalent  among  women  and  ])liysicians  who 
use  the  hypodermic  syringe  for  the  alleviation  of  pain,  as  in  neuralgia  or 


!0!i  has  been 
inch  sorvii'c. 
nly  ell'oi.'tual 
lojii'il  a  '.apso 

L'd  and  carc- 

casL's  u  very 

or  demons. 

ithes  and  ran 

10  was  over- 
;:<,n'avates  the 

case  a  sheet 
ter  tlian  vio- 
Irawn  at  once 

of  cases,  runs 
ons  for  treat- 
lild  cases  lialf 
of  capsicnni 
vice,  and  may 
(le.     Good  re- 
ine-hundredth 
[■rit  of  Ware's 
])lan  of  treat- 
indiscrhninatc 
^'hen  opium  is 
c  ctrect  should 
liu  doses  have 
not  to  pusli  it 

11  cold  douelie 
3es  of  digitalis 

'  treatment  of 
it  stated  inter- 
i<l  alcohol  may 
lonia. 


'mum). 

en  at  first,  as  a 
•adually  enfren- 
us  efPects  vary 
non  as  tohacco- 
jscrvers,  not  so 

])hysieians  who 
in  neuralgia  or 


MORPHIA   HABIT. 


385 


coimir"-'     '^'"'  ""^"'''''""  "^  '^'^  1'"^'''   '"^  ■''   i""-^"  l'>^'n'y   is  rare  in  this 

The  symj.toms  at  first  are  slight,  and  moderate  doses  mav  1,..  taken  for 
months  without  serious  injury  and  without  disturhaiiee  .,f  health      There 
are  exceptional  instances  in  which   for  a  period  of  years  excessive  do<es 
have  heen  taken  without  deterioration  of  the  mental' or  l.odilv  f.,u..tions 
As  a  ruk  tiie  dose  necessary  to  obtain  the  desired  sensation's  lias  giad- 

y  to  he  increased  As  the  elfects  wear  olf  the  victim  c^xpericurs  ^^nsa- 
tion.  ol  lassitude  and  mental  depression,  acc.uupanied  often  witli  sh-ht 
Jjausea  and  epigastric  distress,  symptoms  wliieh  are  relieved  bv  another 
do.e  of  tlie  drug.     The  confirmed  opium-eater  often  presents  a  ^erv  .-har- 

..Imo.t     athogmmionic    ami  he  becomes  emaciated,  grav,  and  prematurely 
ged.     Jle  IS  restless,  irritahle,  and  unable  to  ..eniaCi  ;,i,iet  foi-  any  time 
telling  is  a  common  symptom.     The  sleep  is  disturbed,  the  appet  te  and 
hf  diu"  T        'Tr^'  --^^-<^^^t  wlien  directly  under  the  iullueiice  o 
the  d.ug  the  mental  condition   is  one  of  depression.     Occasionally  there 
are  proluse  sweats,  wlii..h  may  be  preceded  by  chills.     The  pup     ^^^ 
when  un  er  the  direct  inlluence  of  the  drug,  are  dilated,  sluiletimes  m  - 
equal.     1  ersons  addicted  to  nu.rphia  are  inveterate  liars,  and  no  reliance 
Mlmtever  can  be  placed  upon  their  statements.     Jn  manv  insta,u..s  t 
not  confined  to  matters  relating  to  the  vice.    In  women  tlie  svuipt,  ,        a 
be  associated   with  those  of  pronounced  hysteria  or  neurasthenia      T  e 
praetice  may  be  continued  for  an  indefinite  time,  usuallv  re<iuirin.  increase 
m  the  dose  until  ultimately  enormous  quantities  may  be  needed 'to  ol   ah 
he  desired  el<.ct        inally  a  condition  of  asthenia  is  induced,  in  which 
he  VK-tim  takes  little  or  no  food  and  dies  from  the  extreme  bodily  de- 
bility.^ An  increase  m  the  dose  is  not  always  neccssarv,  and  ther^  are 
IMu's  who  reach  the  point  of  satisfaction  with  a  dail^  amount  of  2  or 
3  grains  of  morphia,  and  who  are  able  to  carry  on  successfullv  for  many 
years  the  ordinary  busir.ess  of  lif' .  '  •^ 

The  /mjimrnlof  the  morphia  habit  is  extremely  diiricult,  an.l  can  rarelv 
be  successlully  carrh.l   out   by  the  general   practitioner.      Isolation    svs^ 
tematic  feeding,  and  gradual   withdrawal  of  the  drug  are  the  essent'id 
elements.    As  n  rule,  the  patients  must  be  under  control  in  an  institution 
and  should  be  in  bed  for  the  first  U-n  days.     It  is  best  in  a  majority  of 
eases  to  reduce  the  morphia  gradually.     The  diet  should  consist  of  I„.ef- 
juice,  milk,  and  cgg-wln-fo,  which  should  be  given  at  sliort  iiit<.rvals     The 
sufferings  of  tlie  patients  are  usually  very  great,  more  paWicularlv  the  al> 
.iominal  pains,  sometimes  nau.«ea  and  vomitiuir,  and  the  distresSincr  rest 
lessness.     I sually  within  a  week  or  ten  days  the  opium  mav  be  entirely 
withdrawn.     In  all  cas,^  the  pulse  should   be  carefullv  watVhed  and    if 
feeble,  s  imulants  should  be  given,  with  the  aromatic  Spirits  of  anunonia 
and  digitahs.^   For  the  extreme  restlessness  a  hot  ],ath  is  serviceable     The 
sleeplessness  is  the  most  distressing  .symptom,  and  various  drugs  may  have 
o  be  resor  ed  to,  particularly  hyosoine  and  sulphona!  and  sometimes    if 
the  insomnia  persist,  morphia  itself.  "'-umcb,  ii 

It  is  essential  in  the  treatment  of  a  case  to  be  certain  that  the  patient 


380 


TIIK   INTOXICATIONS   AND  SUN-STUOKR. 


luis  no  moans  of  ol.tMining  morpliia.     Kv^n  nn.lor  tl..>  hivoral.lo  cMiyn.u- 
stancrs  of  socliisiun  in  an  institution,  an<l  constant  watclun-  i.y  a  ni-l.t  and 
a  ,lav  uurso,  1  havi-  i<no\vn  a  patient  to  pvacti.-.'  .Iccoption  lor  a  prno.    o 
tlnvo  nu.ntl.s.     After  an  ap]:.      -t   .luv  tiu-  pati.'nts  are  only  t,.o  apt  tu 
lapse  into  tiie  lial)it. 

Tlie  condition  is  one  whici,  'ocoine  so  common,  and  is  so  nincli  on 

tl.e  increase,  that  pliysicians  .!»..  :d  exercise  ll.o  utmost  cantion  ui  prc- 
scril.inj;  n>orpl.ia,  part'icdarly  to  l..nude  patients.  I'nder  no  creumstances 
whatever  siu.nUl  a  patient  with  n.Mn'al-ia  or  sciatica  he  alh.wcu  to  use  the 
hvi-odermic  syrin;,'e,  ami  it  is  even  safer  not  to  intrust  this  dan-erous 
instrument  to  the  hands  of  the  nurse. 


III.    LEAD-POISONING   {I'lumhism  ;  Satunii.vn). 
Etiology.-The   disease   is   widespread,    particularly    in    lead-w..rl<ors 
and  ainon^  phnnhers,  painters,  and  glaziers.    The  metal  is  introduced  into 
the  svstein  in  many  forms.     Miners  usually  escape,  hut  tlu.se  engaged  in 
the  s\nelting  of  load-ores  are  ..fton  attacked.     Animals  in  the  ne.ghhor- 
hood  of  smelting  furnaces  have  sulfered  with  the  disease,  'J"'!  ^  ^'"      ^ 
birds  that  feed  on  the  h.'rries  in  the  neighborhood  may  be  ailoctod.     Men 
on.ra-od  in  the  white-load   factories  are  particularly   prone  to   plumbism. 
Ac'cidontal  i.oisoning  may  come  in  many  ways;  most  comm.mly  hy  drmk- 
in-  water  which  has  ])assed  through  lead   pipes  or  been  stored   m  lea.l- 
li,rod  cisterns.     Wines  and  cider  which  contain  acids  (puckly  beconi    con- 
taminated in  contact  with  lead.     It  was  the  frequency  of  colic  in  certain 
of  the  cider  districts  of  Dcvonshirowliicii  gave  the  name  of  Devonshire  colic, 
as  the  frecn.oncv  of  it  in  I'oitou  gave  tlie  name  ohra  Pirlonum.     Among 
the  innumorablo  sources  of  accidental  poisoning  may  be  mentioned  nnlk, 
various  sorts  of  bcvcra-es,  hair  dyes,  false  teeth,  and  thread.     A  serious 
outbreak  of  load-].oisoning,  which  was  investigated  by  David  D    Stewart, 
occurred  recently  in   nuladeli-hia.  owing  to  tlu    disgraceful  adulteration 
of   a    baking-powder    with    chromate    of    lead,    which    was    used    to    give 
a  yellow  tint  to  the  cakes.     T.ead  given  medicinally  rarely  produces  poi- 
soning. ,,,1-11  1 

All  a-es  are  atta.'ked.  but  J.  J.  rutnam  states  that  children  are  rela- 
tively les^s  liable.  'Phe  largest  number  of  cases  occur  between  thirty  and 
forty  According  to  Oliver,  from  whose  recent  (^ulstonian  lectures  I  lierc 
quote  females  are  more  susceptible  tlum  males.  He  states  that  they  are 
much  more  quicklv  hrought  und(-r  its  innuenco,  and  in  a  recent  oi.ideiuic 
in  whicli  a  th.nisand  cases  wore  involved  the  proportion  of  lemales  to  males 

was  four  to  one.  ,    ,,      ,  ,,      v      ,■ 

The  load  -mins  entrance  to  the  svstom  through  the  lungs,  the  digestive 
organs,  or  the  skin.  Poisoning  may  follow  the  use  of  cosmetics  contain- 
in"  lead  Through  the  lun-zs  it  is  freely  absorbed.  Tlu-  chief  channel, 
according  to  Oliver,  is  the  digestive  system.  It  is  rai)idly  eluninated  by 
the  kidnevs  and  skin,  and  is  present  in  the  urine  of  lead-workers.  The 
susceptibility  is  remarkably  varied.    The  symptoms  may  be  manifest  within 


•alilc  cin'iiiu- 
,■  a  iii^^lit  and 
r  a  pcii'ui  of 
V  ti'O  a])!  ti» 

-;  sn  imifh  111) 
lit  ion  in  pvc- 
I'iRinnistani'os 
(Mi  to  iiso  llu' 
lis  (lanwroiis 


)• 

li'ad-workovs 
itroihu-ed  into 
se  onf;a<ied  in 
the  neighbor- 
and  I'voii  the 
ilVccti'd.     :Men 

to  |ihinil)isin. 
)nly  by  dvink- 
toi't'd  in  load- 
y  l)oc'oin  con- 
olic  in  certain 
'voiishiro  colic, 
nuiit.  Among 
entioncd  milk, 
lid.  A  serious 
id  D.  Stewart, 
il  adulteration 

used    to    give 

])roduees  poi- 

ildivn  are  rela- 
cen  thirty  and 
lectures  I  here 
s  that  they  are 
•ecent  e])ideinic 
i'males  to  males 

rs,  the  digestive 
metics  contain- 
chief  channel, 
,'  eliminated  by 
l-workcrs.  The 
manifest  within 


LKAD-POISOXINO. 


3Si 


a  niontli  of  exposure.  On  tlie  other  hand,  'ramiuerel  (dcs  rianches)  met 
witli  a  case  in  a  man  wlio  had  iieen  a  Kad-woikcr  lor  lilty-two  years. 

Morbid  Anatomy.— .Small  (luantities  of  imd  occur  in  the  l)ody  in 
health.  .1.  .1.  I'litnanrs  reports  show  that  of  l">n  persons  not  presenting 
symptoms  of  lead  poisoning  traces  of  lead  occurred  in  the  urine  of  •.'."»  per 
cent. 

In  chronic  poisoning  lead  is  found  in  the  various  organs.  The  all'cctcd 
muscles  are  yellow,  fatty,  and  liliroid.  The  nerves  jircsent  the  features  of 
a  i)eriplieral  degenerative  neuritis,  'i'he  cord  and  the  nerve-routs  arc.  as  a 
rule,  uninvolved.  In  the  primary  atro])hie  inrm  the  ganglion  cells  of  the 
anterior  horns  are  prohahly  implicated.  Jn  the  aciite  fatal  cases  there  may 
be  the  most  intense  entero-colitis. 

Clinical  Forms.— .b'»/r  J'oisnnimi.—Wv  do  not  n^tVr  here  to  the 
acciilental  or  suicidal  cases,  which  present  vomiting,  \)ti\n  in  the  abdomen, 
and  coila|)sc  symptoms.  Jn  workers  in  lead  there  are  several  manifesta- 
tions which  follow  a  short  time  after  exposure  and  set  in  acutely.  There 
may  be.  in  the  lirst  place,  a  rapidly  developing  ana-mia.  Acute  neuritis  has 
been  described,  and  convulsions,  epilepsy,  and  a  di'lirium,  which  may  be, 
as  Stephen  Mackenzie  has  noted,  not  enlike  that  prochu'cd  by  aU'oliol. 
There  are  also  cases  in  w'hicli  the  gastro-iiitestinal  symptoms  are  most 
intense  and  rapidly  prove  fatal.  There  was  admitted  under  my  care  in  the 
I'hiladclphia  lIos|)ital  a  painter,  aged  fifty,  sutl'ering  with  ana'uiia  and 
severe  abdominal  pain,  which  had  lasted  aboiit  a  week,  lie  iiad  vomiting, 
constipation  at  first,  al'tcrward  severe  diarrluea  and  mehena,  with  distention 
and  tenderness  of  the  abdomen,  '{'here  were  albumin  and  tube-casts  in  the 
urine,  'i'lie  temperature  was  usually  subnormal.  Death  occurred  at  the 
end  of  the  secoml  week.  There  was  fmind  the  most  inten.<e  entero-colitis 
with  ha-morrhages  and  exudation.  These  acute  forms  develop  more  frc- 
(picntly  in  jiersons  recently  exposed,  and,  according  to  Mackenzie,  are  more 
frecpu'ut  in  winter  than  in  summer.  Da  Costa  has  reported  a  case  of  hemi- 
jilegia  developing  after  three  days'  oxpcsiire  to  the  poison. 

('Iinniir  pDisDiiiiifi  ])resents  the  following  .«ym])t()ms: 

(a)  AiKi'iiiia,  the  so-called  saturnine  cachexia,  which  may  be  profound. 
As  a  rule,  however,  the  corpuscles  do  not  sink  below  50  per  cent.  In  some 
of  the  chnniie  cases  there  may  be  a  ])ersistent  pallor  of  the  face  with  a  tol- 
eral)ly  higli  blood-count. 

{!))  Blue  line  on  the  gums,  whicli  is  a  valuable  indication,  l)nt  not  invari- 
ably present.  Two  lines  nnist  be  distinguished:  one,  at  the  margin  be- 
tween the  gums  and  teeth,  is  on,  not  in  the  gums,  and  is  readily  removed  by 
rinsing  the  month  and  cleansing  the  teeth.  The  other  is  tlic  well-known 
characteristic  bhie-black  line  at  the  margin  of  the  gum.  The  color  is  not 
uniform,  but  being  in  the  ])ai)illa'  of  the  gums  the  line  is,  as  s(>en  with  a 
nia;rnifying-glass,  intcrrui)ted.  The  lead  is  absorbed  and  converted  in  the 
tissues  into  a  black  sul])hide  by  the  action  of  sul])huretted  hydrogen  from 
the  tai'tar  of  the  teeth.  Tlie  line  may  form  in  a  few  days  after  exposure 
(Oliver)  and  disapjiear  within  a  few  weeks,  or  may  persist  for  many  months. 
Philil)son  has  noted  the  occTirrence  of  a  black  line  in  miners,  due  to  the 
deposition  of  carbon. 


T 


388 


THE  INTOXICATIONS  AND  SUN-STROKE. 


The  uw!-t  important  pviiiiitoiiis  of  chronic  Icad-poisonin,!:?  arc  colic, 
load-palsv,  luul  tho  cnccplialopalliy.  01'  these,  the  colic  is  the  nio!«t  fre- 
quent. Of  Taniiiierel's  cases  there  Mere  l/.MT  of  colic,  KU  of  paralysis, 
ami  72  of  encephaloi>athy. 

((•)  Cdlic  is  the  most  common  symiitoni  of  chronic  lead-poisoiiinji.  It 
is  often  preceded  l)y  jrastric  or  intestinal  symptoms,  jiarticularly  constiiia- 
tion.  The  jiain  is 'over  the  whole  abdomen.  The  c(dic  is  nsnally  parox- 
ysmal,  lii<e  true  colic,  and  is  relieved  hy  i)ressure.  There  is  often,  in  addi- 
tion, between  the  paroxysms  a  «hdl,  heavy  i)ain.  There  may  b.'  V()mitinj|. 
Durinjr  tlie  attack,  as  ijiejrel  noted,  the  pnlse  is  increased  in  tension  and 
the  iieiirt's  action  is  retarded.  Attacks  (d'  pain  witli  acute  diarriiieu  may 
recur  for  weeks  or  even  for  three  or  four  years. 

((/)  Lcdil-intlsi/. — This  is  rarely  a  primary  manifestation.  Tlio  onset 
may  be  acute,  subacute,  or  chronic.  Jt  usually  develops  without  fever. 
In  its  distril)ution  it  may  bo  partial,  limited  to  a  nuiscle  or  to  certain  mus- 
cle groups,  or  frencralized,  involving  in  a  short  time  tlie  musdes  of  tlie 
cxtrenuties  and  the  trunk.  :Madanie  Dejerinc-Klumpke  recognizes  the 
following  hiralized  forms: 

(1)  Anti-brachial  typo,  paralysis  of  the  extensors  of  the  fingers  and  of 
the  wrist.  In  this  the'  musculo-spiral  nerve  is  involved,  causing  the  char- 
acteristic wrist-drop.  The  supinator  longus  usually  oscajies.  In  the  long- 
continued  flexion  of  the  carpus  there  may  be  slight  displacement  back- 
ward of  the  bones,  with  distention  of  the  synovial  sheaths,  so  that  there 
is  a  i)rominent  swelling  over  tlie  wrist.  This,  which  is  sometimes  known 
as  Grueblor's  tumor,  though  not  of  any  moment,  is  often  very  annoying  to 
the  patient. 

(',')  Brachial  ty]ie,  which  involves  the  deltoid,  the  biceps,  the  brachi- 
alis  anticus,  and  the  supinator  longus,  rarely  tho  pectorals.  The  atrophy 
is  of  the  scaiiulo-hunioral  form.  It  is  bilateral,  and  sometimes  follows  tho 
first  form,  but  it  may  be  ])rimary. 

(3)  Tho  Aran-Duchcnne  type,  in  wliich  the  small  muscles  of  tho  hand 
and  of  the  thenar  and  hypothenar  eminences  are  involved,  so  that  we  have  a 
paralysis  closely  rosembiing  that  of  tho  early  stage  of  poHo-mi/clillK  aiilerior 
cliruiiica.  The  atro])hy  is  marked,  and  may  be  the  first  manifestation  of 
the  lead-palsy.  Mobius  has  shown  that  this  form  is  particularly  developed 
in  tailors. 

(4)  Tho  peroneal  typo.  According  to  Tanquorel,  the  lower  limbs  are 
involved  in  the  proportion  of  13  to  100  of  tho  upper  limbs.  The  lateral 
peroneal  muscles,  the  extensor  communis  of  the  toes,  and  the  extensor 
proprius  of  tho  big  toe  arc  involved,  producing  the  steppaije  gait. 

(5)  Laryngeal  form.  Adductor  paralysis  has  been  noted  by  Morell 
Mackenzie  and  others  in  load-palsy. 

Generalized  Palsies.— There  may  be  a  slow,  chronic  paralysis,  gradually 
involving  tho  extremities,  beginning  with  tho  classical  picture  of  wrist- 
drop. More  frequently  there  is  a  rapid  generalization,  producing  complete 
paralysis  in  all  the  muscles  of  tho  parts  in  a  few  days.  It  may  ])ursue  a 
course  like  an  ascending  paralysis,  associated  with  rapid  wasting  of  all 
four  limbs.    Such  cases,  however,  are  very  rare.     Death  has  occurred  by 


1!^  arc  colic, 
lie  iiio^^t  iri'- 
dl'  luinilysis. 

loisitiiiiiLT.  It 
irlv  ((m.-tiini- 
siiiilly  piirox- 
I'tl'll,  in  iul'li- 
I).'  vomit iii,!i. 
1  tension  ami 
liarrliu'a  may 

.  The  onset 
,-itliout  fever. 
I  eertain  imis- 
ius(  les  of  the 
eeognizos   the 

1  Hirers  and  of 
;in>;-  the  char- 
In  the  lon;;;- 
ccment  haek- 
so  that  there 
etinies  known 
y  annoying  to 

s,  the  hrachi- 

The  atrophy 

es  follows  the 

s  of  the  hand 
hat  we  have  a 
r/t'/i7i',<  anieriur 
inifestation  of 
irly  developed 

wer  limit?  are 
.     The  lateral 
the  extensor 
lait. 
:ed  hy  ^Morell 

ysis,  gradually 
tiire  of  wrist- 
icing  complete 
may  ]nir?ue  a 
wasting  of  all 
IS  occurred  by 


LEAD-POISONINCl. 


380 


involvement  of  the  diapliragm.  OHver  reports  a  ease  of  l'liilipson*s  in 
which  complete  juiralysis  supervened.  Dejerine-Khimpke  also  reeogniz.s 
a  leltnle  form  of  general  jiaralysis  in  lead-iMtisoning,  whiiii  may  elosely 
reseinl)le  the  .sultacute  s|)inal  paralysis  of  Duehenne. 

There  is  also  a  primaiy  saturnine  muscular  airojih  ■  in  which  the  weak- 
ness and  wasting  come  on  together  aiu'  develop  prupoVtionatcly.  Ii  is  this 
form,  according  to  (lowers,  which  most  frequcnily  assumes  the  Araii- 
Ducheniu'  type. 

The  electrical  reactions  are  those  of  lesions  of  the  lower  uiofur  seg- 
nunit,  and  will  he  deserihed  under  diseases  of  the  nerves.  The  deiicniT- 
ative  reaction  in  its  dillVrcnt  grades  may  he  present,  dependini;'  ujioii  tint 
severity  of  the  disease. 

I'sually  with  the  onset  of  the  paralysis  there  are  pains  in  the  legs  and 
.joints,  the  so-called  saturnine  arthralgias.  Sensation  may,  lioweu'r,  he 
unall'ected. 

(')  The  rnrhral  si/iniitnijif^  are  mnnerous.  Optic  m-uritis  or  nenro- 
retinitis  may  develop.  Hysterical  symptoms  occasii.nally  occur  in  girls. 
Convulsions  are  not  unconunon,  and  in  iits  develo|iing  in  the  adult  the 
jwssihility  of  lead-poisoning  shctuld  always  he  considered.  Tnu'  epilepsy 
may  follow  tiie  convulsicms.  An  acute  delirium  may  occur  with  hdlucina- 
tions.  The  patients  may  have  Irance-Iike  attacks,  which  follow  or  alternate 
with  convtdsions.  A  lew  cases  of  lead  encephalopathy  finally  drift  into 
lunatic  asylums.  Tremor  is  one  of  the  commonest  manifestations  of  Iciid- 
])oisoning. 

if)  Aiicrio-srleroais. — Lead-workers  are  notoriously  suhject  to  arterio- 
sclerosis with  contracted  kidneys  aiul  hypertrophy  of  the  heart.  The  cases 
usually  show  distinct  gouty  dejiosits,  jiarticularly  in  the  hig-toe  joint;  hut 
in  this  country  acute  gout  in  lead-workers  is  rare.  According  to  Sir  Wil- 
liam "Roljcrts,  the  lead  favors  the  jtreciititation  of  the  crystalline  urates  of 
the  tissues.  IJall'e  has  shown  that  lead  diminishes  the"  alkalinity  of  the 
hlood,  and  so  h  "Jcns  the  soluhility  of  the  uric  acid. 

Prognosis. — Tn  the  minor  manifestations  of  lead-poisoning  this  is 
good.  According  to  (lowers,  the  outlook  is  had  in  the  jtrimarv  atrophic 
form  of  paralysis.  Convulsions  are,  as  a  rule,  serious,  and  the  nu>ntal 
symptoms  which  succeed  may  he  permanent.  Occasionally  the  wrist-drop 
persists. 

Treatment. — rroydiylactic  measures  should  be  taken  at  all  lead-works, 
hut,  tniless  employes  are  carcftd,  poisoning  is  apt  to  occur  even  under  the 
most  favorable  conditions.  Cleanliness  of  the  hands  and  of  the  fimxer-nails, 
fre(iuent  bathing,  and  the  use  of  respirators  wlicn  necessary,  should  be  in- 
sisted upon.  "When  the  lead  is  in  the  system,  the  iodide  of  potassium 
should  be  given  in  from  5-  to  10-grain  doses  three  times  a  day.  For  the 
colic,  local  aiijdications  and,  if  severe,  morphia  may  be  used.  An  occa- 
sional morning  purge  of  sidphatc  of  magnesia  may  bo  given.  For  the  anfc- 
mia  iron  should  be  used.  In  the  very  acute  cases  it  is  well  not  to  give  the 
iodide,  as,  according  to  some  writers,  the  liberation  of  the  lead  which  has 
been  deposited  in  the  tissues  may  increase  the  severity  of  the  symjitoms. 
For  the  local  palsies  massage  and  the  c(  nstant  current  sliould  be  used. 


890 


THE   INTOXICATIONS   AND  SUN-STRoKi:. 


IV.    ARSENICAL    POISONING. 

Acitic  pi>\xiin\)uj  liy  arsi'iiic  is  (•(miini.ii,  imrlicnlarly  liy  Paris  grocn  ami 
such  luixtiiiTsas  "  i{(".ii;.'li  on  l.'ats,"  wliicii  air  used  to  dcstmy  viTiiiiu  ami 
iusi'cts.  'I'lic  cliii'l'  syiii|it(.ms  aiv  intense  jiain  in  liie  stoinacii,  vnmitiM;,% 
and,  later,  eolie,  with  diarrh.ea  and  tenesmus;  (leeasionally  tiie  syi  iptnms 
are  tliose  ol'  eollapse.  If  recovery  takes  place,  paralysis  may  follow.  The 
treatment  should  i)e  similar  to  "that  ol'  other  irritant  poi<oiu —rapid  ru- 
iiioval  with  the  stoniacii  pump,  tin'  i.roiiiotion  (d'  vomiting',  and  the  use 
of  milk  ai;d  e.u'^s.  11'  the  poison  has  heen  taken  in  solution,  dialyzi'tl  iron 
may  he  use<l  in  lar<;e  doses  ol'  I'rom  <>  to  H  drachms. 

'ciininir  Arsniintl  I'visunimj. — Arsenic  is  used  extensively  in  the  arts, 
particularly  in  the  inaiiufacture  oi"  colored  papers,  artilicial  llowcrs,  and 
in  many  o"l'  the  fahrics  employed  as  clothing'.     The  c;lazcd  j^reen  and  red 
l)ai)ers  used  in  kindergartens  also  contain  arsenic.     Jt  is  present,  too,  in 
ninny  wall-papers  and  cari)ots.    Much  attention  has  heen  paid  to  this  (lues- 
tion  of  late  years,  as  instances  of  poisonin-(  have  heen  tliou;,dit  to  depend 
ujmn  wall-papers  and   other   household   fahrics.     The  arsenic   compounds 
may  be  either  in  the  form  of  solid  ])articlos  detached  from  the  pajjcr  or  as 
a  gaseous  volatile  hody.    The  investigations  of  (losio.  coiilirmeil  hy  Sanger, 
have  shown  that  a  volatile  compound  is  formed  hy  the  action  on  arsenical 
organic  matter  in  wall-papers  of  several  moulds,  iiotahly  i)eiiicillum  hrevi- 
caule,  mucor  mucedo,  etc.     In  moi.-ture,  and  at  a  temiierature  of  from  (iO° 
to  li')"  F.,  a  volatile  comiiound  is  set  free,  i)rohal)ly  "an  organic  deriva- 
tive of  arsenic  jjontoxide  "  (Sanger).     The  chronic  poisoning  from  fabrics 
and  wall-papers  may  h(>  due.  accm'ding  to  this  author,  to  the  ingestion  of 
minute  continued  <loses  of  this  derivative,  "which  from  its  state  of  oxida- 
tion is  likely  to  he  accumulated   in  the  system,  from  which  it  is  slowly 
eliminated."*    Ars(>ni('  is  eliminated   in  all  the  secretions,  and  has  been 
found  in  the  milk.     ,1.  J.  Putnam,  it  should  he  remembered,  has  shown 
that  it  is  not  uncommon  to  find  traces  of  arsenic  in  the  urine  of  many 
persons  in  apparent  health  (;50  i)er  cent).    The  cd'ects  of  moderate  cpianti- 
ties  of  arsenic  are  not  infrcfiuently  seen  in  medical  practice.      In  chorea 
and  in  iiernicious  anaemia,  steadily  increasing  doses  are  often  given  nntil 
the  i)aticiit  takes  from  lo  to  2t)  drops  of  Fowler's  solution  three  times  a 
day.    Flushing  and  hyiierannia  of  the  skin,  pulTiness  of  the  eyelids  or  above 
the  oyehrows,  nausea,  vomiting,  and  diarrluva  are  the  most  common  symp- 
toms.   Redness  and  sometimes  bleeding  of  the  gums  and  salivation  occur. 
In   the   ]n-otracted    administration    of   arsenic   ]iatients   may   complain    of 
numbness  and  tingling  in  the  lingers.     Tigmentation  of  the  skin   I  have 
seen  on  several  occasions.     In  ehorcMi  neuritis  has  occurred,  and  a  patient 
of  mine  with  TlodgkinV  disease  develojied  multiple  neuritis  after  taking 
=  iv  3  j  of  Fowler's  solution  in  seventy-five  days,  during  which  time  there 
were  foiirtecn  days  on  which  the  drug  was  omitted. 

In  the  slow  poisoning  hy  the  absorption  of  arsenic  in  minute  doses,  as 
from  wall-paper  and  fabrics,  the  symptoms  are  varied.  J.  J.  Putnam  grou])S 
them  into  the  cases  in  which  the  symptoms  mainly  concern  the  general 


FOOD    POISO.VINO. 


891 


iris  j^roon  ami 
ly  Vfi'iiiin  ami 
icli,  vdiiiitiiiu-, 
llic  svniitmus 

t(.ll()\v.  Tlic 
)ii; — rapid  rc- 
,  ami  llio  use 

(lialvzi'il  inm 

y  in  the  art>, 
1   llowcrs,  ami 
^nrc'ii  ami  rt'd 
resent,  too,  in 
il  to  tliis  (jui's- 
;,dit  to  dcpiMul 
ic  fom|)ounds 
ho  paper  or  as 
led  hy  Sunjxer, 
m  on  arsi'iiieal 
[lieilUnn  brevi- 
re  of  from  (10° 
>rganie  deriva- 
g  from  fabrics 
le  in^a'stion  of 
state  of  oxida- 
■li  it  is  slowly 
and   has  heen 
■ed,  has  shown 
urine  of  many 
^derate  (jnanti- 
ee.      In  chorea 
en  fxiven  until 
I  three  times  a 
yelids  or  above 
common  symp- 
divation  occur. 
y   complain    of 
he  skin   I   have 
.  and  a  jtatient 
is  after  takinix 
hieh  lime  there 

linute  doses,  as 
Putnam  <Tron])S 
.>rn  the  general 


nutrition  without  si<;ns  of  lucal  irritation;  ihose  in  which  the  symptoms 
are  due  to  irritation  of  the  coMJumliva',  mouih.  or  pliarynx;  thuse  witii 
symptoms  pointinj;  to  tiie  dijicslivc  trad;  ca.«cs  uiih  marl<ul  nciv-ms  phe- 
nomena; and  those  in  whicli  the  nutritidii  of  >(.me  special  part  of  liic  Ixidy 
is  involved.  The  most  cnmmon  symptom.-  are  those  of  iina'Uiia  and  dchility, 
perhaps  with  sli^dit  ii'iitation  of  the  unicous  incmlMiiiir.  and  luindmess  and 
liii.ulin;.',  and  ^a.-tral;;ia.  How  far  these  symptom.-  are  to  he  atliiliiited  to 
the  sniidl  ipiantilics  of  arsenic  aiisorhcd  from  wall-|iapcis  ami  fahrics  is  by 
some  coM>i(lcrcd  donhlfiil.  'i'liat  children  and  ailulls  niav  take  with  im- 
punity lar.u('  dofcs  foi'  months  without  unpha-ant  ell'ccts.  ami  the  fact  of 
the  <;radual  estaMMimcnt  of  a  lolcratioii  which  enahles  Styriau  peasants 
to  take  as  much  as  .S  grains  of  arsenious  acid  iu  a  day,  speak  stronj;lv 
a^'ainst  it.  On  the  other  hand,  as  Sandier  stales,  we  do  not  know  accurately 
the  cll'icts  of  many  of  the  compounds  in  minute  and  lon;j;-eontinueil  doses, 
uotaMy  the  arsenates. 

Arsfiiicdl  iHinili/si.'i  has  (he  same  characteristics  as  lead-palsy,  but  the 
le<:s  arc;  more  all'ected  than  the  arms,  parlicidarly  the  extensors  and  ))ero- 
neal  frnmp.  so  that  the  imtient  has  the  characteristic  slciij)itije  gait  of 
peripheral  neuritis. 

'i'lu-  electrical  reaction  in  the  muscles  may  he  distiM'licd  before  there  is 
any  loss  of  power,  and  when  the  patient  is  asked  to  extend  the  wrist  fully 
and  to  spread  the  lingers  slight  weakmss  may  he  detected  carlv. 


V.    FOOD    POISONING.     {lhomnl(,lo.n.'<mHs:  V.uujhan). 

There  may  be  "death  in  the  pot  "  from  UKiny  causes.  I'ood  may  con- 
tain the  spccilic  orgaidsms  of  disease,  as  of  tuherculosis  or  trichinosis;  nullc 
and  other  foods  may  hccome  infected  with  typhoid  hacilli.  and  so  convey 
the  disea.<e. 

Animals  (or  insects,  as  bees)  may  feed  (ui  sul;stan(('s  which  cause  their 
ilesh  or  |iroducts  to  be  poisonoiis  to  man. 

Tl'.c  grains  used  as  food  may  be  infected  with  fungi  and  cause  the  epi- 
demics of  ergot  isjn,  etc. 

Foods  of  all  sorts  may  beoouie  contannnated  with  the  bacteria  of  |)utre- 
faction,  the  products  of  which  may  be  highly  poisonous. 

For  a  full  description  (d'  food  poisoning  see  Vaughan's  section  on  the 
sul)ject  in  vol.  xiii  of  the  Twentieth  Ct'iitury  Practice. 

.\mong  the  more  common  forms  are  the  following: 

(1)  Meat  Poisoning  (/\'m;^u/.sm».s).— Cases  have  usually  followed  the 
eating  of  sausages  or  jutrk-pie  or  head-cheese,  and  also  occasionally  hcef,veal, 
and  mutton.  Sausage  ])oisoning.  which  is  known  by  the  name  id'  linhilisiii 
or  (illinilinsis,  lias  long  been  recognized,  and  there  have  been  numerous 
outbreid<s.  ]inrticnlai'ly  in  parts  of  (lermany.  Sinnlar  al(ack<  have  been 
Itroduced  hy  ham  and  by  head-cheese.  The  ])recise  nature  of  the  kreotoxi- 
cons  has  not  yet  been  deternnned.  Other  outbreaks  have  followed  the 
eating  of  beef  and  veal.  In  the  majority  of  these  oases  the  meat  has  under- 
gone decomi)osition,  though  the  change  may  not  have  been  evident  to  the 


'If  0 


TllH  INTOXICATIONS  AND  SUN-STIloKK. 


ta^te.  Tlu.  sv..,i.ton.s  ..f  in.s.t  lu.isonin-  an"  Uk-so  <.f  a.iit.  pistru-intostinal 
irritalion.  liallar.rs  .IrMriptinn  of  tl..  WrlHurk  cas.s,  .i.mti.d  hy  \  aiigluni. 
hultl!*  k'ooil  I'lT  a  inajnrit.v  ol'  tlicin:  . 

"  A  IRTin.l  ..r  iiu'iihati^m  |.i...r.l(..l  the  illnc-s.     In  :.l  .'ascs  whore  tins 
couM  1.0  acnratclv  .Ut-.nniH.l,  it  was  tw.lvo  lu.ur«  cr  less  in  5  cason;  l.e- 
twfcn  twelvo   an.l   thirtv-six   honrs   in   ;!l   rases;  botwoen   tlurty-s.x   an.l 
fortv-eigl.t  hours  in  S  eases;  and  later  than  this  in  only  j  ca-es.      n  many 
cage's  the  llrst  (lelinite  symptoms  ueeiirre.l  suddenly,  an.l   esideutly   unex- 
IHHtedlv,  hut   in  some  eases   there  were  ohserved  during  the   ineul.alion 
more  or  less  feelinj;  of  ian-uor  and  iU-lH.alth,  loss  uf  ai^Hite,  nausea    ..r 
Cuive.  .ri,,inK  l.dns  in  the  helly.     In  ahuut  a  third  ot  the  eases  the  first 
definite  s^m  .t.Mu  was  a  sense  of  eliilliness,  usually  with  ri>rors,  or  trem- 
bling, in  one  case  aeeoiuimnied  hy  dyspiuea;  in  a  iVw  .ases  •»   ^v"^  ^"ddi- 
ness "villi  laiiitn..ss,  sometimes  aeeom,miiied  hy  a  cold  sweat  and    ottering 
in  others  the  first  svini^tom  was  headaehe  or  paiu  samew  hmv  in  the  trunk 
of  the  l,o,!v-e.g.,  in  the  ehest,  l.aek,  between  the  shoulders,  or  iii  the  ab- 
duiiH.n.  to  which  part  tl.«  pain,  wherever  it  might  have  eoinnu.iHed,  subs.^ 
(.uentlv  e.Ntende.l.     Jn  one  ease  the  first  symptom  noticed  was  a  <lilhcult 
in  swallowing.    In  two  eases  it  was  intense  thirst.    lUit  however  the  atta.k 
niav  have  conniH.nced,  it  was  usually  not  long  before  pain  m  the  abdomen, 
diaVrluea.  and  vomiting  came  on,  diarrluea  being  of  more  certain  occur- 
rence than  vomiting.     The  pain  in  several  cases  commenced  in  the  chest 
or  between  the  shoulders,  and  extended  first  to  the  upper  and  then  to    he 
lower  part  of  the  abdomen.     It  was  usually  very  severe  indee.l,  (imeklv 
producing  prostration  or  faintness,  with  c.dd  sweats.     It  was  variously  de- 
scribed as  crampv,  burning,  tearing,  etc.     The  diarrlueal  disehargcs  were 
in  some  cases  (piitc  nnrestrainable,  and  (where  a  description  ol  them  could 
be  ..btained)  were  said  to  have  been  exceedingly  oiVensive  and  usually  ot  a 
dark  color.     Muscular  weakness  was  an  early  and  very  remarkable  synqi- 
tom  in  nearlv  all  the  -ases,  and  in  many  it  was  so  great  thai  the  patient 
could  onlv  stand  bv  holding  on  to  something.    Headache,  sometimes  severe, 
was  a  connnon  and  early  svmptoin;  and  in  most  cases  there  was  thirst,  often 
inten-^e  and  most  distressing.     The  tongue,  when  observed,  was  descrihei 
u-uallv  a-  thieklv  coated  with  u  brown,  velvety  fur,  but  red  at  the  ti].  ami 
ed'a's."    In  the  eiirlv  stage  the  skin  was  often  cold  to  the  touch,  butjifter- 
wanl  fever  set  in,  the  temperature  rising  in  some  cases  to  lul°,  103%  and 
101°  r     In  a  few  severe  cases,  where  the  skin  was  actually  cold,  the  patient 
complained  of  heat,  insisted  on  throwing  off  the  bedclothes,  and  was  very 
re4le««      The  pulse  in  the  height  of  the  illness  became  (puck,  counting 
in  «ome  cases  100  to  158.    The  above  were  the  symptoms  most  frecpiently 
noted     Other  symptoms  occurred,  howeyer,  some  in  a  few  cases,  and  some 
only  in  solitary  cases.     These  I  now  proceed  to  enumerate.     Excessive 
«weatin.^  cramps  in  the  legs,  or  in  both  legs  and  arms,  crmvulsive  flexion 
of  the  hands  or  fingers,  muscular  twitchings  of  the  face,  shoulders,  or 
hands,  aching  pain  in  the  shoulders,  joints,  or  extremities,  a  sense  of  stifT- 
ne«s  of  the  joints,  prickling  or  tingling  or  numbness  of  the  hands  lasting 
far  into  conv  'escence  in  some  cases,  a  sense  of  general  compression  of  the 
skin    drowsiness,  hallucinations,  imperfection  of  vision,  and  intolerance 


nstro-intcstimil 
'd  liy  N'aiigliiiii. 

list's  wlu'io  this 
ill  T)  case's;  lic- 
tiiirty-six  and 
:UH'S.     Ill  many 
.'vidi'Utly  uiu'x- 
tlio   iiHiil»atii)n 
'titc,  nausea,  or 
e  nisi's  tlie  first 
rigors,  or  tivm- 
I'S  it   was  gidtli- 
t  and  tottcrinj.'; 
■re  in  tlii'  trunk 
•s,  or  ill  the  ali- 
niiU'iK'i'd,  suljsc- 
wns  a  dilliculty 
Acvcr  the  attack 
in  the  alidonieii, 
c  certain  oceur- 
■ed  in  the  chest 
and  then  to  the 
indeed,  quickly 
ills  variously  do- 
discharges  wore 
n  of  them  conld 
and  usually  of  a 
■iiiarkiihlo  syinp- 
thiil  tlio  patient 
iometinios  severe, 
was  thirst,  often 
■d,  was  deserihcd 
'd  at  the  tij)  and 
touch,  but  aftor- 
)  101°,  103%  and 
cold,  the  patient 
les,  and  was  very 
quick,  counting 
5  most  fro(iuontly 
V  cases,  and  some 
orato.     Excessive 
['(mvulsive  flexion 
ice,  shoulders,  or 
s.  a  Ponso  of  stifF- 
the  hands  lasting 
ompression  of  the 
,  and  intolerance 


Food  poisoxixg. 


'M 


ua 


"f  ight.  In  thnr  cases  (one  (hat  ..f  a  medical  man)  tlioro  was  ..hsorved 
yellowness  .,|  the  skin,  eitiior  general  or  c.iUin.d  «.  the  face  and  eves  I  a 
one  case,  at  a  int..  Mage  of  the  illness,  there  was  some  pulmonary  congestion 
i"id  an  attack  ol  what  was  regarded  as  g.,ut.  In  tiie  fatal  cases  death  was 
i"'''''"'''l  I'V  cullapse  like  that  of  clioleni,  c..ldno>s  uf  the  surfiuv,  pinched 
loaturos  ami  hl,u,,css  „f  the  lingers  ami  toes  and  ai-nnd  Ih..  sunken  eves 
nio^dchility  of  c.nvalescence  was  in  nearly  all  cases  piotra.K.l  to  several 

'•The  mildest  cases  were  characterized  usiiallv  hv  little  ivinarkahle  l.e- 
yond  the  lullmving  symptoms,  viz..  alidnmiual  pain's,  v-miting.  diarrh.oa. 
hir>t.  hciidache,  and  mu.cular  weakness,  any  one  or  two  of  «lii..h  mi<dit 
oe  alisent.  " 

.Alany  instances  are  on  recrd  of  poisoning  hv  canned  goods,  particu- 
larly  moat.  Some  of  these,  according  to  John  (1.  Johnson,  have  hoeii  ca^cs 
ot  c(.rro.sivo  poisoning  from  muriate  of  zinc  and  muriate  of  tin  u<vd  as  an 
aniaigain.  hut  poison.nis  ollVcts  identical  with  tlmse  just  deserihcd  have 
lollowcd  the  use  of  canned  meats. 

Certain  game  birds,  particularly  the  grouse,  are  stated  to  be  poisonous, 
in  sjiocial  districts  and  at  certain  seasons  of  the  year 

(-.0  Poisoning  by  Milk  Products.-^,)  (lah,rU,,isnnis,  indicatin-^  the 
l-oisonous  cllects  which  follou-  ,iie  drinking  of  milk  infect..!  with  ^apro- 
phy  ic   -actena,  ,s  c.msideivd  in  the  section  on  the  .liarrlnea  of  infants 

h  l,rrsr  P.,.,,,,,;,  (Tyrotoxisnius).-A-arioiis  milk  prodmt.s,  ice  civam, 
cu>a  ,1.  an.l  choose  may  prove  highly  poisonous.  Among  the  poLsons 
Aaughan  now  .Mates  that  the  tyrotoxicon  "is  not  ,h..  one  most  frequently 
presc'iit  nor  i..  ,t  the  most  active  one."  In  one  epidemic  he  and  Xovy  have 
isolated  Iron.  choe.<e  a  substance  belonging  to  the  j.oi.sonous  albumin^ 
and  in  an  extensive  ice-cream  ephlomic  Vauglian  and  Perkins  found 
m  the  ICO  cream  a  highly  pathogenic  hacilliis,  but  its  toxine  has  not  been 
separated. 

The  symptoms  are  those  of  acute  gastro-intestinal  irritation,  and  are 
similar  to  those  alroadv  detailed  by  I'.allard. 

(3)  Poisoning  by  S'hell-flsli  and  Fish.-(,,)  ^fnssrl  Pohoninq  (Afvtilo- 
toxismiis).-l',neger  has  separated  a  ptomaine— mvtilotoxin-wliich  oxi^s 
chiefly  m  (ho  liver  of  the  mussel.  The  observations  of  .Schmidfmannand 
Camenm  hav  shown  that  the  mus.-^ol  from  the  open  .sea  onlv  becomes 
poisonous  when  placed  in  filthy  waters,  as  at  Wilhelmshafen.       ' 

The  symptoms  of  mus.scl  poisoning  follow  the  eating  of  ei(l,er  raw  or 
cooked  mussels.  The  symp(oms  are  (hose  of  an  acKe  poisonin-  with  pro- 
lonnd  aotH.n  on  (ho  nervous  system,  and  without  gastro-intestin'al  manifes- 
tations. J  here  are  numbness  and  coldness,  no  fc'ver.  dilalod  pupils,  and 
raj.id  i)ulso;  death  occurs  sometimes  uithin  two  hours  with  cr.llapse  svmi)- 
totns.  Poisoning  occasionally  follous  the  eating  of  ovstors  which  aro^stale 
or  decompo.sod.    The  symi^toms  are  usuallv  gastro-intestinal 

(h)  Fish  rohonlncj  (Tch(hyotoxismus).-.Thore  arc  two  dislinct  varie- 
ties: ,n  one  the  poison  is  a  i)hysiological  ,.roduct  of  certain  ^lands  of  (he 
lish  m  the  other  it  is  a  product  of  bacterial  growth.  The  salted  stur-eon 
used  m  parts  of  Russia  has  sometimes  proved  fatal  to  larire  numbers  of 


394 


THE  INTOXICATIONS  AND  SUN-STROKE. 


persoiit;.  In  tlu-  middle  parts  of  Kuroiio  tlio  barb  is  stated  to  lie  somotimos 
poisonous,  prodiu'ini;  the  so-called  "  huiiirii  rliulrni."  In  China  and  .lapaii 
various  species  of  tiie  Idnnbui  are  also  toxic,  sonietii'ies  causin>,'  death  within 
an  hour,  with  svniiitojus  of  intense  disturi)ance  of  the  nervous  system. 
l)eri-i)eri  is  thonjiiit  hy  some  to  Ije  due  to  the  eonsnmpi;<ui  of  certain  kinds 
(*f  iisli. 

(4)  Grain  Poisoning  (SilohKrininx). 

(!)  Kn/oli-'iiii. — The  prolonjred  use  of  incjal  niaile  from  jxrains  contam- 
inated with  the  ergot  fungus  {chirirrps  fiurpuveu)  causes  a  series  ol  symj)- 
toms  known  as  ergotism,  epidemics  of  which  have  prevailed  ,n  dilferent 
l»arts  of  Europe.  Two  forms  of  this  chronic  ergotism  are  descriheil — the 
one,  gangrenous,  is  believed  to  l)e  due  to  the  sphacelinic  acid,  the  other, 
convulsive,  or  spasmodic,  is  due  to  the  cornutin.  In  the  former,  nKuliHea- 
tion  all'ects  tlio  extremities— usually  the  toes  and  lin<rers,  less  commonly 
the  ears  and  nose.  I'rt'ceding  the  onset  of  the  gangrene  there  are  usually 
ana-sthesia,  tingling,  ])ains,  sp;!sinodic  movements  of  the  muscles,  ami  grail- 
ual  blood  stasis  in  certain  vascular  territories. 

The  nervous  manifestations  are  very  remarkable.  After  a  pro(bomal 
stage  of  ten  to  fourteen  days,  in  whicli  the  [latient  com])lains  of  weakness, 
hcwlaehe,  and  tingling  sensations  in  did'erent  parts  of  the  l)ody,  ijerliajis 
accompanied  with  slight  fever,  symptoms  of  spasm  develop,  i)rodncing 
cramps  in  the  muscles  and  contractures.  The  arms  are  Hexed  and  the 
legs  and  toes  extended.  These  spasms  may  last  from  a  few  hours  to  many 
days  a)id  relapses  are  frecpient.  In  severer  cases  epilepsy  develops  and  the 
ynitient  may  die  in  convulsions.  :Mental  sym])toins  are  common,  manifested 
sometimes  in  a  i)reli!ninary  delirium,  but  niore  connnonly,  in  the  chronic 
poisoning,  as  melancholia  or  dementia.  Posterior  s],inal  sclerosis  occurs 
in  cbronic  ergotism.  In  the  interesting  group  of  21)  cases  studied  by 
Tuczek  and  Siemens,  1)  died  at  various  periods  after  the  infection,  and 
four  ])ost  mortems  sbowed  degeneration  of  the  posterior  columns.  A  con- 
dition similar  to  tabes  dorsalis  is  gradually  produced  by  tliis  slow  degenera- 
tion in  the  s])inal  cord. 

{•I)  Lathiirisiii  (Lupinosis). — An  affection  produced  by  tlie  nse  of  meal 
from  varieties  of  vetches,  chiefly  the  Latliyrus  sativns  and  L.  circrn.  The 
grain  is  ]'op\darly  known  as  the  cliick-]iea.  The  grains  are  usually  i)ow- 
dered  and  mixed  with  the  meal  from  other  cereals  in  tbe  itrejiaration  of 
bread.  As  early  as  tbe  seventeenth  century  it  was  noticed  that  the  nse 
of  flour  with  wiiich  the  seeds  of  tbe  Lallnirus  Mere  mixed  caused  stiifness 
of  the  legs.  The  subject  did  not,  however,  attract  much  attention  before 
the  studies  of  James  Irving,  in  India,  who  betw<>en  IS.")!)  and  ISdS  pub- 
lished several  important  conimnnications,  describing  a  form  of  spastic 
paraplegia  affecting  large  nundiers  of  the  inhabitants  in  certain  regions  of 
India  and  due  to  the  nse  of  meal  made  from  the  Lallnirus  seeds.  It  also 
produces  a  spastic  para])legia  in  animals.  The  Italian  observers  describe 
a  similar  form  of  parajilegia.  and  it  has  been  observed  in  .Mgiers  by  the 
French  physicians.  The  condition  is  that  of  a  spastic  paralysis,  involving 
chiefly  the  legs,  which  may  proceed  to  complete  parajilegia.  The  arms 
are  rarelv,  if  ever  aiTected.    It  is  evidently  a  slow  sclerosis  induced  nnder 


I  {ii)il  .liiimii 
k'iilli  williin 
outi  systoin. 
citain  kinds 


liiis  c-jntam- 
ifs  of  syni])- 
,11  (lillVivnt 
scrilii'il — the 
1,  the'  other, 
T,  luiirtiru'a- 
;s  coinmonly 
.'  arc  usually 
•s,  and  grail- 

a  prodromal 
of  WL'akiu'ss, 
i)dy,  perhaps 
),  prodncinj; 
xed  an<l  tlie 
)nrs  to  many 
lops  and  the 
1,  manifested 
1  the  eliroiue 
erosis  occurs 
^  studied  liy 
li'eetion,  and 
nils.  A  con- 
o\v  dt'u'enera- 

'  use  of  uieal 
rircra.  The 
usually  ])o\v- 
reparation  of 
that  the  use 
used  stilfness 
I'Ulion  before 
id  ISdS  pull- 
in  of  spastic 
lin  reirioiis  of 
eeds.  It  also 
rvers  describe 
d<;iers  by  tlic 
'sig,  involvin,ir 
1.  The  arms 
iiduccd  under 


SUN-STROKE. 


395 


i.u  a.  1  (a    aKXTtuin,  l,as  not  yet  been  determined. 

the  uilf  !;r  /^'"'*"^'"S-?^'''^  '^  '  ""^"^'"""1  disturbance  due  to 
tia    i^e  ol  altered  maixe.     Tiie  disease  occurs  extensivdv  in  ..•,rt.  <.r  If.lv 

It  tount.y  .1  ..  iR.ts,  and  appears  to  be  associated  in  some  way  with  tl.P 

ipgiiiiiiii 

rai^::;mr'-n.rir;x;%;^^ 

tion  of  the  maize.  '         '        "  l"-«l''>Jla-vis,  proper  preserva- 

VI.    SUN-STROKE  (Siriasis). 
ineatE.rhrusUon;  Insolation;  Thermic  Fcn-er ,-  Ileat.Mroke  ,■  Coup  de  Soleil.) 
Deflnition.--A  condition  produced  by  exposure  to  excessive  heat 


ggg  THE  INTOXICATIONS  AND  SUN-STROKE. 

..rily  bo  expoKHl  to  the  .liroct  rays  of  the  sun,  but  the  comlition  may 
:.ome  on  at  nijrht  or  when  working  in  eh.se  conlined  rooms.  ;»'>(;;;;' 
follow  exposure  to  great  artificial  heat,  as  in  the  enguie  rooms  ol  the  Atuin- 

'"^:S  or  Thermic  Fever.-'n>e  casos  are  ehielly  f<-;;  i;^i;;-- 
who,  while  working  very  hard,  are  exposed  to  the  sun.     Sol  he      on  t   . 
nuu-ch  with  their  heavy  aecoutremei^ts  are  P^^^^'^'" '"•'^;/;f ';;;,;:  .f';:;^ 
In  tlie  larger  c.ties  of  this  country  the  cases  are  almost  exdu^ml,  on 
lined  to  workmen  who  are  nu.ch  exposed  and,  at  the  same  tune,  have  been 

drinking  lieer  and  whisky.  .  „„,i,. 

Morbid  Anatomy  and  Pathology.-//'^-'-  vwrhs  occurs  ea,l>. 
PutSu'^  changes  dl.el..p  witii  great  rapidity.     The  venous  engorge- 
me  t  i      xlrenu",  i^articularl  •  in  the  cerebrun..     The  left  ventrn-le  .s  con- 
ed (\V.>od),  ami  the  right  c'luunber  dilated.    The  blood  ,s  nsually  iUud, 
the  lungs  are  inten.sely  congested.     Parenehymatons  changes  occur  in  the 

^'''Ac^.hmMrWood,  "heat  exhaustion  with  lowered  temperature  repre- 
sents a  sndden  vaso-motor  palsy,  i.e.,  a  condition  in  which  the  existing 
^  t  of  the  heat  paraly.es  the  centre  m  the  n.edulla."  On  the  other  hand, 
tl  mnic  fever  is  held  to  bo  due  to  paralysis  under  the  .ntluenco  of  be  ex- 
treme external  heat  of  the  centre  in  the  medulla  which  regulates  the  dis- 
position of  the  bodily  heat.  Owing  to  this  disturbance,  more  boat  is  pro- 
duced and  less  given  ofT  than  normally.  ,  ,  •  •  • 
Sai;^>rrm  hZ  recently  (H.  M.  J.,  1S9S,  i)  advan  ed  the  vh.w  that  s.riasis 
is  an  infectious  disease.  He  argnes  that  beat  alone  cannot  cause  it.  that 
i^  occnrs  in  certain  localities  and  in  ei)idemic  outbursts,  and  i)ers<nis  ac- 
climatized have  a  relative  immunity,  etc.     The  question  is  one  worthy  ot 

most  careful  study.  -ii  •      „„ 

Symptoms.— 'Hie  patient  may  be  struck  down  and  die  within  an 
hour  with  svmptoms  of  heart-failure,  dyspn.ra,  and   coma.     This  f.u'ni, 
sometimes  known  as  the  aspbyxial,  occurs  obiefly  in  soldiers  and  is  graphic- 
all  v  described  by  Parkes.     Death  indeed  may  be  almost  instantaneous,  the 
victims  falling  as  if  struck  upon  the  bead.     The  usual  form  in  this  lati- 
tude comes  on  during  exposure,  with  pain  in  the  bead,  dizziness,  a  feel- 
in-^  of  oppression,  and  sometimes  nausea  and  vomiting.     A  isual  disturD- 
an'es  are  common,  and  a  patient  may  liave  colored  vision.     DiarrlHini  or 
froonent   micturition  may  supervene.     Insensibility   follows,   winch   may 
be  transient  or  whicb  deepens  into  a  profound  coma.     The  patients  are 
usually  admitted  to  bosjiital  in  an  unconscious  state,  with  the  face  flushed, 
the  «kin  pungent,  the  pulse  rapid  and  full,  and  the  temperature  ranging 
from  107°  to  110°,  or  even  higher,  as  sbown  in  the  accom]ianying  chart. 
F    .\    Packard  states  tbat  of  the  31  cases  admitted  to  the  Pennsylvania 
ITo«pital'  in  the  summer  of  18S7,  in  a  majority  of  them  tbe  temi)erature 
was  between  110°  and  111°.    In  one  case  the  temperature  was  U2  .    Ihe 
hreatbinfr  is  labored   and   deep,   sometimes  stertorous.     T^sually   there   is 
completc%elaxation  of  the  muscles,  but  twitchings.  .ia<^tit;\tion    or  very 
rarolv  convulsions  may  occur.     The  puj.ils  may  at  first  be  dilated,  but  by 
the  time  the  cases  are  admitted  to  hospital  they  are  (in  a  majority)  ex- 


Sl'N-STROKK. 


307 


ulition  may 
It  may  also 
if  the  Atlan- 

l  in  persons 
iliors  on  tho 
o  to  attack, 
lusively  con- 
lO,  liave  bocn 

occurs  early, 
oils  eiigorgc- 
tricle  is  con- 
usually  tluid; 
occur  in  the 

?rature  reprc- 
the  exist  in,!]; 
0  other  hand, 
ice  of  the  ex- 
ilates  the  dis- 
e  heat  is  pro- 

w  that  siriasis 
cause  it.  that 
1(1  ])ors(nis  ac- 
me worthy  of 

die  within  an 
.     This  form, 
ind  is  <i;ra])hic- 
iintaneous,  the 
in  in  this  lati- 
zziness.  a  feel- 
visual  disturh- 
Diarrlura  or 
•s,   which   may 
le  i)atients  are 
le  face  flushed, 
■raturo  raupinji; 
i]ianyin<i:  chart, 
e  Pennsylvania 
he  temi)eraturc 
was  Ur.    The 
"sually  there  is 
tation,  or  very 
dilated,  but  by 
a  majority)  ex- 


tremely contracted,  retcdiitv  may  bo  present  upon  the  skin.  In  the  fatal 
cases  the  coiuii  deeiiens,  tlic  canHac  pidsatioiis  ln'conie  more  rapid  and 
feel)le,  the  breatliing  hccomes  hurried  and  sliallow  and  of  the  Clieyne- 
!Stokcs  ty]ie.  The  fatal  tci-niiiiation  may  occur  within  twenty-four  or 
thirty-six  hours.  FavoraMe  indications  are  the  return  of  cousfiousne.ss 
and  a  fall  in  tlie  fever.  'J'!ie  recovery  in  tlu'.^^e  eases  may  be  complete.  In 
otiier  instances  there  are  remarkaljle  after-ell"ects,the  most  constant  of  whicii 
is  a  i>ermanent  inability  to  bear  higii  temperatures.  Such  patients  become 
very  uneasy  when  the  thermometer  reaches  !S()^  !■'.  in  tlie  sliade.  Loss  of 
the  power  of  mental  concentration  and  failure  of  mcnu)ry  are  more  con- 
stant and  very  troublesome  seipiehe.    .Such  jmlienls  are  always  worse  in  the 


DAY 

JUNE  2      1                                             3                                      1 

" 

i^OUR 

'I'l 

=  ,,o|n 

A.M.!    :           1    1    i 

1|!,3H|5|C,7I0    , 

1  i  if-'i'-    •  1  M           '     ;«■'■'•      .  1  '  '     '. 

la  nil;  1  12    ,j,  .-,'.;.  7  t;    s  1.5,1  12  i  u    ,',    ^'r.    ,,,.  ,  1 

n 

TZ»P, 
109 

ll» 

107 
108 
105 
104 
103 
109 
101 
100 
Sit 

97 
06 
W 
94 
93 
9! 
91 

1   1 

„Li  U 

I 

i  !  ■  ,  1  i  '  '  '  ; 

'    '    , 

•^1- 

,1  i  1 

t-l 

" 

■ 

^: 

1  1 

1 

'" 

— 

1 

'"H  f- 

1 

-" 

- 

-■ 

- 

-- 

■" 



'"  "■ 

1 

~ 

- 

- 

1 

U 

\J 

- 

■ 

f 

z 

1  ;si 

i\ 

-- 

g 

u 

L  TV 

' 

\ 

1 

°-\   !£i 

-- 

"I' 

"r 

- 

—  - 

" 

■"" 

W*-i- 

_j] 

J 

fl 

1! 

1 

' 

^■i    '  Uf_ 

~iO 

- 

-  L  - 

~l: 

; 

■" 

"i"i  1  ;"l  1 

(^    L! 

1      i 

t 

i,l 

1 

1 

nl 

r\ 

z 

1 

^A 

',  t 

/ 

1 

" 

— ^- 

s 

'            1      1 

.  ^ 

A'A^ 

r'\ 

ky-^ 

I  - 

1.^ 

^ 

*A  U 

A     1 

-- 

t.  _ 

t/ 

^ZlXI    L:V. 

1 

- 

-/ 

-"\^- 

.: 

- 

-j- 

-t\    \}    \    \     1 

*i 

-[-- 

K— — 

< 

'F — 

- 

1 1;  i ,  /    .V'  L-  L 

1 

\ 

\ 

M-AL,    :         i-^ 

-- 

J- 

__l 

H-- 

4H 

.. 

V 

--< 

— 

^^-Mf 

b= 

'^T- 

*|--i  i  i  rri 

i   .   1 

r ! 

-  — 

J  " 

33 
1 

— 

&.^_ 

- 

~ 

■-  = 

,  LL!_l_il 

-■i-^ 

-pC-- 

\-^ 

1 1 1 1 

~ 

— 

1 

Mil 

-^ 

- 

" 

j 

- 

- 

•—4i 

i 

l-j-- 

I' 

1 

1 

ir  ~r 

11 

j 

~ 

— 

m.i 

- 

i 

■ 

1  ■ 

- 

- 

-■ 

1   1^ 

:\ 

I 

1 

I 

1 

1 

1 

-:- 

1 

PUJ-SE 

ilil  2,2=1  III  ■! 

1 

i\  li! 

li  il'  'f 

1 

3 

:' 

\1l  1  ]  'S'  1 

flESP. 

'!i1\'7.:&^_    1    iS;    !S 

Si  is:  \t  '7.[  f.  ^%  \  \  ''M  \ 

It  1 

H I , . . 

ChaRT  XIII. — Case  of  sun-stroko  treated  with  the  ice-bath  ;   recovery. 
(Rectal  temperatures). 

lint  weather.  Occasionally  oonvulsinns  and  marked  mental  disturbanro 
tiiay  develop.  Dercum  has  dcscrilied  ])eri])h('rnl  neuritis  as  a  secpience,  and 
the  ]iatient  whose  chart  is  here  <riven  develo])ed  an  acute  neuritis  in 
tlie  legs.  This  is  a  jioiiit  in  favor  of  the  infectious  nature  of  the  dis- 
ease. 

Ouiteras  has  called  attention  to  a  form  of  fever  occurring  in  the  South, 
known  in  Florida  as  "  Florida  fever,"  in  the  Oarolinas  as  "country  fever," 
and  in  trojiical  countries  as  fii'nr  iiifJammatoiir.  The  cases  last  for  a  vari- 
able time,  and  are  mistaken  for  malaria  or  typhoid;  but  he  believes  them 


T 


mv 


398  THE  INTOXICATIONS  AND  SUN-STROKE. 

to  be  entirely  distinct  and  due  to  a  prolonped  notion  of  tlic  high  jompcra- 
tures     lie  has  eallod  the  condition  a  "continued  thermic  fever 

Tlic  diagnosis  of  lieat  exhaustion  from  tliermic  fever  is  midily  made, 
as  the  diirerence  between  tlie  two  conditions  is  striking.  "In  solar  ex- 
haustion the  skin  is  moist,  pale,  and  cool;  the  breathing  is  easy  though 
hurried-  the  pulse  is  small  and  soft;  the  vital  forces  fall  into  a  temporary 
collapse;  the  senses  remain  entire"  (Dowler);  whereas  in  sun-stroke  or 
heat  aimplexy  there  is  usuallv  unconsciousness  and  pyrexia. 

The  mode  of  onset,  together  with  the  circumstances  und^r  which  it 
occurs  and  the  high  temperature,  permits  thermic  fever  to  be  readily  dif- 
ferentiated from  apoplexy  and  coma  from  other  conditions. 

Treatment.— In  heat  exhaustion  stimulants  should  be  given  freely, 
nnd  if  the  temperature  is  below  normal  the  hot  bath  should  be  used. 
Ammonia  mav  be  given  if  necessary.     In  thermic  fever  the  indications 
are  to  reduce* the  temperature  as  rapidly  as  possible.     Ihis  may  be  done 
by  packing  the  patient  in  a  bath  with  ice.    Kubbing  the  body  with  ice  was 
practised  at  the  New  York  Hospital  by  Barrach  in  18-57,  and  is  an  excel- 
lent procedure  to  lower  the  temperature  rapidly.    Ice-water  enemata  may 
also  be  emploved.     At  the  T'ennsylvania  Hospital  in  the  summer  of  18S7 
the  ice-pack  was  used  witli  great  advantage.     Of  31  eases  only  12  died, 
results  j.roljably  as  satisfactory  as  can  be  obtained,  considering ^tliat  many 
of  the  jiaticnts  "are  almost  moribund  when  brought  to  hospital.    They  should 
be  compared  with  Swift's  statistics,  in  which  of  150  cases  78  died.    In  the 
cases  in  which  the  symptoms  are  those  of  intense  asphyxia,  and  in  wluch 
death  may  take  place  in  a  few  minutes,  free  bleeding  should  be  practised, 
a  procedure  which  saved  Weir  Mitchell  when  a  young  man.    For  the  con- 
vulsions chloroform  should  be  given  at  once.    Of  other  remedies,  the  anti- 
pyretics have  been  employed,  and  may  be  given  when  there  is  any  special 
objection  to  hydrotherapy,  for  which,  however,  they  cannot  be  substituted. 


ligli  tompcra- 
■vor." 

readily  mado, 
'  In  solar  ex- 
I  easy  tlioii<,'h 
)  a  temporary 
sun-stroke  or 

idor  which  it 
jc  readily  dif- 

given  freely, 
ould  be  used, 
lie  indications 

may  be  done 
y  with  ice  was 
id  is  an  excel- 

enemata  may 
mmer  of  18S7 

only  Vi  died, 
ing  that  many 
.  They  should 
5  died.     In  the 

and  in  which 
d  be  practised, 
For  the  eon- 
edies,  the  anti- 
)  is  any  special 
be  substituted. 


SECTION  IV. 
COiiJ'STITUTIO:XAL  DISEASES. 


I.   ARTHRITIS    DEFORMANS. 

Deflziition. — A  chronic  disease  of  the  joints  of  doubtful  etiology, 
characterized  by  changes  in  the  cartilages  and  synovial  membranes,  with 
peri-articular  formation  of  bone  and  great  deformity. 

Long  believed  to  be  intimately  associated  with  gout  and  rheumatism 
(whence  the  names  rheumatic  gout  and  rheumatoid  arthritis),  this  close 
relationship  seems  now  very  doubtful,  since  in  a  majority  of  the  cases  no 
history  of  either  aifection  can  be  determined. 

Etiology. — Afje. — A  majority  of  the  cases  are  between  the  ages  of 
thirty  and  fifty.  In  A.  E.  Garrod"s  analysis  of  500  cases  there  were  only  25 
under  twenty  years  of  age. 

>S'f.r.— Among  Garrod's  500  cases  there  were  411  in  women.  In  James 
Stewart's  recent  report  of  40  cases  from  the  Koyal  Victoria  Hospital  only 
20  were  in  females.  In  women  its  close  association  with  the  menopause 
has  been  noted.  It  seems  to  1)e  more  frequent,  too,  in  those  wlio  have  had 
ovarian  or  uterine  trouble  or  who  arc  sterile. 

Hereditary  Frcdi^s  posit  ion. —hi  216  cases  in  Garrod's  series  there  was  a 
family  history  of  joint  troubles.  Two  or  three  children  in  a  family  may 
be  affected.  It  is  stated  also  that  the  disease  is  more  common  in  families 
with  a  phthisical  history. 

Ehevmatism  and  Gout.— In  nearly  a  third  of  Garrod's  cases  there  was 
a  history  of  gout  in  the  family;  of  rheumatism  in  only  04  cases. 

E.rposure  to  cold,  wet  and  damp,  errors  in  diet,  worry  and  care,  and 
local  injuries  arc  all  spoken  of  as  possible  exciting  causes.  ^ 

At  present  there  are  two  chief  views  prevailing  as  to  the  etiology  of 
arthritis  deformans— one  that  it  is  of  nervous  origin,  the  other  that  it  is  a 
chronic  infection. 

The  Relation  of  Arthritis  Deformans  to  Diseases  of  the  Nervous  Sys- 
tem.— Our  accurate  knowledge  of  arthropathies  of  nervous  origin  dates 
from  the  papers  of  J.  K.  Mitchell,  of  Philadelphia,  in  1831  and  1833,  in 
which  he  reported  cases  of  inflammation  of  the  joints  in  connection  with 
caries  of  the  spine  and  concussion  of  the  cord.  Acute  and  chronic  forms 
of  arthritis  may  occur  with  gross  lesions  of  the  cord;  the  former  are  found 

809 


^Q^  CONSTITUTIONAL  DISEASES. 

in  -icute  nivclitis,  t1io  latter  ^vitl.  s.'loro.is  of  the  postcri-n-  c..lumns.  Tho 
^r  ,i  a  art!  ritis  i-rscnts  anatunmally  inllaunnatiun  of  ,_ho  sjrnoval 
h  l.r  of  tl.o  til.rou.  inv..stMu.nt  of  tho  articulafmns.  The  chron.- 
I^  h  i«  1  id.  .0  .00  in  svvin,o,nvolia,  talu.,  and  honup  o,m  pro.ont.  a 
"  i  ;>t  n  of  atrophy  and  hvporph.sia  of  tho  bonos,  w.th  t  uckon.ng  ol 
0  !'  0  s  and  n.oro  or  los.  olVusion.  A,ain,therc  aro  jomt  !;->-;  >;;; 
fohw  iniurios  <.f  tho  norvo  trunks  tho.nsolvos,  oasos  ot  ^vhu;h  have  ho 
r  0    hv  S.  Woir  Mit.-holl.    Tho  following  aro  tho  n.a.n  p..u.ts  ^.r-.n!  m 

. V  0  norvons  origin  of  tho  di.oaso:  First,  tho  art.cidar  ohangcs  a  o 

n    a     t      if   not  idontioal   with,  thoso  of  tho  ol.ron.o   sp.nal   arUmn-- 
;,t  S  .ondlv,  tho  froqnont  assooiation  in  ailhrd.s  dolormans  o    dj.- 

ClH-  of  tho  skin  (,h,ssy  skin),  nails,  honos,  ""^ --^^^-^  >;;;;^  ^^  l^*^ 
are  ovidontly  of  nonrotio  orif^in.    In  oortam  oasos  thoro  is  ina.kod  '"u   t.u  > 
Xilv        tho  nu.solos.     Ord,  in.lood,  thinks  that  tins  atrophy  with  tho 
^  ^      r  losL  fonns  a  dystrophy  anal-.ons  to  pro,rosslve  --ular^  r^ 
phY     Thirdly,  tho  synnnotrioal  onsot  and  progress  <.l  tho  d.soaso.    1  ourth 
t^'inu  i  -at  .  n  of  norvo  trnnks.     Thoro  n.ay  ho  not  only  nmnbness  and 
i   Ji        h       in  oortain  casos  oxoruoiatin,  pains.     I'ost  nu>r  om,  nonnt.s 
:ri; ;:;;  fonnd  m  sovoral  casos,  bnt  .hothor  primary  - --'^^^^y  .s  d.nd,t- 
ful      Tho  rofloxos  aro  not  infro^p.ontly  inoroasod,  ,n  33  of  .,0  of  (;ai    >  1 
OS     Wo  nood  information  as  to  tho  condition  of  tho  spinal  cord  in  1 1. 
ca  OS  of  arthritis  dotonnans.     Trihonlot  and  Thomas  havo  roportod  fi   n. 
Do  orine'     orvice  a  case  of  a  woman  with  chronic  arthritis,  in  whom  th 
Xsr^nnv       'sclerosis  of  tho  posterior  columns  of  the  cord  in  the  dorsa 
;      on  and  of  the  columns  of  (ioll  in  tho  cervical  region,  with  degeneration 
of  the  posterior  roots.    The  history  indicated  that  the  arthritis  developed 

nftor  a  iniorneral  infection.  „     .        ,,  .    n 

Arthritis  Deformans  as  a  Chronic  Mection.-Dnrmg  the  past  few 
years  the  idea  has  1>een  gaining  ground  that  the  disease  is  of  m.crohic  origin. 
^Uisfactory  evidence  for  this  view  is  not  yet  forthcoming.  ScluiUor,  Ban- 
natyne  and  Blaxall,  and  sovoral  Fronch  <.hsorvors  have  found  micro-oi^n- 
isms  in  the  flnid  of  the  joints.  More  valuable  really  is  the  frocinont  asso- 
ciation of  arthritis  deformans  with  previous  acute  infections;  thus  in  Jamc^, 
Ston-art's  casos  there  was  a  history  of  gonorrluea  in  30  per  cent  of  the  males, 
and  in  his  series  of  40  cases  50  per  cent  had  had  previously  some  infectious 
trouble.  Of  late  years  we  have  learned  to  recognize  cases  which  liave  lol- 
lowod  directly  upon  a  severe  attack  of  influenza.  .    .    ,• 

Tlio  acute  mode  of  onset  in  some  instances  is  suggestive  of  an  infection 
The  joints  may  be  red  and  swollen  and  painful,  and  present  the  clinical 
picture  of  an  acute  i;  .octivo  process.  .       ,  ., ,         ,       .,    i  i,„  oini 

\nd  lastlv,  a  consideration  of  the  form  m  children  described  by  Stil 
lends  weight  "to  this  view,  particularly  in  the  widespread  enlargement  ot 
the  lymph-lands  and  the  swelling  of  the  spleen.  A  number  of  the  very 
best  students  of  the  disease,  as  l',aumler,  of  Freiberg  have  accepted  the 
infective  theory  of  the  disease,  but  at  present  I  think  the  evidence  is  quite 
as  much  in  favor  of  the  older  neurotic  view. 

Morbid  Anatomy. -The  changes  m   the  jo.nts  diff.vr  essentially 
from  those  of  gout  in  the  absence  of  deposits  of  urate  of  soda,  and  from 


AIlTnillTIS  DEFORMANS. 


401 


oluning.    Tlio 

f  tlio  synoviiil 

The  L'lironic 

jria  ])R'^i'ul!-  a 

thickoniiig  of 
t  k'fiions  wliicli 
ich  have  l)oen 
loiiits  ur}j;o(l  in 
ar  changes  aio 
pinal  arthrop- 
innan>;  ot  dys- 
-chaiigos  whicl\ 
irkod  and  early 
•uiiliy  with  the 

muscular  atro- 
■atie.    Fourthly, 

numbness  anil 
ortem,  neuritis 
ndary  is  douht- 

50  of  (iarroiVs 
al  cord  in  these 
I  reported  from 
s,  in  whom  the 
ird  in  the  dorsal 
th  degeneration 
liritis  developed 

g  the  past  few 
microhic  origin. 
Schiiller,  Ban- 
nd  micro-organ- 
c  frequent  asso- 
;;  thus  in  James 
L'ut  of  the  males, 
■  some  infectious 
Mhich  have  fol- 

'  of  an  infection, 
sent  the  clinical 

escrihed  by  Still 
i  enlargement  of 
nber  of  the  very 
ave  accepted  the 
evidence  is  quite 

differ  essentially 
f  soda,  and  from 


chronic  rheumati.«m  in  the  existence  of  extensive  structural  alterations, 
jiarticiilarly  in  the  caitiliiges.  We  are  largely  iiidel)ted  to  tin'  magnilieent 
work  of  Adams  for  our  knowledge  of  tiie  anatomy  of  this  disease,  'riie 
changes  begin  in  the  cartilages  and  synovial  membranes,  the  cells  of  which 
jiroliferate.  The  cartilage  covering  the  joint  undergoes  a  peculiar  lil)ril!a- 
tion,  beeomes  soft,  and  is  either  absorbed  or  gradually  thinned  by  attri- 
tion, thus  laying  bare  the  ends  of  the  bone,  which  become  smooth,  polished, 
and  eburnateil.  At  tiie  margins,  where  the  pressure  is  less,  the  proliferating 
elements  may  develo])  into  irregular  nodules,  which  ossify  ami  I'nlarge  the 
heads  of  the  bones,  forming  osteo|iiiytes  which  eomitletely  lock  liie  joint. 
Tiie  periosteum  may  also  form  new  bone.  There  is  usually  great  thicken- 
ing of  the  ligaments,  and  finally  complete  anchylosis  rt'sults.  This  is  rarely, 
however,  a  true  anchylosis,  but  is  caused  by  tiie  osteophytes  and  tliicki'iied 
ligaments.  There  are  often  hyperostosis  and  increase  in  the  articular  ends 
of  the  bone  in  length  and  thickness.  In  long-standing  cases  and  in  old 
jiersons  there  may,  on  the  other  hand,  be  great  atrophy  of  the  heads  of  the 
atVected  bones.  The  spongy  substance  becomes  friable,  and  in  the  hip-joint 
the  wasting  may  reach  such  an  extreme  grade  that  the  articulating  surface 
lies  between  the  trochanters.  This  is  sometimes  called  iiujrhus  Cd.ra-  senilis. 
The  anatomical  changes  may  lead  to  great  deformity.  The  metacariial 
joints  are  enlarged  and  thickened,  and  the  lingers  are  di'llected  toward  the 
ulnar  side.  The  toes  often  show  a  similar  dellection.  The  exostoses  at  the 
joints  are  known  as  Ilaygarth's  nodosities. 

The  radiographs  of  arthritis  deformans  arc  very  instructive.  The  clear 
interosseous  spaces  at  the  level  of  the  joints  disajipear  early,  the  hyper- 
trophy and  deformity  of  the  articular  extremities,  and  more  jiarticularly 
the  exostoses  at  the  margins,  give  a  very  distinctive  picture  of  the  dis- 
ease. 

The  muscles  become  atrojihied,  and  in  some  cases  the  wasting  reaches 
a  high  grade.     Neuritis  has  been  demonstrated  in  the  nerves  about  the 

joints. 

Ssnuptoms. — Charcot  makes  a  convenient  divisicm  of  the  cases  into 
those  with  Ileberden's  nodes,  the  general  progressive  form,  and  the  partial 
or  mono-articular  form. 

Heberden's  Nodes. — In  this  form  the  fingers  are  alTected,  and  "  little 
hard  knobs"  develo))  gradiially  at  the  sides  of  the  distal  phalanges.  They 
are  much  more  common  in  women  than  in  nuMi.  They  begin  usually  be- 
tween the  thirtieth  and  fortieth  year.  The  subjects  may  have  had  digestive 
troubles  or  gout.  Ileberden,  however,  says  "  they  have  no  connection  with 
gout,  being  found  in  persons  who  never  had  it."  In  the  early  stage  the 
joints  may  be  swollen,  tender,  and  slightly  red,  i)articularly  when  knocked. 
The  attacks  of  ])ain  and  swelling  may  come  on  in  the  joints  at  long  inter- 
vals or  follow  indiscretion  in  diet.  The  little  tubercles  at  the  sides  of  the 
dorsal  surface  of  the  second  ])halanx  increase  in  size,  and  give  the  charac- 
teristic a])pearance  to  the  affection.  The  cartilages  also  become  eotr, 
and  the  ends  of  the  Ixmos  eburnated.  T^ratc  of  soda  is  never  deposited 
(Charcot).  The  condition  is  not  curable;  but  there  is  this  liojieful 
feature — the  subjects  of  these  nodosities  rarely  have  involvement  of  the 


^■^ 


402 


CONSTITUTIONAL  DISEASES. 


larger  joints.  They  have  l)t'cn  regarded,  too,  as  an  indiciition  o)'  loiigovity. 
C'liarcot  states  that  in  wDnicn  witii  these  nodes  cancer  sicnis  more  lie- 
qnent. 

General  Progn^essive  Form. — 'I'iiis  oecnrs  in  two  varieties,  aeuto  and 
chronic.  The  ariilc  I'orni  may  resemi)le,  at  its  outset,  ordinary  articular 
rheumatism.  There  is  involvement  of  many  joints;  sweliin^f,  particularly 
of  the  synovial  sheaths  and  bursa';  not  often  redness;  hut  there  is  mod- 
erate fever.  Ifoward  describes  this  condition  as  most  fre(|ucnt  in  young 
women  from  twenty  to  thirty  years  of  age,  often  in  connection  with  recent 
delivery,  lactation,  or  ra]>id  c!iil(l-l)earing.  Acute  cases  may  develop  at 
the  menopause.  It  may  also  come  on  in  children.  "  These  patients  suiter 
in  their  general  health,  become  weak,  ])ale,  depressed  in  spirits,  and  lose 
flesh.  In  several  cases  of  this  form  markeil  intervals  of  im]>rovement  have 
occurred;  the  local  disease  has  ceased  to  ])rogress,  and  tolerable  comfort 
has  been  experienced  jierhaps  until  pregnancy,  delivery,  or  lactation  again 
determines  a  fresh  outl)reak  of  the  disease." 

Tlie  chronic  form  is  by  far  the  most  common.  The  joints  are  usually 
involved  symmetrically.  The  first  symptoms  are  ])ain  on  mnvcment  and 
slight  swelling,  which  may  be  in  the  joint  itself  or  in  the  ])eri-articular 
sheaths.  In  .«ome  cases  the  efl'usion  is  marked,  in  others  slight.  The  local 
conditions  vary  greatly,  ami  ])eriods  of  inijirovement  alternate  with  attacks 
of  swelling,  redness,  and  ])ain.  At  first  only  one  or  two  joints  are  alVected; 
nsually  the  joints  of  the  hands,  then  the  knees  and  feet;  gradually  other 
articulations  are  involved,  and  in  extreme  cases  every  joint  in  the  body 
is  alTected.  Pain  is  an  extremely  varial)le  symptom.  Some  cases  pro- 
ceed to  the  most  extreme  deformity  without  it;  in  others  the  suH'ering  is 
very  great,  particularly  at  nigiit  and  during  exacerltations  of  the  disease. 
There  are  cases  in  which  jiain  of  an  agonizing  character  is  an  almost  con- 
stant symptom,  RMpiiring  for  years  the  use  of  morphia. 

Gradually  the  shape  of  the  joints  is  greatly  altered,  partly  by  the  pres- 
ence of  ostcoi)hytes,  ])artly  liy  the  great  thickening  of  the  capsular  liga- 
ments, and  still  more  by  the  retraction  of  the  muscles.  In  moving  the 
affected  joint  cre])itation  can  be  felt,  due  to  the  ebnrnation  of  the  articular 
surfaces,  ritimately  the  joints  l)econie  completely  locked,  not  by  a  true 
bony  anchylosis,  but  by  the  osteophytes  which  form  around  the  articular 
.surfaces,  like  ring-l)one  in  horses.  There  is  also  a  spurious  anchylosis, 
caused  by  the  thickening  of  the  caji^ular  ligaments  and  fibrous  adhesions. 
The  muscles  about  the  joints  undergo  important  changes.  Atrophy  from 
disuse  gradually  su])ervenes,  and  contractures  tend  to  Ilex  the  thigh  upon 
the  al)domen  and  the  leg  u])on  the  thigh.  There  are  cases  with  rapid 
muscular  wasting,  symmetrical  invol-  ,ent  of  the  joints,  increased  reflexes, 
and  trophic  changes,  which  strongl>  suggest  a  central  origin.  Xund)ness, 
tingling,  pigmentation  or  glossiness  of  the  skin,  ""d  onychia  may  be  ])res- 
ent.  In  extreme  cases  tlie  patient  is  completel\  ,el])less,  and  lies  on  one 
side  with  the  legs  drawn  up.  the  arms  fixed,  and  all  the  articulations  of  the 
extremities  locked.  Fortunately,  it  often  happens  in  these  severe  general 
cases  that  the  joints  of  the  hand  are  not  so  much  affected,  and  tlie  patient 
may  bo  able  to  knit  or  to  write,  though  unable  to  walk  or  to  use  the  arms. 


ARTITUITIS  DRKORMAXS. 


403 


ni'  longevity, 
lis  111010  i'l'L'- 

's,  ncMito  1111(1 
lury  iii'tiriiliir 
',  piirtii'iilariy 
here  is  iiiod- 
L'lit  ill  yoiinj;; 
11  with  recent 
y  develop  at 
latients  suiTcr 
rits,  and  lose 
)veiiieiit  have 
•ahlc  comfort 
ctatiou  again 

;s  are  nsiially 
oveiiient  and 
])eri-artieu]ar 
,t.  The  lueal 
witli  attacks 
;  are  atVeeted; 
iidiially  otiier 
in  the  body 
le  cases  ])r()- 
e  siilTering  is 
f  the  disease. 
1  almost  con- 
by  the  pres- 
•a])siilar  liga- 
i  moving  the 
the  articular 
lot  by  a  true 
the  articular 
IS  anchylosis, 
us  adhesions, 
atrophy  from 
e  tliigli  ujion 
s  with  rajiid 
?aped  reflexes. 
,  Xunibness, 
may  lie  jires- 
1  lies  on  one 
hit  ions  of  the 
evere  general 
d  the  patient 
use  the  arms. 


Tt  is  surprising  indeed  imw  niiuli  certain  patients  with  ailvanced  arthritis 
(Ifformans  can  accomplisli.  No  one  who  iiad  .-ecu  tlu-  iicantiriil  models 
:in(l  miero,<copic  preparations  of  the  late  II.  ]>.  Schmidt,  of  New  Orleans, 
coiild  imagine  that  lie  had  been  aniicteil  for  years  with  a  most  e.vtreme 
graile  of  this  terrible  disease.  In  many  cases,  after  involving  two  or  three 
joints,  the  di.sease  becomes  arrested,  and  no  further  development  occiiis. 
it  may  be  limited  to  the  wrists,  or  to  the  knees  and  wrists,  or  to  the  knees 
and  ankles.  A  majority  of  the  patients  tinally  reach  a  (luie.scent  stage,  in 
wiiich  tliey  are  free  from  ))ain  and  enjoy  excellent  health,  sutfering  only 
from  the  inconvenience  and  crippling  necessarily  associated  with  the  dis- 
ea.se. 

Coincident  atl'ections  are  not  uncommon.  In  the  active  stage  the  ])a- 
tients  are  often  aiKemic  and  siiil'er  from  dyspepsia,  which  may  recur  at 
intervals.    There  is  no  tendency  to  involvement  of  the  lu'art. 

The  partial  or  mono-articular  form  alTects  chieily  old  persons,  and  is 
seen  particularly  in  the  hip,  the  knee,  the  spinal  column,  or  shoulder.  It 
is.  in  its  anatomical  features,  identical  with  the  general  disease.  In  the 
hi|)  and  shoulder  the  muscles  early  show  wasting,  and  in  the  hip  the  con- 
dition ultimately  becomes  that  already  deseril)ed  as  inarhiis  ei).v(v  senilis. 
These  cases  seem  not  infrecpiently  to  follow  an  injury.  They  dilTer  from 
the  jiolyarticular  form  in  occurring  chiefly  in  men  and  at  a  later  period  of 
life.  One  of  tiie  most  interesting  forms  alfects  the  vertei)ne,  coin|)Ietcly 
locking  the  articulations,  and  producing  the  condition  known  as  sp'iii(h/Iili>i 
(Irformaiis.  When  the  cervical  s])ine  is  involved,  the  head  cannot  be  moved 
11])  and  dowu,  I)Ut  is  carried  stillly.  Usually  rotation  can  be  elVected.  The 
dorsal  and  lumbar  spines  may  also  be  involved,  and  the  body  cannot  be 
flexed  in  the  slightest  degree.  Other  joints  may  not  be  atfected,  or  with  the 
spine  the  hi])  and  slioulder  joints  may  be  anchylose(l.  ^farie  has  described 
this  condition  as  spoiidi/lDsp  rIil:oiiii'li(iiie.  The  smaller  joints  are  not  af- 
fected. There  is  a  remarkable  specinicn  of  it  in  tiie  niiiseuiu  of  the  Uni- 
versity of  Buffalo. 

Arthritis  Deformans  in  Children.— .\.  K.  flarmd  remarks  that  all  tlie 
cases  which,  on  account  of  tlieir  clinical  features,  are  clas.^ed  as  exami»les 
of  arthritis  deformans  in  children  are  not  truly  of  that  nature.  Some 
examples  certainly  resemble  clo.sely  the  disease  in  adults.  In  others  there 
are  very  striking  diiTerenees.  A  very  interesting  variety  has  been  diifer- 
entiated  by  Oeorge  F.  Still,  in  which  the  general  enlargement  of  the  joints 
is  associated  with  swelling  of  the  lym])li-glands  and  of  the  s])leen.  He  has 
studied  22  cases  of  this  character.  The  following  are  among  the  more 
striking  peculiarities.  The  onset  is  almost  always  l)efore  the  second  denti- 
tion. Girls  are  more  frequently  alTeeted  than  lioys.  The  sym])toms  coni- 
]>lained  of  are  usually  slight  .^tilfness  in  one  or  two  joints:  gradually  others 
1)ecome  involved.  The  onset  may  be  more  acute  with  fever,  or  even  with 
chills.  Tlie  enlargement  of  the  joints  is  due  rather  to  a  general  thickening 
of  the  soft  tissues  than  to  a  bony  enlargement.  There  is  no  bony  grating. 
The  limitation  of  movement  may  be  extreme,  owing  to  the  fixation  of  the 
joints,  and  there  may  be  much  muscular  wasting.  The  enlargement  of  the 
lympli-glands  is  most  striking.    In  a  case  at  present  under  my  observation 


5 


i^* 


404 


CONSTITUTIONAL   DISEASKS. 


tlio  sJiipratroclilcar  <rlaii(ls  iiiv  as  Iarj,'o  as  liazcl-mits.  Tlic  ciilargenicnt  i~ 
jic'iieral.  Tlic  rdge  of  tlif  splffii  lan  usually  lie  IVlt  lu-low  the  costal  iimrj:iii. 
Swcuting  is  ol'toii  profuse  and  tliere  may  l»e  aiuemia,  l)ut  heart  idniplieation-^ 
are  rare    The  ehihlri'ii  look  [luuv  ami  j,'enerally  show  arrest  of  ileveloiuneiil. 

Diagnosis.— Arlhritis  (klnrmans  in  au  ailvaneed  sta;,'e  can  rarely  he 
luistakeii  for  either  rheumatism  or  gout.  Kavly  cases  are  dillieult  or  impos- 
silile  to  (listiiij.Mii>h  from  ehr(>Mi<'  rlu'umatism.  It  is  important  to  distin- 
guish from  the  mono-articular  form  the  hieal  .(rthritis  of  the  shoiiider-joint 
which  is  characterized  hy  pain,  thickening  of  the  capsule  and  of  the  liga- 
ments, wasting  of  the  shoulder-girdle  muscles,  and  sDUietimes  hy  . 'urili.-. 
This  is  an  ail'ection  which  is  quite  distinct  fnau  arthritis  (klurmans,  ami  's 
moreover,  in  a  majority  of  cases  curahle. 

Treatment.— Arthritis  deformans  is  an  incuralde  disease.  In  many 
cases,  after  invcdvement  of  two  or  three  joints,  the  pro-ress  is  arrested. 
Too  often  it  invades  successively  all  the  articulations,  and  in  ten,  liftcen, 
or  twenty  years  the  crippling  liecomes  general  and  jiermanent. 

The  hest  that  can  i)e  hoped  for  is  a  gradual  arresc.     it   is  useless  to 
saturate   the   patients   with   iodide   of   imtassium,   salicylates,   or  (piinine. 
Arsenic  seems  to  do  good  as  a  general  tonic.     The  improv^'ment  may  he 
marked  if  large  doses  of  it  are  given.     Iron  should  he  used  freely,  if  there 
is  ana'n\ia.    An  old  recipe,  called  the  "  ('hel^^ea  I'ensioner,"'  containing^sul- 
]ihur  ,-,j,  cream  of  tartar  .=,j,  rhuharh  .">  iv,  gum  guaiacum  ."  j,  honey  ,",  xvj 
(Sig.;","ij   night  and  morning  in  warm  wine),  was  formerly   mucl;   used. 
faTefui  attention  to  the  digestiim,  plenty  of  good  food,  and  fresh  air  are 
imiiortant   measures.     Hydrotherapy,  with   carefully   performed   massage, 
is  liest  for  the  alleviation  l)f  the  pain,  and  may  possihly  restrain  the  progress 
of  the  ail'ection.     In  early  cases  local  improvement  and  often  great  gain  in 
the  general  strength  follow  a  prolonged  treatment  at  the  liot  mineral  haths; 
hut  the  practitioner  should  exercise  care  in  recommending  this  mode  of 
treatment,  whicli  is  of  very  doulitful  value  when  the  disease  is  well  estah- 
lishcd.    I  have  repeatedly  known  cases  to  he  rendered  much  worse  hy  resi- 
dence at  these  institutions.    When  good  results,  it  is  largely  from  change 
of  scene  and  climate,  and  the  careful  regulation  of  tlie  diet.     The  local 
treatment  is  of  benefit  in  arresting  the  progress.     When  there  are  much 
heat  and  pain  the  limb  should  be  at  rest,  cold  compresses  ai)i)lied  at  night, 
the  joints  wrapixnl  in  oiled  silk,  and  in  the  morning  thoroughly  massaged. 
It  is  suri)rising  how  much  can  be  done  by  carefully  aiiiilicd  friction  to  re- 
duce the  thickening,  to  ])romote  absorjjtion  of  offusi(m,  and  to  restore 
n\obility.    Massage  is  also  of  special  benefit  in  maintaining  the  nutrition  of 
the  muscles,  which  early  tend  to  atroi»hy.     In  the  case  of  the  knees  this 
mode  of  treatment  will  sometimes  prevent  the  retraction  of  the  muscles 
and  the  gradual    \'xion  of  the  legs  on  the  thighs.    Xo  benefit  can  be  ex- 
pected from  electricity.     The  hot  air  treatment,  recently  introduced,  should 
be  given  a  thorough  trial,  as  it  has  ])roduced  good  results  in  some  eases. 

In  children  much  may  be  done  surgically  in  the  way  of  breaking  up  the 
fibrous  adhesions. 


CIlllONIC  UIIKUMATISM. 


405 


cnlargeiiient  i> 
L'  cos-tal  iimr>.'iii. 
:t  (•(iiniiliiatinii-^ 
oi  dvwUi\Hnvn\.. 

0  fun  I'uroly  Itf 
iViciilt  or  imiKis- 
rtiint  to  tlistiii- 
c  slioiiider-joiiit 
ui'l  of  the  liga- 
lU's  by  ."iivilis. 
I'oniiaiis,  ami 

case.     Tn  many 
ri'ss  is  arrcsU'd. 
in  ton,  lit'tci'U, 
lent. 

it  is  usi'U'ss  to 
:i's,  or  (luiuim'. 
ivcnifnt  may  be 

1  I'l'L'oly,  if  tliori' 
containing  siil- 

a  j,  honey  ,",  xvj 
■rly  mnch  used, 
ml  frc'sli  air  aro 
ormc'il  massago, 
■a in  tho  progress 
en  great  gain  in 
it  mineral  baths; 
ig  this  mode  of 
ise  is  well  estah- 
•h  worse  l)y  resi- 
flv  from  change 
diet.     The  local 

there  are  much 
i])plied  at  night, 
lughly  massaged, 
d  friction  to  re- 
,  and  to  restore 

the  nutrition  of 
if  the  knees  this 
L  of  the  muscles 
mefit  can  be  ex- 
itroduced,  should 
n  some  cases. 

breaking  up  the 


II.    CHRONIC    RHEUMATISM. 

Etiology.— '11  lis  alVcition  may  follnxr  an  acnte  or  subaeiitc  attack,  but 
iiiori'  commoidy  comes  on  insidiously  in  persons  wiio  liave  passid  tlie 
middle  period  of  life.     In  my  exiterience  it  is  extremely  rare  as  n  secpience 

acnie  rheumatism.  It  is  most  common  among  the  po(ir,  particularly 
washer-women,  day-h'.borers,  and  those  whose  oc(upation  exposes  them  to 

cold  and  damp. 

Morbid  Anatomy. — 'I'he  synovial  membranes  are  injected,  liut  there 
is  usiudlv  not  much  dVusioii.  'I'he  capsule  and  liganu'nts  of  the  joints  are 
thickened,  and  the  sheaths  of  the  tendons  in  the  neighborhood  undergo 
similar  alterations,  so  that  the  free  play  of  the  joint  is  greatly  impaired. 
In  long-stiUiding  cases  the  carlihiges  also  undergo  changes,  and  m;iy  show 
erosions.  Even  in  cases  with  the  severest  symptoms,  tiie  joint  nuiy  In,' 
very  slightly  altered  in  api>earanee.  Important  changes  take  place  in  the 
muscles  and  lu'rves  adjacent  to  chronically  inilamcd  joints,  jiarticularly 
in  the  mono-articuhir  lesions  of  the  shoulder  or  hip.  Muscular  atrophy 
supervenes  i)artly  from  disuse,  partly  through  nervous  inlluences,  either 
centric  or  rellex  (Vnlpian),  or  as  a  residt  of  peripheral  neuritis.  In  some 
cases  when  the  joint  is  nuudi  distended  the  wasting  may  be  due  to  pressiire, 
cither  on  the  nniscles  themselves  or  on  the  vessels  sujiplying  them. 

Symptoms. — Stiffness  and  jiain  are  the  chief  features  of  chronic 
rheunuitism.  'I'he  latter  is  very  lial)le  to  exacerbations,  especially  dur- 
ing changes  in  the  weather.  The  joints  nniy  be  tender  to  the  touch  and  a 
litUe  swollen,  but  are  seldom  reddened.  As  a  ride,  many  joints  are  aifecte(l; 
but  there  are  instances  in  which  the  disease  is  confined  to  one  shoulder, 
knee,  or  hi]).  The  stiil'ness  and  jiain  are  more  nuirked  after  rest,  and  as  the 
day  advances  the  joints  may,  with  exertion,  become 
Tlie  general  health  may  not  l)e  seriously  imjiaircd.  T 
mediately  dangerous.  "Anchylosis  may  occur,  and  ultimately  the  joints 
may  become  nnudi  distorted"!  Tn  many  instances,  particularly  those  in 
which  the  pain  is  severe,  the  general  health  may  be  seri<nisly  involved  and 
the  subjects  become  anamiic  and  very  apt  to  suffer  with  neuralgia  and  dys- 
pe])sia. '  Valvular  lesions,  due  to  slow  sclerotic  changes,  are  not  uncommon. 
They  are  associated  with,  not  dependent  upon,  the  articular  disease. 

The  profiting  in  is  not  favorable,  as  a  majm-ity  of  the  cases  resist  all  meth- 
ods of  treatment.  It  is,  however,  a  disease  wliich  persists  indefinitely,  and 
does  not  necessarily  shorten  life. 

Treatment.— Internal  remedies  are  of  little  service.  It  is  important 
to  maintain  the  digestive  functions  and  to  keep  the  general  health  at  a 
hich  standard.  Iodide  of  potassium,  sarsaparilla,  and  guaiacum  are  some- 
times beneficial.    The  •^alicvlates  arc  useless. 

Local  treatment  is  very  beneficial.  "  Firing  "  with  the  ra(inelin  cautery 
relieves  the  pain,  and  it  is  perhaps  the  best  form  of  counter-irritation. 
]\rassage,  with  passive  motion,  helps  to  reduce  swelling,  and  prevents  anchy- 
losis. ^Tt  is  particularly  useful  in  cases  which  are  associated  with  atrophy 
of  the  muscle.?.     Electricity  is  not  of  much  benefit.     ""      "     '      '        "■ 


mucli  more  su])ple. 
he  disease  is  not  im- 


Climatic  treatment 


i 


a; 


4UG 


COXSTITUTIOXAL  PISEASRS. 


is  very  ndvniitngcons.  !Miuiy  c'lisi's  nri'  j^rcatly  luliu'd  l)y  prolonjiod  rcsi- 
(lonco  in  Houtlii-rn  Juiropo  i>r  Soiitlicrii  I'alirDriiia.  Uiili  imticiitrf  should 
always  wiutiT  in  the  South,  and  in  lliis  way  avoid  tho  cold,  daui[)  weather. 
llydrolhcrain'Utic  ineasuirs  uro  spci'ially  IxMicliriai  in  chronif  riicunia- 
tisiu.  (Jmit  relief  is  all'orded  hy  wniitpinjr  the  all'eeted  joints  in  eold  cloths, 
covered  with  a  thin  layer  of  lilankct,  and  protected  with  oiled  silk.  The 
Turkish  hath  is  useful,  hut  the  full  henelit  of  tiiis  treatment  is  rarely  .seen 
except  at  batliinj;  e,<tal)lishinents.  The  hot  alkaline  waters  are  particularly 
nseful,  and  a  residence  at  thi'  Hot  Spring's  of  Vir;.nnia  or  Arkansas,  or  at 
llanir,  in  the  Kocky  .Mo\intains,  on  the  (.'anadiaii  Pacilic  Itailway,  will  sonie- 
tinies  cure  even  obstinate  eases. 


III.    MUSCULAR    RHEUMATISM   (Myalgia). 

Definition. — A  i)ainful  afTcction  of  the  voluntary  muscles  and  of  the 
fascia'  and  |ieriosteum  to  which  they  are  attached.  The  all'eetion  has  re- 
ceived various  names,  according,'  to  its  seat,  as  torticollis,  lumbago,  pleuro- 
dynia, etc. 

Etiology. — The  attacks  follow  cold  and  exposure,  the  usiial  conditions 
favorable  to  the  development  of  rheumatism.  It  is  ])y  no  means  certain 
that  the  muscidar  tissues  are  tlie  seat  of  the  disease.  >[any  writers  claim, 
])erhaps  correctly,  that  it  is  a  neuralgia  of  the  sensory  nerves  of  the  mus- 
cles. Until  our  knowledge  is  nu)re  accurate,  however,  it  may  be  considered 
under  the  rheumatic  aiTections. 

It  is  most  commonly  met  with  in  men,  i)articnlar]y  those  exposed  to 
cohl  and  whose  occupations  are  lahorions.  It  is  apt  to  follow  exposure  to 
a  draught  of  air,  as  from  an  open  window  in  a  railway  carriage.  A  sudden 
chilling  after  heavy  exertion  may  also  bring  on  an  attack  of  luml)ago. 
Persons  of  a  rlieumatic  or  gouty  habit  are  certainly  more  ])rone  to  this 
afTcction.  One  attack  renders  an  individual  ^nore  liable  to  another.  It  is 
usually  acute,  but  may  become  suliacute  or  even  chrouic. 

Symptoms. — The  all'eetion  is  entirely  local.  The  constitutional  dis- 
turbance is  .slight,  and,  even  in  severe  cases,  there  nuiy  be  no  fever.  Pain 
is  a  prominent  symjjtom.  It  may  1)0  constant,  or  may  occur  only  when 
the  muscles  are  drawn  into  certain  positions.  It  may  1)0  a  dull  ache,  like 
the  pain  of  a  bruise,  or  sharp,  severe,  ■  -  mp-like.  It  is  often  sufllcicntly 
intense  to  cause  the  ]iatient  to  cry  c  sure  on  the  affected  part  usually 

gives  relief.    As  a  rule,  myalg'  sient  afTecticni,  lasting  from  a  few 

hours  to  a  few  days.    Occasi  is  prolonged  for  several  weeks.    It  is 

very  a])t  to  recur. 

The  following  are  the  ]n'incipal  varieties: 

(1)  Lumbago,  one  of  the  most  common  and  painful  forms,  affects  the 
muscles  of  the  loins  and  their  tendinous  attachments.  It  occurs  chiefly  in 
workingmen.  It  comes  on  suddenly,  and  in  very  severe  cases  completely 
incai)acitates  the  ]iatient,  who  may  be  unable  to  turn  in  bed  or  to  rise  from 
the  sitting  posture. 

(2)  Stiff  neck  or  torticollis  affects  the  muscles  of  the  antero-lateral 


|irol(Mijjo(l  rcsi- 
tiitifiiti^  should 

(liiiiip  wcallicr. 
iruiiii'  rlieiiiiiii- 

in  cold  L'lotlis, 
ik'd  silk.  Thu 
t  is  rarely  set'ii 
\rc  particularly 
\rkaiisas,  or  at 
wav,  will  soiuo- 


clos  and  of  tlio 
[fcction  has  ro- 
iiibago,  jtleuro- 

isual  conditions 
means  certain 
r  writers  claim, 
•es  of  the  nuis- 
y  be  considered 

ioso  exposed  to 
ow  ex])osure  to 
iijre.  A  sudden 
•k  of  luniba<;;o. 
'  ])rnno  to  this 
another.     It  is 

istitutional  dis- 
110  fever.  Pain 
'cur  only  when 
dull  ache,  like 
ftcn  sufllciently 
ted  i)art  usually 
ing  from  a  few 
al  M'ecks.    It  is 


rnis,  alTects  the 

ccurs  chiefly  in 

ases  completely 

or  to  rise  from 

e  antero-latcral 


GOUT. 


407 


region  of  tlie  nock.  It  is  very  common,  and  occurs  most  frci|iieiitly  in 
the  \ouiig.  The  |iatient  holds  the  head  in  a  |ic(  idiar  manner,  and  rotates 
the  whole  body  in  alteini>ting  to  turn  it.  IsumIIv  the  attack  is  eonlined  to 
one  side.    The  muscles  at  the  back  (d'  the  neck  may  also  be  alVected. 

(;i)  Pleurodynia  invcdves  the  intercostal  muscles  on  one  side,  and  in 
some  in.^tances  the  pectorals  and  serratiis  niagniis.  This  is,  [leriiaps,  the 
most  painful  form  of  the  disease,  as  the  chest  cannot  be  at  rist.  It  is  more 
common  on  tlie  left  tlian  on  the  right  side.  A  deep  lireath,  or  coughing, 
causes  very  intense  pain,  ami  the  respiratory  movements  are  restricted  on 
the  alTected  side,  'i'liere  may  be  pain  on  ;'ressure,  sometimes  over  a  very 
limited  area.  It  may  be  ditlicult  to  distinguish  from  intercostal  neuralgia, 
in  which  aiVeclion,  however,  the  pain  is  usually  more  eircumseiibed  and 
paroxysmal,  and  there  are  tender  jjoints  along  the  course  <d'  the  nerves. 
It  is  pometimes  mistaken  for  pleurisy,  but  careful  physical  examination 
readily  tlistinguishes  between  the  two  alfections. 

(1)  Among  other  forms  which  nniy  be  mentioned  are  cephalodynia, 
affecting  the  muscles  of  the  head;  scapulodynia,  omodyiiia,  and  dorsodynia, 
ail'eeting  the  muscles  about  the  slinublcr  and  upper  [lail  (d'  tin;  liack.  My- 
algia may  also  occur  in  the  abdominal  muscles  anil  in  the  muscles  of  the 
extremities. 

Treatment. — I'est  of  the  all'ected  muscles  is  of  the  first  im|iortancc. 
8tra|)ping  the  side  will  sometimes  completely  relieve  pleurodynia.  Xo 
belief  is  more  widespread  anu)ng  the  pid)lic  than  in  the  ellicacy  of  ponms 
jilasters  for  muscular  pains  of  all  sorts,  ])articularly  those  about  the;  trunk. 
If  the  pain  is  .^'vere  and  agonizing,  a  hyiiodermic  of  morphia  gives  im- 
mediate relief.  For  lumbago  acnpunctiu'e  is,  in  acute  cases,  tlie  most  elli- 
cient  treatment.  Needles  of  from  three  to  four  inches  in  length  (ordinary 
bonnet-needles,  sterilized,  will  do)  are  thrust  into  the  luml)ar  muscles  at 
the  seat  of  the  i)ain,  and  withdrawn  after  five  or  ten  minutes.  In  many 
instances  the  relief  is  immediate,  and  I  can  corrol)orate  fidly  the  state- 
ments of  IJinger,  who  taught  me  this  iiractice,  as  to  its  extraordinary  and 
])rom])t  efllcaey  in  many  instances.  The  constant  current  is  sometimes 
very  beneficial.  In  many  forms  of  myalgia  the  thcrmo-cantery  gives  great 
relief.  In  ol)stinate  cas(>s  blisters  may  be  tried.  Hot  fomentations  are 
soothing,  and  at  the  outset  a  Turkish  "bath  may  cut  short  the  attack.  In 
chronic  cases  iodide  of  potassium  may  be  used,  and  l)oth  guaiacum  and 
sul]dnir  have  been  strongly  recommended.  Persons  subject  to  this  affec- 
tion should  be  warndy  clothed,  and  avoid,  if  possible,  exposure  to  cold 
and  damp.  In  gouty  persons  the  diet  should  be  restricted  and  the  alkaline 
mineral  waters  taken  freely.  Large  doses  of  nux  vomica  are  sometimes 
beneficial. 

IV.    GOUT   {Podaijra). 

Definition.— A  nutritional  disorder,  one  factor  of  which  is  an  ex- 
cessive formation  of  uric  acid,  characterized  clinically  by  attacks  of  acute 
arthritis,  by  the  gradual  deposition  of  urate  of  soda  in  and  aliout  the  joints, 
and  by  the  occurrence  of  irregular  constitutional  symptoms. 


1.1  iff* 


408 


CONSTITUTIONAL  DISEASES. 


Etiology.— The  pivciso  luiiure  of  the  disturbance  in  inotaholism  is 
not  known.     Tlieie  is  prolmhly  defective  oxidation  of  tlu>  foodstulVs.  com- 
hined  witli  imperfect  elimination  of  the  waste  i-roducts  of  the  l.o<ly. 
Anion"-  impoitaut  etiolo«:ieal  factors  in  gout  are  the  foUowmg: 
(„)  Jlcmlilan/  //*////r/(ft-s.— Statistics  sliow  tliat  in  from  :)«  to  00  per 
cent  of  all  eases  "the  disease  existed  in  the  parents  or  grandparents.     Ihe 
triiiMui<Mon  is  supposed  to  be  more  marked  from  the  male  side.     Cases 
uith  a  strong  hereditary  taint  have  liecn  known  to  develop  before  pulierty. 
The  disec.se  has  been  seen  even  in  infants  at  the  lireast.     Males  are  more 
subject  to  the  disease  than  females.     It  rarely  develops  before  the  thirtieth 
year,  and  in  a  large  majority  of  tlic  oases  the  iirst  manifestations  appear 
before  the  a-a'  of  tiftv.    (b)  Mcnhol  is  the  most  ])otent  factor  m  the  etiology 
„f  the  disease.     J-enneuted  li(iuors  favor  its  development  much  more  than 
di-tilled  siiirits,  and  it  ])revails  most  extensively  in  countries  hko  England 
and  (iermany,  which  consume  the  most  beer  and  ale.     The  lighter  licers 
n«cd  in  this  country  are  much  less  liable  to  i)roduce  gout  than  the  heavier 
I'li-dish  and  Scotch  ales,     (r)  Fuod  plays  a  ivlc  equal  in  importance  to  that 
of  alcohol.    Overeating  without  a     've  bodily  exercise  is  regarded  as  a  very 
suecial  prcdisix.sing  cause.    A  fo.iu  of  gouty  dyspepsia  has  been  descril)e(l. 
A  robust  and   active    ligestion  is,  however,  often   met  m  gouty  persons. 
Ciout  is  by  no  means  confined  to  the  rich.     In  Knghind  the  combination 
of  ])oor  food,  defective  hygiene,  and  an  excessive  consumption  of  malt 
liquors  makes  the  "  iioor  man's  gout"   a   common  aifcction.     (d)  Lead. 
(iarrod  has  shown  that  workers  in  lead  are  specially  prone  to  gout.    In  30 
i)er  cent  of  the  hosj.ital  cases  the  patients  had  been  jiainters  or  workers  m 
lead.     The  association  is  i.robahly  to  ))e  sought  in  the  production  by  this 
])oison  of  arterio-sclerosis  and  chronic  nephritis.     Chronic  lead-poisonmg 
is  here  frecpiently  associated  with  arterio-sclerosis  and  contracted  kidneys, 
but  lead-gout  is  "comparatively  rare.     Gouty  deposits  are,  however,  to  be 
found  in  the  big-toe  joint  and  in  the  kidneys  in  cases  of  chronic  jilumbi.-m. 
The  nature  of  gout  is  unknown.    That  there  is  faulty  metabolism,  asso- 
ciated in  some  very  sjjccial  way  with  the  chemistry  of  uric  acid,  we  know, 
but  nothing  more.    The  remainder  is  theory,  awaiting  refutation  or  con- 
firmation.   The  conditions  of  life  favorable  to  the  development  of  gout  arc 
iiresent  in  too  maiiv  of  us  after  the  middle  jieriod  of  life— more  fuel  in  the 
form  of  meat  and  drink  than  the  machine  needs.    G.  15.  Balfour  put  it  well 
when  he  says:  "  The  g(nity  diathesis  is  only  a  comiirehensive  term  for  all 
those  changes  in  the  character  and  compositioii  of  the  blood  induced  by 
the  evils  of  civilization— deficient  exercise  and  excess  of  nutriment.  .  ;  . 
Gont,  on  the  other  hand,  is  the  name  given  to  all  those  modifications  of  our 
metabolism  caused  by  the  gouty  diathesis,  as  well  as  to  all  the  symptoms 
to  which  those  modifications  give  rise.'' 

The  views  regarding  uric  acid  and  its  relation  to  gout  are  very  nu- 
merous. 

Garrod  holds  that  with  lessened  alkalinity  of  the  blood  there  is  an  in- 
crease in  the  uric  acid,  due  chiefly  to  diminished  elimination.  He  attrili- 
ntes  the  deposition  of  the  urate  of  soda  to  the  diminished  alkalinity  of  the 
plasma,  which  is  unable  to  hold  it  in  solution.    In  an  acute  paroxysm  there 


ctabolism  is 
IstiilVs.  coin- 
luxly. 
ing: 

}{)  to  00  per 
ireiits.     The 
side.     Cases 
lovo  puberty, 
k's  are  more 
tlie  thirtieth 
tions  a|)pear 
the  etiology 
h  more  tlian 
like  I'higland 
lighter  beers 
1  the  heavier 
tance  to  that 
led  as  a  very 
vn  deseril)ed. 
)iity  jiersoiis. 
combination 
tion  of  malt 
1.     {(1)  Lead. 
gout.    In  30 
or  workers  in 
iction  by  this 
ead-poisoning 
Lcted  kidneys, 
owevcr,  to  be 
lie  j)lumbi.-m. 
abolisni,  asso- 
eid,  we  know, 
ation  or  cou- 
nt of  gont  are 
)re  fuel  in  the 
)ur  put  it  well 
e  term  for  all 
id  induced  by 
itrimcnt.  .  ;  . 
ications  of  our 
the  symptoms 

are  very  nu- 

there  is  an  in- 
n.  Tie  attril)- 
kalinity  of  the 
)aroxysm  there 


GOUT. 


4U0 


is  an  accumulation  of  the  urates  in  the  blood,  and  the  inflammation  is 
lansed  l)y  tlieir  sudden  deposit  in  crystalline  form  al)out  the  joint. 

Jlaig  tliinks  tliat  there  is  no  increased  formation  of  uric  acid  in  gout, 
liut  that  the  l)lood  is  less  alkaline  than  normal,  and  less  al)le  to  hold  the 
uric  acid  or  its  salts  in  solution. 

According  to  Sir  William  Koberts,  the  chalk-like  deposits  are  formed 
of  the  crystalline  biurate  of  sodium,  and  "'the  artiiritit'  incidents  of  gout 
may  be  said,  not  improperly,  to  be  simjily  incidents  pertaining  to  the  pre- 
cipitation of  these  crystals  in  the  structures  of  tiie  joints." 

Levison  (Die  Ilarnsiiurediathese,  lierlin,  IS!);!)  adopts  IIorl)aezewski"s 
views  that  the  uric  acid  is  related  csi)ecially  to  the  nuclcins  of  the  body, 
and  is  derived  in  great  i)art  from  the  destruction  of  the  white  blood-cor- 
l)uscles,  the  excretion  increasing  pari  paf<su  witii  the  intensity  of  the  leuco- 
cytcxsis.  'While  this  is  true  in  many  diseases,  as  in  i)neumonia,  Richter,  in  a 
careful  study,  has  ,<hown  that  there  are  imjwrtant  excejitions. 

Kl)stcin  thinks  that  the  first  change  is  a  nutritive-tissue  disturbance, 
which  leads  to  necrosis,  and  in  the  necrotic  areas  the  urates  are  de[)osited 
—a  view  which  has  lieen  modified  by  von  Xoorden,  who  holds  that  a  spe- 
cial ferment  leads  to  ti)e  tissue  change,  to  which  the  (le[)osil  of  the  urates 
is  secondary. 

Kolisch  believes  that  the  kidneys  not  only  have  the  function  of  excret- 
ing but  also  that  of  forming  uric  acid,  lie  holds  that  the  graver  mani- 
festations of  gont  only  nuike  their  appearance  when  the  functions  of  the 
kidney  become  iini)aired  from  .«ome  cause.  Jn  his  studies  on  metabolism 
in  gout,  he  finds  tiiat  the  total  alloxuric  bodies  (uric  acid  and  xanthin  bases) 
are  increased  in  the  urine,  'i'liis  is  due  to  an  increase  of  the  alloxuric  or 
xanthin  bases  and  not  of  the  uric  acid,  which  in  reality  is  diminished.  In 
ne])hritis,  Kolisch  found  that  althougli  the  total  alloxuric  l)odies  were  elim- 
inated in  normal  amount,  yet  the  xanthin  bases  were  markedly  increased 
at  the  expense  of  the  uric  acid  excreted.  With  the  kidneys  healtiiy,  the 
greater  ]iart  of  the  alloxuric  bodies  is  eliminated  as  uric  acid,  but,  when  dis- 
eased, Kolisch  holds  that  the  uric  acid  becomes  diminished  and  the  xanthin 
liases  are  relatively  increased.  This  leads  him  to  l)elievc  that  the  kidney 
normally  produces  uric  acid.  He  demonstrated  the  toxic  effects  of  the 
xanthin"  bases  on  the  kidneys  by  injecting  rabbits  and  guinea-pigs  subcu- 
taneonsly  with  hypoxanthin  for  periods  of  one  to  two  months.  In  this  way 
definite  parenchymatous  degeneration  was  ]iroduced.  Having  shown  that 
the  xanthin  bases  were  also  increased  in  gout,  he  believes  that  they  are  con- 
cerned in  the  production  of  the  kidney  affection  which  precedes  the  develop- 
ment of  gout.  Garrod  now  holds  that  uric  acid  is  normally  formed  in  the 
kidneys,  and  that  when  it  aiijiears  in  the  blood  this  results  from  its  reabsorp- 
tion  after  having  been  formed  in  these  organs.  LntY  claims  that  uric  acid 
under  normal  condition*  is  produced  only  in  the  kidneys.  Latham  also  is 
of  the  opinion  that  the  final  f(n-mation  of  uric  acid  takes  ])lace  in  the 
kidneys,  where  it  is  produced  by  the  union  of  sulistances  formed  in  the 
liver  and  convoyed  to  them  by  the  blood  current. 

Cullen  held  that  gout  was  ].riniarily  an  affection  of  the  nervous  system. 
On  this  nervous  theory  of  gout  there  is  a  basic,  arthritic  stock— a  diathetic 


1! 


J  j*' 


^^y  '  CONSTITUTIONAL  DISEASES. 

Iribit  of  which  gout  an.l  rheumatism  arc  two  distinct  branches.  The 
1 ;  uty'  diathesis  is  expressed  in  (.)  a  neurosis  of  tlie  nerve-centres,  wlucl| 
my  be  mlierited  or  ac.qnired;  and  (l>)  "a  peculiar  .ncapac.ty  lor  norma 
elaboration  wUhin  the  whole  h..dy,  not  n.erely  .n  the  hver  or  in  one  o  to 
ca-ans,  of  food,  thereby  uric  acid  is  b.rmed  at  times  in  excess,  or  is  i  - 
c  pabl     of  bein^^  duly   transformed   into   more  soluble   and   less   noxious 

>   .ducts-  (Du.Uorth).     The  explosive  neuroses  and  the  ^-^^^f^ 
pressinj,^   circumstances,   physical  or  mental,   iKunt  strongly     o  the     ait 

.laved  by  the  nervous  svstem  in  the  disease.     The  recents  works  o    Duck- 
;S  and  William  K wad  may  be  consulted  for  a  full  d.scussu.i.  ot  the  van- 

ous  theories  on  the  nature  of  gout. 

Morbid  Anatomy.-The  hhod  is  statc.l  to  have  an  excess  of  m  c 
acid      It  mav  be  ..btaincd  from  the  blood-serum  by  the  method  known  as 
(Jarrod-s  uri^-acid  thread  experiment,  or  from  the  serum  obtained  from  a 
blister      To  oi)  of  s<.rrm  add   m  v-vj  of  acetic  acid  m  a  watch-glass.     A 
thread  immersed  in  this  may  show  in  a  few  hours  an  incrustation  ..1  unc  acid. 
The  experiment  is  rarely  successful  even  in  cases  of  manifest  gou  .     Uus 
excess,  also,  is  not  peculiar  to  g.nit,  but  occurs  in  leuka^nua  and  chloroM> 
'    In  LSi.4  Xeu>ser  described  a  peculiar  black  granulation  over  and  about 
the  nuclei  of  the  leucocytes  in  the  bhx.d  of  gouty  patients.     He  termed  thcmi 
"  perinuclear  basophilic  granules,"  and  demonstrated  them  by  using  a  modi- 
fied Khrlich's  triacid  mixture.    They  were  particularly  numerous  abou      he 
m.clei  of  the  mo.u.nm.lear  leucocytes.     He  believed  that  they  wc.;e  of    ho 
nature  of  a  nuclco-albumin,  and  claimed  that  cases  showing  thcmi  eliminated 
uric  acid  in  excess.     Ho  held  that  these  gramiles  constituted  the  mother 
.ub^tance  from  which  the  uric  acid  was  formc.l,  and  that  i.ationts  showing 
the<o  .rranules  were  siilfering  from  a  iiratic  or  gouty  diathesis.     Subsequent 
work  bv  Futcher  and  others  H^ems  to  have  shown  that  there  is  no  associa- 
tion betwwn  the  abundance  of  these  granules  and  the  elimination  oi  uric 
acid  or  of  the  total  alloxuric  bodies.  r^,      n    ,  ■  ■   ,     e 

The  important  changes  are  in  the  articular  tissues.     The  first  joint  ot 
the  "feat  too  Is  most  freciiientlv  involved;  then  the  ankles,  knees,  and  the 
«maii  ioints  of  the  hands  and  wrists.    The  deposits  may  be  in  all  the  pints 
of  the  lower  limbs  and  absent  from  those  of  the  npper  limbs  (Gorman 
^loorc)      If  death  takes  idaoe  during  an  acute  paroxysm,  there  are  signs 
of  inllanimation,  hvpenvmia.  swelling  of  the  ligamentous  tissues    and  of 
elfusion  into  the  joint.     The  jn-imary  change,  according  to  W'^tcMn,  is  a 
local  necrosis,  due  to  the  i.rosence  of  an  excess  of  urates  m  the  blood,     ilus 
is  «een  in  the  cartilage  and  other  articular  tissues  in  which  the  nutritional 
currents  are  slow.     ^lordhorst  holds  that  the  deposition  of  the  urates  is 
T.rimarv.  and  that  the  necrosis  of  the  tissues  takes  jdaco  as  a  result  of  tins 
deposit     In  those  areas  of  coagulation  necrosis  the  reaction  is  always  acH 
and  the  neutral  urates  are  dojiosited  in  crystalline  form,  as  msolublo  acul 
urates     The  articular  cartilages  are  first  involved.    The  gouty  deposit  may 
be  uniform,  or  in  small  areas.     Though  it  looks  superficial,  the  (l^Mio^it  is 
invariablv  interstitial  and  covered  by  a  thin  lamina  of  cartilage.    The  de- 
posit is  thickest  at  the  part  most  distant  from  the  circulation.    The  liga- 
ments and  fibro-cartilage  ultimately  bocomo  involved  and  are  infiltrated 


GOUT. 


411 


anchos.  Tho 
■fiitros,  wliicli 
ty  t'ur  norinal 
in  one  or  two 
ot'si!?,  or  is  in- 
i  less  noxious 
lliionce  of  ik'- 
,•  to  t!'.e  part 
orliN!  of  Duc'lv- 
oi:  of  the  vari- 

exc'CPS  of  uric 
hod  known  as 
)taine(l  from  a 
•ateh-glass.     A 
on  of  uric  aeitl. 
■st  gout.     This 
and  chlorosis. 
Dver  and  about 
[e  termed  theni 
y  using  a  niodi- 
jrous  about  the 
ley  ■were  of  tho 
hem  eliminated 
tt'd  the  mother 
at  lent  s  showing 
is.    Snbseqnent 
•e  is  no  associa- 
lination  of  uric 

he  first  joint  of 
knees,  and  the 
in  all  the  joints 
limbs  (Norman 
there  are  signs 
tissues,  and  of 
to  Ebstein,  is  a 
the  blood.    This 
1  the  nntriticmal 
of  the  nrates  is 
;  a  result  of  this 
in  is  always  acid 
IS  insoluble  acid 
)Mtv  deposit  may 
il.  the  deposit  is 
rtilage.     The  de- 
ition.     The  liga- 
d  are  infiltrated 


willi  chalky  dejiosits,  the  so-called  clialk-st()n(>s,  or  tn|)lii.  These  arc  usuallv 
idvcrcd  by  skin;  i)Ut  in  some  cases,  |iarticiilarly  in  the  nietacar|i(>-]ihalaiigeal 
iiiticuialions,  this  ulcerates  and  llie  clialk-stmics  a|i|Pcar  exlcriially.  'I'lic 
-yiiovial  tluid  may  also  contain  crystals.  In  very  long-standing  cases,  owing 
to  an  excessive  deposit,  the  joint  liccoiiies  inimoi)ilc.  'I'lic  marginal  out- 
growths in  gouty  arthritis  are  true  exostoses  (Wynne).  'I'iic  cartilage  ol' 
the  car  may  contain  tophi,  which  arc  seen  as  whitish  nodules  at  the  margin 
of  the  iielix.  'I'he  cartilages  of  the  nose.  eyeli(l>.  and  larvnx  arc  less  fre- 
ipK'ntly  alVected. 

Of  changes  in  the  internal  organs,  those  in  the  renal  and  vascular  sys- 
tems are  tiu'  most  imjiortant.  The  kidney  ciuuiges  believed  to  be  charae- 
icristic  of  gout  are:  (n)  \  dc|)osit  of  urates  chietly  in  the  region  of  the 
papilla'.  'I'his.  howevci'.  is  less  common  than  is  usually  siippo.-^cd.  \orman 
.Moore  found  it  in  only  Iv!  out  of  SO  cases.  The  apices  of  the  pyramids  show 
lines  of  whitish  di'posit.  On  micro.sco|)ical  examinatimi  the  material  is  seen 
to  be  largely  in  the  intertuhular  tissue.  In  some  instances,  however,  the 
(Icjjosit  seems  to  i>e  both  in  the  tissue  and  in  the  tul)iiles.  {•'.bstein  has  de- 
scribed ami  figured  areas  of  necrosis  in  both  cortex  and  medulla,  in  the 
interior  of  which  were  crystallin(>  deposits  of  urate  of  soila.  Tlie  iircsciice 
of  these  nratic  concretions  at  the  apices  of  the  jiyramids  is  not  a  ])ositive 
indication  (d'gmit.  'Hicy  are  not  infi'ecpu'nt  in  this  country,  in  which  gout 
is  rare,  (h)  An  interstitial  m^phritis,  cither  the  ordinary  "contracted  kid- 
ney" or  the  artcrio-sclerotic  form,  neither  of  which  are  in  any  wav  dis- 
tinctive. It  is  not  ])ossilile  to  say  in  a  given  case  that  the  condition  has 
l)een  due  to  gout  uidcss  marked  evidences  of  the  disease  coexist. 

The  metatarso-|)lialiingeal  joint  of  the  big  toe  should  be  carcfnllv  I'x- 
amined.  as  it  may  show  typical  lesions  of  gout  without  any  outward  token 
of  arthritis. 

Ai'terio-sclerosis  is  a  very  constant  lesion.  With  it  the  heart,  particu- 
larly the  left  ventricle,  is  found  hyjierlrophied.  Acc(U'ding  to  some  authors, 
concretions  of  urate  of  soda  may  occur  on  the  valves. 

Changes  in  the  respiratory  system  are  rare.  ne])osits  have  been  found 
in  the  vocal  cords,  and  urie-aeid  crystals  have  been  met  in  the  s])nta  of  a 
gouty  jiatient  (.1.  W.  Moore).  Kmpliysema  is  a  very  constant  condition 
in  old  eases. 

Symptoms. — Oout  is  usually  divideil  into  acute,  chronic,  and  irregu- 
lar forms. 

Acute  Gout. — Premonitory  symptoms  are  common — iwinges  of  pain  in 
the  small  joints  of  the  hands  or  feet,  nocturnal  restlessness,  irritabilitv  of 
temper,  and  dyspepsia.  The  urine  is  acid,  scanty,  and  high-colon>d.  ft 
deposits  urates  on  cooling,  and  there  may  be.  according  to  Oarrod.  tran- 
sient albiuninnria.  There  may  be  traces  of  sugar  (gouty  glycosuria).  Before 
an  attack  the  ontpiit  of  uric  acid  is  low  and  is  also  diminished  iTi  the  early 
part  of  the  paroxysm.  Tlie  ndation  of  uric  and  phosphoric  acids  to  the 
acute  attacks  is  well   reiirescnted    in   Chart   XTV.*   lu'cparcd   bv   Futcher. 


',-•1 

It 

li  i 


*  The  uric  iioid  wns  dptprmiticil  liy  llic  (lowliiiiil-Ilopkins  inothoci  ami  the  jihosjjlioric 
ueid  l)y  the  uranium-nil  rate  proness. 


u 


412 


(JOXSTITUTIONAIi   DISEASES. 


Hot!)  were  cxtri'iiiclv  low  in  tlic  intcrviils,  liiit  iviichcd  within  normal  liinil- 
shortly  iil'tcr  the  onset  of  the  -icuti'  >>niiilonis.  'I'lif  |iho<iiiiorir  acid  and 
uric  acid  show  almost  parallel  curves.  The  |ialienl  was  on  a  very  light  diet 
at  the  time  the  determinations  were  made,     in  some  instances  the  throat 


i.i 


1.1 


1.0 


0.9 


0.8 


JkNUARY 


FEBRUARY 


I  M  —    O  '■£  <-  2 


'i    I  -  oo    S»    O    —   7» 

■7  '7  "  T  *f  " '  "V 


]-jz: 


r 


m 


Tl 


S  y  ?i  S  S  s  -  ^,  =7  -  .,  .^  ,.  ,  =,  o  2  ::  V  5  T  ■;•  H'  7  T  f  -'  *•  *;  2  i  X  3/ J 


t 


^- 


V-t- 


.,.-L4' 


iTli      (Iliininmi'Flt'UJ 


^r!7i- 


It- 


W-VS. 


-H- 


C'liAUT  XIV.— Showing  urk'  acid  and  iiiiesphorie  auid  (iut|mt  in  ease  of  uculo  g( 


ml. 


is  sore,  and  there  may  he  asthmatic  sym]itoms.  'Hie  attack  sets  in  usually  in 
the  early  moniiiig  hours.  The  patient  is  aroused  hy  a  severe  pain  in  the 
in(>taiafsn-phalaii,i:eal  articulation  ol'  the  hig-  toe,  and  more  commonly  on 


GOUT. 


413 


niiriiial  limil- 
uric  acid  and 


(TV  lifiht  ilict 
cs  the  tlii'uai 


t\: 


±i 


T- 


of  iiculo  gout. 

Is  ill  usually  in 

'PC  |iain  in  tin' 

coinmonly  on 


the  riirht  tliaii  on  the  left  >idi'.  'I'lir  pain  is  ajronizinir,  and,  as  Sydi'iiliani 
says,  ••  insinnatt's  itscll'  with  tli  iimst  cxiiuisitf  crncity  aiiKiiiij;  the  nuiiicr- 
ous  small  hniifs  nl'  the  tarsns  aiTd  nictatarsns.  in  the  li^ainciits  (d'  wliicli  it 
is  liirkiiiji."  'I'hc  juint  swells  rapidly,  and  lieeomes  hot,  tense,  and  shiny, 
le  sensitiveness  is  extreme,  and  the  pain  makes  the  patient  I'eel  as  if  the 
int  were  lieiii^'  pressed  in  a  vi<c.  'I'lii'i'e  is  fever,  and  the  temperature  may 
rise  tn  Id'.''  or  in;'.".  Towai'd  mornini:  the  severity  of  the  symptoiiis  siih- 
sides,  and,  althoiijili  the  joint  remains  sw(dlen,  the  day  may  he  passed  in 
(omparative  ((mifort.  The  syiiipt(mis  reeiir  the  next  iiiji'ht,  and  the  fit, 
as  it  is  ealleil,  usually  lasts  for  fnnn  live  to  eif^dit  days,  the  severity  of  the 
symptoms  ^I'adiially  ahatiii;/.  Oeeasioiially  other  joints  are  involved,  par- 
tienlarly  tlie  lii;^'  toe  of  the  opposite  foot,  'i'he  inilammation.  however  in- 
leiise.  never  "'oes  on  to  snppnrat inn.  With  the  siihsidenee  of  the  swellinj^ 
the  skin  des(piamates.  After  the  attack  the  .u'ciienil  health  may  he  much 
improved.  As  Arela'iis  remarks,  a  person  in  tlu'  interval  has  won  the  race 
at  the  Olympian  ;:'aines.  llt'curreiices  are  fre(pieiit.  Some  ]iatients  have 
iliree  or  four  attacks  in  a  year;  others  at  loiio-er  intervals. 

'I'he  term  rrlrnccdnil  or  sii/ijirr.-isi'il  o-ont  is  ajiplied  to  serious  internal 
sym|it(mis,  coincident  with  a  I'apid  ilisap]>earanee  or  iiii]iroveineiit  of  the 
loeal  siiiiis.  N'ery  remarkahle  manifestations  may  occur  under  thest>  cir- 
cumstaiiees.  'i'he  jiatieiil  may  have  severe  i^astro-intt'stinal  symptoms — - 
pain,  vomit inj:-.  diariiuea.  and  ^reat  depression — and  death  may  occur  diir- 
iiiL;-  such  an  attack.  Or  tlieiv  may  he  cardiac  manifestations — dyspmea, 
pain,  and  irrej^ular  action  of  the  heart,  in  some  instances  in  which  the 
pint  is  said  to  attack  the  heart,  an  acute  jiericarditis  develops  and  proves 
fatal.  So.  too.  there  may  he  marked  cerehral  manifestations — delirium 
or  coma,  and  even  apoplexy — hut  in  a  majority  (d'  these  instances  the 
syniptoins  are.  in  all  prohahility.  ura>iiiic. 

(ioul  is  a  comparatively  rare  disease  in  America.  .\inou^-  the  well-to-do, 
and  even  amoiiu'  cluh-men — a  class  ]iarticularly  liahle — it  is  infrcipieiit.  in 
comparison  with  the  prevalence  in  the  cori'espimdiiiLT  classes  in  JMiLiland. 
^Feii  in  lar.u-e  family  iiractice  may  ]iass  a  year  or  iiKnv  without  seeim:'  a  case. 
It  has  hecome  mori'  c(mimoii.  however.  diirin.<r  the  past  twenty-live  years, 
and  T  llnd  a  marked  increase  in  hospital  practice. 

Chronic  Gout. — With  increased  freipiency  in  the  attacks,  the  articular 
sym]>toms  jiersist  for  a  loiiuer  time,  and  i;radiially  many  joints  hecome 
all'eett'd.  Dejiosits  of  urates  take  ]ilace,  at  first  in  the  articnlar  ■  artila.ires 
and  then  in  the  liuaments  and  capsular  tissues;  so  that  in  the  .onrse  of 
years  the  joints  liecome  swollen.  irre<rular.  and  deformed.  'Phe  feet  are 
nsiially  first  affected,  then  the  hands.  In  severe  cases  there  may  lie  extensive 
(oncretions  about  the  elhows  and  knees  and  almtir  the  tendons  and  in  the 
liiirsa'.  The  tophi  appear  in  the  ears.  Finally,  a  nniqno  clinical  picture  is 
jirodnced  which  cannot  he  mistaken  for  that  of  any  other  alfection.  The 
skin  over  the  tophi  may  rnptnre  or  nlcerafe.  ami  ahout  the  knuckles  the 
chalk-stones  may  he  freely  exposed.  PaiiiMiis  with  chronic  iiont  are  nsnally 
dvspeptic.  often  of  a  sallow  compleximi,  and  show  sii;ns  of  arterio-sclorosis. 
The  inilse  tension  is  imnvased.  the  vessels  are  stilf.  and  the  left  ventricle 
is  hypertrnphied.  The  nrinc  is  increased  in  ainonnt,  is  of  low  specific  grav- 
20 


^'1 


1 1 


H 

u 


4U 


CONSTITUTION  A  L   OlSEASKS. 


itv  Mu.l  iisuiillv  cdiitirms  a  sli-lit  iiinoimt  n(  all.mniii.  with  a  few  livaliiir 
ca.-'ts.  liUrrcuiTciit  attacks  cl'  aciilc  polyarthritis  may  .level.. p,  iii  whuL 
the  j. Milts  lurome  iiillaine.l,  aii.l  the  leiii|HTatiiiv  v:uv^v>  In.iu  KH"  to  lo:;  . 
The'iv  mav  he  pain.  r.Mlness.  an.l  sweliiiiji  of  M'veral  j.Miits  with. nit  l.'ver. 
Ineinia.  pleiiii>v,  periearclitis,  peritonitis,  an.l  nu'iiin-itis  are  ooiniu..n  ter- 
iiiiiial  ai'vecti.ins."  Patients  with  eiiroiiic  ^oi't  iHii.V  ^'i''^^'  ivinarkahle  mental 
aml'even  ho.lilv  vi-..r.  Certain  of  the  most  .listin-uishe.l  memhors  of  ..ur 
i.role-sioii  have  i.een  terrihle  sulVerers  rr.nn  this  .lisease,  notal)ly  th"  elder 
k-aliger,  Jerome  Canlan,  an.l  Sy.leiiham.  whose  statement  that  ••more 
wise  men  than  I'.x.ls  are  vielims  ..I'  the  alVeetion  "  still  hoi. Is  p).-l. 

Irregular    Gout.— This  is  a  motl.'V.  ill-.lellne.l  -n.iip  of  symi»t..ms.  maiii- 
festatiuiis  of  a  condition  oi'  .lisor.lere.l  niitrith.n,  to  which  the  terms  //n///// 
(lialhcsis  or  lilliannr  ..laic  have  he.-n  given.     Cases  are  seen  m  meiuhers  ..I 
gouty  families,  wh..  mav   n.'ver  themselves  have  siiiV.'re.l    fp.m   th.'  a.-nt.' 
di-ea'^e    an.l  ill  persons  who  have  live.l  n.-t  wisely  hut  t.m  well,  wh..  have 
eaten  an.l  .InniU  lai-elv,  lived  sedentary  lives,  an.l  yet  hav(>  heen  fort  .mat,. 
en..u..h   t..  escape  an  acute  attack.      It    is  interesting  t..   ii..te  the   vari..i.> 
mani'feslati.ins  ..f  the  .lisease  in  a  family  with  marke.l  hereditary  .lisp..^i- 
tion.     The  daughters  often  escape,  whih'  one  s..n  may  have  -..nty  attack. 
of  frreat  severitv,  even  thoii-h  he  lives  a  tcmp.'rate  lif.'  an.l  tries  in  evry 
way  t.)  av..i.l  tile  c.n.liti.ms  fav..rino.  the  disor.ie.'.     An..ther  s.>n  has,  jier- 
hai'.s.  onlv  the  irreoular  manifestations  and  never  the  acute  artu-ular  all.r- 
tioii.     While  the  irrefiular   features  are  j.erhaps  more^ often    ni.'t    with    m 
the  here.litarv  atVecti.m,  thev  are  hy  im  means  infreciuent  in  pers.)ns  wh.. 
appear  to  have  a..piire<l  the  .lisease.     The  teiideii.'y  in  some  families  is  to 
call  every  aiVecti..n  g.nity.     Kven  infantile  complaints,  such  as  scal.l-h.'a.l, 
uaso-pha"rvii--eal  ve-vtations,  an.l  cnuivsis,  air  ..fteii  r.-ar.le.l,  with. .lit  sul- 
iici.'iit  -rounds,  1  helieve.  as  evi.lcnc.'s  ..f  the  family  ailm.'iit.     .\iii..n,u-  the 
commonest  manif.'stati.ms  ..f  irre-ular  p.ut  are  the  followin.ii-: 

(,/)  Cithiiirniis  /•;;•»/<//■";(.>.•— Cam..!  an.l  oth.'rs  have  call.'.!  spc.-ial  att.'n- 
tion  t.>  the  fre,|U.'iit  associati..ii  .-f  .■./..■ma  with  the  -outy  hahit.  The 
French  in  jiarticular  insist  up..n  tli.'  s|.e.-ial  liai.ility  of  o-„„ty  pers..ns  t.) 
skin  alVecti.uis,  the  (irllirilidrs.  as  tlu^y  call  th.'iii. 

(M  <;aslni-iitlrsl!inil  /;,Vo;v/n'.v.— .\ttacks  of  what  is  termed  hilmiisn.^ss. 
in  which  the  l..ii-ue  is  furred,  the  hrealh  f.ml.  the  \nA\cU  eoiistii.ated.  an.l 
the  acti.in  ..f  the  liver  L.rpid.  are  ii..t  uii.-..niiii.>n  in  -'..uty  pers.ms.  A 
<j;outv  i.ai'otitis  is  desci^ih.^.l.  _     , 

(',)  Ciinliii-nisritliir  .<///*(///")»v.— With  the  litluemia.  art.'ri..-scler.>sis  is 
fr...liu^iitlv  associated.  Tli.«  l.l<...d  teiisi..u  is  persistently  liiu'li.  the  vessel 
walls  heconie  stilV.  an.l  .ar.liac  and  ■■•■nal  .-lian.uvs  aradually  d."vel.)p.  In 
this  c.mditi.)'^  the  manifestati..us  may  he  renal,  as  when  the  alhuminuria 
!..■.■.. ni.'s  uiore  marlx.'d,  ..r  dmiisical  symptoms  supervene.  The  manif.-sla- 
th.ns  mav  he  cardiac.  wli.'U  the  hypertr.)phy  .d'  tli."  h^ft  v.^ntri.'le  fails  an.l 
th.'re  ar.'  palpitation,  irre.uular  a.-ti.)n.  an.l  ultimat.dy  a  c.iiditi.iu  ..f  asys- 
t.de.  Or,  fmallv.  th.'  uiauif.'statious  mav  !..■  vascular,  and  thntmhosis  .>f 
tlie  c^rouarv  arteri.'s  uiav  .-anse  sudd.^n  .l.'aili.  .\neiirism  may  d.'v.^l.>p  and 
l.rove  fatal!  or.  as  most  fre.iueiitly  ha|.p.'ns.  a  hl....d-vessel  oives  way  in 
the  hraiii.  and  the  patieut  di.'s  <d'  ap..pl.'xy.     It  makes  hut  little  diifereiice 


I  few  liyaliin 
l(i|),    ill    wllirl' 

KU"  to  lo:!  . 

vitllllllt     I'cVlT, 

coiiniKiii  tci- 

rkaliU'  iiiciital 

I'liihcrs  of  iiiii' 

alily  til"  cldtT 

tliat    '■  luniv 

JO(il. 

niitiinis.  inani- 
ic  terms  (jmilii 

II  llU'lulll'l'S  dl' 
■iilU  IIh'  aclllr 
VvW,   will!    lia\r 

liccu  rortuiiatr 
tc  tlu'  varidu- 
(litary  (lis|Mi-i- 
jiiiiity  atta(k> 
tries  ill  every 
!•  son  lias,  jier- 
articiilar  all'ee- 

I  met    with    in 

II  lUTSOllS  wlio 
'  families  is  In 

as  seahl-lieail, 
li,  without  siif- 
t.  Auiiiii^'  llie 
iiu': 

1  special  atteii- 
y  lial>it.  The 
iiity  ]H'i'sons  to 

leil  liiliousiiess. 
oiistipated.  ami 
ty   |iersoiis.     A 

erio-selei'osis  is 
liii'li,  the  vessel 
Iv  ilevelop.  In 
he  alhiimiiiiiria 
Tlie  rmiiiiresta- 
itriele  fails  and 
ml  it  ion  of  asys- 
1  tlironiliosis  o 
lav  de\('lo]i  and 
A  iiives  way  in 
little  diU'eroiice 


noi'T. 


41:. 


whether  we  rc^^ard  this  oomlition  as  |iiiinarily  an  artorio-selerosis,  or  as  a 
gouty  nephritis;  the  point  tu  bo  ronieinhered  is  that  tlio  nutritional  dis- 
order with  which  an  excesis  of  nrie  acid  is  associated  induces  in  tinio  in- 
creased tension,  arterio-sclerosis.  ciironic  interstitial  nephritis,  and  ehanjxes 
ill  the  myocardium.     JVricarditis  is  not  an  infretiiieiit   terminal  coiniilica- 

lioll   of  gout. 

((I)  \rn;iiix  Manifrsliilidiix. —  lleada-he  and  megrim  attacks  are  not 
infre(|ueiit.  iiaig  attributes  them  to  an  excess  of  uric  acid.  Xeuralyias  an; 
not  iineommon;  sciatica  and  paru'sthesias  may  develo]).  A  c(uiiiiion  gouty 
manifestation,  upon  which  l)iickw(ulh  has  laid  sti\'ss.  is  the  oeciirnMiee  of 
hot  or  itching  feet  at  night.  Plutarch  meiilioiis  that  Straho  called  this 
byniptoin  "the  lisping  of  the  gout."'  Cramps  in  the  legs  may  also  he  very 
troiihlesoine.  liutcliiiison  has  called  attention  to  hot  and  itching  eyeballs 
as  a  frecineiit  sign  of  masked  gout.     .More  serious  cerebral  manifestatioiis 

rvxiiU  i'v a  condition  of  ai'terio-sclerosis.    Apoplexy  is  a  coinmon  termimi- 

tioii  of  gout.     Meningitis  may  develop,  usually  basilar. 

{(•)  rriiKtri/  Disanh'rs. — The  urine  is  highly  acid  and  high-colored,  and 
may  deposit  on  standing  crystals  of  litliic  acid.  Transient  ami  temporary 
increase  in  this  ingredient  cannot  be  regarded  as  serious.  In  many  cas("s 
of  chronic  g(uit  the  iiiuoiint  may  be  diminished,  and  only  increased  at  eer- 
in  periods,  forming  the  so-called  iiric-aeid  showers.  The  chart  on  page  11-3 
illustrates  this  very  well.  Sugar  is  found  intermittently  in  the  urine  of 
gouty  persons — gouty  glycosuria.  It  may  pass  into  true  diabetes,  but  is 
usually  very  amenable  to  treatment.  Oxaliiria  may  also  be  present,  (ioutv 
|)ersoiis  are  specially  jiroiie  to  calculi,  -Jerome  Cardan  to  the  contrary,  who 
reckoned  freed(uii  from  stone  among  the  chief  of  the  ilnmi  piii/di/rd'.  Minute 
([uantities  <>{  albumin  are  very  eomiiKui  in  perxtns  of  goutv  dvscrasia.  ami. 
when  the  renal  changes  are  wi'll  established,  tube-casts,  rretliritis,  accom- 
panied with  a  well-marked  piiruleiil  discharge,  may  develop,  so  it  is  stated, 
usually  at  the  end  of  an  attack.  It  may  occur  spoiitaneouslv.  or  follow  a 
pure  connection. 

(/')  I'lihiidiKiri/  DIsiinlrrs. — There  are  no  characteristic  changes,  but, 
as  (irceiihow  has  iiointed  out.  chronic  broiichili.--  occurs  with  great  fre- 
quency in  persons  of  a  gouty  habit. 

(ll)  (•''  eye  all'ections,  iritis,  glaucoma,  luemorrhagic  retinitis,  and  sup- 
jHirative  paiiopthalinitis  have  been  described. 

Diagnosis. — liecurring  attacks  of  arthritis.  liniite(l  to  the  iiig  toe  and 
to  the  tarsus,  occurring  in  a  member  of  a  gouty  family,  or  in  a  man  who 
has  liv(>d  too  well,  leave  no  (|nesii()ii  as  to  the  nature  (d'  the  trouble.  There 
are  many  cases  of  gout,  however,  in  which  the  feet  do  imt  sulfer  most  se- 
verely. .\fter  an  attack  or  two  in  one  toe.  other  joints  may  b(>  all'ected, 
and  it  is  just  in  such  eases  of  polyarthritis  that  the  dilliculty  in  diagnosis  is 
apt  to  arise.  AV(>  have  had  of  late  years  several  cases  admitted  for  the  third 
or  fourth  lime  with  involvement  of  three  or  more  n\'  the  larger  joints.  The 
u'esence  if  tophi  has  settled  the  nature  of  a  tr(mble  which  in  the  jirevious 
attacks  had  been  regarded  as  rheumatic.  The  following  are  suggestive 
jioints  in  such  oases:  (1)  The  patient's  habits  and  occupation.  Tn  this  conn- 
try  the  brewery  men  and  barkeepers  are  often  aifected.     ("?)  The  presence 


i 


416 


fUXSTITl'TlONAI.    DISKASKS, 


,,1'  tophi.     Till'  I'livs  sliMiil.l  iil\v;iy<  !..■  I'.^lt   in  a  case  ol'  polyartliviti^.     Tlir 
(lia-nnsis  iiinv  ivst  with  a  small  K.phus.    Tlu'  stiidciit  -hould  learn  to  rcco-- 
iii/.i"  on  tiu'  I'ar  inar-iii  \V(.olmrV  tip,  iii>n.i<|  n(Mlulr>,  and  small  sohairmis 
tumors.     Tho  latter  are  easily  ncoLMiixed   microsi'opieally.     The  urate  ol 
MMla  cvstals  are  ilistinctive  in  tlu'  tophi.     (:!)  The  condition  of  th.^  nnn.  . 
As  shown  in  Chart   XIW  lii.'  urie-aeid  onlpiit   is  nsiially  very  l-.w  dnnn;: 
the  intervals  of  the  paroxy>m.     There  may.  indeed,  he  no  exeretioii  what- 
ever.    At  the  hei<iht  ni  tliV  attack  the  elimination,  as  a  ride,  is  ^rreatly  in- 
creased     'I'he  ratio  ol'  the  uric  acid  to  the  urea  excretion  is  di>tnrlicd  in 
onntv  cases,  and  mav  fall  as  low  as  1  to  CD  ..r  1  to  SO.     (1)  The  -outy  poly- 
iirthiilis  mav  he  al'elirile.     .\  patient  with  three  or  fonr  j.nnts  red,  >w,dlcn. 
and  painrnlin  acnte  rlieumatiHii  has  fever,  and.  while  pyrexia  may  he  pres- 
ent and  (d'ten  is  in  -ont.  its  ahseiice  is.  1  think,  a  valuahle  dia,--iiostic  si'rn. 
Treatment. --////'/''■"''■•— '"'li^'"'""^''  ^^'"*  ''"^'^'  i'lh^'rited  a  tendency 
to  ,--oiit.  or  who  have' >liown  any  manil'estations  of  it.  slioiiM  live  temper- 
atelv.  ah.-tain   from  alcoli.d.  and   eat   nioderat.dy.     An   open-air  life,  with 
plenty  (d'  exercise  and  re-nlar  hours.  <1(hs  nindi  to  connteract  an  inhoni 
tendency  to  the  disease.     The  skin  shoidd  lie  kept  active;   if  Hie  iiaticnt  is 
rohiist.  hy  the  mornin-i-  cold  hath  with  friction  after  it:  hnt   if  he  is  weak 
or  (lehilitate<l   the  evenin--  warm   hath   should    he  snhstitnled.      An   occa- 
sional Turkish   hath  with  active  shampooin.u'  is  very  advanta.uvoiis.     The 
patient  slnudd  dress  warmly,  avoid   rapid  alterations  in  ti'mperainre,  and 
he  carefid  not  to  have  the  skin  snddi'idy  idiilled. 

DU'lciir. — With  few  exceptions,  pei'soiis  over  forty  eat  too  much,  and 
the  lir-^t  injunction  to  a  -only  person  is  to  kceji  his  apjictite  within  reason- 
ahle  iHiumis.  to  eat  at  stated  hours,  and  to  take  plenty  of  time  at  his  nmals. 
In  the  matter  (d'  food,  (piaiuity  is  a  factor  of  more  imiiortance  than  ipiality 
with  manv  ,i:(mty  persons.  .\s  Sir  William  Kolierts  well  says.  "  Nowhere 
perhaps  is  it  more  iiecosary  than  in  gout  to  consider  the  man  as  well  as 
the  ailment,  and  very  often  mi>re  the  man  than  the  ailment."" 

\'ery  remarkahle  diirercni'cs  of  opinion  exi>t  as  to  the  most  s\iitahle 
diet  in  "this  disease,  some  uru'ing  warmly  a  vegetahle  diet,  others  allowing 
a  very  liheral  amount  of  meat.  On  the  one  hand,  the  author  just  (pioted 
savs:""'rhe  most  tvu>lworthy  c.xperiincnts  indicate  that  fat.  >tarcli,  and 
.suiiar  have  not  the  least  direi-t  intlueiice  on  the  production  of  ui'ic  acid; 
hut  as  the  free  consumption  (d'  these  articles  naturally  operates  to  restrict 
the  intake  of  the  nitrogenous  food,  their  use  has  indirectly  the  eU'ect  cd" 
diminishing  the  average  production  td'  uric  acid."'  On  the  other  hand. 
W.  II.  Draper  says;  ••  The  conversion  (d'  azotizeil  food  is  more  complete 
with  a  minimum  <d'  carhohydrates  than  it  is  with  an  I'Xcess  of  them;  in 
other  words,  one  of  the  hest  nutans  of  avoiding  the  accumulation  (d'  lithic 
acid  in  the  hhiod  is  to  diminish  the  cari)oliydrati's  rather  than  the  azotized 
foods."  The  weight  (d'  opinion  leans  to  the  use  of  a  modilied  nitrogenous 
diet,  without  excess  in  starchy  and  saccharine  articles  (d'  food.  Fri'sli  vege- 
tahles  and  fruits  may  he  used  freely,  hnt  among  the  latter  strawherries  and 
bananas  should  he  avoided. 

Khstein  urges  strongly  the  use  id'  fat  in  the  form  of  good  frosh  huttor, 
from  2^  to  o.i  oniu'cs  in'  the  day.     lie  says  that  st(uit  gouty  sulijects  not 


(}()UT. 


417 


hritis.  Tlir 
irn  to  rw'ou- 
ill  solmccMiiis 
'ho  uniti'  111 
if  the  iirinr. 
•  Itiw  (Inriiii: 
rctioii  wliiil- 
s  jrn'iiily  in- 
(listiirlicil  ill 
'  polity  I'lily- 
nil,  >\V()lk'n. 
iniiy  lie  |>rcs- 
iLi'iiostic  f^\>^u. 
1  a  ti'iKU'iicy 

live   tcllllHT- 

lir  lil'o,  with 
c't  nil  inliiini 

:!ic  imtii'iit  is 
if  hi'  is  wcjik 
1.  An  iKia- 
a,uc'i>iis.  'i'lic 
pi'i'aiiirt',  mill 

lo  iiun-h,  ami 
iitliiii  icasoii- 
'  at  his  nmals. 
■  than  (|uality 

S,    "  ^NllwlU'IT 

'an  as  well  as 

nmst  snitahh' 
luTs  aUowiniT 
ir  jnst  ([notcil 
t,  starch,  and 

of  nric  acid: 
tcs  to  restrict 

tlic  ctl'cct  (d' 
L'  otlicr  Inmd, 
norc  complete 
s  of  them;  in 
alion  id'  litliic 
n  the  azotizcd 
■d  nilro,i:'enoiis 
.  Fresli  ve^'c- 
rawlierries  and 

1  fresh  hnttor, 
y  snltjeots  not 


iinlv  do  not  increaM'  in  weijziit  uitli  pleniy  id'  tai  in  llie  f 1.  hnt  llial  they 

acliially  iiecoinc  thin  and  the  general  condilioii  iniprovcs  very  much.  Hot 
liread  of  all  Mirt>  and  the  various  ai'tii  le,-  of  food  |irc|iarcd  from  Indian 
coi'n  should.  a>  a  rule,  he  avoided.  Iiohert-  ad\i>es  joiiiy  |ialienl>  to  re- 
strict as  far  as  iiraclicahlc  the  use  id"  common  salt  with  their  meals,  since 
•  he  sodium  hiurale  very  I'cadily  cry>lalli/.c.>  out  in  li>sncs  with  a  lii^h  per- 
ceutau'c  of  >!idiiini  >alt,~. 

in  thi,-  nialter  of  diet  cacdi  individual  case  must  I'eceive  separate  con- 
^•idcralion. 

There  are  very  few  comlition-  in  the  ,:;-oiily  in  which  stimulants  id'  any 
sort  are  ii'iiuircd.  Whenever  indicated,  ulii>ky  will  he  found  |icihaps  the 
most  M'rviceahle.  While  all  are  injurious  to  tlioe  patient-.  >niiii-  ai'c  much 
more  .-o  than  others,  particularly  malted  liipiors,  champagne,  port,  and  a 
\ery  lar,i:e  proportion  of  all  the  li^lit  wines. 

Miiicnil  W'dlrrs. — All  forms  may  1h>  said  to  lie  henelicial  in  j^out,  as  the 
main  clement  is  the  water,  and  the  inufedients  are  usually  indilVereiit. 
.Much  of  the  humhu,i:-gery  in  the  pi'ofe-.-ioii  -till  lingers  almut  mineral  waters, 
more  particularly  ahoiit  the  so-called  lilliia  waters.  For  a  careful  consid- 
eration of  the  ipiestion  the  ri'adcr  is  rid'erred  to  William  I'lwart's  recent 
work  oil  ( iout  and  (loutiness. 

The  (lueslinn  of  the  utility  of  alkalies  in  the  treatnu'iit  of  <;out  is 
closely  connected  with  this  >ulije<-t  of  iniiieral  waters.  This  deep-rooted 
helief  in  llu'  profes.-ion  was  rudely  -liakcu  a  \'vw  years  api  liy  Sir  William 
IJoherts,  who  (daims  to  have  ,-hou  ii  conclusively  that  alkalescence  as  siiidi 
has  no  iidlueiicc  whatever  on  the  sodium  hiuratc.  The  sodium  salts  arc 
helievcd  hy  this  author  to  he  particularly  harmlul.  hut,  in  spite  of  all  the 
theoretical  denuncialion  of  the  use  of  the  soiliiim  salts  in  ,uoul.  the  ^outy 
from  all  jiarts  of  the  world  Hock  to  those  very  Continental  sprin,i;s  in  whiidi 
these  salts  are  most  pri'doininant. 

Of  the  mineral  springs  hest  suited  for  the  LTiuity  may  he  mcntiiuieil, 
in  this  country,  those  of  Saratoga,  I'.eill'oi'd,  and  the  White  Sulphur;  l)U.\toii 
and  liath,  in  I'ln.iiiand;  in  France,  Ai-\-les-l!ains  and  Contrexuville;  and  in 
(u'lniany,  Carlshad,  \\'ildliail,  and  llomhurij:. 

'i'hc  ellicacy  in  reality  is  in  the  water,  in  the  way  it  is  taken,  on  an 
empty  stomach,  and  in  lar<i-e  ipiantities;  and.  as  every  oiu'  knows,  the  im- 
portant accessories  in  the  modilied  dii'l,  proper  hours,  regular  e.vereise, 
with  haths,  dmiches,  etc.,  play  a  very  imjiortant   n'llr  in  the  "  cure." 

Mnliiiinil  I'lrithiiriil. —  In  an  acute  attaid<  the  liiiih  should  lu'  elevated 
and  the  aiVected  joint  wrappt'd  in  cotton-wool.  Warm  fomentations,  or 
Fuller's  lotion,  may  he  used.  The  local  hot-air  treatmi'iit  may  he  tried. 
A  hrisk  mercurial  imrgc  is  always  advantaueoiw  at  the  outset.  The  wine 
or  tincture  of  colchicum,  in  do,<cs  of  •.'(!  to  :i(i  minims,  may  he  ;.nv(>n  every 
four  hours  in  condiination  with  the  citrate  of  ]iotash  or  the  citrate  of 
lithium.  The  action  of  the  colchicum  should  he  carerully  watched.  Tt 
has.  in  a  majority  of  the  cases,  a  powerful  inlluence  over  the  ,<ymptoms — 
rc'lievin<r  the  pain,  and  reducinjr,  souu'tinie?  with  jii-cat  rapidity,  the  swell- 
iiiir  and  rednc.-s.  It  .-honld  he  ])romptly  stopped  so  soon  as  it  has  relieved 
the  pain.     In  cases  in  which  the  pain  and  sleeplessness  are  distressing  and 


.11 


«■* 


418 


C'ONSTlTL'TKiNAL   DISEASKS. 


do  not  yioUl  to  colclucu.n,  .nori-hia  i.  nc.rssarv.     '11...  pntu'tit  sl,n..l.l    ... 
„|,,,,,,1  on  a  .lift  dii..|lv  ..!■  milk  and  harl..v-wat...-.  Imt   it  th...',.  ..  any  .l.- 
l„l„v.  stn.n-  l.n.th^  niav  In.  ^iv..n.  or  r^iX^.     U  is  ...•.•a>in..ally  n......ssary  lo 

L'ivc.'hn.ail  .luantitio.  of  stin.nlants.     Durin-  ,...nval..>....n.r  ni..ats  an.l  U>U 

an.l  -;„„..  may  i...  lak...i,  an.l  -ra.lually  the  |,ali..nt  may  iv.nna.  th..  .li..t 

p^^.vi(>n^lv  laiil  dnwii.  ,    •        •        mi 

In  nmR.  ..r  Iho  sni.a.nt..  intcirnnvnt  alta.k>  of  ailhntis  m  old.  .Il- 
lornu.d  inint>.  th..  so.linm  s.li.'ylat..  is  o.rasi.M.ally  nMlul,  hut  us  a..nnnis- 
tration  n,u.-t  h.'  wat.h.'d  in  .a^.s  of  .-anlia.'  ami  ivnal  inM,ni.-u.n..y.  It  is 
aJM,  nnuh  a.lvu.at.'.l  hy  Hai-  in  th..  uric-aci.l  hahit. 

'PI,,  ,l,,,.ni,.an.l  inv-nh.r  forms  of  -.ml  aiv  lH.>t  tivat.'.!  hy  tlH._<lK.t..tu> 
„„.l  hN-i..ni..  m..aMnvs  al.va.ly  nhTiv.!  t...  i-ii.!..  -f  |.ntass,um  is  s.m.o- 
tini.'s  us..ful.  and  piviMration^  .d'  Mn,iM.-niH.  .ininin.'.  ami  ih..  hitt.-r  tonu's 
«-,,inhin..d  witii  alkali. 's  aiv  und..uht...lly  .d'  h..n..|it. 

rilHTa/in  has  h.-.n  mn.h  lau.h.d  as  an  ol1ici..nt  aid  m  th..  s.dntion  .d 
,„,i,  ,,i,i.  Th..  .•lini..al  ivsnlts,  liowc.vcr.  aiv  xwy  .iis...r.lai.t.  It  may  he 
^,,H|,lov...i  in  dos..s  of  from  i:.  to  :iO  -rains  in  th..  .lay.  an.l  is  conveniently 
given 'in  aerate.l  water  containing  5  grains  to  the  tumhlerlid. 


V.    DIABETES    MELLITUS.* 

Definition.— A  dis.irder  of  nutrition,  in  wiii.h  sugar  accumulatos  in 
the  hino.l  an.l  i>  excrete.1  in  the  uriii...  the  .laily  ani..unt  .d  which  is  greatly 

incr.'asi.d.  .    . 

For  a  case  to  he  c..nsi<l..r..d  one  .d'  dialu'tes  ineilitus  it  is  n.-cessary.  a.- 
cor.limr  to  von  X.-ordeii.  that  the  form  of  sugar  cliniinat...l  in  the  urmc 
l.c  -rai...  Mi-ar.  that  it  must  I...  ..liininat...l  lor  w.rks.  months,  or  y..ars.  and 
lluU  the  exeivtiou  of  sugar  nin>t  tak.'  pla.r  alter  the  ingvstion  of  moderate 
amounts  of  carhohydrates. 

Etiology.— //'•'•'"''/'"•,'/  '"/''"'"'•'■^'  I'kiy  ;>"  im|>ortan1  ri'lr.^  and  .-ascs 
are  on  n..-..rd  .d'  its  oceurren.-e  in  many  iii..inh..rs  of  the  same  family.  Of 
liie  T;  .'asi's  whi.'h  have  heeii  tr..nl..d  in  th..  m...1icnl  wards  an.l  disi.ensarv 
of  tlu.dohns  Hopkins  Hospital,  only  ■-'  gave  a  hiMory  .d'  dialu.t.'-  in  r..lativ..s 
(Fntcher).  There  are  instanci.s  of  tiie  co..xistenc..  of  the  dis.'as..  m  man  and 
uitV  Schmidt  first  drew  attention  to  th.'  possihility  <.f  diMh..t..s  l.eing  con- 
la-ious  Out  .d'  his  s..ri..s  of  2.^-20  cas.-  he  h..1i..v..d  that  -.m;  instanc..s  w<.re 
the  iv-idt  ..f  conta-ion.  In  the  majority  of  the  cast's  the  wife  c<mtra.-t..d 
Ihc  dis.'as..  lat..r  iliaii  the  linshand.  >V.r.— Mi'ii  are  moiv  fr(..inently  airi.et..d 
than  women.  lh..  ratio  heing  alnrnt  tliive  t..  two.  K..rty-s..v..n  cast.s  of  the 
h..<pital  seri.'s  were  in  mal.v  and  3()  in  females.  It  is  a  dis..aso  of  adult  lite; 
a  majoritv  ..f  the  cas..s  o.cur  from  tlie  third  to  the  sixth  di^cade.  Of  the 
TT  cases,  the  lariicst  numher— 'M.  or  ;n.l  ]W  cent— occurred  Ixiwi'en  fifty 


*SiiK..'tho  '^ocond  edition  of  tliis  work  tlie  litovntur..  1ms  l.oon  enri..|i..d  l.ylnvys 
Croonian  Lofturps.  tho  sown,!  ...lilion  of  Sann.U.y's  work,  tin- inonocraplis  of  von  Noor- 
(Icn  (2.1  P.I..  ISOS)  nn.l  WilHninson,  nii.1  l.y  tlic  nmffnificpnt  work  of  Nuunyn  {W[)8),  which 
unfoiumatplv  arriv...!  too  lute  to  l.e  fully  iitilizt.d  for  thp  revision. 


DIABKTES  MKLMTUS. 


419 


it  should  1)1' 
V  is  any  iK'- 

llcccssiivy  In 
cuts  1111(1  tisli 
lino  tlu'  ilii't 

•;   in   oM,  lU'- 

ils  lu'iiiiiiiis- 

■icni'V.     It  is 

y  the  (lii'tclif 

iuin  is  soino- 

liittcr  tniiio 

ic  solution  ol' 
.  it  niiiy  1h! 
{■(invoiiiuiitly 


c'C'uimilatcs  in 
lic'li  is  <;roatly 

necessary,  ae- 

I  in  tile  urine 
,  or  years,  ami 

II  ol'  moderate 

■nil',  and  cases 
le  family.  <>f 
ind  dispensary 
tes  in  relatives 
ise  ill  man  and 
'tes  Iteiii;:  coii- 
iiistaiices  were 
iil'e  contracted 
uently  alTectcd 
I'll  cases  of  the 
-e  of  adult  life; 
ocade.  Of  the 
d  bcuveen  fiftv 


[iriclic'l  liy  T'dvy's 
iiplis  of  von  Xoov- 
invn  (1S!)8),  which 


and  sixty  years  of  a;.'c.     These  li<.Mires  a;.M'i'e  closely  with  tho.-e  of  Freriehs, 
Seejreii.  and   I'avy,  all  of  whom  found  the  lar;:vst  iiuniiier  of  cases  in  tliu 
sixth  decade,  their  iiereenta^i's  iieiuLT  ".'"'i.  :"•.  and  ;'>(l.T  lesiiectively.     it   is 
rare  in  chililhood.  luit  ca>es  are  on  rt'cord  in  children   under  one  year  id' 
aut'.     l'ei>oiis  of  a  neurotic  Inn iivniinvnl  iirc  often  all'ecteil.     it   is  a  disease 
of  the  hi.Lrher  classes.      \'ou   N'oordcii  states  that   the  >tati-ties  for   London 
and  JJerliii  show  that  the  niimhcr  of  caso  in  the  upper  ten  thou.sind  ex- 
ceeds tliat    in   llie   lower  hundred   llunisand   inhaipitaiit.-.      Umr. —  llehrews 
.-I'cin  e-pecially  prone  to  it:  one  fourth  of  Krerich>'  patients  ucre  of  tlm 
Semitic  race.     1  have  liccii  much  impressed  with  the  fre(|Uciicy  of  the  dis- 
ear-e  aiiionir  them.   (M'thcla>t  HI  ca>es  which  I  have  had  in  pri\,ite  practice. S 
were  in  llehrews.    l»iaheles  is  coiii|iarativ('ly  rare  in  the  eidiU'ed  race,  hut  not 
-o  uncommon  as  was  formerly  .-upposed.     Of  the  series  of  'i'i  eases,  S,  or  IH.;} 
per  cent,  were  in  iie^n'oes  (Kulcher).     The  r;itio  of  males  io  females  all'i'cted 
is  almost  exactly  the  reverse  (d'  that  in  the  w  lute  race;  :!  of  the  S  eases  wero 
in  males  and  5  in  females.     In  a  coiisideraole  proportion  of  the  cases  of 
diahetes  the  suhjects  have  hi'cii  exees>ively  fill  at  the  heuinniiiL;-  of,  or  prior 
to,  the  onset  of  the  disease.     A  slight  trace  of  siipir  is  not  very  iincomuioii 
in  ohcM'  persons.    This  ,>;o-called  lipoji-eiiie  olyeosiiria  is  not  of  urave  si,oiiili- 
caiicc,  and   is  only  occasionally   f(dlowed   hy  true  diahetes.     <tii   the  other 
hand,  as  von  N'oorden  has  shown,  there  may  lie  a  "  dialietou-eiioiis  ohoity," 
in  whii'li  diahetes  and  ohesity  develop  in  eaily  life,  and  these  cases  are  very 
iinfavorahle.    'J'liere  are  instances  on  record  in  which  ohesity  with  diahetes 
has  occurred  in  three  venerations.     Oiaheles  is  iikh'c  eoinmon  in  cities  than 
in  country  districts.    (Joiit,  syphilis,  and  malaria  have  heeii  reyardeil  as  ]ne- 
disposinj:  causes.     Jhirdel  and  Calmette  think  that  malaria  is  an  important 
prcdis]iosin,ir  etiolooical   l'act(U-.      In  only   1   of  the  7T   cases  could   malaria 
he  considered  more  than  a  possihie  cause  of  the  dialicte,-  ( l-'ulcher).     Mental 
>hock.  severe  nervous  strain,  and  worry  |)recede  many  cases,     in  one  caso 
the  svmptoms  came  on  suddenly  after  the  patient  had  heeii  nearly  >ulVocated 
hy  smoke  from  liavin.u'  iieeii  (■onliiied   in  a  cell  (d'  a  hurnin.i;'  Jail.     Shock 
and  the  toxic  ell'ects  of  the  smoke  may  hotli  have  hceii  factors  in  this  case. 

The  coiiihinaliou  (d'  intense  application  to  hu-iiiess,  over-indul.u'cnce  in  f 1 

and  drink,  with  a  sedentary  life.  .<eems  particularly  prone  to  induce  the  dis- 
ease. (Jlycosuria  may  set  in  diirinj,'  pre.iiiiaiiey.  and  in  rare  instances  may 
only  occur  at  this  period.  Trou.<seau  thmioiit  that  the  oirs|irin,o-  of  i.hthisi- 
cal  ]iarents  were  jiarticularly  imme  to  diahetes.  Iiijnni  to  or  disease  lA  the 
spinal  cord  or  hrain  has  Ikh'ii  followed  hy  diahetes.  In  the  carefully  ana- 
lyzed cases  of  Freriehs  there  were  iSn  instances  (d'  m'-anic  disease  of  these 
fiarts.  The  medulla  is  not  always  involved,  in  only  I  id'  his  eases,  which 
showed  oriranic  disease,  was  there  sclerosis  or  other  anomaly  of  this  part. 
An  irritative  lesion  of  i'.ernard's  diahetie  centre  in  the  medulla  is  an  occa- 
sional cause.  I  saw  with  IJciss.  at  the  Friedrichshain,  lierlin,  a  woman  who 
had  anomalous  cerehral  symptoms  ami  diahetes.  and  in  whom  there  was 
found  ]>ost  mortem  a  cysticereus  in  the  fourth  ventricle.  I'lhstein  has  re- 
cently recorded  1  cases  in  which  there  was  a  coincident  occurriMice  of  oiii- 
]e]isy  and  diahetes  mellitus.  Tie  thinks  that  in  the  majority  of  rasps  the 
two  diseases  arc  dependent  on  a  common  cause.     Tie  helieves  that  the  asso- 


..s.* 


42(1 


CONSTITrTlONAL   DISKASKS. 


ciillillll    WduM    lie    IoIIIkI    lllllcil    lIHU'l'   I  iMllIUnlllv    ill    J  llik^i  111  ill  II    Cllilrp^y    tllllll 

lias  lii'fii  till'  cMsi'  licicloluii'.  ir  iiinji'  (iirrliil  mill  >_v>tiiiiiilic  cxaiiiiiiiitinn- 
III'  the  urine  were  niiidc 

'I'lif  disciisi'  lijis  (It  lii-idliiillv  InlluNwd  tlir  liifnilniis  /V/'c/'.v.  I'm^cs  lia.v 
liccii  rcconlcd  iis  ucciiriiii^f  diiiiii;.^  or  iiiiiiu'diiiti'ly  iilU'C  di|ilitln'riii.  iiillii- 
cii/ii,  ihciiiiiiiti.-iii.  I'liUric  li'ViT.  and  >y|iliilis.  A  IVw  him's  have  rnllnwcd 
iiijiirv  witlmiit  involvement  of  tlie  Itraiii  (H'  enrd. 

Ill  cniniiaiixiii  with  its  incidence  in  l\iii(i|ican  cniintries  diaheles  is  a  rare 
disease  in  America.  The  last  cen>us  ^ave  <iiily  li.N  per  Init.iMKt  id'  |i(i|mla- 
lidii,  airain.-t  a  latin  id'  lidin  ">  t<i  I  \  in  the  I'nrmer.  The  death-!  te  has  been 
f,'radiially  (iii  the  increa^t'  in  I'aris  diii'inn'  the  last  three  nr  i'niir  decade>. 
reaehin;:  1  I  tn  the  Kmi.imki  df  |iii{iiilatiiiii  in  I.^IM.  Fur  the  same  year  the 
nmrtality  in  Malta  uas  l:!.!  In  the  Kmi.ihio  (d'  ]iii|inlatii»ii.  Tlu'  disease  is 
•rradiially  (Hi  the  increase  in  llie  I'liited  Slates.  Tlu'  statistics  J'ui'  l.s^d  nave 
2A\  l'(ir  iNSii.  v'.S;  and  Tnr  l.siMi,  ;!..s  deaths  to  the  Km. nun  |i(i|iulat  ion.  in 
this  ri'^Mon  the  incidence  oJ'  the  diseax'  may  he  gathered  Irom  the  hid  that 
anion^f  170,000  patients  uiuler  treatmeiil  at  the  Johns  Hopkins  Hospital 
jind  Dispensary  (liirii)<,f  the  nine  years  i-iiice  it.-  opeiiiii^i'  there  have  hccn  "T 
casi's.  l)urinjf  the  nine  years  r)".^,(i(iO  inedieal  eases  were  treated,  the  dia- 
bolic jiatient:*  constituting-  only  d.li  per  cent  of  the>e  ( l''iitcliei).  i'ldin  a 
Htiidy  of  the  statistics  of  Jell'erson  (.'olU';:e  Jlo.spital.  JIare  conclndes  that 
diahetes  is  beeominf:  more  conitnon. 

We  are  ignorant  of  the  nature  (if  the  disease.  Xormally  the  cai'bo- 
Iiydi'ates  taken  with  the  food  are  storcij  in  the  liver  and  in  the  musck's  as 
}ilyeoj;en.  and  tiii'U  utilized  as  neeiK'd  hy  the  system.  (Ilycojz'eii  can  also 
be  foiined  from  the  pi'oteids  of  the  food,  and  under  certain  eireiimstanees 
sii,i:ar  may  he  dii'cclly  fornu'd  from  the  body  proteids.  ^\'henc\■er  the 
sii^^ar  in  the  .systemic  hlood  c.Nci'eds  a  delinite  amount  (ahoiit  O.'J  per  cent) 
it  is  discliarued  by  the  kidneys,  prodiicinji-  j^-lycosuria.  Theoretically  dia- 
betes may  he  supposed  to  he  induced  by: 

(a)  The  ingestion  of  a  ]art;-er  cpiantity  of  carbobydrates  and  iieptones 
than  can  be  warehoused,  so  to  speak,  in  the  liver  as  ^iyc(i<ren.  so  that  part 
has  to  pass  over  into  the  hepatic  blood.  Some  of  the  instances  of  lipogenic 
or  dietetic  fiiycoi«uria  are  of  this  nature. 

{h)  J)isturl,>ances  of  the  liver  function:  (1)  Changes  in  the  circulation 
iindcr  lUTvons  inHncnces.  J'uncture  of  the  medulla,  lesions  of  the  cord, 
and  central  irritation  of  various  kinds  are  followed  by  jrlycosuria,  which 
is  attributed  to  a  vaso-motor  jiaralysis  (more  rapid  blood-llow)  induced 
by  the.se  causes.  On  this  view  the  disease  is  a  neurosis.  (V)  Tnstaiiility  of 
the  frlycoiicn,  ovi-in<r  either  to  iniiierfect  formation  or  to  conditions  in  the 
colls  which  render  it  less  stable.  I'hiorid/.in  and  other  substances  which 
cause  diabetes  very  proliably  act  in  tliis  way:  i»hloridzin  acts  priniarilv  on 
the  ri'ual  i'])ithelium.  destroyino-  its  jiowor  of  keciunfr  back  the  supar.  As 
to  the  jiOFsihility  of  a  renal  form  of  diabetes  in  man,  consult  Xaunyn. 
])aj:'e  lOfi. 

(r)  Defectivo  assimilation  of  the  trincose  in  the  system.  TTow  and  und(^r 
what  normal  circumstances  the  sujzar  is  ntilized  wo  do  not  yet  know. 
Thoorotically  faulty  metabolism  would  explain  the  condition. 


i^^g^M 


iilr|i-y  tliaii 
^aiiiiiiiitiiiiis 

Tn.-cs  liinr 
ii'riii.  iiillii- 

VC    I'nIliiWl'il 

Mcs  is  n  rare 

I    III'    |lii|iulil- 

\v  lias  iicrii 

111!'    (lrfailr>. 

inc  year  tln' 
If  iliscasc  is 
!!■  Is"; (I  ;:avr 
ilalidii.  Ill 
lie  fact  that 
lis  ll(i,-iiilal 
a\('  liccn  "  7 

Cli.    till'    (li.l- 

r).  I'"ri)iii  a 
iclmli's  that 

till'  carho- 
'  iiiiisck's  as 
en  can  also 
rciiiiistaiU'i's 
u'lK'Vcr  the 
.V  per  criit ) 
L'tically  (lia- 

1(1  ]i('|)tonf.'s 
s(i  that  ]iart 
(if  ri|)()goiiic 

cii'cuhition 
)f  the  cnrrl, 
airia,  which 

i\\)     illillU'(Ml 

iistahility  of 
lions  ill  tlie 
iiiccs  whicli 
iriiiiarily  on 
'  siipir.  As 
lit  Xannyii. 

V  anrl  iin(l(T 
:  yet  know. 


DIAIIKTKS   MKLLITIS.  4'2\ 

Morbid  Anatomy.— Saunilliy  (l.rcinrr- mi  Ihaiiitr-.  l>:tl )  ha- gi\rii 
a  pMid  .-iiiMiiiaiy  nt  the  aiiatiuiiii  al  chaiii:!'-: 

'I'hi'  iwrrmis  si/sli'in  shows  no  cniistant  li'>iiiii>.  In  a  f<\\  in-taiico  thrrc 
have  lit'iii  tiiiiioi'.-  (ir  xlmi-is  in  liic  iiiciliilla.  or.  a>  iii  liic  la-c  almw  iiim- 
tiiiiicil,  a  (■y>ticfi'(ii>  has  |ii('.->('(l  on  tlic  liimr.  (  y>t>  have  liccii  met  with 
ill  tlif  whiti'  iiialtiT  of  tht'  ccii'liniin  ami  |ii'ri\a>cnhii'  (.•hain:(^'s  lia\i'  lu-'cii 
ili'scrilirih  < Jlyco;:('ii  lia>  lirni  fmiml  in  tlir  -|iiiial  cniM.  In  the  |irii|ih('i'al 
lUTVoiis  system  there  arc  iii>taiiees  in  which  tiimms  \\n\v  hecii  fniiinl  |ire:-s- 
iiijj  on  llie  vajziis.  A  secondary  niiilti|i|e  neiirili-  i-  not  rare,  ami  In  il  the 
s(i-calh'(l  (liaiietic  lahes  is  |iriilialily  iliie.  it.  'I'.  WilliaiiiMni  ha-  fniimi 
chanji'i's  in  the  iinsterior  cnliimiis  of  the  conl  similar  to  ihn-c  which  occur 
in  |ieriii"i(iiis  amemia. 

Ill  the  syni|iatlictic  system  ihe  ;ian,L:lia  iiave  hei'ii  eiilar,^iil  ami  in  mhiic 
instances  sderoM'il.  hut  there  i>  milhiii:.:-  pcciiliar  in  ihe-e  clianji'cs.  Tlio 
IiIiiikI  may  contain  a-  liij:h  as  n.  1  per  I'ent  of  >ii,L:ar  in.-tcail  nf  (i.l'i  per  cent. 
Tlie  ]ilasnia  is  usually  loadeil  with  fat,  the  iiKileciiles  of  which  may  he  seen 
as  line  particles.  When  drawn,  a  white  creamy  layer  cuats  the  cnaLiiilnm. 
and  there  may  he  lipa'iiiic  clots  in  the  small  ves-el-.  There  are  no  >pecial 
cliaii^'es  in  the  red  or  white  corpuscles.  The  pnlyniiclear  leucocytes  con- 
tain eiycdocii.  (ilyc();;eii  can  occur  in  iinrmal  hlnnd.  Km  it  i>  here  extra- 
cellnlar.  It  has  iic'cii  also  found  in  the  polyiiiiclear  leiicncytes  in  leiika'mia. 
The  lictni  is  liy|iertrophicd  in  Mime  cases.  hjidncardilis  is  very  rare. 
Artorio-sclerosis  is  comnion.  'i'he  hnn/s  show  impnrtaiii  change-,  .\ciite 
hroncho-piu'iinioiiia  or  croupous  pneumonia  (either  of  which  may  terminate 
in  ^faii<,n'i'ne)  and  tnhercnlosis  arc  c(iiniuon.  The  so-called  diahetic  phthisis 
is  always  tiiiicrcnioiis  and  results  from  a  caseatiii.u'  liroiicho-pneiimnnia.  In 
rare  cases  there  is  a  chronic  interstitial  piieumiiiiia.  ndii-tiilierciilous.  J-'at 
emliolism  of  the  |)iilmonary  vessels  has  heeii  de.-criljed  in  connection  with 
(liaiietic  coma. 

The  lircr  is  iisnally  ciilarired;  fatty  i!(\i;-eneration  is  coiumoii.  In  the 
.so-called  diahetic  cirrhosis — the  i-irrlmsi'  j'liitHcnliiirc — the  liver  is  eidai'ireil 
and  sclerotic,  and  a  cachexia  dcvelojis  with  nicianoderma.  I'ossilily  the 
disease  is  a  separate  niorliid  entity.     Dilatation  of  the  -tomacli  is  comniiin. 

The  Pancreas  in  Diabetes. — J.e.-ions  of  this  oruan  are  met  with 
ill  aliout  .')()  per  cent  of  the  cases  ( llansemann).  \'on  .Merinu'  and  Min- 
kowski have  shown  that  extirpation  of  the  .u'land  in  do,u's  is  followeil  hy 
glycosuria,  hut.  if  a  small  portion  remains.  sii;.;i(r  does  not  a|ipear  in  tlie 
urine,  facts  which  have  heeii  conliriiieil  liy  Lcpiiie  and  others.  Tlic  )i:iii- 
creas.  on  this  view.  has.  like  tln^  liver,  a  douhle  secretion — an  exterpal. 
which  is  ])oni'e(l  into  the  intestines,  and  an  internal,  which  jiasscs  into  the 
lilood.  This  latter  is  supposed  to  he  of  the  nature  of  a  ferment,  in  the 
presence  of  which  alon(>  the  normal  assimilative  processes  can  take  place 
with  the  jrlycogen.  Disea.se  of  the  ])anci'eas  causes  diahetes  liy  |ireveiitiiiir 
tlie  formation  of  the  jjlycolytic  ferment.  Even  M'lien,  ns  in  a  majority  of 
instances  of  dialietes,  the  orjriin  is  apjiareiitly  normal,  a  functional  Irouhje 
may  disturh  the  formation  of  thi.e  ferment.  The  fact  that  if  a  small  ]ior- 
tion  of  the  <i;land  is  left,  in  the  exiieriments  ii]ion  dours.  diahetes  does  not 
occur,  iii  analofTous  to  the  remarkable  circumstance  that  a  small  frairment 


ri 


■^'22 


CONSTITUTIONAL  DISEASES. 


or  ihc.  tl>yroul   is  .ulliei.nt  K.  inrvent  the  drvduiuucnt  of  nrtilu.iMl  .nyx- 

''"^T'pMti.nt  or  W.  T.  IW.ll  dic.l  or  diaU.U.s  aU.v  oxlirpati.m  of  the  pun- 

,,..;.     In  .on.e  ins,a.u-c.s  thcv  i>  a  pi;:u,entary  eirrhosis  anah>g<n,s  to    ha 

1   ,,h  uc-eurs  in  the  liver,  an.i  this  induration  s.en.s  to  he  an  un,.o,tant 

,  ;,„  "^.,„,.,,  ,„.,  ,,,,.„,i  In.ve  heen  nu.  .ith;  and  Longstre  h  lound, 

;!:::;;  inlanee.  .,>.ie  dis.ase  of  the  panereas.     Fat  neeros.s  oi  the  organ 

"''^;':;;i;:;;;::,;':-  ;:'uninea  the  panereas  in  .3  eonsecntive  cases  of  diah^es 
,nd  inn.l  pathoh,.ieal  changes,  clneily  atrophy,  in  11.     He  also  analw-e.l 

no  al  Jr  diahetes  colhvted  I'ron.  the  li.eratnre  in  wlueh  ,  e  pan<.  ea> 
M-a.  di<..as..d.     .More  than  50  per  cent  o(  these  showed  more  or  less  nunkcd 

;;:o,;:v:|-a,tydegenerat,on  was  present  in    ir,ahs..essn,^ 

and   cvstie  defeneration    in   S   .-as.s.      Ol    n.y  s.nes  ot    .  .    '••>^^-  :^'     " 
''.„;,   i„  ,„„;ii,,,i  ,vards  or  the  Johns  Hopkins  llosp,  a  1    and   1.   te.  n - 


;:,  ',„,K,     Autopsies  were  ohtained  in  S  cases    and  th        -     '      - 
,.„„„1  „„„,,•„,.  1..SS  atrophied  in  (i  of  then..     In  only  or-'  ol  h  > -1     a  it  p 
sic.s  in  .liahefs  could  Naunyn  attrihute  the  .lis.ase  to  t!      eond,tu,n  ol  the 

'""Thr^/-/.rv.  show  usually  a  dilVus.  nephritis  with  fatty  ;lo^--J'>tion. 
A  hvaline  change  occurs  in  the  tulml  .pithHiunu  part.cularly  <>•  the  - 
s,rndi,>g  lind.  -r  the  hn.p  of  Jienle.  and  also  ,n  the  capdlary  vesK.l>  oi  the 

'""symptoms.— I r»/.'  and  rlmmir  lorn.s  are  recogniz.'d.  hut  there  is 
no  esS  litVerence  hetween  then,,  except  that  in  the  lornu.r  the  patients 
arc.  vounuer.  11..  eour>e  u.ore  rapid,  and  the  cnuu.at.on  '-'"'v  ""n'ked. 
\..ni..  c-a^es  ,nav  o<..nr  in  the  age.l.  1  saw  with  Sowers  ,n  \\aslungt..n  a 
inan  age.l  scvcnty-thre..  in  wluuu  tin.  entire  c<nirse  ol  the  disease  was  le>s 

than  three  weeks.  .  .       .     „.i  •  i, 

It  is  also  possihle  to  divide  the  cases  into  (1)  hi,n,,rn,r  or  ^hvlrlu.  Nvhidi 


includes  the  transient  glycosuria  < 


r  stout  itersons;  CD  iininilir,  due  to  m- 


h,ric<  or  functional  disorders  ..r  the  nervous  system:  and  (l.)  paunrnhr, 
,  ,,,,i,„  ,lu.re  is  a  l.^sion  of  the  pancreas,  it  is.  however  hy  no  nu-ans 
,,n<v  to  discriminate  in  all  cases  h..tween  these  iorms.  Attemi-ts  ha^e 
lu.:n  mad.,  t,.  s..paratc  a  .•lini...l  variety  anah.g.uis  t..  exp.>rinumt>U  inm- 
,,vatic  diahet.'s.  llirs.-hfeld,  fr.nn  (iuttmann  s  clinic,  has  .lescnh..d  cas.  s 
,nnnin^  a  raiud  and  sev..re  course  nsnally  in  y.mng  and  nuddle-aged 
,K.i-.ui<  Th..  p..lvuria  is  less  ..oiiinmn  ov  even  ahsent.  and  there  is  a  stiik- 
\\v.  der,.ct  in  the  assimilati.m  of  the  alhumin.hds  and  fats,  as  shown  hy 
the  cxanhnntion  of  the  faeces  and  nrine.  Tn  4  .vf  7  eases  autopsies  were 
,nad..  and  the  pancivas  was  f.uind  atrophic  in  two.  ciin<.'r.ms  ,n  one.  and 
in  the  fourth  exceedingly  soft.  .        . 

The  o„srt  o{  the  dis.'as..  is  gradual  and  ..ith-.r  tiv.pi..iit  nn.'tuntu.n  or 
inovdinate  thirst  nrst  attracts  att..ntion.  V..ry  raivly  it  sets  in  ra,ud  y^ 
art..r  a  sn.1d.m  em..ti<in.  an  injnry.  or  aft.'r  a  sc^vere  chill.  ^Mlen  fully 
estahlished  tlio  disease  is  cliaracterix,.d  hy  great  thirst,  the  passage  of  large 

*  Medical  Chronicle,  Mr};  1897. 


rtiluinl  iny\- 

1  ol'  the  paii- 
ijroiis  to  that 
nil  iinpnrliiiit 
stivtli  I'ouiul, 
oi:  the  organ 

OS  of  diabetes 

also  analyzed 

the  iiancrras 

ir  less  marked 

.  eaneer  in   S, 

uses,    IC)    were 

uid   K   ternii- 

panei'eas  was 

his  -111  autop- 

ndilion  ol'  the 

degeneration. 
I'lv  of  the  de- 
vessels  of  the 

.  hut  there  is 
ev  the  i)atients 

more    markeil. 

Washington  a 
lisease  was  less 

(lirlclir.  which 
olir,  duo  to  in- 

{;])  iiinicrcdiir, 
\  hy  no  means 
Attempts  have 
leriniental  pan- 
descrilu'd  cases 
id  middlo-nged 
tliere  is  a  strik- 
s,  as  shown  by 

auto])sies  were 
)iis  in  one.  and 

nnetnrition  or 
sots  in  rapidly, 
11.  AVhon  fully 
passage  of  large 


DIABETES  MELLITUS. 


423 


(|uanlities  of  saeeharine  urine,  a  voracious  appetite,  and,  as  a  lulc.  ]irn- 
gicssive  emaciation. 

Among  the  <jcticr(il  nijiiijihiiii.f  id'  the  diseii>e  IliirsI  is  one  of  the  most 
distressing.  A  \ery  large  amount  id'  watei'  is  I'eijnireil  to  keep  (he  sugar 
lu  solution  and  for  its  excretion  in  the  urine.  'I'in-  amount  of  water  cdU- 
>umed  will  ho  found  to  hear  a  deliinte  ratio  to  tin'  iiuantity  excreted.  In- 
stances, however,  are  not  uncommiui  of  pronounced  diahetes  in  which  the 
lhir>t  is  iKit  excessive:  hut  in  such  cases  the  amount  of  urine  passed  is 
never  lai'ge.  'I'he  thirst  is  most  intense  an  iiour  or  two  afli'r  meals.  .\s 
a  rule,  the  digestion  is  good  and  the  ap|H'tite  inor<linate.  'i"he  condition 
is  s(unetinies  lei'nu'd  hulimin  or  jiiiliijihdijin. 

'I'he  tongue  is  nsually  dry.  red,  and  glaxed.  iind  the  saliva  scaidy.  The 
gums  may  hecoiiie  swollen,  and  in  tiie  later  stages  aphthous  stomatitis  is 
(■(uumon.     ( 'onstipatiiui  is  the  rule. 

In  s|iite  id'  the  eiioi'mims  amount  of  food  consumed  a  patient  may  lic- 
c(une  rapidly  emaciated,  'j'his  lo.-s  of  jlesli  iiears  some  ratio  to  the  poly- 
ui'i:i.  ami  when,  under  snitahle  diet,  the  sugar  is  reduced,  tlu'  ])atit'nt  may 
(puckly  gain  in  llesh.  The  skin  is  dry  and  harsh,  and  sweating  rarely  occurs, 
except  when  phthisis  coexists.  Drenching  sweats  have  l)eon  known  to  alter- 
nate with  excessive  ])olynria.  The  tein])erature  is  often  suhiiormal;  the 
pulst'  is  usually  fre(|uent,  and  the  tension  increased.  ]\Iany  dial)etics.  how- 
evi-r,  do  not  show  marked  emaciation.  J'atients  ])ast  the  ndddle  jjcriod 
of  life  may  have  the  disease  for  years  without  much  disturi)ance  cd'  the 
health,  and  may  remain  wi'll  noui'ishcd.  These  are  the  cases  of  the  flinhrle 
ijnis  in  contradistinction  to  didhrlr  niii'Kjn'. 

The  Urine. — The  anH)unt  varies  from  (!  or  S  ])ints  in  mild  cases  to  :5() 
or  10  pints  ill  very  severe  cases.  In  rare  instances  the  (|nantity  of  urine 
is  not  much  increased.  I'lider  strict  diet  the  amount  is  much  lessened,  and 
in  intercurrent  felirile  all'ections  it  may  Ite  reduced  to  normal.  The  specilie 
gravity  is  high,  ranging  from  l.d'i.")  to  1.01.");  hut  in  exceptional  cases  it 
may  ho  low,  1.01. "5  to  l.d'^O.  The  highest  s|ieciiic  gravity  recorded,  so  far 
as  I  know,  is  hy  Trousseau — l.oM.  \'ery  liigli  specilie  gravities — l.OTO-f- 
— suggest  fraud.  The  urine  is  |iale  in  color,  almost  like  wat<r,  and  has  a 
sweetish  odor  and  a  distinctly  sweetish  taste.  The  reaction  is  acid.  Sugar 
is  present  in  varying  amonnts.  In  mild  cases  it  does  not  oxcood  H  or  'i  jior 
cent,  hut  it  may  reach  from  5  to  1()  per  cent.  The  total  amount  excreted 
in  the  fwenty-fonr  hours  may  range  from  10  to  20  ounces,  and  in  exceiitional 
eases  from  1  to  "^  jiounds.    The  following  are  the  most  satisfactory  tests: 

Frliliiifi's  Test. — The  solution  consists  of  sulphate  of  eo])per  (irrs.  !H).l), 
neutral  tartrate  of  jiotassium  (grs.  'M-\),  solution  of  caustic  soda  (II.  ozs.  -1), 
and  distilled  water  to  make  up  C>  ounces.  Put  a  drachm  of  this  in  a  test- 
tuhe  and  hoil  (to  test  tln^  reagent):  add  an  eipial  (piantity  of  urine  and  boil 
auain.  wdten,  if  sugar  is  ])rosent,  the  yellow  suboxide  of  cop|ier  is  thrown 
down.     The  sidution  must  be  freshly  prepared,  as  it  is  apt  to  decompose. 

Trnnniirr'.^  Tcsl. — To  a  draclim  of  urine  in  a  test-tube  add  a  few  drojis 
of  a  dilute  snl)diato-of-copper  stdntion  and  then  as  miicb  lir/imr  palasm 
as  urine.  On  boiling,  the  coimer  i'^  reduced  if  sugar  be  ])rosent,  forming 
the  yellow  or  orange-red  pnboxide.    There  are  certain  fallacies  in  the  copper 


i* 


42i 


CONSTITUTIONAL   DISEASES. 


tesK  Thus,  u  s.il,.-tMiRf  calU..I  olvrun.nic  :u'i<l  is  mot  with  m  thr  unnr 
sifUT  Ihr  use  .it  crrtain  .lruos_,.hl.,n.l.  plu'iuuvtin,  nmrphia,  chlnrolcniK 
etc-— wliich  mhurs  copper.  Jlonio-entisinic,  un.k'UciuRs  and  -lyc.su.ir 
afi.ls,  which  arc  licld  tu  he  tiic  cauM'  ul  ak-apt-mnna,  may  a  su  pruve  a 
source  ..f  error  (see  Alcaptonuria,  hy  T.   li.   Futcher,  N.   \.  Me.l.  Jour., 

^^''%'rwn.lal!u,,  VV^/.-This  is  tr...  tn.ui  all  .hmht.  Place  a  small  i'ra- 
„i..ni  ot  veast  in  a  test-tuhe  full  .,]'  urine,  which  is  then  inv.Mled  e,cr  a 
ah,.s  ves;cl  containing  the  same  llui-l.  It  su-ar  is  present,  icrn.entation 
Vroc.s  on  with  the  formation  of  carh.m  dioxide,  \vhich  a.ruu.ulates  in  the 
upper  imrt  of  the  tui.e  and  gradually  expels  the  urine.  n  douhlul  cases 
..Vnntrol  test  sh.mld  always  he  used.     For  lahoratory  work  the  polarisropc 

is  of  'Hvat  value.  ■  , 

Uf  other  iim-redienls  in  the  urine,  the  urea   is  lucrcase.l,  the  uric  aeul 
does  not  show  special  ehaii,ues,  and  the  ph.,sphates  may  he  u'reatly  m  ex- 
ec-     llalfe  has  descrihed  a  }xn'n\  increase  in  the  phosphates,  and  m  s.nne 
of  these  cases,  with   an   excessive  excretion,  the   symptoms   may    he   vers 
similar  to  those  of  .liah..tes.  th..u,uli  the  su-ar  may  not  he  constantly  pres- 
ent     The  term  pliosphatic  diahetes  has  sonietinu's  heen  ai)plied  to  them. 
Acchnf    and    acetone-formin-    suhstances    are    not     infre.iueiitly    invsent. 
Lichen's  test  is  as  follows:  The  urine  is  distilh.l  aiul  a  few  cnhic  centimetres 
of  the  distilhite  are  rendered  alkaline  with  liquor  pota>sa'.     A  lew  drops  ot 
Luo'oFs  solution  are  then  added,  when,  if  acetone  he  present,  ihe  distillate 
ii.^umes  a  tnrhid  vellow  color,  <lue  to  the  forinati..n  of  lodolorni.  winch  is 
m-o-ni/ed   hv   its' o.lor  and   hv  the   forniati.m  of  mmute  hexa-oual   an. 
stellate  crvstals.    Diaci'tie  acid  is  s.)metimes  pirsent,  and  may  h..  ivcojinix.c 
from  the"fa.'t  that  a  soluth.n  of  the  chloride  ..f  in.n  yiel.ls  a   h.'autilul 
Bordeanx-red  color.     Other  suhstances,  as  formic,  .•arh..lic,  an.     salu'Vlie 
•ici.ls    oive  the  same  reacth.n   in  hotli  fresh  and   prevmiisly  h..ile.l    urine, 
whilJ  .^acetic  acid  d..es  n.)t  pive  the  reacth.n   in  urine  pivvmnsly  hoile.l. 
Mnns.m  holds  that  diactic  acid  -ives  the  characteristic  -  dia/o-rea.tion 
of  Khrli.'h.      In  testing  Tor  diacetic  acid  i)erfectly  fresh   urine  slmiild   ho 
used  as  it  rapi.llv  hec.)nies  hroken  uj.  into  acet.nio  and  carlmli.'  a.'i.l.    ^-.)xy- 
hntvrie  acid  sh.u'ihl  he  tested  f..r  where  oma  is  present.     .V  .luantity  of  the 
nrino  is  tlion.uohlv  fermented,  filtered  till  i.orfoctly  ch-ar.  and  ..xamin.'.l 
with  the  polaris...i.e.     If  it  he  i.resent.  the  rays  ..f  i.olanzed  li-ht  aiv  .  .- 
fleeted  to  the  left.     The  nrinc  also  yiel.ls  a-cr.)tonic  acid  crystals  l.y  the 
111. 't  hod  recommended  hy  Knlz. 

J'.r.'mer  finds  that  diahetic  nrine  has  the  power  of  diss.dvm-r  -entian 
violet,  whereas  normal  nrino  fails  to  do  so.  Vnfortnnatoly.  the  urine  in 
diahetes  insipidus  and  in  certain  f.n-ms  of  ].olynria  r.'a.'ts  similarly.  l-r.)h- 
lich  has  recently  devised  a  tost  hased  on  the  hu't  that  diahetic  urine  has  the 
proiierty  of  d.'.'..l.)rizins  s.ilutions  of  methylene  lilue. 

Clhi'rnqpii  has  also  hoen  descrihed  as  present  in  the  nrino. 
Mhiimin  is  not   infre.iuent.     Tt  occurred  in  nearly  'Pu   per  cent  of  the 
exaniiuatious  made  hy  Lippman  at  f'arlshad. 

rnnnmfurw,  \hv  formati.m  of  -as  in  the  nnne,  due  to  fermentative 
processes  in  the  hladdor,  is  occasionally  met  with. 


1  till'  urmi' 
(•lildi'ororui, 
I  Lilycusurii' 
Isi)  provL'  a 
Mod.  Jour., 

siuiill  J'l'ap- 
■  rtcd  i:<vv  a 
(■niu'iilaUDii 
la'.rs  ill  tliL' 

lllit  fill    C-arM'ff 

|)(ilai'isc()iH' 

he  uric  acid 
■(■ally  ill  c.\- 
aiid  in  SDiiu' 
nay   lio  very 
stanlly  \nv>- 
icd  to  tlunu. 
itly    ])rcsi'nt. 
3  cent  i metres 
few  drojjs  ol' 
the  distillate 
na,  wiiieh  is 
'xajionai   and 
le  rccofinix.ed 
;  a   i)eautii'ul 
and   salicylic 
lioilcd    urine, 
ioiisly  lioiled. 
i/.o-reaction  " 
ne  should   lio 
acid.    jS-oxy- 
laiitity  of  tlio 
iiid   examined 
liulit  are  de- 
•ystals  liy  tlie 

Ivinj:  iJfentian 

the  urine  in 

ilarly.     Frilh- 

urine  has  the 


T  cent  of  the 
)  fermentative 


DIABKTHS   MKLLITI'S. 


425 


Fat  niav  1)C  passi'il  in  the  urine  in  the  form  of  a  line  emulsion  (lipiiria). 

Diabetes  in  Children.— Stern  has  analyzed  1  IT  eases  in  ehildreii.  They 
u>ually  occur  anions  the  lietter  cla.-ses.  Six  were  under  one  yt'ar  (d'  au'e. 
Hereditary  intiiienees  were  marked.  Tln^  course  (d'  the  dis<'ase  is,  as  a  rule, 
luucii  more  rapid  than  in  adults.  The  shortest  duration  was  two  days.  In 
;  ca^es  it  did  not  last  a  month.  One  case  is  mentioned  of  a  child  aiii)arcntly 
horn  w  itli  the  fflyeosuria.  who  recovered  in  eii;ht  months. 

Complications.— ('0  Cutaneous. —  Uoils  and  carhuncles  are  extremely 
comiiKni.  I'aiuful  onychia  may  occur.  Fcxeiiia  is  also  met  with,  and  at 
times  an  intoleral)le  itchin;.;'.  in  women  the  irritation  of  the  uiiue  may 
cause  the  most  inten>e  pruritus  pudeiidi,  and  in  men  a  halauitis.  llarer 
all'ections  ari'  xanthom;i  and  pui'|piira.  (Jan^reiie  is  not  iincoinmon,  and 
is  associated  usually  with  artcrio-siderosis.  William  Hunt  has  analyzed 
()  1  cases.  Ill  .■)(!  the  localities  were  as  fi>llow>:  I'cet  and  Ic^'s.  .'IT:  tlii,t;li  and 
huttock.  ■-':  nucha.  ".';  external  ucnitals.  1;  liiii;j.-s,  ;i;  lin^u'ers.  ;j;  hack.  1; 
eyes,  1.  I'erforatiiii;'  ulcer  of  the  foot  may  occur.  r>roii/dn,<x  of  the  skin 
{diohilr  liniir.f).  a  rare  feature,  is  ineV  with  in  tonnection  with  a  peculiar 
type  of  cirrhosis  of  the  liver.  With  the  onset  of  severe  complications  the 
tolerance  of  the  carhohydrates  is  much  increased. 

(//)  Pulmonary. — 'i'iie  patients  are  not  infrc(|ucntly  carried  oil'  hy  uriih', 
piK'iiiiiiiiiiii.  which  may  lie  lohar  or  l(d)ular.  (laii'irrnc  is  very  ajjt  to  super- 
vene, hut  the  hreath  does  not  necessarily  have  the  foul  odor  of  ordinary 
^^an/xrene. 

'J'lthrrciihiiis  liriinclio-jiiiciiiiiniiid  is  \ery  e(nnmon.  It  was  formerly 
thon.irht.  from  its  rapid  course  and  the  limitation  of  the  disease  to  the  lung, 
that  this  was  not  a  trne  tnliercidotis  all'ectioii:  hut  in  the  cases  which  have 
come  under  my  notice  the  hacilli  have  heeii  present,  and  tiie  condition  is 
now  Li(>nerally  I'euardcd  as  tuherculons. 

(r)  Renal. — Alliiiiininirln  is  a  t(derahly  frecpieut  complication.  The 
amount  varies  greatly,  and.  when  slight,  does  not  seem  to  he  of  much  mo- 
ment. (I'jlema  of  the  feet  and  ankles  is  not  an  infrequent  symptom.  Gen- 
eral anasarca  is  nire.  hinv(>ver,  owing  to  the  marked  polyuria.  It  was  pres- 
ent in  a  marked  degree  in  one  of  my  TT  cases.  It  is  sometimes  associated 
with  arterio-sclerosis.  It  occasi(mally  precedes  the  lU'Vclopnient  of  the  dia- 
betic coma.     Occasionally  cystitis  develops. 

(fl)  Nervous  System.— (l)  Dinhrlir  coma,  first  studied  liy  Kiissmaul, 
comes  on  in  a  cnnsiderahle  ])To])ortion  of  all  eases,  jiarticularly  in  the  yoiiiig. 
Stephen  ^[aclvonzio  states  that  of  the  fatal  cases  of  diabetes  collected  from 
tin-  n'gisters  of  the  London  TIos])ital.  all  nnder  th(>  age  of  twonty-five,  with 
but  one  excei)tion.  had  dii'd  in  coma.  Tn  Freriehs'  series  coma  ])receded 
death  in  15'2  instances  out  (d'  a  total  of  ^^-)0  fatal  cases.  Of  17  fatal  cases 
at  the  Johns  Tloplsins  Hospital,  coma  occurred  in  1'^.  It  may  supervene 
when  diabetes  is  unsuspected,  as  in  '2  cases  re))orted  by  Francis  ^Tinot. 
Freriehs  recognized  three  gnnips  of  cases:  (")  Those  in  which  after  exer- 
tion tlie  iiatients  were  snddenly  attacked  with  weakness,  syncope,  somno- 
lence, and  gradually  deepening  unconsciousness:  death  or-cnrring  in  a  few 
hours,  ili)  Cases  with  ]ireliminary  gastric  distn-baiice.  such  as  nausea  and 
vomiting,  or  some  local  aiTection,  as  pharyngitis,  nlilegmon,  or  a  pulmonary 


1' 


l^i» 


426 


CONSTITUTION  A  I.   DISEASES. 


I 


complication.  In  such  cases  tlic  attack  licjiins  witii  headache,  dcliriiiiu. 
great  distress,  and  dys|in(ea,  alVectin,t;-  butli  insi)iration  and  expiration,  a 
condition  called  liy  Kussniaul  air-liiuii/cr.  Cyanosis  may  or  may  not  Ik; 
jircscnt.  11'  it  is,  tlie  pulse  becomes  rapid  and  wvnk  and  the  jiaticnt  ji'rad- 
ually  siidvs  into  coma;  the  attack  lastin.ii  I'mm  one  to  live  days.  There 
may  he  a  very  heavy,  sweetish  odor  of  tiie  hreath,  duo  to  the  presence  of 
acetone,  (y)  Cases  in  which,  without  any  previous  dyspno'a  or  distress,  liie 
])atient  is  attacked  with  headache  and  a  I'eelin;;-  of  intoxii'ation,  and  ra[)i(lly 
ialls  into  a  dee})  and  fital  coma.  riuTc  are  aty|)ical  cases  in  which  the  coma 
is  due  to  ura'niia,  to  apoplexy,  or  to  uu'iiin^itis. 

There  has  heen  much  dispute  as  to  the  nature  of  these  symptoms,  l)Ut 
our  knowledjic  (d'  the  disease  is  not  yet  sulliciently  advanced  to  fiive  a 
rational  explanation.  The  character  of  the  attack  and  the  sinularity,  in 
many  instances,  to  nra'Uiia  would  indicate  that  it  depended  upon  some 
toxic  a;,'cnt  in  the  hlood.  For  many  years  it  was  almost  universally  held 
that  this  toxic  material  was  acetone,  hut  this  theory  is  no  loiijicr  tcnahle, 
as  it  has  heen  repeatedly  shown  experimentally  that  acetone,  when  admin- 
istered to  animals,  does  not  i)roilnce  symptoms  resemhling  those  of  diabetic 
coma.  It  is,  however,  almost  c(mstantly  present  in  the  nrine  and  Ijreath 
of  coma  ])atients.  Later,  the  coiua  was  attributed  to  the  iireseiice  of  dia- 
cctic  acid  in  the  blood,  but  this  theory  in  turn  <:ave  way  to  that  of  Stadtd- 
mann,  Kiilz.  and  .Minkowski,  who  believe  that  diabi'tic  coma  is  an  auto- 
intoxication due  to  /?-oxy-butyric  acid  in  the  circidatin,<j:  blood.  In  18SI 
these  ol)servcrs,  workinji"  indi'iiendi'utly.  almost  simultaneously  found  this 
acid  in  the  nrine  of  patients  with  diabetic  coma.  /3-oxy-butyric  acid  is  now 
believed  by  most  observers  to  be  the  excitinf;-  cause  of  the  coma.  The 
amount  of  the  acid  excreted  in  the  twenty-four  hours  may  he  enormous. 
Kiilz  i'ound  in  'A  cases  (JT,  100.  and  'i'ii')  <rramnies  res])ectively.  It  is  a  de- 
composition ])roduct,  iv'sulting  from  the  disinte<j;ration  of  the  tissue  albu- 
nnns.  .\cetone  and  diacctic  acid  are  believed  to  be  derivative  from  (3-ox\- 
bntyric  acid. 

SamnU'i's  and  Hamilton  have  described  cases  in  which  the  lunji'  ca- 
])illai'ies  were  lilocked  with  fat.  They  atlriliuted  the  sympt(uns  to  fat  em- 
holism,  but  there  are  many  cases  on  recoi'd  in  which  this  condition  was  not 
found,  thon.uh  lipavnua  is  by  no  means  infre(pient  in  diabetes. 

'i'he  svmplouis  havo  been  altril)nted  to  ura'una,  and  albunnnuiia  fre- 
qtu'Utly  precedes  or  accompanies  the  attack. 

(".')  Prriphcntl  Xfiirilis. — The  iiciinilijlds,  lunnbness,  ami  lin,L;lin,i:-.  which 
are  not  uncommon  symptoms  in  diabetes,  arc  probably  minor  nenritic 
manifestations.  Ilerpi'S  zoster  may  occur.  iVi'loratin^-  ulcer  of  the  foot 
may  develop. 

niiihcllc  Tdhrs  (so  calle(l). — This  is  a  ]ieripheral  neuritis,  cliaracteri/ed 
bv  lightning  pains  in  the  legs,  loss  of  knee-jerk — which  may  occur  with- 
out th'^  other  symptoms — and  a  loss  of  power  in  the  extensors  o''  the  feel. 
The  ci.ii  is  the  characteristic  slrppiujo,  as  in  arsenical,  alcoholic,  and  other 
foi'ins  of  mnirilic  jiaralysis.  Charcot  slates  that  there  may  bi-  atrophv  of 
the  optic  nerves,  ('hangi's  in  the  posterioi'  columns  of  the  cord  have  been 
found  liv  Williamson  and  others. 


diabp:tes  mellitus. 


427 


I',  (Icliniini. 
\|iii'iitiim,  ii 
iiiiiy  iKit  111! 
iitit'iit  <irail- 
avs.     TIr'1\' 

lirt'sciu'o  of 
distress,  tlir 

and  ra|)i(lly 
ell  the  euiiui 

nptoins,  but 
d  ti)  <iivo  a 
iniilaritv,  in 

upon  sonic 
■iTsally  held 
ijicr  tc'nai)li', 
ilicn  adniiu- 
L)  of  dial)('tic 

and  IjR'atli 
vuci'  of  (Ha- 
lt of  Stadcl- 

is  an  auto- 
d.  In  1881 
,•  found  til  is 
•  acid  is  now 
coma.  The 
le  enormous. 
It  is  a  dc- 

1  issue  alliu- 

fmni  (3-()sy- 

ho  lunu-  ca- 
is  to  fat  eni- 
tion  was  not 

nnnuiia   fre- 

iLiiin.i:'.  wliich 
nor  ncnritic 
■  of  the  foot 

I'liaracteri/cd 
•iccur  witli- 
•;  o''  (lie  fe(>i . 
ic,  and  other 
e  atropliv  of 
rd  liave  been 


Didhflir  Paraplrriia. — This  is  also  in  all  |»rol)ainlit y  ^\\v  to  neuritis. 
Tiiore  are  cases  in  which  power  has  iurn  lost  in  hotli  anus  and  ie:;s. 

(3)  Mental  Sijmidums. — The  patients  are  often  morose,  and  there  is  a 
strong  tendency  to  l)ecome  liypochondriaca'.  (iencral  paralysis  has  been 
known  to  develop.  Some  jjatients  display  extraordinary  degree  of  rest- 
lessness and  anxiety. 

(-1)  Siiccial  Senses. — Cataract  is  lial)le  to  oeeur,  and  may  dcveloi)  with 
rajiidilv  in  young  persons.  Diabetic  retinitis  idosely  rescnd)les  the  all)U- 
minurie  birm.  Ihcmorrhages  arc  common.  Sudden  amaurosis,  snnilar 
to  that  which  oceurs  in  uraania.  may  oeeur.  I'araiysis  of  the  muscb's  of 
accommo(hition  may  be  present;  and  lastly,  atrophy  of  tlu'  oplie  ni'rvcs. 
Aural  symptoms  may  come  on  witii  great  rapidity,  eitiu'r  an  otitis  media, 
or  in  some  instance's  inilammation  of  tlu'  mastoid  c-t'Us. 

(.->)  Sc.riKtl  Fiinrliiui. —  Impotence  is  common,  and  may  bo  an  early 
svin])tom.  Conception  is  rare;  if  it  occurs,  aliortioii  is  ajit  to  f(dlow.  A 
d'ialietic  motiu'r  may  l)ear  a  healthy  child;  there  is  no  Isuown  instanci-  of  a 
diabetic  mother  iiearing  a  diabi'tic  cliild.  'i'lii'  course  of  tlie  disease  is 
usually  aggravated  after  delivery. 

Course. —  In  children  the  disease  is  rapidly  jirogressive,  and  may  provt- 
fatal  in  a  few  days.  Jt  may  lie  stated,  as  a  general  ride,  that  the  older  the 
patient  at  the  time  of  onset  the  slower  the  course.  Cases  without  hereditary 
influences  arc  the  nu)st  favorable.  In  stout,  elderly  men  diabetes  is  a  murh 
more  hopeful  diseasi'  than  it  is  in  thin  |iersons.  .Middle-aged  |)atienls  may 
live  for  many  years,  and  jii'isons  are  met  with  who  have  had  the  disease 
for  ten,  twtdve,  or  even  lifteen  years. 

.  Diagnosis. — As  stated  in  the  delinition,  b)r  a  case  to  be  eonsidcrcd 
dial)ctes  the  sugar  elinnnated  in  the  ui'ine  must  lie  grape  sugar,  it  shoidd 
be  ])rcscnt  for  weeks,  months,  or  years,  and  the  excretion  of  sugar  must 
take  ])lace  after  the  ingestion  n\'  moderate  amounts  of  earhohydrales.  As 
a  rule,  there  is  no  dillicidly  in  detei'iuiiung  the  presence  (d'  diabetes.  The 
urine  tests  already  given  are  distinctive. 

Hriniin-'s  llhioil  Trsl. — This  author  claims  that  be  is  able  to  make  a  diag- 
nosis of  diabetes  from  the  exanunation  of  a  drop  of  the  patient's  blood,  dc- 
])ending  (Ui  the  fact  that  it  reacts  dilferently  from  normal  blood  to  variinis 
aniline  dyes. 

His  latest  published  method  is  brietly  as  bdlows:  leather  thick  sm(>;irs 
of  susjiecteil  and  normal  blood  are  made  on  or<linary  nucroseopie  slides. 
They  are  then  heated  in  a  thermostat  up  to  i:!.")"  ('.,  and  when  sulliciently 
cooled  are  stained  in  a  oiu'-pcr-ccnt  a(|uoous  solution  of  Congo-rcil  for  oiu' 
and  a  half  to  two  nnnutes.  Slides  of  the  ]ion-diaI»ctic  and  diabetic  blood 
are  jilaced  back  to  back,  so  that  each  will  be  exposed  to  the  same  conditions. 
The  excess  of  the  stain  is  washed  olT.  and  if  the  suspected  patient  has  dia- 
betes the  blood  will  be  unstained,  whereas  the  normal  blood  takes  a  dis- 
tinct Cona-o-red  stain.  Ibvmer  obtains  this  reaction  in  the  ])rediabetic 
stage,  and  also  in  the  intervals  when  the  patienfs  urine  is  temiiorarily  free 
from  sugar.  TTe  thinks  tlie  reaction  is  du(>  to  a  (pialitaiive  change  in  the 
la'uioglobin  of  the  red  blood-cells,  and  not  to  an  excess  of  grajio  sugar  in 
he  blood.     Tn  a  nninb(>r  of  cases  in  mv  wards,  in  which  the  test  has  been 


lA' 


m^ 


428 


CONSTITUTIONAL  DISPUSKS. 


lH'rl'(.riiu'(|.  tin-  iciutinii  has  Ixrii  ivpciiti'illy  olitiiiiuMl.  l)ut  it  was  not  |u)s- 
silile  to  liillv  I'oiilinii  I'.ithut's  statement  that  the  reaetioii  was  also  present 
when  the  ui'ine  was  temporarily  free  from  suj:ar.  Aeeonlin^j  to  IJ.  'V.  Wil- 
liamsun,  diabetie  hlood  has  the  jiower  to  deeolorize  weak  alkaline  solutions 
oi'  methylene  Idne  to  a  yellowi^h-.ui'eeii  or  yellow  cdlor.  lie  has  (U'vised  a 
hl(Hid  te"st  for  diaheles,  nsin,u-  deliiiite  proportions  ol'  hlood  and  the  reap'nt. 
Williamson  has  obtained  the  reaction  in  every  one  of  11  eases  of  diabetes 
in  whieh  the  test  was  tried,  Imt  failed  to  -et  it  in  a  sin-ie  instance  In  the 
hlund  u\-  11H»  m.n-diabetie  i-a>es.  lie  is  inclined  to  the  view  that  the  reaction 
is  due  to  an  t'xee>s  of  Mi;:ar  in  the  blood.  The  r.'action  was  o:)tained  by 
Kutcher  in  T  eases  in  which  it  was  trii-d  in  my  wards  (I'liila.  Med.  .lournal, 
Februarv  l".',  1.^!>S). 

Deception  may  be  ])ractiscd.  A  y(.un-  ,-:irl  under  my  care  had  iinne 
w  ith  a  specilie  >;nnity  n{  1  .(HI,-).  The  reactions  were  for  cane  su-ar.  'I'liere 
is  one  <-a>e  in  tlu'  literature  in  which,  after  the  cane-su-ar  fraud  was  de- 
tected, the  woman  liou-iit  grape  supir  and  put  it  into  her  bladder! 

Prognosis.  —  in  triu'  diabetes  instances  of  cure  are  rare.  On  tin: 
other  liaud.  tl'.e  tran^ient  or  intermittent  glycosuria,  met  with  in  stonl 
overfeeders.  or  in  pcr.-ons  who  have  underLidiie  a  severe  mental  strain,  is 
very  amenable  to  treatment.  Not  a  few  of  the  cases  of  reputed  cures  be- 
lon'jr  to  this  division,  i'racticidly,  in  cases  under  forty  years  of  a.Li'c  the 
(Uithiok  is  bad:  in  older  perxms  the  di>ease  is  less  serious  and  much  more 
amenable  to  treatment,  it  is  a  -ood  plan  at  the  outset  to  deternnne  whether 
the  urine  of  a  patient  i-oiitaiiis  su.L^ar  or  not  on  a  diet  absolutely  free  from 
carbohydrates.  In  ndld  ca<es  the  su-ar  di.-appears;  in  the  severer  ca.^es  it 
continues  to  be  fcu'ined  from  the  jiroteids. 

Treatment. — In  families  with  a  marked  jiredisposition  to  the  disease 
the  u>e  (d'  >tarchy  and  saccharine  articles  of  diet  should  be  restricted. 

The  personal  hy.uieiie  of  a  diabi'tic  patient  is  of  the  first  imiiortance. 
Sources  of  worry  sliould  be  avoided,  and  he  should  leail  an  even,  ipuet  life, 
if  po.->ible  in  an  opiable  climate.  Flannel  or  silk  should  be  worn  next  to 
the  skin,  and  the  jz'reate.-t  care  >liould  lie  taken  to  |>ronioti  its  action.  A 
lukewarm,  or  if  tolerably  robust,  a  cohl  liath.  should  be  taken  every  day. 
An  occasional  Turki>li  bath  is  useful.  Systematic,  moderate  exercise  should 
lie  taken.  When  this  is  not  feasible,  mas.sige  should  be  given.  It  is  well 
to  study  accurately  the  dii'tetic  capabilities  oi  each  case. 

/;,V). — Our  in'junelions  to-day  are  those  of  Sydeidiam:  "  T.et  the  pa- 
tient eat  food  of  easy  digcstiim.  such  as  veal,  mutton,  and  the  like,  and  ab- 
stain from  all  sorts  of  fruit  and  garden  stnlf." 

Diabetie  patients  admitted  to  the  nu'dical  wards  of  the  dolins  TIo]ikins 
Hospital  are  kept  for  three  or  four  days  on  the  ordinary  ward  diet,  which 
contains  moderate  amounts  n\'  carbohydrates,  in  order  to  ascertain  the 
jimmint  of  sugar  excretion.  Tliey  are  then  jdaced  on  the  following  stand- 
ard non-carbohydrate  diet,  arranged  from  a  diet  list  recommended  by  von 

Xoordeii: 

Biriikfdsl:  r.ntt,  :.  grammes  (.",  i)  of  tea  steeped  in  -.'00  ec.  (=  vi)  of 
water;  loO  grammes  (.=,  iv)  (d'  boiled  ham:  one  egg. 

lAinrh:  1-3.30,  SdU  grammes  (=,  vi)  cold  roast  beef;  GO  grammes  (,=,  ij) 


DiAiu<yn<:s  mellitus. 


4-J'.> 


was  not  |ii)s- 

lllso    pl'l'St'Ilt 

()  1{.  T.  Wil- 
iuf  solutions 
las  (li'viscil  a 

tlio  rca.ui'iit. 
s  ol'  (lialiotcs 
-tauci'  ;n  llu' 
t  tlic  reaction 

obtaincil  !)}• 
h'(i.  .loiiriial, 

re  had  urine 
upir.  There 
rand  was  de- 
der! 

ire.  On  the 
vitli  in  stoiil 
ital  strain,  is 
ited  eures  l)e- 
rs  of  a,L;'e  the 
d  niueli  uiore 
mine  \\  lu'lher 
ely  iVee  from 
■verer  eases  it 

to  tlie  disease 
strieted. 
t  importance, 
en,  (juiet  life, 
worn  next  to 
its  action.  A 
en  every  day. 
.xei'cise  should 
■n.     it   is  well 

'■  T.et    the   [la- 
'  like,  and  ah- 

olms  IIo]ikins 
rd  diet,  which 
ascertain  tlie 
llowiu;;  staiul- 
icnded  hy  von 

)   cc.    (.',  vi)   of 

rrammes  (,",  ij) 


fresh  oueumher  nr  celery,  with  .")  ^■ramme<  (.">i)  vineizar;  in  j;rammcs 
(Tiiiss)  olive  oil,  Willi  sail  and  |ie|)|ief  to  taste;  -.'n  cc.  (7}  \  )  whisky,  wilh 
10(1  cc.  (f,  iij)  water;  (in  cc.  (.",  iv)  colVee,  withon.l  milk  or  su,i;ar. 

Diniwr:  (!  !'.  M..  >!(H»  ec.  eleai'  houillim;  V*.")(l  grammes  {,",  viiss)  roast 
lieef;  lo  .grammes  (.">  iiss)  liutter;  Sd  ^-rammes  (f,  ij)  jiceen  salad,  with  Ki 
grammes  (."iiss)  viiu'^ar  and  'JO  <iraniines  (."v)  olive  oil,  or  three  taiilc- 
spoonsful  of  some  well-cooked  jireeii  veyctahlc;  three  sai'diues  a  1  liuille; 
•.'(I  ec.  (7t\)  whisky,  wilh   100  cc.  (,",  xiij)  water. 

Slipper:  !•  r.  m.,  two  e^j;s  (raw  or  cooked):  100  cc.  (,",  xiij)  water. 
'I'liis  diet  contains  about  ^'00  i;raiiimes  of  all)umin  and  about  i;?"> 
^n-ammes  of  fat.  'i"he  etl'ect  of  the  diet  on  the  su;;ar  excretion  is  remai'k- 
able.  In  many  cases  there  is  an  entire  disappearance  of  the  snyar  from 
the  urine  in  thri'e  or  four  days.  Chart  X\'  shows  very  graphically  the 
remarkable  drop  in  the  suj^ar  ext'retion  l'(U'  llu'  lirst  twenty-four  hours  in 
a  case  |)laced  on  the  standai'd  diet.  The  sui^ar  failed,  however,  in  this  par- 
ticular case  to  t'litindy  (lisap|ieai'  from  the  urine  excejit  on  one  day,  al- 
thon,i;h  he  was  kept  on  the  diet  for  over  two  months.  Jn  cases  in  which 
the  uriiu'  bceouu's  free  from  suuar  gradually  iiicreasino-  (piantitii's  of  starch 
up  to  2[),  50,  and  loo  uiamnies  are  adiK'(l  daily.  White  bread  contains 
(iftv-live  ])er  cent  (d'  starch.  The  etl'ect  of  the  non-carbohydrate  diet,  ac- 
conlin,ir  to  von  Xooi'deii,  is  to  improve  the  nu'tabolic  functions  so  that  the 
svstem  can  warehouse  t-onsiderable  quantities  of  carbohydrates  witiioiil 
supir  apiiearinj,'-  in  the  nriiu'.  lie  advises  that  patients  should  return  to 
the  strict  iion-carbohydrate  rejiimeii  at  intervals  (d'  three  or  four  months, 
so  as  lo  increase  their  power  of  warehousini;-  cariiohydratcs. 

In  cases  in  which  a  staiulard  diet  is  not  ordered  it  is  well  to  l)e,uin  cut- 
tint;-  oil'  article  by  article  until  the  sujjar  disa|)])ears  fnun  the  urine.  Within 
a  uionlh  or  two  the  patient  may  be  allowi'd  a  nuu'c  liberal  diet,  testing'  the 
dili'erent  kinds  of  food. 

The  b)llowin>;'  is  a  list  of  article^  which  diabetic  patients  may  take: 

iiiipiids:  Soujis — ox-lail.  turtle,  bouillon,  and  other  clear  soups.  Lem- 
ouade.  cotVee.  tea,  chocolate,  and  cocoa:  these  lo  ln'  taken  without  sugar, 
Imt  they  may  be  sweetened  with  sacclrffrin.  Potash  or  soda  watei',  ami 
ApoUinaris.  or  the  Saratoga-Mchy.  and  milk  in  uujderatiou,  may  be  used. 

Of  animal  food:  Fish  of  all  sorts,  im  liuling  crabs,  lobsters,  and  oysters; 
sail  and  fi'csh  bntclu'rV  meat  (with  the  exception  of  liver),  poultry,  and 
game.     I''.ggs,  butter,  buttermilk,  curds,  and  cream  cheese. 

Of  bread:  (iluteii  and  bran  bread,  aiul  almond  and  coeoanul  biscuits. 

Of  vegetables:  Lettuce,  tmuiiloes.  spinach,  ehicorv.  soi'rcl.  radishes, 
asparagus,  water-cress,  muslard  and  cress,  cucumbers,  celery,  and  en<lives. 
Tickles  of  vai'ioiis  sorts. 

Fruits:  Lenums  and  oranges.  Currants.  ]ilunis.  cherries,  pears,  apples 
(lart).  melons,  raspberries  and  strawberries  may  be  taken  in  uioderation. 
Nuts  are,  as  a  rule,  allowable. 

Among  prnlilhih'tl  (irlicli's  are  the  following:  'IMiick  so\ips  aiul  liver. 

Ordinary  bread  of  all  sorts  (in  (|uautity').  rye,  wheaten,  brown,  or  wdiite. 
All  farinaceous  |ireparations.  >nch  as  luuuiny,  rice,  tapioca,  semolina,  cirrow- 
root,  sago,  ami  vci'nncelli. 


«■* 


4'M 


CONSTITUTIOXA  h  DISEASES. 


I* 


or  vcj,^'! allies:  rdlatdcs.  tiirni|is.  |l;n■^lli|l^.  siiuaslu's,  vc;:cUililc  marniw 
of  all  liiiids,  lii't'ts,  cnin.  aiticluikt's. 

Of   li.|iii(ls:   iU'C'r.  s|.arkliii;z-  wine  <.l'  all   sorts  and   tlu'  swci'l   ai'iatcd 

drinks. 

In  rccdinj.^  a  dialictic  |iaticnt  <iik'  oi'  llir  >;rcat(st  dillicidtics  is  in  arraiiji- 
iii"-  a  snhstitiilc  for  bread.  Of  the  ^diitcii  hrcads,  many  arc  very  un- 
lialalahlc:  others  are  frauds. 


Cu.viiT   \V.— Illustriiting  intluunce  of  diul  on  sufjar  and  lunount  of  urino. 


A  K"<'<1  fll'di'Ti  Hour  is  made  l)y  the  Battlo  Creek  Sanitarium  ('ompany. 
Michigan.  Other  substitutes  are  the  almond  food,  the  Aleuroiiat  bread, 
and  soya  bread,  hut  these  and  otiier  substitutes  are  not  satisfactory  as  a 
rule.     For  sweetening  jjurposes  saccharin  may  he  used,  of  wliicli  tablets  are 

prei)ared. 

Medicinal  Treatment.— This  is  most  unsatisfactory,  and  lU)  one  drug 
appears  to  bave  a  directly  curative  influence.  Opium  alone  stands  the 
tost  of  experience  as  a  remedy  capable  of  limit iutr  the  iirogress  of  the  dis- 
ease.    Diabetic  iiatients  seem  to  bave  a  special   tolerance  for  this  drug. 


DIABHTKS  MKLLITUS. 


431 


ililc  maiTDw 

Vl'L't     iU'IiltC'd 

is  ill  arnuifi- 
vv    very    im- 

llth 


I 
T1 


of  uriiio. 

mil  Coinjiany, 
iirniint  l)rc'iicl. 
isfactory  as  a 
icli  tal)U'1s  are 


(o.lria  is  i.ivlVm.l  liv  raw,  and  ha.  llu'  adva.ita-c  oi  luMii-  U'ss  cuiisti- 
„i„„.  il„„  lunrpi.ia.'  A  iMtin.t  may  iu-iii  will,  half  a  -ram  thrr."  tuiu^s 
',  ,la\"  whi.i  iiiav  1...  -ra.hially  iiuivasr.l  to  (1  ..,•  S  .raiiis  in  tlu'  iwriily- 
r,,m."hnurs.  Xot  "luiuh  HVr.t  is  nntic...l  unless  the  i-alU'iil  is  cii  a  ri-i.l  .li.|t 
Wlicn  the  siM^ar  is  nMJiufd  to  a  miniinuiii,  or  is  ahseiit,  the  oi'Him  should 
1,,.  ,rn,diiallv  withdrawn.  The  pati.'iits  not  only  l.uar  woll  these  lar-e  .loses 
of  t"he  .Iru--.  l.ut  thev  stand  its  -radual  reduction,  i'otassium  hronnde  is 
often  a  useful  adjun'et.  The  ar>einte  of  bromine,  a  solution  (d'  arsenioiid 
aeid  with  liroinine  in  ^dv.erin  (dose,  :!  to  .-.  niiniius  after  meals),  iuis  heeii 
verv  lii--lilv  reeonunend'ed.  hut  it  is  iiy  no  means  so  certain  as  oi-uim. 
\r^eni.'"al<".ne  mav  he  used.  Antipyrin  may  l>e  ^nven  in  doses  of  10  f^rains 
three  times  a  dav,"  and  in  eases  with  a  marked  neurotic  constitution  is  some- 
times satisfactory,  'i'lie  salieylati's.  io.hdorm,  nitro.irlycerin.  .jamhul.  the 
lithium  salts,  .str'vehnine,  creasote,  and  lactic  acid  have  been  employed. 

I'rcpinations'of  the  jmnereas  (j-lycerin  extracts  of  the  dried  an<l  fresh 
■  dandl  have  been  u>ed  in  the  hope  that  they  would  supply  the  internal  secre- 
Uon  necessarv  to  normal  snpir  metabolism.  The  success  has  not,  however, 
iicen  ill  anv  wav  comparable  with  that  obtained  with  the  thyroid  extract  m 
nivxiedenia.  I'.ejiine  has  isolate.]  a  glycolytic  ierment  fr,)m  the  pancreas 
aii.l  also  from  the  malt  .liastase.  an.l  has  used  it  with  s..mo  success  in  -t  eases. 

Of  the  complications,  the  iinirihi.<  and  crvmit  are  best  treated  liy  cool- 
in-  loti.nis  of  boric  aci.l  or  liyposulphite  of  soda  (1  ounce;  water,  1  quart), 
or  the  use  of  iclithvol  an.l  Ian. )lin  ointment. 

In  the  thin,  nerv.ms  cases  the  bowels  sh..nld  be  kej-t  open  an.l  the  tirinc 
tested  at  short  intervals  for  acet.nie  and  diacetic  acid— the  derivatives  .jf 

/J-oxv-hntvrie  acid.  t   i    w  t 

the  rnnm  is  an  almost  hopeless  complication.  Inhalations  ot  ox>-en 
have  heen  recommended.  The  use  of  bi,.irb..nate  of  s.)da  in  very  lai-e  doses 
i.  recommen.led  to  neiitralixe  the  acid  intoxi.-ati..ii.  It  may  be  use.l  intra- 
venouslv:  as  much  as  80  -rammes  have  been  injectc.l. 

The  subcutancus  and  intravenous  injection  <d'  physml..oieal  salt  solu- 
tion tlmuo-h  raivlv  curative,  has  prohably  o-ivon  the  best  resiilts.  ihis 
tvcatment'was  us.hI  in  my  wanls  in  10  cd"  the  U  cases  m  which  coma  oc- 
curiv.l  In  -i  cases  the  j.atients  weir  restored  to  complet."  cons,  lonsness, 
so  that  th.'V  w.>nld  have  been  .luite  capable  of  inakin-  a  will  i'.oth  cases 
eventnallv  terminated  fatally,  however.  In  three  instance,  ther..  was  mi- 
prov,.ment  in  the  ,n.lse.  and  the  res,,irati..ns  were  much,  less  labored,  tliou-h 
eonscionsness  never  return.Hl.  In  the  remainin-  ."i  cases  there  was  no 
a,,p,,H-ialde  improvement.  IJeyimlds  pnblished  2  cases  ot  recovery  a  iter 
l',';i„,.istration  of  a  d..se  of  castor  oil,  followed  by  30  to  HO  trains  ..t 
citrate  of  p,itassinni  .^verv  li.™r  in  eopi.n.s  drau-hts  of  water.  The  bowels 
of  a  diabetic  patient  should  be  ke,.t  actin-  freely,  as  constipation  is  believed 
to  predisjiose  to  the  development  of  coma. 


no  .tne  drug 
lie  stands  the 
ess  of  the  flis- 
for  this  clniir. 


27 


Bidn 


^■A 


432 


CONSTITUTIONAL   DISKASHS. 


VI.    DIABETES    INSIPIDUS. 

Definition.— A  clinniic  iilVcclinn  cliiUiUtcriz.Ml  by  (lie  |i;issii<;c  (if  lar;:.' 
(juaiililii's  (if  iKUinal  urine  (if  liiw  s|i('tilic  ;:ravit_v. 

The  condition  is  to  ho  (listinjiuishcd  from  (liurcsis  or  polyuria,  wliich 
is  a  fro(inent  syni|itoni  in  hysteria,  in  I'.ri^'ht's  (li>ease,  and  oeeasionally 
in  t'erelira!  or  otluT  atVeetions'  Willis,  in  KIT  I,  liist  reeo^iuized  the  dl.-tint- 
iion  iietween  a  saeeharine  and  non-saeeharine  form  of  dialietes. 

Etiology. — 'l"he  disease   is  most   common   in  yoniii;  jiersons.     Of  the 
.S,-)  eases  eonected  hy  Strauss,  !l  were  under  live  years;    IV  hetweeii   live  and 
ten   years;  ;i(;    Iietween    tei\   and    tui'nty-iive   years.      .Males   are    more    fre- 
(luently  attacked  tiian  females.     Tiie  all'ection  may  he  conjienital.     A  liered- 
itaiy  tendency  has  iieeii  noted  in   many  instances,  the  most   extiaordinary 
of  which  has'iieen  reiported  hy  Weil.     Of  '.»1  niemlicrs  in  four  .u'eneration-. 
'2.]  had  jicrsistent  polyuria  without  any  deterioration  in  health.     Injury  to 
the  nervous  system  has  heen   |ireseiit   in  certain  cases,  ami  the  disease  ha> 
followed   sunstroke,   or   a    violent    emotion,   such    as    fri,i:lil.      'I'raiimatism 
has  occasionally  iieen  the  e.xcitin^^  cau.-e.     'I'he  injury   may  have  iieeii   to 
the  head,  hut  in  other  cases  it  has  lieen  to  the  truid<  or  to  the  liiidis.     Trous- 
pcau  stated  that  the  iiareiits  of  children  with  diaoetes  insipidus  fi'e(inciilly 
iiave  <:lycosuria  or  alhununuria.     K'alfe  stated  that  malnutrition  is  an  im- 
portant prcdisiiosin^f  I'actor  in  children.     The  disease  has  followed  rapidly 
the  coiiious  driidvinj:  of  cold  water,  or  a  drinkinfr-hout ;  or  has  set  in  duiinu 
the  convalescence  from  an  acute  diseasi'.     Tumors  of  the  hrain  and  lesion> 
of  the  medulla  have  heen  nu't  with  in  a  few  instaiu'cs.     Cases  of  polyuria 
have  heen  accomjiained  liy  jiaralysis  of  the  sixth  nerve.     Ma^uire  has  seen  an 
instance  after  ineninjiitis  inwhich  jiaralysis  of  the  sixth  ]iair  occurred  with  it. 
IJernard,  it  will  he  rcniendiercd,  discovered  a  spot  in  the  floor  of  the  fourth 
ventricle  of  animals  which,  when  punc^tured,  jiroduced   ]iolyuria.      Lesions 
of  the  orjians  of  the  alidomiMi  may  he  associated  with  an  excessive  How  of 
urine,  which,  however,  should  not  he  re>;ardcd  as  tiue  dialietes  insipidus. 
Dickenson   nu'ntions   its  occurrence   in   ahdominal   tmnors;   K'alfe,   in   ah- 
doniinal  aneurism.     1   have  noted   it  in  several  cases  of  tuherculous  peri- 
tonitis.    There  have  lie(>n  only  'i  cases  of  dialietes  insipidus  out  of  a  total 
of  l.'iO.ono  ])atients  treated  at  the  .Tohns  Ilojikins  Hospital  and  Dispensury. 
The  nature  of  the  disease  is  unknown.      It   is,  douhtless.  of  nervous 
ori;iin.     The  most  reasonahle  view  is  that  it  results  from  a  vaso-m(>((ir  dis- 
turhance  of  the  renal  vessels,  due  eitlier  to  local  irritation,  as  in  a  case  of 
ahdominal   tumor,  to  central   disturhance  in   cases  of   hrain-lesion,  or  to 
functional  irritation  of  the  centre  in  the  nu>dulla,  "iving  rise  to  continuous 
renal  contrcstion. 

Morbid  Anatomy. — There  are  no  constant  anatomical  lesions.  The 
l-i(hieiii^  have  heen  fonnd  enlarged  and  congested.  The  hhuhla-  has  heen 
found  hypertrophied.  Dilatation  of  the  nreters  and  of  the  pelves  of  the 
kidneys  iias  heen  present.  Death  has  not  infrc(iuently  resulted  from  chronic 
pulmonary  disease.  Very  varied  lesions  have  been  met  with  in  the  nervous 
system. 


^ii;;f  (if  liir;:v 

I'liriii.  wliicli 
occiisiiiiially 
the  (ll.-tiiic- 

illS.      Of   thr 
cell   live  Mini 

('     lIKll't'     fl'f- 

il.     A  liiTcd- 
xliiionliiiary 

UflUTiltidll-, 
I  MJlll'V    til 

■  (li>('ii.»('  \\;[- 
'I'riuiiiiiitisni 
iiivc  liocii  t<i 
111  IS.  Tniiis- 
is  fi'i'(inciillv 
nil  is  an  iiii- 
iwi'd  rapiilly 
-rt  ill  (liiriiiL: 
1  and  lrsiiiii~ 
-  (if  |i()lyiii'ia 
I'  lias  seen  an 
unvdwitli  it. 
)f  the  fdiirtli 
ria.  Lesions 
'ssive  tl<i\v  (if 
cs  insipidus, 
{alfe.  in  ab- 
rciildiis  peri- 
iit  (if  a  total 
1  Dispensary. 
;.  of  nervous 
so-ino(or  dis- 
in  a  case  of 
lesion,  or  to 
()  continuous 

lesions.  The 
(Icr  has  been 
pelves  of  the 
from  chronic 
1  the  nervous 


DIABHTKS   INSIPIDUS. 


4;i;i 


tliymptoms. - — 'I'he  di-ease  may  c(iiiie  mi  rapidly,  as  after  a  fright  or 
an  injury.  More  ((iiniiKinly  it  develops  .-hiuly.  Accord  in;.;'  to  Ifalfc.  the 
|iaticiits  often  t'om|ilain  in  tiit;  early  sta;:'es  nf  >evere  rackiii;.'  pains  in  the 
liiniliar  region  shooting  down  the  thighs.  A  copious  secretion  of  urine, 
with  increased  thir>t.  are  the  incimiiiciit  features  nf  the  disease,  'i'he 
amoiinl  of  urine  in  the  tweiity-fniir  hours  may  range  from  '.'n  to  10  pints, 
er  even  iiKire.  'rroiisseaii  s]ieak>  (if  a  jiatieiit  ulm  c(iii>imiei|  ,")il  pints  of 
lliiid  daily  and  |iassed  ahoiit  oii  jiints  (if  urine  in  the  t wciity-foiir  hours. 
'I'he  specilic  gravity  is  hiu.  l.iiiil  td  i.(Hi.">;  the  enlor  is  extremely  pale  and 
watery.  The  total  solid  constituents  may  iKit  he  rc(lnee(|.  The  amount  of 
urea  has  sometimes  Ijeen  found  in  excess.  Ahiiormal  ingredients  are  rare. 
.Musele->iigar,  iiKisitc,  has  lieeii  occasionally  fnuiid.  .Mliiiinin  is  rare. 
Traces  (if  sugar  have  liecii  met  with.  Naturally,  with  the  pa>sage  of  such 
eiKirmniis  (piantitics  (if  urine,  there  is  a  prdpnrtionale  thirst,  and  the  only 
inc(in\(iiience  df  the  di>case  i.«  the  necessity  fdr  frci|Ueiit  micturilidii  and 
l're(|Ueiit  drinking.  'I'he  appetite  is  usually  gddd.  rarely  excessive  as  in 
dialietes  mellitus;  hut  'l'rdU>~eau  tells  of  the  terror  iiisjiircd  hy  one  of  his 
patients  in  the  keepers  of  tlio>e  eating-li(iu.-es  where  lii^ad  was  alhiwed  with- 
out extra  charge  to  the  extent  of  each  customer's  wishes,  aiid  says  that  he 
was  procnted  with  money  to  prevent  him  coming  hack  to  dine.  'I'he 
patients  may  he  well  iiduri>hcd  and  healthy-looking.  The  disease  in  many 
instances  does  not  appear  td  interfere  in  any  way  with  the  general  health. 
'I'he  pei'spiratidii  is  naturally  slight  and  the  >kin  is  harsh.  The  ainoiint 
of  .siliva  is  small  and  the  mouth  usually  dry.  Cases  have  iieeii  descrihed 
in  which  tlie  i.ileraiice  of  alcolml  has  been  remarkable,  and  patients  have 
lieeii  kii(i\\  ■!  Id  lake  a  couple  of  jiiiits  of  brandy,  or  a  dozen  or  iiiore  bottles 
of  wiur.  in  the  day. 

The  course  depends  entirely  upon  the  nature  of  the  jiriinary  trouble. 
Sdiiietimes,  with  orgaiiic  disease,  either  cerebral  or  abdominal,  the  general 
health  is  much  iinpaire(l;  the  jiatient  beconies  thin,  and  rajiidly  loses 
strength.  In  the  essential  nr  idiopathic  cases,  good  health  may  lie  main- 
tained for  an  indelinite  period,  and  the  all'ection  has  been  known  to  pt'rsist 
for  fifty  years.  Death  usually  results  from  some  intercurrent  all'ection. 
Spontaneous  cure  may  take  place. 

Diagnosis. — .V  low  s]u'cific  gravity  and  the  absence  of  sugar  in  the 
urine  distinguish  the  disease  from  diabetes  mellitus.  Hysterical  jiolyuria 
may  sometimes  simulate  it  very  cloxdy.  The  amount  of  urine  excreted 
may  be  enormous,  and  only  the  development  of  other  hysterical  manifesta- 
tions may  enable  tho  diagnosis  to  be  made.  This  condition  is,  however, 
always  transitory. 

Tn  certain  cases  of  chronic  Wright's  disease  a  very  large  amount  of 
urine  of  low  specific  gravity  may  be  jKissed,  but  the  jiresence  of  albumin 
and  of  hyaline  casts,  and  the  existence  of  heightened  arterial  tension,  still' 
vessels,  and  liyiicrtrophied  left  ventricle  make  the  diagnosis  easy. 

Treatment. — Tlic  treatment  is  not  satisfactory.  Xo  attemjit  should 
be  made  to  reduce  the  amount  of  li(iuid.  0]uuiii  is  highly  recomtnendcHl, 
but  is  of  doubtful  service.  The  preparations  of  valerian  may  be  tried: 
either  the  jiowdered  root,  beginning  with  5  grains  three  times  a  day.  and 


4.'.4 


CONSTITUTION. Mi   OISKASF.S. 


iiKiViicii);:  iiiiiil  •.'  ilni(liin>  lUf  takni  in  \hv  day.  or  tlio  viilorinnato  of  zinc. 
in  l.')-j;riiiii  linsi's.  ;:ni(liiallv  iiicrca-i'd  to  ;!(•  <:raiiis.  lliri'c  tiiiio  a  dav.  l-lr-iot, 
t'l'-rotiii.  aiiti|i\riii,  tlii'  saiicvlali's,  iirx'iiic.  strvihiiiiic  tiii'|icntinc.  ami  tin- 
|iri)iiii(li'H  liavi'  l)irii  Rrtniiiiu'inlinl,     J'lk'ctricity  may  hv  nscil. 


I 
n 


VII.    RICKETS  {lihnchith). 

Definition. — A  iV\>vi\>v  nl'  iiiraiit>.  cliaractt'ii/cd  l)y  ImpninMl  initritinn 
of  the  I'litiiv  lindy  and  alterations  in  tlu'  ^n-owinj:  liones. 

(Ilissoii.  tlic  !inatnnii>t  of  the  livof,  accurately  descriiicd  the  discnsc  in 
the  >e\cnteentli  ccnliiry.  'I'lie  name  is  derived  ffom  tiic  old  Kn^ilisli  word 
irrirlrkni.  to  t\vi>t.  (ili.-son  sii<.';;-ested  to  cliaujio  tile  name  to  rliacliitis,  froin 
the  (iieek,  ("ix'-'''  l'"^'  -I'inf.  "^  't  "'"'  •""•'  "'  ^''^'  '""''"*  1"""*'^  alfeeted,  ami 
also  ffom  the  similarity  in  the  sound  to  rickets. 

Etiology.— Wickets  e.\i>ts  in  all  parts  of  the  world.  I. lit  is  i)articularly 
marked  amon.ir  the  jioor  of  the  larucr  cities,  wIk-  are  liadly  housed  and  ill 
fed.  It  is  much  more  common  in  i'lurope  than  in  .\merica.  In  N'icnmi  and 
I.ondon  from  .")<l  to  Mi  per  cent  (d'  all  the  children  at  the  cliiues  i)rcsent 
sij.nis  of  rickets,  ll  is  a  comiiaratively  rare  disease  in  Canada.  In  the  cities 
of  tills  continent  it  is  very  prevalent,  particularly  anumj;  the  children  of 
the  ne,i;ro  and  of  the  Italian  races.  Want  of  sunlight  and  im|)ure  air  are 
important  factors.  l'rolon,<red  lactation  and  sucklin;:-  the  child  during  |)reg- 
iiancy  are  accessory  intlueiices  in  some  cases. 

There  is  no  evidence  that  tlie  disease  is  liereditary. 

tickets  atl'ects  male  and  female  children  eipuilly.  It  is  a  di.sease  of  the 
first  and  second  years  of  life,  rarely  hcginning  hefore  the  si.xth  month. 
Jeiiner  has  descrihed  a  late  rickets,  in  which  form  the  disease  may  not  ap- 
pear until  the  ninth  or  even  until  the  twelfth  year.  It  has  heen  held  that 
rickets  is  only  a  manifestation  of  congenital  syjiliilis  (Parrot),  hut  this  is 
certainlv  not  correct.  Syphilitic  hones  rarely,  if  ever,  i)resent  the  sjiongy 
tissue  iieculiar  to  rickets,  and  rachitic  hones  never  show  tlie  multiple  oste- 
ojilivtes  of  syphilis.  "  Syithilis  modilics  rickets;  it  does  not  create  it  " 
(Cheadle).  A  I'aulty  diet  is  the  essential  factor  in  the  production  of  the 
disease.  Like  scurvy,  rickets  may  l)e  found  in  the  families  of  the  wealthy 
under  |ierfect  hygienic  ('(mditioiis.  It  is  most  common  in  children  fed  on 
condensed  milk,  the  various  proprietary  foods,  cow's  milk,  and  I'ood  rich 
in  starches.  "  An  analysis  of  the  foods  on  which  rickets  is  most  frecjucntly 
and  certainly  ])roduced  shows  invariahly  a  deficiency  in  two  of  the  chief 
elements  so  ]ilentiful  in  the  standard  food  of  youni:-  animals — namely,  ani- 
mal fat  and  proteid  "  (Cheadle).  I'dand  Sutton's  interesting  experiment 
with  the  lion's  enhs  at  the  "Zoo"  illustrates  this  ])oint.  When  milk, 
pounded  hones,  and  cod-liver  oil  were  added  to  the  meat  diet  the  rickets 
disajipeared.  and  for  the  first  time  in  the  history  of  the  society  the  cuhs 
were  reared.  Associated  with  the  defect  in  food  is  a  lack  of  jiroper  assimila- 
tion of  the  lime  salts. 

Morbid  Anatomy. — Tht'  hones  show  the  most  important  changes, 
particularly  the  ends  of  the  long  hones  and  the  rihs.     Ik^tween  the  shaft 


lato  of  zinc. 

lie.   mill    tin' 


(m1  initi'itimi 

If  disfiisL'  in 
!n;.'lish  wiml 
iciiilis,  inmi 
illVftt'd,  anil 

particularly 
iMscil  anil  ill 

N'icnna  and 
nics  pn'scnt 
111  the  ritii'S 

children  of 
i|)iiri'  air  an' 
during  i)ivg- 


iscaso  of  tho 
ixtli  month, 
may  not  ap- 
('11  held  that 
I,  liut  this  is 
I  the  spongy 
lultiple  oste- 
t  create  it  " 
iction  of  the 
tho  wealthy 
Idreii  fed  on 
lid  I'ood  rich 
st  frequently 
of  the  chief 
•naiiu'ly.  ani- 
r  experiment 
When  milk, 
t  tho  rickets 
ety  the  cubs 
iper  assimila- 

ant  cliaiigos, 
'Oil  the  shaft 


RICKETS. 


435 


nnd  cpipliysos  n  sliplit  hulging  is  apparent,  and  on  section  the  /one  o|  pro- 
liferation, which  iioriiially  is  repre^-eiitcd  l>y  two  Hiirniw  hands,  is  greatly 
ihickt'iied.  hluish  in  color,  more  irregular  in  outline,  and  \ery  miu  h  softer. 
The  width  of  this  cushion  of  cartilage  vaiii's  from  ■'>  to  l.'i  mm.  'l"he  lino 
of  nssilication  is  also  irri'gular  and  more  spongy  and  \aMular  tliun  normal. 
The  |ieriosteiim  strips  olf  very  nadily  from  the  >liaft,  and  iieiiealh  it  there 
may  he  a  spongioid  tissue  iioi  unlike  decidcilii'd  hone.  The  practical  out- 
come of  these  changi's  is  a  delay  in.  and  imperfect  performance  nf.  ihc 
oSfiiication.  .^o  that  the  iione  has  neither  the  natural  rate  i)f  grouih  imr  the 
normal  lirmiiess.  In  the  cranium  there  may  he  hi rge  areas,  parliciiliiiiy  iii 
the  iiaricto-occipital  region,  in  which  the  os>iliciitioii  i<  driaycd.  producing 
the  so-called  cranio-tahes.  so  that  the  hone  yields  readily  to  pri's.-iiie  with 
the  iinger.  There  are  locali/.ed  depressed  spot>  (d'  atrophy,  wliiili,  mi 
pressure,  give  the  Mi-called  "  paiehiiicni  criicklini:-.'"  Flat  hyperosioses  de- 
velop from  tho  outer  tahle,  ])artienlaiiy  on  tin'  frontal  and  parietal  hone-, 
and  ]iroiliice  the  charaeteristic  hroad  foicheail  with  ipromineiil  frontal  emi- 
nences, a  condition  sometimes  mistaken  for  hydrocephalus. 

Kassowitz,  the  leading  authority  on  the  unatoniy  of  rickets,  regard-: 
the  hy|H'ra'mia  of  tho  periosteum,  the  marrow,  the  cartilage,  and  of  the 
hone  itself  as  the  primary  lesion,  out  of  which  all  the  others  develop.  This 
disturbs  the  normal  development  ol'  the  growing  hone  and  excites  changes 
in  that  already  formed.  'J'he  cartilage  vv\\>  in  eoiiseipu'iico  ]iroliferate, 
the  matrix  is  softer,  and  as  a  result  the  hone  which  is  formed  from  this 
unhealthy  cartilage  is  lacking  in  lirmne->  and  solidity.  In  the  hone  already 
formed  this  excessive  vascularity  exaggerates  the  normal  processes  of  ah- 
sorption.  so  that  the  relation  holweeii  removal  and  deposition  is  distiirhed. 
ahsnrption  taking  jilace  too  rapidly.  The  new  material  i>  poor  in  lime  salts. 
Kassowitz  has  i>roveil  exiu'rimeiitally  that  hypera'inia  id'  hone  results  in 
defoetivo  deposition  of  lime  salts.  It  is  interesting  to  note  that  (ilissoii 
attributed  rickets  to  disturbed  nutrition  by  arterial  hlood.  and  believed 
the  changes  in  tlie  long  bones  to  be  ibie  to  excessive  va.-cularity. 

Tho  chemical  analysis  of  rickety  bones  shows  a  marked  diminution  in 
the  calcareous  salts,  which  may  be  as  low  as  ■'.'>  or  ;>.")  per  cent. 

The  liver  and  siiloeii  are  usually  c'lilarged.  and  somotime.s  the  mesen- 
teric glands.  As  (ice  sugeests,  these  conditions  probably  result  from  the 
general  state  of  the  health  associated  with  ricki'is.  Heiieke  lias  descrilpod 
a  relative  increase  in  the  size  of  the  arteries  in  rickets. 

Symptoms. — The  di.-oase  comes  on  insidiously  alioiit  tho  jteriod  of 
dentition,  before  tho  child  begins  to  walk,  ^lild  grades  of  it  are  often  over- 
looked in  the  faTiiilies  id'  the  well-to-do.  In  many  cases  digestive  disturb- 
ances precede  the  ai)|iearanco  of  the  characteri.-tic  lesions,  and  the  nutrition 
of  the  child  is  markedly  impaired.  There  is  usually  slight  fever,  the  child 
is  irritable  and  restless,  and  sleeps  badly.  If  the  child  has  already  walked, 
it  shows  a  marked  disinclination  to  do  so.  and  seems  feeble  and  unsteady 
in  its  gait.  Sir  William  denner  has  called  attention  to  three  general  symp- 
toms of  great  imiiortanee:  First,  a  dilVuse  soreness  of  the  body,  so  that 
tho  child  cries  when  an  attempt  is  made  to  move  it,  and  jirofers  to  koo]) 
porfootly  still.    This  is  often  a  marked  and  suggestive  symptom.    Secondly, 


43(3 


CONSTITUTIONAL  DISEASES. 


S! 


f^liglit  f(.'vcT  (100°  to  101.5°),  witli  iKictunial  ri'stlcs^ness,  and  a  tondon- 
(■y'"t()  llirow  oil'  tlio  bi'<k-lotli(s.  Tliis  may  be  i)artly  due  to  the  iact 
li)at  tlie  guiR'i-al  soii,sitivi.'ii('>s  is  sucli  tliat  ovi'ii  tlii'lr  \\ei<ilit  may  be  dis- 
tressing. And,  tliirdly,  profuse  sweating,  jiartieularly  about  tiie  bead 
and  neek,  so  tbat  in  tlie  morning  tiie  jiillow  is  found  soaked  witb  perspi- 
ration. 

Tbe  tissues  lieeonie  soft  and  flal)i)y;  tiie  skin  is  jiale;  and  from  a 
liealtiiy,  plump  condition,  tlie  ebild  lieeomes  puny  and  feeble.  Tin  mus- 
cular weakness  may  lie  luarked,  ])artieularly  in  tlie  legs,  and  paralysis  may 
be  suspected.  Tbis  so-called  jiseudo-paresis  of  rickets  results  in  jiart  from 
tbe  llabby.  weak  condition  of  tlie  legs  and  in  iiart  from  tbe  pain  associated 
vitb  tbe  "movements.  I'oincident  witb,  or  following  closely  upon,  tbe  gen- 
eral symptoms  tbe  cbaracteristic  skeletal  lesions  are  observed.  Among 
tbe  first  of  tbese  to  a]»i)ear  are  tbe  cbanges  in  tbe  ribs,  at  tbe  junction  of 
tbe  l)one  witb  tbe  cartilage,  forming  tbe  so-called  rickety  rosary.  AVbeii 
tbe  cbild  is  tbin  tbese  nodules  may  be  distinctly  seen,  and  in  any  case  can 
be  easily  maik'  out  by  toucli.  'i'liey  very  rarely  apju'ar  bei'ore  tbe  tliird 
niontb.  Tbey  may  iiuM-ease  in  size  up  to  tbe  second  year,  and  are  rarely 
wen  after  tbe  fiftb  year.  Tbe  tborax  undergoes  important  cliauges.  Just 
outside  tbe  junction  of  tbe  cartilages  witb  tbe  ribs  tbere  is  an  obli(iue, 
fiballow  (b'liression  extending  downward  and  outward.  A  transverse  curve, 
sometimes  called  Harrison's  groove,  ])asses  outward  from  tbe  level  of  tbe 
ensiform  cartilage  toward  tlie  axilla  and  may  be  (b'cpened  at  eacb  inspira- 
tion. It  is  rendered  nunv  piominent  by  tbe  eversion  and  lU'oniineiice  of 
tbe  costal  border.  Tbe  sternum  i>rojects,  particularly  in  its  lower  balf, 
forming  tbe  so-called  jiigeon  or  cbickeii  breast.  Tbese  cbanges  in  tbe 
tluu'ax  are  not  peculiar,  liowever,  to  ricki  ts.  and  are  niiu'b  more  commonly 
associated  witb  bypertro]iby  of  tbe  ton<il.-.  or  any  trouble  wbicb  interferes 
witb  tbe  free  entrance  <d'  air  into  tbe  lungs.  Tbe  spine  is  often  curved 
iiostt'riorly,  tbe  ju'ocesses  are  jirominent;  lateral  curvature  is  not  so 
ctinunon. 

Tlie  bead  of  a  rickety  cbild  usually  looks  large  in  jiroportion  botb  to 
tlu'  body  r'ld  tbe  face,  and  tbe  fontanelles  remain  open  for  a  long  time. 
Tbere  are  areas,  particularly  in  tbe  jiarieto-occipital  regions,  in  wbicb  ossi- 
fication i^  imperfect;  ami  tbe  bone  may  yield  to  ibe  ]ircssure  of  tbe  finger, 
a  condition  to  wbicb  tbe  term  rriuiiii-hilirfi  bas  lieen  givi'U.  Tbe  relation 
of  tbis  condition  to  rickets  is  still  somewbat  d(Uililful.  as  it  is  very  often 
associated  witb  syiibilis— in  -IT  of  KiO  cases  studied  by  (ieorge  Carpenter. 
C'oincidcntly  witb  tbis.  byperpbisia  i)roceeds  in  tbe  frontal  and  jiarietal 
eminences,  so  tbat  tliese  ])orti(ms  of  tbe  skull  increase  in  tbickness,  and 
niav  form  irregular  bosses.  In  one  tyjie  tbe  skull  may  l)e  large  and  ebui- 
gated.  witb  tbe  top  considerably  flattened.  In  anotber,  and  perba])s  more 
common  case,  tbe  sbai)e  of  tbe  skidl,  wlien  seen  from  above,  is  reetangidar 
— tbe  cdinit  qiiadraiiim.  Tbe  skull  looks  large  in  ])roportion  to  tbe  face. 
Tbe  for(>bead  is  broad  and  s(piare,  and  tbe  frontal  eminences  marked.  Tbe 
anterior  fontanelle  is  late  in  closing  and  may  remain  open  until  tbe  tliird 
or  fonrtb  year.  Tbe  skin  is  tbin,  tbe  veins  are  full  and  prominent,  and  tbe 
liair  is  often  rubbed  from  tbe  back  of  tbe  skull.    In  contradistinction  to  tbe 


RICKETS. 


437 


(1  a  t on (1  on- 
to tlio  iiiot 
may  bo  dis- 

.it  tiio  lioad 
with  perspi- 

and  from  a 
.  Th'  mus- 
laralysis  may 
in  i)art  I'roni 
in  associated 
)on,  tlio  •roll- 
ed. A  mollis 
.'  junction  of 
sary.  Wlioii 
any  oaso  can 
ii'o  tlio  tliird 
id  aro  rarely 
ian,u'es.  Just 
;  an  olili(|uo, 
isvei'so  curve, 
level  of  tlio 
each  inspira- 
roininonco  of 
s  lower  half, 
iini;'es  in  the 
ro  coinnionly 
icli  interferes 
often  curved 
e    is    not    so 

rtiou  both  to 
a  loiiix  time, 
n  which  ossi- 
of  the  finuer, 
The  relation 
is  very  often 
ixo  Carpenter, 
and  |)arietal 
hicknoss,  and 
ry-o  and  olon- 
]iorhaps  more 
is  roctanirular 
1  to  the  face, 
marked.  The 
ntil  the  third 
nont.  and  the 
Inction  to  the 


cranio-tabos  is  the  condition  of  cranio-sclorosis,  which  lia.«  also  boon  ascribed 
to  rickets. 

On  placini:  the  oar  over  the  anterior  fontanollo,  or  in  the  temporal 
region,  a  sy.stolic  niurimir  may  fro(|ueiitly  lio  lioard.  This  condition,  linst 
described  by  .lolin  JJ.  Fisher,  of  J>oston,  in  ]<s;5;5,  is  hoard  with  the  groatost 
frocpioncy  in  rickets,  but  its  presence  and  i)orsistonco  in  perfectly  healthy 
infants  have  Itoon  anijily  domonstratod.*  'J'lio  murmur  is  rarely  hoard  after 
the  fifth  year.  A  knowledge  of  the  existence  of  this  systolic  brain  murmur 
may  jiroveiit  errors.  A  case  iu  which  it  was  well  marked  was  reported  as  an 
instance  of  supi)osed  guniiuy  tumor  of  the  lirain,  in  which  the  murmur 
was  thought  to  be  due  to  pressure  on  the  vessels  at  the  base. 

Changes  oceiir  in  the  bones  of  the  face,  chiefly  in  the  maxilla',  which 
are  reduced  in  size.  The  normal  process  of  dentition  is  much  disturi)ed; 
indeed,  late  teething  is  one  of  the  marked  features  in  rickets.  The  teeth 
which  ajipear  may  be  small  and  liadly  forinod. 

Jn  the  upper  limbs  changes  in  the  .«capul;o  aro  not  common.  The 
clavicle  may  l)o  thickened  at  tlio  sternal  end,  and  there  may  be  thickening 
near  the  attachinont  of  t.^o  sierno-cloido  musclo.  The  most  noticoablo 
cliaugos  aro  at  the  lower  ends  of  tho  radius  and  ulna.  The  enlargoinent 
is  at  llie  juiiction-area  id'  the  shaft  and  ojtipliysis.  Less  evident  enlargo- 
lueiits  may  occur  at  the  lower  end  of  the  hunierus.  Jn  severe  eases  the 
natural  sliajio  of  the  Ixmos  of  the  arm  may  be  much  altered,  since  they  have 
had  to  support  the  weight  (d'  tlie  child  in  crawling  on  the  floor.  'J'lio 
changes  in  the  pelvis  are  of  special  iniportance,  ]iarticularly  in  female  chil- 
dren, as  in  extreme  cases  they  lead  to  great  deformity  iUid  narrowing  of  the 
outlet,  in  the  legs,  tlie  lower  end  of  tho  tibia  first  bocomos  enlarged;  and 
in  slight  cases  it  may  alone  he  all'octed.  In  the  severe  forms  the  U[i|)er  end 
id'  the  boiu'.  the  corres|K)nding  ])arts  of  the  fibula,  and  the  lower  end  of 
the  femur  bccdme  greatly  thickened.  If  tlu'  child  walks,  slight  bowing  of 
the  tibia'  inevitably  results.  In  more  advanced  cases  the  tibiio  and  oven 
the  femora  may  bo  arched  i'orward.  in  other  instances  tho  condition  of 
knock-knee  occurs.  I'lKpicstioiiably  tho  chief  cause  of  those  (hd'orniities  is 
the  weight  id'  the  body  in  walking,  biu  muscular  actiiui  takes  part  in  it. 
The  groon-stick  fracture  is  not  unconinioii  in  the  soft  bones  of  rickets. 

These  changes  in  the  skeleton  ])roceod  slowly,  and  the  general  symp- 
toms vai'y  a  good  doiil  with  their  jirogress.  The  child  becomes  more  or 
less  emaciated,  though  "  fat  rickets  "  is  by  no  means  uncommon,  and  a  child 
may  lie  well  nourished  but  "  jiasty  "'  and  llabliy.  Fever  is  not  constant,  but 
ill  actively  progressing  changes  in  the  bono  there  is  usually  a  slight  ])yre\ia. 
The  abdomen  is  largo,  "' iiot-ludliod,"  due  ]iartly  to  flatulent  distention, 
partly  to  eiilargeniont  of  tho  liver,  and  in  severe  cases  to  diminution  of 
the  vidume  of  the  thorax.  The  spleen  is  often  enlarged  and  readily  ]»al- 
liable.  The  urine  is  stated  to  contain  an  excess  of  lime  salts,  but  Jacobi 
ami  I>arlow  say  this  has  not  boon  proved.  Xo  sjiocial  or  peculiar  changes, 
indeed,  have  as  yet  boon  described.     There  is  usually  sliglit  arnvmia,  the 

*  OsIpv,  On  the  SysteHc  Brain  Murmur  of  Children,  Boston  Meilioal  and  Surgicnl 
Journal,  1880. 


43S 


CONSTITUTIONAL  DISEASES. 


hannaglobiii  is  absdlutely  aii'l  rclativfly  deeroascMl;  a  k'ucocytosig  may  or  may 
not  1)0  present;  it  is  more  (  >iiinioii  with  enlar;^('iiient  oi'  the  sulecn  (Morse). 
I\lany  ricketv  cliildren  siiou  marked  nervous  symiitonis;  irritalnlity,  peev- 
islmess,  and"  sleejilessness  are  eonstantly  im-sent.  Jeniier  called  attention 
to  the  close  relationship  wliicii  existed  between  rickets  and  infantile  con- 
vulsions, i)artieularly  to  the  tits  which  occur  al'ti  r  the  sixth  month.  Tetany 
is  by  no  means  uncommon.  Jt  involves  most  frequently  the  arms  and 
hands:  occasionally  the  le^s  as  well.  Lnryn,-.'ismus  stridulus  is  a  c(,inmon 
complication,  and"  though  not,  as  some  state,  invariably  associated  with 
this  disease,  vet  it  is  certainly  much  more  fre(|uent  in  rickety  than  in  other 
children,  s'were  rickets  interfere  seriously  with  the  {-rowth  of  a  child. 
Extreme  examples  of  rickety  dwarfs  are  not  uncomnKni.  The  disease  known 
as  acute  rickets  is  in  reality  a  manifestation  of  .<curvy  and  will  he  described 

with  that  disease. 

Prognosis.— The  disease  is  never  in  itself  fatal.  l)ut  the  condition  ot 
the  child  is  such  that  it  is  readily  carried  oif  by  intercurrent  alfection>. 
l)articularlv  those  (d'  the  rcsjiiratory  orpins.  Sjiasm  of  the  larynx  and 
convulsion's  occasionally  cause  death.  In  females  the  deformity  ol  the 
pelvis  is  serious,  as  it  may  lead  to  diiliciilties  in  parturition. 

Treatment.— The  better  the  condition  of  the  mother  during  preg- 
nancy the  less  likelihood  is  there  of  the  development  of  rickets  in.  the 
child.  IJapidly  rejieated  i)re,i;naiicii's  and  suckling  a  child  during  preg- 
nancy seem  important  factors  in  the  ]n'odiiction  of  the  disease.^  Of  the 
general  treatment,  attention  to  the  feeding  of  the  child  is  the  first  con- 
sideration. If  the  mother  is  unhealthy,  or  cannot  from  any  cause  nuive 
the  child,  a  suitable  wet-nurse  should  be  iirovided,  or  the  child  must  be 
artiiicially  fed.  Cows'  milk,  diluted  according  to  the  age  of  the  child, 
should  constitute  the  chief  food.  Care  should  be  taken  to  examine  the 
condition  of  the  stools,  and  if  ctirds  are  present  the  child  is  taking  too 
much,  or  it  is  not  sutliciently  diluted.  lUirley-water  or  carefully  strained 
and  well-l)oiled  oatmeal  gruel"  form  excellent  additions  to  the  milk. 

The  child  should  be  warmly  clad  and  should  Ije  in  the  fresh  air  and 
sunshine  the  greater  part  of  the  day.  It  is  a  "vulgar  error"  to  supi)ose 
that  delicate  children  cannot  stand,  when  carefully  wrajiped  u]).  an  even 
low  temiierature.  The  child  should  be  bathed  daily  in  warm  water.  Care- 
ful friction  with  sweet  oil  is  very  advantageons,  and.  if  proi)crly  performed, 
allays  rather  than  aggravates  the  sensitiveness.  Siieeial  care  should  be 
taken  to  prevent  deformity.  The  child  should  not  be  allowed  to  walk,  and 
for  this  ]mr]iose  sjilints  ai)iilied  so  as  to  extend  beyond  the  feet  are  very 
eifective.  Of  medicines,  phosphorus  has  been  warmly  recommended  by 
Kassowitz,  and  its  use  is  also  advised  by  Jacol)i.  The  child  may  be  given 
gr.  ^^  two  or  three  times  a  day,  dissolved  in  olive  oil.  Cod-liver  oil,  in 
doses  of  from  a  half  to  one  teas'poonful,  is  very  advantage.us.  The  syrnp 
of  the  iodide  of  iron  may  be  given  with  the  oil.  The  digestive  disturbances, 
together  with  the  res])iratory  and  nervous  complications,  should  receive 
appropriate  treatment. 


OBESITV. 


r.'A) 


■  may  or  may 
cell  (Morso). 
Ijility.  ju'c'v- 
t'd  attention 
il'antik'  coii- 
iili.  Tetany 
le  arms  and 
.<  a  ci.nininn 
Dciated  with 
lian  in  otluT 
ol'  a  child, 
isease  Icnnwn 
be  dej^crihed 

fonilition  of 
It  atV('ctiiin>, 
'  larynx  and 
'mity  1)1'   tlu' 

during  i)ro,i:- 
c-kcts  in  the 
during  ]>reg- 
■ase.  Of  the 
lie  first  eon- 
•  cause  nurse 
hi  Id  must  he 
of  the  child. 

examine  the 
is  taking  too 
fully  strained 
milk. 

fresh  air  and 
■'  to  su|)])ose 

u]i.  an  even 
water.  Ca  re- 
ly performed, 
re   should   lie 

to  walk,  and 
feet  are  very 
mimended  by 
may  be  given 
d-liver  oil,  in 
5.  The  syrup 
'  disturbances, 
liould  rt.'ceive 


VIII.    OBESITY. 

Corpulence,  an  excessive  develo]imen1  of  ihe  bodily  fat — an  '•oily 
dropsy."  in  the  words  of  J^ord  Hyron — is  a  condition  for  which  the  physi- 
cian is  friMpU'iitly  consulted,  and  for  which  much  may  he  done  liy  a  .jiidicimis 
arrangement  of  the  diet.  The  Tendency  to  polysarcia  or  oh.'sity  i>  often 
hereditarv,  and  is  particularly  apt  to  he  manifest  after  the  middh-  perioil 
of  life,  it  may,  however,  be  seen  early,  and  in  this  country  it  i>  not  very 
uncommon  in  young  gii'ls  a. id  young  hoys. 

A  very  important  factor  is  overeating,  a  vic-e  which  is  more  prevalent 
and  only  a  little  behind  overdrinking  in  its  disastrous  ell'ects.  A  majority 
(pf  iierso'ns  over  forty  years  of  age  habitually  cat  too  ninch.  In  some  of  ilii> 
most  aggravated  oases  of  obesity,  however,  this  plays  no  part,  and  the  un- 
fortunate victim  may  be  a  notoriously  small  eater.  .\  secoiiil  element  is 
lack  of  proiK'r  exercise:  a  third  less  ini|iortant  factor  is  the  taking  largely 
of  alcoholic  beverages,  particularly  beer. 

In  obesity  it  is  now  generally  conceded  that  the  carbohydrates,  wliicii 
were  so  hmg' blamed,  are  not  at  fault,  since  they  are  themselves  converted 
into  water  and  carbon  dioxide.  On  account,  however,  t>(  the  facility  with 
which  they  are  utilized  for  the  ]uirposes  of  oxidation,  the  albuminous  ele- 
ments of  the  food  are  less  readily  oxidized,  and  not  so  fully  decomposed,  ami 
the  fat  is  in  reality  separated  from  them.  So,  too,  the  fats  themselves  are 
not  so  prone  to  cause  obesity  as  the  carbohydrates,  being  less  readily  oxidized 
and  interfering  less  with  the  couiiilcte  metabolism  of  the  albuminous  ele- 
ments. 

Many  plans  are  now  advised  for  'be  reduction  of  fat.  the  most  important 
of  whieli  are  those  of  JJanting,  Ehst.  ,i.  and  Oertel.  In  the  i'.anting  method 
the  amount  of  food  i.s  reduced,  the  li(iuids  are  restricted,  and  the  fats  ami 
carbolivdrates  excluded. 

Kltstein  recommends  the  use  of  fat  and  the  rapid  exclusion  ct  the 
carbolivdrates.    The  following  is  an  example  of  bis  dietary: 

nrnd-fast  (fi  A.  .M.  in  summer,  ::M>  a.  .\f.  in  winter).— White  bread,  well 
toasted  (rather  less  than  •^  ounces)  and  well  covered  with  butter.  Tea, 
witlunit  milk  or  sugar,  S  or  9  ounces. 

J>iinifi:  'i  v.^]. — Soil])  made  with  beef-marrow.  Fat  meat,  with  fat 
since  4  to' 5  ounces.  A  moderate  quantity  of  asparagus,  spinach,  cabbage, 
]icas,  or  beans.  Two  or  three  glasses  of  light  white  wine.  After  the  meal, 
a  laru^e  cup  of  tea  without  milk  or  sugar. 

Supper,  at  7.30  p.  m.— An  egg.  a  little  roast  meat,  with  fat.  About  an 
ounce  of  bread,  well  covered  with  butter.     A  large  cup  of  tea,  without  milk 

or  sugar.  •  ,     i 

Oertel's  method  will  be  considered  later  in  connection  with  the  treat- 
ment of  fatty  heart,  and  is  combined  with  systematic  bodily  exercise.  It 
is  iiarticularlv  adaj^ted  for  stout  persons  with  weak  hearts. 

The  so-called  Schweninger  cure  is  in  reality  Oertel's,  with  the  sole 
modification  of  the  forbidding  of  any  fluid  at  meals.  Liquid-s  must  be 
taken  more  than  two  hours  after  the  fooil. 


440 


CONSTITUTIONAL  DISEASES. 


Yeo,  after  a  full  consideration  of  tlic  various  methoils,  gives  the  follow- 
ing useful  summary: 

"  The  albuminates  in  the  form  of  animal  food  should  be  strictly  lim- 
ited. Farinaceous  and  all  stareliy  foods  should  he  reduced  to  a  niininuim. 
Sugar  should  he  entirely  ])roliiliited.  A  moderate  amount  of  fats,  for  tlie 
reasons  given  by  Ebstein,  should  be  allowed. 

"  Only  a  small  quantity  of  fluid  should  he  permitted  at  meals,  l)ut 
enough  sliould  he  allowed  to  aid  in  tlie  solution  and  digestion  of  tli',  food. 
Hot  water  or  warm  aromatic  beverages  may  be  talcen  freely  between  meals 
or  at  the  end  of  the  digestive  process,  esjjecially  in  gouty  cases,  on  account 
of  tiieir  eliminative  action. 

"  No  ))eer,  ])orter,  or  sweet  wines  of  any  kind  to  be  tal<en;  no  spirit, 
except  in  very  small  quantity.  It  siiould  be  generally  recognized  that  the 
use  of  alcohol  is  one  of  tiie  most  common  provocatives  of  obesity.  A  little 
Ilock,  still  Moselle,  or  light  claret,  with  some  alkaline  table  water  is  all 
that  should  be  allowed.  The  beneficial  cU'ects  of  such  diet  will  be  aided 
])y  abundant  exercise  on  foot  and  by  the  free  use  of  saline  ])urgatives,  so 
that  we  may  insure  a  comi)lete  daily  unloading  of  the  intestinal  canal. 

*'  It  is  only  necessary  to  mention  a  few  other  details.  Of  aninuil  foods, 
all  kinds  of  lean  meat  may  be  taken,  jmultry,  game,  fish  (eels,  salmon, 
and  mackerel  are  ])est  avoided),  eggs. 

"  ]\Ieat  should  not  be  taken  more  than  once  a  day,  and  not  nu>re  than 
n  ounces  of  cooked  meat  at  a  time.  Two  lightly  boiled  or  poached  eggs 
may  be  taken  at  one  other  meal,  or  a  little  grilled  li^^ll. 

"  Bread  should  be  toasted  in  thin  slices  and  completely,  not  In'owned  on 
tlie  .surface  merely. 

'*  Hard  ca])tain's  biscuits  may  also  he  taken. 

"  Soups  should  be  avoided,  exce])t  a  few  tal)les])oonfuls  of  clear  soup. 

"  ]\Iilk  should  l)e  avoided,  unless  skimmed  and  taken  as  the  chief  article 
of  diet.  All  milk  and  farinaceous  ]mddings  and  pastry  of  all  kinds  are 
forl)idden.     Fresh  vegetables  and  fruit  are  permitted. 

"  It  is  imiiiH'tant  to  bear  in  miiul  that  the  actual  quantity  of  food  per- 
mitted must  have  a  due  relation  to  the  physical  dovelo]mient  of  the  indi- 
vidual, and  that  what  would  be  adeciuate  ii.  one  case  might  be  altogether 
inadeijuate  in  the  case  of  another  ])erson  of  larger  physique."  * 

The  thyroid  extract  has  been  used  in  obesity,  in  a  few  cases  with  suc- 
cess.   It  may  l)e  tried  1)eginning  witli  small  doses,  as  in  myxcedema. 


*  A  System  of  Therapeutics,  vol.  i,  edited  by  H.  A.  Hare,  Philadelphia,  1891. 


I 


?  the  follow- 
strictly  liin- 
a  mininuim. 
fats,  for  I  lie 

;  meals,  Ijiit 
of  til',  food, 
tweeii  ineals 
,  on  account 

a;  no  spirit, 
zed  that  the 
ity.  A  little 
water  is  all 
I'ill  he  aided 
urjfatives,  so 
lal  canal, 
ninial  foods, 
.'els,  salmon, 

it  more  than 
•oaelied  eggs 

hrowned  on 


dear  sonp. 
chief  article 
ill  kinds  are 

of  f(Hid  per- 

of  the  indi- 

10  altogether 
* 

:es  with  snc- 
denia. 

lia,  1891. 


SECTIOX  V. 
DIGEASES  OF  THE  DIGESTIVE  SYSTEM. 


I.   DISEASES   OF  THE  MOUTH. 
STOMATITIS. 

(1)  Acute  Stomatitis.— Simple  or  erythcmatons  stomatitis,  the  com- 
monest form  of  inllammation  of  the  nniutli,  results  from  the  action  of 
irritants  of  varions  sorts.  It  is  frequent  at  all  ages.  In  children  it  is  often 
associated  with  dentition  and  with  gastro-intestinal  disturhance,  ]iarticu- 
larly  in  ill-nourished,  unhealthy  suhjeets.  Jn  adults  it  follows  the  overuse 
of  tohacco  and  the  use  of  too  iiot  or  too  highly  seasoned  food.  It  is  a  fre- 
quent concomitant  of  indigestion,  and  is  met  with  in  the  acute  specific 
fevers. 

The  affection  may  he  limited  to  the  gums  and  lips  or  may  extend  over 
the  whole  surface  of  the  mouth  and  include  the  tongue.  Tliere  is  at  first 
su])erricial  redness  and  di-yncss  of  the  membrane,  followed  by  increased 
secretion  and  swelling  of  the  tongue,  which  is  furred,  and  indented  by  the 
teeth.  There  is  rarely  any  ccmstitutional  disturhance,  but  in  children  there 
may  be  slight  elevation  of  temperature.  The  condition  is  sutllcient  to 
cause  consideralile  discomfort,  sometimes  amounting  to  actual  distress  and 
])ain.  ])articularly  in  mastication. 

In  infants  the  mouth  should  be  carefully  s])ongecl  after  each  feedin"-. 
A  mouth-wash  of  l>orax  or  the  glycerin  of  borax  may  be  used,  and  in  se- 
vere cases,  which  tend  to  become  chronic,  a  dilute  solution  of  nitrate  of 
silver  (3  or  4  grains  to  the  ounce)  may  be  apidied. 

(9)  Aphthous  Stomatitis.— This  form,  also  known  as  folUnilnr  or  vesicu- 
lar gtomatitis,  is  characterized  by  the  presence  of  small,  slightly  raised 
spots,  from  2  to  4  mm.  in  diameter,  surrounded  by  reddened  areol's?.  The 
spots  appear  first  as  vesicles,  which  rujiture,  leaving  small  ulcers  with 
grayish  bases  and  bright-i.-^d  margins.  They  are  seen  most  frequently  on 
the  inner  surfaces  of  the  lips,  the  edges  of  the  tongue,  and  the  cheeks. 
They  are  seldom  present  on  the  mucous  membrane  of  the  plurynx.  This 
form  is  met  with  most  often. in  children  under  three  years.  It  may  occur 
cither  as  an  indejiendcnt  affectirn  or  in  association  with  any  one' of  the 
felirile  diseases  of  childhood  or  with  an  attack  of  indigestion.     The  crop 

441 


442 


DISEASES  OF  THE    DIGESTIVE  SYSTEM. 


silver  iind    \hv   iiimilli 

A  wash  of  clilorate  of 

'Ih'  cMmstitulidii!!!  >\n\\)- 


„f  vi-iclo^  cnmos  out  witli  iirvni  rapidity  nn.l  tlio  litll.'  uUits  iiuiy  ho  fu  ly 
f„niu'<l  witliin  twontv-fuur  lioins.  Tlu'  fliil.!  (M.iui.lams  nl  soivncss  ot  tlir 
inoutli  and  takes  food  with  ivhutan.-.'.  'VUv  Im.-.al  srcivtions  arc  incmisi'd. 
and  tlu.  l.irath  is  hoavv.  hut  not  foul.  Tho  institutional  syniptmns  ar.. 
usually  thoso  of  tlic  disease  with  which  the  aiditlnv  are  assonate.l.  liie 
disease  must  not  he  eoufounded  with  thrush.  No  special  parasite  has  heeii 
f„„„d  in  connection  with  it.  It  is  not  a  serious  condition,  and  heals  raiadly 
uith  the  inu.roveiuent  .d'  the  constitutional  state.  In  severe  eases  it  may 
exten.l  to  the  pillars  of  the  fauces  and  to  the  pharynx,  and  pr.diue  ulcers 
uhich  are  irritatin-;  and  dillicult  to  heal. 

Kach  ulcer  should  l>e  touched  with  nitrate  (d 
t^hould  he  thorou^dily  cleansed  after  takiu'z-  food.^ 
])otassiiiin.  or  of  ixu'ax  and  jiiycerin.  may  Ik-  Used.  '1 
toms  should  receive  careful  attenti(Ui.  ,     ,         ,  , 

Here  mav  he  mentioned  a  cnriiuis  atfectioii  which  has  lieen  ol>- 
perved  chiellv  in  southern  Italv,  and  whhh  is  charaeterixod  hy  a  pearly- 
c.dored  memln-aiu'  with  in.luration.  immediately  heneath  the  toii-ue  .m 
the  fnvnum  (h-i-a's  disease).  There  .r,ay  Ik.  iiiih-1i  induration  and  ultimately 
ulceration  It  occurs  in  hoth  healthy  and  cachetic  children,  usually  al)oui 
the  time  of  the  orui)tion  of  the  first  teeth,     it  is  sometimes  epidemic 

(3)  Ulcerative  Stomatitis.— This  form,  uhich  is  also  known  hy  the 
nnmos  of  fclid  slimniiilis.  or  /nz/nW  .^ove  wmilli.  occurs  particularly  m  clid- 
dren  after  the  first  dentition.  It  may  prevail  as  a  widespread  ei)ideinic  in 
institutions  in  Mhich  the  sanitary  conditions  are  defective.  It  has  hecu 
met  with  in  jails  and  camps,  hisnlhoient  and  unwholesome  food,  impvciper 
ventihvion,  and  ].rolonned  damp,  cold  weather  seem  to  he  s])ecial  predw- 
i.osin.--  causes.  Lack  of  cleanliness  of  the  month,  the  jn-esence  of  carious 
teetlN  and  tlie  collection  of  tartar  around  them  favor  the  develoimient  ol 
the  disease.  The  affection  spreads  like  a  specilic  disease,  hut  the  microhe 
has  not  vet  heen  isolated.  It  has  hecn  held  that  the  disease  is  the  same 
as  the  foot-and-mouth  disease  of  cattle,  and  that  it  is  conveyed  hy  the  milk, 
l)ut  there  is  no  positive  evidence  on  these  jioints.  Payne  suggests  that  the 
virus  is  identical  with  that  of  contagions  impetigo. 

The  niorhid  process  1)egins  at  the  margin  of  the  gums,  which  hecome 
swollen  and  red,  and  hleed  readily.  I'lcers  form,  the  hascs  of  which  are 
eovered  with  a  gravish-wliite,  firmly  adherent  memhrane.  In  severe  cases 
the  teeth  may  liecome  loosened  and  necrosis  of  the  alveolar  in-ocess  may 
occur.  The  "ulcers  extend  along  the  gum-line  of  the  n])]m'  and  lower 
jaws:  the  tongue,  lips,  and  mucosa  of  the  cheeks  are  usually  swollen,  hiii 
rarely  ulcerated.  There  is  salivation,  the  hrcath  is  foul,  and  mastication 
is  ])a'infnl.  The  sulmiaxiUarv  Ivmith-glands  are  enlarged.  An  exanthem 
often  develops  and  mav  be  mistaken  for  measles.  The  constitutional  symp- 
toms are  often  severe."  and  in  institutions  death  sometimes  results  m  the 
case  of  debilitated  children. 

In  the  treatment  of  this  form  of  stomatitis  chloratt  of  potassium  has 
been  found  to  be  almost  specific.  It  should  be  giver,  ir.  doses  of  10  grains, 
three  times  a  dav.  to  a  child,  and  to  an  adult  double  that  amount.  Locally 
it  may  be  used  as  a  mouth-wash,  or  the  ptnvdered  salt  may  bo  applied  <b- 


STOMATITIS. 


44:5 


luiy  111'  full) 

•I'lU'SS   of   till' 

rv  iuci'casi'.l. 
viii|itnins  ail' 
ciiUcd.  Tlu' 
site  has  hwn 
heals  viipidly 
cases  it  may 
i-(  'luce  uleei~ 

1  tlie  inoulli 
f  chlorate  <il' 
iti<uial  syin|i- 

las    liecn    oli- 
hy  a  pcai'ly- 
le    tdli.uue    <Hi 
11(1  ultimately 
usually  ahdui 
lideiuic. 
uowii   Ity   til" 
ilarly  in  cliil- 
;1  epidemic  in 
It  has  been 
ood.  imiirdper 
:i)eeial  jtredi-- 
ice  of  carious 
3vclo])iiiont  of 
t  the  mierolie 
;o  is  tlie  same 
:1  by  tlie  milk, 
:gcsts  that  the 

whic'li  become 

of  which  are 

n  sovore  cases 

r  jiroccsp  may 

ler  and   lower 

Y  swollen,  bill 

id  mastication 

An  cxantliem 

tutional  symp- 

results  in  the 

]iotassi\im  has 
's  of  10  jrrains. 
mint.  Locally 
bo  applied  di- 


rectly to  the  ulcerated  surfaces.  When  there  is  much  fetor,  a  itermanga- 
nate-of-potash  wash  may  be  used,  and  an  application  uf  nitralo  of  silver  may 
he  made  to  the  ulcers. 

There  are  several  ullirr  nirlclicx  of  ulcerative  sore  mouth,  which  dilTor 
entirely  fiom  this  form.  T leers  of  the  mouth  are  common  in  nursing 
women",  and  are  usually  seen  on  the  mucous  membrane  of  the  lijjs  aiul 
cheeks.  They  develop  from  the  mucous  follicles,  and  are  from  3  to  5  mm. 
in  diameter."  They  may  cause  little  or  no  inconvenience;  but  in  some  in- 
stances they  are  very  painful  and  interfere  seri(nisly  with  the  taking  of 
food  and  its  mastication.  As  a  rule  they  heal  readily  after  the  application 
of  nitrate  of  silver,  and  the  condition  is  an  indication  for  tonics,  fresh  air, 
and  a  better  diet. 

IJecurring  outbreaks  of  an  heritetie,  even  pemphigoid,  eru])tion  are 
seen  in  neurotic  individuals  {■■iloinaUtis  neurutua  chrunica,  Jacubi).  Jn 
some  cases  it  is  associated  with  an  erythema  multiforme. 

Parrot  describes  the  occasional  ap])earance  in  the  new-born  of  small 
ulcers  iiynimetrically  iilaeed  on  the  hard  palate  on  cither  side  of  the  middle 
line.  They  are  met  with  in  very  debilitated  children.  The  tdcers  rarely 
heal;  usually  they  tend  to  increase  in  size,  and  may  involve  the  bone. 

Ik'dnar's  aphtha:  consist  of  small  iiatches  and  nlcers  on  the  hard  jialatc, 
caused  as  a  rule  in  young  infants  by  the  artiticial  nijiple  or  the  nurse's 
linger. 

(4)  Parasitic  Stomatitis  (77/ ;v/s//.-  ^'^om-;  Muijucl).—'nu^  at?ection,  most 
commonly  seen  in  children,  is  depeiidiut  upon  a  fungus,  the  sarcliunmuiccs^ 
(ilhiraiis,'ca\kH\  by  Ifobin  the  o-i,liuiii  alhiraiis.  It  belongs  to  the  or<ler  of 
veast  fungi,  and  "consists  of  branching  lilaments.  from  the  ends  of  which 
"ovoid  torula  cells  develo]i.  The  disease  does  not  arise  ajiparently  in  a  nor- 
mal mucosa.  The  nse  of  an  imjiroper  diet,  nncleanlincss  of  the  UKUith, 
the  acid  fermentation  of  remnants  of  food,  or  the  develoi)ment.  from  any 
cause,  of  catarrhal  stomatitis  predispose  to  the  growth  of  the  fungus.  In 
institutions  it  is  fre(|uently  transmitted  by  unclean  feeding-bottles,  spoons, 
etc.  It  is  not  confined  to  children,  but  is  met  with  in  adults  in  the  final 
stages  of  fever,  in  chronic  tuberculosis,  diabetes,  and  in  cachectic  states. 
The  jiarasite  develoiis  in  the  upiier  layers  of  the  muco.-^a.  and  the  filaments 
form  a  dense  felt-work  among  the  eiiithelial  cells.  The  disease  begins  on 
the  tonirue  and  is  seen  in  the  form  of  slightly  raised,  iiearly-white  sjiots, 
which  increase  in  size  and  gradually  coalesce.  The  membrane  thus  formed 
can  be  readilv  scraiied  otf,  leaving  an  intact  mucosa,  or.  if  the  ]irocess  ex- 
tends deeply.' a  bleeding,  slightly  ulcerated  surface.  The  disease  spreads  to 
the  cheeks.lips.  and  hard  palate,  and  niiiy  involve  the  tonsils  and  pharynx. 
Tn  very  severe  cases  the  entire  buccal  mucosa  is  covered  by  the  grayish- 
white  membrane.  Tt  may  eve.i  extend  into  the  (rsoi)hagus  and,  according 
to  Parrot,  to  the  stomach  and  ca'cnm.  It  is  occasionally  met  with  on  the 
vocal  cords.  TJobust,  well-nourished  children  are  sometimes  atYected,  but 
it  is  usually  met  with  in  enfeebled,  emaciated  infants  with  digestive  or  in- 
testinal tronbles.     Tn  such  cases  the  disease  may  persist  for  months. 

The  affection  is  readilv  recognized,  and  must  not  be  confounded  with 


444 


DISEASES  OF  THE   DKiESTIVE  SYSTEM. 


aphtl.(,us  st...natitis.  in  which  th.  ul.rrs.  ^m'wM  hy  thr  l..niuUion  nt 
v'.<i(l(-  iiiv  iHTlVrtIv  (listiiutivr.  Ill  tll^u^h  llu'  iMirrns.oi.Kal  exiuiuimtn.n 
«ho\\-  the  pivseiier  ul'  the  dianutcrislic  lim-us  thn.i.-h.nit  the  iMcinhniiir. 
In  tlu>  c-..n.liti..n,  too,  iho  n.outh  is  usually  dry— a  strikin-  n.ntra^t  l^ 
the  salivatioiMuc'omimnyiiijX  aphtha-. 

Tlirush  is  inoiv  iTa.lilv  ituvhUcmI  than  ivihov.m].  1  ho  clnl.l  s  ,„nu  h 
sluuihl  lu.  k..i,t  s.ru,.ul..us!y  cl.an,  a.uU  if  artilirially  I.mI,  tlu-  hottl.s  shmiM 
1,,.  ihorounhlv  stcrilizril.  Linu-watcT  or  any  other  alkalmc  llui.l.  such  a- 
llu.  hicarlM.natc  of  so.la  (a  .Irachu.  to  a  tun.hlcr  of  water)  nay  he  em- 
l.love.l.  When  the  patehes  are  proent  these  alkaline  ninmh-washes  may 
,  he  nnitinue.1  atter  ea.'h  IVe.iin-.  A  spray  of  horax  or  of  sulphite  ..1  so,la 
(a  .Iraclnn  to  the  (U.nee)  or  the  Mark  v.ash  with  olvfc-rin  may  he  employe.l. 
The  pennanj...nate  of  potassium  i>  also  userul.  The  eonstitutional  treat- 
ment is  of  equal  importanee.  au.l  it  will  often  !..■  foun.l  that  the  thru-h 
persists,  in  spite  of  all  local  ineaMires.  until  the  General  health  ol  the  mianl 
is  improve.1  hv  ehan-e  of  air  or  the  relief  of  the  diarrh.ea.  or.  m  ohstmate 
oase<   the  sul)stitution  of  a  iiatMal  for  the  artificial  diet. 

(5)    Gangrenous    Stomatitis    (Canrnim     Ons:    .\„wn).—\n    ailection 
characterized  hv  a  rapidly  pro-rosin-  -MU-ivne.  starlm-  on  the  -un.s  or 
cheeks,  and  leadin-  to  extensive  slouniiin-  and  dotructu.n.      1  his  ternl.le. 
hut  fortunatelv  rare,  disease  is  seen  only  in  children  under  very  insanitary 
conditions  or'durinjr  convalescence   from   the   acute    levers.      It    is   more 
common  in  -iris  than  in  hoys.     It  is  met  with  hetween  the  a-es  o    two 
iuid  live  years.     In  at  least  one  half  of  the  eas.-s  the  disease  has  develop.Ml 
durin-  convalescence  from  measles.     Cases  have  heen  seen  also  alter  scar- 
let fever  and  tvphoid.     The  mucous  memhrane  is  first  atfecte<l,  usually  of 
the  -nms  or  of  one  cheek.     The  process  he-ins  insidiously,  and  when  first 
se.'irthere  is  a  slon-hin-  ulcer  of  the  mucous  memhrane,  which  spreads  rap- 
idly and  leads  to  hrawnv  induration  of  the  skin  and  adjacent  j.arts.     The 
slcm-hin-  extends,  and  in  severe  cases  the  .heek  is  perforated.     The  disease 
inay''si)read  to  the  ton-ne  and  chin:  it  may  invade  the  hones  of  the  jaws  and 
even  involve  the  evelids  and  ears.    In  mild  cases  an  ulcer  forms  on  the  inner 
surface  of  the  chedc,  which  heals  or  may  perforatt;  and  leave  a  fistulous  open- 
in-.     Xatnrallv  in  such  a  severe  alTection   the  constitutional  disturhance 
is  very  preat,  the  pulse  is  rajiid,  the  prostrati(m  extreme,  and  death  usually 
takes  "place  within  a  week  or  ten  days.    The  temiierature  may  reach  ln;?°  or 
104°.     Piarrluea  is  usuallv   iirc-sent.  and  aspiration   imeunionia  often   de- 
velops.    H.  R.  Wharton  has  descrihed  a  case  in  which  there  was  extensive 
colitis.     Risho])  and  IJyan  have  i.<olated  an  or-anism  which  resemhles  m 
all  itnints  the  diphtheria  bacillus  of  reduced  virulence. 

The  treatment  of  the  disease  is  unsatisfactory.  In  many  cases  the 
onset  is  so  insidions  that  there  is  an  extensive  slou-hing  sore  when  the  case 
first  comes  nnder  ohservation.  Tiestrnction  of  the  sore  hy  the  cautery. 
either  the  Pacuielin  or  fuming  nitric  acid,  is  the  most  effectual.  Antis.'ptic 
aiiplications  shonld  he  made  to  d.>stroy  the  fetor.  The  child  .should  he 
carefullv  nourished  and  stimulants  -iven  freely. 

(0)  iVIercurlal  Stomatitis  {Pfiin]!:<ni).— An  inflammation  of  the  mouth 
and  salivary  glands  may  be  caused  by  mercury.     It  occurs  chiefly  in  persons 


STOMATITIS. 


445 


I'onniUion  of 
1  t'Xiiiiiiimtidii 
11.'  im'iiil)raiu'. 
If  contrast   l'> 

■hildV  mniilli 
liottlcs  slitiuM 
lliiid.  such  ii- 

i;ia_v  1)C  Clll- 
li-waslu's  may 
l|iliit('  <il'  si>ila 

he  cniiilnyccl. 

utiniial  trcat- 
at  till'  tlini-li 
I  of  the  infant 
r.  in  iilistinatt' 

-An    alVcction 
1  the  i>uiiis  (ir 

This 'tcrriiilc, 

cry  insanitary 

It    is   niDic 

le  a.u'cs  of  two 

has  ilcvcloju'd 
ilso  after  scar- 
ted,  usually  of 
and  whon  first 
L'h  spreads  raji- 
nt  parts.  The 
I.  The  disease 
)f  the  jaws  and 
lis  on  the  inner 

fistulous  opeii- 
lal  (listurl)ance 
1  death  usually 
y  reach  ln;?°  or 
lonia  often  de- 
e  was  extensive 
:h  resembles  in 

nany  cases  tho 
[>  when  the  case 
ly  the  cautery, 
iial.  Antis(>p1ie 
?liild  shoulil  he 

1  of  the  mouth 
licfly  in  persons 


who  liave  a  special  susoeptihility,  and  rarely  now  as  a  result  of  the  excessive 
u-e  of  tiie  <!ru-'.     It  is  met  with  aUo  in  persons  wliose  occupation  neco 
.i'tates  the  constant  handlin,!.'  of  mercury.     It   often  follows  the  admini>- 
,,,,ti„„  „f  rcpeate.l   small  d.M'>.     Thus,  a   patient   with  lieart-di.-caM'  who 
wa<  or.lercd  an  ei-htli  of  a  -rain  of  cah.mel  every  three  hours  lor  diurcUe 
purposes  had,  after  takin-  ei-ht   or  ten  doses,  a  >cvcre  stomatitis,  whuli 
uT-isted    for  several   we.'l<s.      1   have   known   it    t.,   follow  the  administra- 
tion of  small  doses  of -rav  powder.    'Ihe  patient  complains  first  ol  a  ui.'tailic 
ta<te  in  the  mouth,  the  -uuis  become  swollen,  red,  and  sore,  mastication 
i.  ditlicult    and  soon  there  is  a  -r.al  iiuivaM'  in  the  -ccretioii  ol  tlu'  saliva, 
,vhich  Hows  freelv  from  the  nioulli.     Th.'  toii-ue  is  >wollen.  the  breath  has 
,  f„ul  .Mior.  and.'if  the  alVedion  pro-iv......  ihciv  may  be  ulceration  ol  t  le 

,nuco>a,  an.l.  in  rare  in.tan.-es.  iiccioh>  of  ,he  Jaw.  AHhoi,,h  troub  e- 
soiiie  and  .listressiii-.  the  disease  i~  raivly  serious,  and  recovery  usually 
takes  pla.c  in  a  couple  of  wc-'k,-.  !n>tauces  in  which  the  teeth  become 
l„„sened  or  .letached  or  in  which  the  inilammali^m  cM.'iuN  to  the  pharynx 
and  luishichian  tubes  are  rarely  seen  now. 

The  administration  of  mnvury  should  be  suspended  so  soon  as  tlie 
nuiHs  are  "  touched."  Mild  ca>es  of  liie  alVcctioii  sub>ide  within  a  b'W  days 
and  require  onlv  a  simple  mouth-wa>li.  in  .ev.'rer  cases  the  chlorate  ol  po- 
ta-ium  niav  be' given  internally,  and  Used  to  rinse  tlie^nou  h.  1  he  lioweU 
should  be  freelv  opened:  the  patient  should  take  a  hot  bath  every  evening- 
and  should  .irink  plentifully  of  alkaline  mineral  waters.  Atropine  is  some- 
times serviceable,  and  may  be  jiive.i  in  doses  of  ,1^  of  a  grain  twi.r  a  -ay. 
L.dine  is  also  recommended.  When  the  salivation  is  severe  and  protracted, 
„„,  ,tienl  becomes  much  debilitated,  ana'.uia  develops,  and  a  supporting 
tJnient  is  imlicated.  The  diet  is  necessarily  li.pml,  lor  the  patient  linds 
^,,,  ^.,,i,f  .litliculty  in  taking  food.  If  the  pain  is  severe  a  Dover  powder 
niav  be  given  at  night. 


ti 


'•llcr^mav  be  appro,nMately  mentioned  the  infiuence  of  stomatitis,  par- 
the' mercurial  bu^n.  npon  the  developing  teeth  ol  '-I;''; -■;•;;; 
,„„li,i;„  u,,.wn  as  rrosi.n,  in  whi.-h  the  teeth  are  ''""">-'";''""  ,'  '  ' 

,,,^.i„^,.  t,  defective  formation  of  enamel,  is  indicative   as  a  rule   ..1  ml  . utile 
t  ,1  at  tis      Such  te<'th  mtist  be  distinguished  carefully  trom  those  of  con- 
:'  Vpbilis.  which  may  of  course  <.oexis,,  but  the  two  conditio,,  are 

distinct  ■  The  honevcombing  is  frequently  seen  on  the  incsors:  In  t,  a  - 
::  ,g  to  Jonathan  lIut..hinson.  the  test  teeth  ol  ,n  antile  jtomatitis  a  . 
tlte  i\M  permanent  molars,  then  the  incisors,  "winch  are  almost  as  c  - 
s-ntlv  pitted,  eroded,  and  of  bad  color,  often  showing  the  transverse  f u- 
'r::Vl  cr;sses  all  the  teeth  at  the  saine  level."  Magitot  regar  s  t,^ 
trausverse  furrows  as  the  result  of  infn.Uile  .'onvulsion.s  or  ol  scncu  il  n^ 
dming  earlv  life.  11'  thinks  they  are  analogous  to  the  furrows  <.n  the 
nails  which  so  often  follow  a  serious  disease. 

(7)  Eczema  of  the   Tongue   i(h'o„raphU'nl   Ton,iur).-\   rvmnvkauu 
desquamation   of   the   superficial    epithelium    of   the   tongue    ^^c^n^na^ 
patches,  wim'h  s,u-ead  while  the  central  portions  heal.     1-nsion  ol  ,utcl 
Ads  to  areas  with  sinuous  outlines.     When  extensive  the  tongue  may  he 
e<;verc^    w  th  these  areas,  like  a  geographical  map.    The  alVeetion  eauses  a 


j^,.  DISKASKS  OF   THE  DIGESTIVE  SYSTEM. 

I  .U.,1  or  iu-hin-  Miul  lu.it.  .ml  may  hv  a  soiiivc  -l'  iii.uh  im'ntal  Nvorvy 

i"u  ti.e  uaticils,  wlu.  ..Ite.i  .livad  K-l  il  may  l.r  a  conuuem'in-  c-aiicer 

'riu'  .■u,.l..j:v  ..f  the  .liM'a>L.  is  unknown.  It  oce'urs  m  xntants  am  clul- 
.|,,n  ami  it  is"  not  vctv  inliv.iuent  in  a.lults.  It  ha.  heoii  regarded  as  a 
.outv  manitVstatinn,  and  tran>irnt  attacks  may  a.comi.any  mdijiost.on. 
h  is'v.rv  liable  to  irlap-o.  in  adults  it  may  i.n.VL'  very  ol.stinute  and  1 
know  of'.nR.  instance  m  whieh  the  -lisease  persisted  in  spite  ot  all  treat- 
invni  lor  nu.re  than  two  years.  Solutions  .d'  nitrate  of  sdv.r  -ne  tue  most 
^ati>faetorv  results  in  rrlirvin-  the  intense  imrnin;:. 

(y)  LeukopJakia  buCCalis.-Samuel  IMuml^e  <les.Tihe.l  the  eom  itioii  as 
{rllu,L<  lin,iu.il,r.  It  has  al.o  \>vvn  ealled  biural  y,s.n\,.sTs  and  l^eralos,s 
,nurns,r  oris.  There  are  un^ymmetrieal  i^atehes  of  various  shajK'S,  vvhitiMi 
ur  often  pearlv  white  in  eolor,  Muooth.  and  without  any  tendeiuy  to  ule.'r- 
ate  Thev  iiave  been  ealled  lin-ual  e..nis.  The  intensity  of  tlu'  opa-iue 
whilo  color  depends  upon  the  thickness  of  the  epidermis.  Uie  patches 
niav  extend  and  become  sli-htly  papillomatous.  There  are  mstames  m 
which  -ennine  epithelioma  has  deveh.i.e.l  from  them.  The  condition  is 
met  wi"h  most  commonlv  in  heavy  smokers,  aii.l  is  sometimes  known  a< 
the  smoker's  ton-ue.  An  iiiterestiniz  .[uestion  is  the  relatu.n  to  syphilis. 
While  somewhat  similar  patches  devel..].  in  infected  jiersons  the  true 
«vphilitic  Ldossitis  rarelv  lurscnts  the  same  opa-pie  white,  smooth  a|.pear- 
ance.  Jt  is  more  commonly  at  the  ed-e  and  the  point  of  the  ton-ue  than 
on  the  dorsum,  and  vields  lu'omptly  to  specilie  treatment. 

Leukoplakia  is  a  verv  obstinate  alVection  and  resists  as  a  rule  all  orm- 
of  treatment.  All  irritants,  such  as  smoke  and  very  hot  too.l,  sliouhl  be 
avoided  Local  treatment  with  (uu-half-pei-eent  corrosive  suldimate  ..r  a 
one-per-cent  chromic-acid  s^dution  has  l,een  recommended.  ^  'I  he  proprietv 
„r  active  local  treatment  is  doubtful.  The  appearance  .d  anythin-  hke 
IKipillomat.ms  out-rowths  should  be  regarded  as  an  indication  for  surgical 
intervention. 


II.    DISEASES   OF  THE   SALIVARY   GLANDS. 

1    Supersecretion    {rhinli.^w).—The   normal    amonnt    of   saliva    varies 
I'nmi  ■'   to  :J  i-ints  in  the  twentv-four  hours.     The  secretion  is  increased 

.hirin  ■■  the  takin^r  „r  f 1  and  in  the  physiolo,i:ical  processes  of  dentition. 

V  n-reat  increase,  to  uhich  the  term  t>h/(ili<,u  is  applied,  is  met  with  nnder 
manv  circnnistances.  It  occurs  occasionally  in  mental  and  nervous  allec- 
tions  and  in  rabies.  Occasionally  it  is  seen  in  the  acute  fevers,  particnlarly 
in  small-pox.  It  occurs  sometimes  with  disease  of  the  pancreas.  It  has 
been  met  with  during  gestation,  nsually  early,  though  it  may  persist 
throu'di.nit  the  entire  course.  It  has  l,een  known  to  occur  at  each  men- 
strual' period:  and.  lastlv.  it  is  a  common  effect  of  certain  drugs,  ^yiercury, 
..■old  c<^i)i.er.  the  iodine  compounds,  and  (among  vegetable  remedies) 
^aborandi.  nniscarin.  and  tobacco  excite  the  salivary  secretion.  Of  these 
we  most  fre(iiiently  see  the  elVect  <d'  mercury  in  producing  iityalisin.  Lhe 
salivation  may  he  present  without  any  iidlammatitm  of  the  nnmtli. 


DISEASES  (»P  THE  SALIVARY   GLANDS. 


447 


luciilal  \v(inv 
ciiiicor. 
,iUrf  and  cliil- 
x-fiiirdod  as  n 
'  iudi<.a'stiuii. 
itinato,  and  1 
;  of  all  ti'cat- 
j:i\L'  till)  luo-l 

■  condition  a-i 
and  ke  ml  us  Is 
nijivs.  \vliiti.-'i 
(Mu-v  lo  uIiht- 
il'  till'  ojiaque 
The  patches 
i  instances  in 
L'  condition  is 
nos  known  ii< 
)n  to  sypiiiiis. 
ons,  tlic  true 
inootli  apjiear- 
c  tonixne  thaii 

rule  all  forms 

)(id,  should   he 

Mihliinate  or  a 

The  propriety 

anything;  like 

on  lor  sur'dcal 


.NDS. 

f  saliva  varies 
in  is  increased 
I's  of  dentition, 
net  witli  nnder 
1  nervous  alVec- 
?rs,  ])articnlarly 
ncreas.  It  has 
it  may  persist 
r  at  each  luen- 
rntrs.  ^rercury, 
tahle  Tcmedies) 
tion.  Of  these 
ptyalisni.  The 
month. 


2.  Xerostomia  {Anrsl  of  Ihc  Sullninj  and  Buccal  Seririinns;  Dri/ 
Mdulh). — In  thiri  condition,  liist  dcscrihcd  liy  Jonathan  iliitehiniion,  tiio 
secretions  of  the  nuiidli  ami  salivary  glands;  arc  suppressed.  The  lon<,Mio 
is  red,  Honietinics  cracked,  and  (pute  dry;  (he  mucous  nu'iid)rane  of  the 
iheeks  and  of  the  palate  is  smooth,  shinijig,  and  dry;  and  mastication, 
de-iliitition,  and  articidation  are  very  dilTicult.  The  condition  is  not  coni- 
nion.  A  majority  of  the  cases  arc  in  women,  and  in  several  instances  have 
liieii  associated  with  nervous  phenomena.  The  general  iiealth,  as  a  rule, 
is  unini|)aire(l.  Jiadden  suggests  that  it  is  due  to  invidvcincnt  of  some 
centre  which  controls  the  secretioi<  u[  the  salivary  and  huccal  glands.  A 
well-maikcd  case  came  untk'r  my  ohscrvatioji  in  a  man  aged  thirty-two, 
who  was  sent  to  me  hy  Donald  llayiics  on  account  of  a  peculiar  growth 
in  the  mouth.  This  proved  to  he  the  rcmnaids  of  food  which,  owing  to 
the  ahscnce  of  any  salivary  or  huccal  secretions,  collected  along  the  gums, 
iiecanu'  hardeiu'd,  and  a<lhered  to  them.  The  condition  lasted  for  three 
weeks,  aiul  was  cured  hy  the  galvanic  current. 

;3.  Inflammatiou  of  the  Salivary  Glands. 

{(()  S/tccific  rurolilis.     (Sec  iMlMi's.) 

{!/)  Si/nijilinnalic  jiardtilis  or  pfimtid  httho  occnrs: 

(1)  In  the  course  of  the  infectious  fevers — typhus,  typlioid,  ]monmonia, 
jiya'mia,  etc.  In  ordinary  practice  it  occnrs  ofteuest,  perhaps,  in  typhoid 
fever.  It  is  the  residt  cither  of  soiitic  infection  through  the  lilood,  or  the 
inilammalion,  in  many  cases,  jiasses  up  the  salivary  diut,  ami  so  reaches 
the  gland.  The  process  is  nsnally  very  intense  and  leads  rai)idly  to  sup- 
])uration.  It  is,  as  a  nde,  an  nnfavoralile  indication  in  the  course  of  a  fever. 
I  have  seen  recently  parotitis  in  secon<lary  .sy|iliilis. 

(2)  In  connection  with  injury  or  disease  of  the  a])domen  or  j)clvis,  a 
condition  to  Mhich  Stephen  Paget  has  called  special  attention.  Of  l(tl 
case  of  this  kind,  "  10  followed  injury  or  disease  of  the  nrinary  tract,  18 
were  due  to  injury  or  disease  of  the  alimentary  canal,  and  23  were  due  to 
injury  or  disease  of  the  ahdominal  wall,  the  j)eritona'um,  or  the  ])elvie 
cellidar  tissue.  The  remaining  oO  were  due  to  injury,  disease,  or  tempo- 
rary derangement  of  the  genital  organs."  V>y  temporary  derangement  is 
meant  slight  injuries  or  natural  ))roces?cs — a  slight  blow  on  the  testis,  the 
iidroduction  of  u  pessary,  menstniation,  or  pregnancy.  The  etiology  of 
this  form  of  ])arotitis  is  obscure.  Wo  have  had  3  cases.  !Many  of  them 
are  undoubtedly  septic. 

(3)  In  association  with  facial  jiaralysis,  as  in  a  case  of  fatal  peripheral 
neuritis  descril)ed  by  (Jowers. 

In  the  treatment  of  parotid  lnd)o  the  ajjplication  of  half  a  dozen  leeches 
will  sometimes  reduce  the  inflammation  and  promote  resolution.  When 
supjjuration  seems  inevitable  hot  fomentations  should  be  api)licd.  A  free 
incision  should  be  made  edvh/. 

(r)  Clironic  parolilis,  a  condition  in  which  the  glands  are  enlarged, 
sometimes  painful,  has  been  described,  following  in  one  case  inilammation 
of  the  throat,  in  another  mumps.  Salivation  may  be  present.  It  may 
be  due  to  lead  or  mercury.  It  is  met  with  occasionally  in  chronic  Bright's 
disease.  Mikulicz  has  described  a  remarkable  condition  of  chronic  sym- 
28 


tv 


4^g  DISRASK8   OF  TIIK   DKIRSTIVE  SYSTKM, 

metrical  oiilar^omoiit  of  tlu!  salivary  an.l  la.l.rymal  glands.  Tlio  nondi- 
ti.m  may  persist  for  years.  Tin.  case  iin.U'r  my  caro  m.-ntw.no.l  .n  tii. 
goc.md  clition  <.t'  tliis  work  .ii.'.i  sul.s...|.uMitly  of  ti.t)(-rciilos.s  (.\m.  Jr.  M.'d. 

(,/)  (lasi'ous  Tnwors  of  Stnio's  Diirl  and  of  Ihr  I'arotid  (,land-\u 
Klass-ldowors  and  musicians  St.-no's  duct  may  l..romc  u.llato.l  witli  u.r 
mid  form  a  tumor  the  size  of  a  nut  or  of  an  e-'.  Some  have  contained  a 
mixture  of  air.  saliva,  and  ims.  In  rare  cases  there  are  gaseous  tumors  ..1 
the  glands,  which  give  a  sensation  of  crepitation  on  palpation. 

HI.    DISEASES  OF  THE  PHARYNX. 

(1)  Circulatory  Disturbances.— (<')  Unporwinia  is  a  common  condition 
in  acute  and  chronic  atl'ections  of  tiie  throat,  and  is  frequently  seen  as  a 
result  of  irritation  from  tol)acco  smoke.  Venous  stasis  is  seen  in  valvular 
di«ca*e  of  the  heart,  and  in  mechanical  ohstruction  of  the  superior  vena 
cava  1)V  tumor  or  aneurism.  In  aortic  insufTicicncy  the  capillary  pulse  may 
sometimes  he  seen  and  the  intense  throl.bing  of  the  internal  carotid  m:iy 
be  mistaken  for  aneurism. 

{h)  Jhvmorvhiqe  is  found  in  association  with  bleeding  from  other  mucous 
surfaces,  or  it  is'due  to  local  cuises  in  the  i)haryn.x  itself.  In  the  latter 
ca-e  it  may  be  mistaken  for  hu'-norrliage  from  the  lungs  or  stomach.  J  he 
bleediii''  mav  come  from  granulations  or  vegetations  in  the  naso-])harynx. 
Sometimes  the  patient  finds  the  pillow  stained  in  the  morning  with  bloody 
accretion.  The  condition  is  rarely  serious,  and  only  requires  suitable  local 
treatment  of  the  ])harvnx.  Occasionally  a  hannorrhage  take.-!  place  into 
the  mucosa,  producing  a  pharyngeal  luvmatoma.  I  have  thrice  seen  a 
condition  of  the  uvula  resembling  ha>morrhagic  infarction.  One  was  in  a 
patient  with  acute  rhcumalism,  to  whom  large  doses  of  salicylic  acid  had 
been  given;  the  other  two  were  instances  of  peliosis  rheumatica,  m  Ixjth 
of  which  iiartial  sloughing  of  the  uvula  took  place. 

(r)  (Edema.— An  infiltrated  (edematous  condition  of  the  uvula  and 
adiacent  parts  is  not  very  uncommon  in  conditions  of  debility,  in  profound 
anlvmia,  and  in  r.righfs  disease.  The  uvula  is  sometimes  from  this  cause 
enormously  enlarged,   whence   may  arise  difficulty   in   swallowing   or  in 

breath  m"'. 

(2)  Acute  Pharyngitis  (Sm-e  Throat,-  Angina  S ! ni phw) .—Tho  entire 
].haryngeal  structures,  often  with  the  tonsils,  are  involved.  Tiie  condition 
may'foflow  cold  or  exposure.  In  other  instances  it  is  associated  with  con- 
stitutional states,  such  as  rheumatism  or  gout,  or  with  digestive  disorders. 
The  patient  complains  of  uneasiness  and  soreness  in  swallowing,  of  a  feel- 
in-'  of  tickling  and  drvnes,-  in  the  throat,  together  with  a  constant  desire 
to'hawk  and  cough.  Frequently  the  inflammation  extends  into  the  larynx 
and  produces  hoarseness.  Xot  uncommonly  it  is  only  part  of  a  general 
naso-pharvngeal  catarrh.  The  process  may  pass  into  the  Eustacliian  tubes 
and  cause' slicrht  deafness.  Tliere  is  stitfiiess  of  the  neck,  the  lymjih-glands 
of  which  mav  be  enlarged  and- painful.     The  constitutional  symptoms  are 


ki 


&vi 


<^     x-vk   '*^"'    r\ 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


/ 


^/ 


'V 


m 


o 


'^"m:^ 


i/i 


v.. 


1.0 


I.I 


■  56 


IIM 

IIM 


I"  m 

VL 

I. 

I. 


|40 


||M 
20 

1.8 


125      1.4 

1.6 

„ 6"     — 

► 

Photographic 

Sciences 

Corporation 


29  WEST  MAIN  STREET 

WEBSTER,  N.\.  14580 

(716)  872-4503 


"% 


:^^ 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Kistorical  Microreproductions  /  Institut  canadien  de  microreproductions  historiques 


WV- . 


m^ 


n 


°^ 


DISEASES  OF  THE   PUAllYNX. 


449 


rarely  severe.  Tlie  disease  sets  in  with  a  cliilly  feeling  pnd  sli<j:lit  fever; 
the  i>ulse  is  inereasi'd  in  frecjueney.  Oceasionally  llie  I'eltrile  symptoms 
are  more  severe,  particularly  if  the  tonsils  are  specially  involved.  The  ex- 
amination of  the  throat  shows  general  congestion  of  tlie  mucous  memhrane, 
uliich  is  dry  and  glistening,  and  in  places  covered  with  sticky  secretion. 
The  uvula  may  he  much  swollen. 

Acute  pharyngitis  lasts  only  a  few  days  and  recpiires  mild  measures. 
JC  tlie  tonsils  are  involved  and  tlie  i'ever  is  high,  aconite  or  sodium  salicylate 
may  be  given.  (Juaiacum  also  is  hciieiicial;  hut  in  a  majority  of  tiie  cases 
a  calomel  purge  or  a  saline  aperient  and  inhalations  with  steam  meet  the 
indications. 

{',])  Chronic  Pharyngitis. — Tliis  may  follow  repeated  acute  attacks.  It 
is  very  common  in  jiersons  who  smoke  or  drink  to  excess,  and  in  those 
wlio  use  the  voice  very  nuicii,  such  as  clergymen,  hucksters,  and  others. 
It  is  frequently  met  with  in  chronic  nasal  catarrh.  Tlie  naso-pharynx  and 
the  posterior  wall  are  the  jiarts  most  frequently  affected.  The  mucons 
memi)rane  is  relaxed,  the  venules  are  dilated,  and  roundish  liodies,  from 
5i  to  4  mm.  in  diameter,  reddish  in  color,  project  to  a  variable  distance 
beyond  the  mucous  memliranc.  These  represent  the  jiroliferations  of  lymph 
tissue  about  the  mucous  glands.  They  may  be  very  abundant,  forming 
elongated  rows  in  the  lateral  walls  of  the  pharynx.  With  this  tliere  may 
he  a  dry  glistening  state  of  the  pharyngeal  mucosa,  sometimes  known  as 
phnri/iKjilis  sicca.  The  ])illars  of  the  fauces  and  the  uvula  are  often  much 
relaxed.  The  secretion  forms  at  the  back  of  the  jiharynx  and  the  patient 
may  feel  it  droj)  down  from  the  vault,  or  it  is  tenacious  and  adherent,  and 
is  only  removed  l»y  repeated  efforts  at  hawking. 

In  the  treatninif,  special  attention  must  be  j)aid  to  the  general  health. 
If  possil)le,  the  cause  should  lie  ascertained.  The  <ondition  is  almost 
constant  in  smokers,  and  cannot  be  cured  witliout  slopping  the  use  of 
tobacco.  The  use  of  food  either  too  hot  or  to<»  much  sjiiced  should  l)e  for- 
liidden.  When  it  de])ends  n])on  excessive  exercise  of  the  voice,  rest  siiould 
he  enjoined.  In  many  of  these  cases  change  of  air  and  tonics  help  very 
much.  In  the  local  treatment  of  the  throat  gargles,  washes,  and  pastilles 
of  various  .^orts  give  temiMirary  relief,  but  when  the  hy|)ertroi)iiic  condi- 
tion is  marked  the  spots  should  lie  thoroughly  destroyed  by  the  galvano- 
cautery.  In  many  instances  this  affords  great  and  permanent  relief,  but 
in  others  the  condition  persists,  and  as  it  is  not  nnbearable,  the  patient 
gives  n])  all  hojio  of  permanent  relief. 

(4)  Ulceration  of  the  Pharynx.— (a)  Follicular.  The  nlcers  are  usually 
^mall.  superficial,  and  generally  associated  with  clironic  catarrh. 

(h)  Syphilitic  nlcers  are  usually  jiainless,  and  most  fmiuentiy  situated 
on  the  posterior  wall  of  the  pharynx.  They  occur  in  the  secondary  stage 
as  small,  shallow  excavations  with  the  mucous  ])atches.  In  the  tertiary 
staire  the  ulcers  are  due  to  erosion  of  gummata,  and  in  healing  tiiey  leave 
whitish  cicatrices. 

((•)  Tuberculous  nlccration  is  not  very  uncommon  in  advanced  cases 
of  jihthisis,  and.  if  extensive,  is  one  of  the  most  distressing  features  of  the 
later  stages  of  the  disease.    The  ulcers  arc  irregular,  with  ill-defined  edges 


■I  1 


.- 


^^ 


450 


DISEASES  OF   TUE  DIGESTIVE  SYSTEM. 


and  .'rayi.h-ycllow  base^.  The  posterior  wall  of  the  pharynx  may  have  an 
cHKled,  w,.rn.-eaten  appeanuue.  These  ulcers  are,  as  a  rule,  iuten>ely  luun- 
ful.     Ueeasionally  the  primary  disease  is  ahuut  the  tousds  and  the  pdlars 

ol  the  fauces.  . 

((/)  ricers  oeeur  in  conneetion  with  pseudo-niendjranous  mllanunation, 
partieularly  the  .lii)]itheritie.  In  cancer  and  in  lupus  ulcers  are  also  present. 
(e)  Ulc'ers  are  met  with  in  certain  of  the  fevers,  particularly  m  typhoid. 
In  many  instances  the  diagnosis  of  the  nature  of  pharyngeal  ulcers  is 
very  ditlicult  The  tuberculous  and  cancerous  varieties  are  readily  recog- 
nized, but  it  happens  not  infrequently  that  a  doubt  arises  as  to  the  syph- 
ilitic charac'ter  of  an  ulcer.  In  many  instances  the  local  conu-tions  may 
be  uncertain.  Then  other  evidences  of  syphilis  should  be  sought  for, 
and  the  patient  should  bo  place.l  on  mercury  and  iodide  of  potiissium, 
nnder  which  remedies  sY]ihilitic  ulcers  usually  heal  with  great  rapidity-. 

(5)  ^cute  Infectious  Phlegmon  of  the  Pharynx.— I  nder  this  terni 
Senator  has  described  cases  in  which,  along  with  dillicnlty  in  swallowing, 
soreness  of  the  throat,  and  sometimes  hoarseness,  the  neck  enlarges,  the 
idiaryngeal  mucosa  becomes  swollen  and  injected,  the  fever  is  high,  the 
constitutional  symptoms  arc  severe,  and  the  inilammation  passes  on  rap- 
idly to  suppuration.  The  symptoms  are  very  intense.  The  swelling  ol  the 
pharyncreal  tissues  early  reaches  such  a  grade  as  to  impede  respiration.  \  cry 
similar^symptoms  may  be  produced  by  foreign  bodies  in  the  iduiryn.x. 

(0)  Retro-pharyngeal  abscess  occurs:  (l)  In  healthy  children  between 
six  months  and  two  years  of  age.  The  child  becomes  restless,  the  voice 
chan<a>s;  it  becomes  nasal  or  metallic  in  tone,  and  there  are  pam  and  difli- 
cnlty^'in  swallowing.  Inspection  of  the  pharyn.x  reveals  a  projecting  tumor 
in  tiie  nnddle  line,  or  if  it  be  not  visihle,  it  is  readii-  felt,  on  palpation,  pro- 
jecting from  the  posterior  wall.  This  form  has  been  carefully  descrdied  by 
koi.lik  C^)  As  a  not  infrequent  sequel  of  the  fevers,  particularly  of  scarlet 
fever  and  diphtheria.  (3)  In  caries  of  the  bodies  of  the  cervical  vertebnv. 
Tlie  diagnosis  is  readily  made,  as  the  projecting  tumor  can  be  seen,  or 
felt  with  the  finger  on  the  posterior  wall  of  the  ])harynx. 

(7)  Angina  Ludovici  {Lndwufs  Angiitd;  Cellulitis  of  ilie  Xfd-).—lYL 
medical  practice  this  is  seen  as  a  secondary  inflsmmation  in  the  specific 
fevers,  particularly  diiihthcria  and  scarlet  fever.  It  may,  however,  occur 
idiojiathically  or  result  from  trauma.  It  is  probably  always  a  streptococcus 
infection  which  sjtrcads  ra])idly  from  the  glands.  The  swelling  at  first  is 
most  marked  in  the  submaxillary  region  of  one  side.  The  symptoms  are, 
as  a  rule,  intense,  and,  unless  early  and  thorough  surgical  measures  are  em- 
idoyed,  there  is  great  risk  of  systemic  infection.  Felix  Semon  holds  that 
the  various  acute  septic  inflammations  of  the  throat— acute  oedema  of  the 
larynx,  phlegmon  of  the  pharynx  and  larynx,  and  angina  Ludovici— 
"  represent  degrees  varying  in  virulence  of  one  and  the  same  process.' 


ACUTE  TONSILLITIS. 


401 


ly  liave  an 
isely  i)ain- 
thf  pillars 

aiuiuation, 
so  present. 
in  typhoid, 
il  ulcers  is 
(lily  recog- 
)  the  syph- 
'tions  may 
io light  for, 

])otassiiim, 
apidity. 

this   term 
swallowing, 
ilarges,  the 
s  high,  the 
ses  on  rap- 
lling  of  the 
tion.    Very 
laryn.x. 
en  between 
3,  the  voice 
in  and  diffi- 
cting  tumor 
i])ation,  pro- 
lescribed  by 
ly  of  scarlet 
al  vertebra\ 

be  seen,  or 

Xcd-).—Jn 
the  specific 
vever,  occur 
treptoeoccus 
ig  at  first  is 
mptonis  are, 
nres  are  cm- 
n  holds  that 
dema  of  the 

Lndovici — 
process." 


IV.    DISEASES   OF  THE   TOXSILS. 
ACUTE   TONSILLITIS. 

(1)  Follicular  or  Lacunar  Tonsillitis.— l"or  ],raclical  jmrposes,  under 
this  name  may  l»e  described  tiie  various  forms  wliieii  have  l.eeii  called  ca- 
tarrhal, eryljieniatous,  ulcero-membraiious,  and  herpetic. 

Etiology.— The  disease  is  met  with  most  frequently  in  young  ])ersons. 
but  in  children  un<Ier  ten  it  is  less  common  tlian  the  eiironic  form.  It  is 
rare  in  infaiits.  Sex  lias  no  special  inllueiice.  Kxi)osure  to  wet  and  cold, 
and  bad  hygienic  surroundings  appear  to  have  a  direct  etiological  connec- 
tion with  the  disease.  In  so  many  instances  defective  drainage  has  been 
found  associated  with  outbreaks  of  follicular  tonsillitis  that  .sewer-gas  is 
regarded  as  a  common  exciting  cause.  One  attack  renders  a  i)atient''more 
liable  to  sul)se(pient  infection.  S])ecial  stress  is  laid  by  some  writers  upon 
the  coexistence  of  tonsillitis  with  rheumatism.  Chcaille  describes  it  as 
one  of  the  pha.«es  of  rheumatism  in  childhood  witli  which  articular  attacks 
nuiy  alternate.  I  cannot  say  tluit,  in  my  ex]HMience,  the  connection  between 
the  two  aU'eetions  has  been  very  striking,  excejtt  in  one  ])oint,  \h.,  that 
an  attack  of  acute  rheumatism  is  not  infre(iuejitly  ])receded  by  inllamma- 
ti(m  of  the  tonsils.  The  existence  of  ])ains  in  tlie  limbs  is  no  evidence  of 
tlio  connection  of  the  affeetion  with  rlunniatism.  A  disease  so  common 
and  widespread  as  acute  tonsillitis  necessarily  attacks  many  persons  in 
whoso  families  rlieumatism  prevails  or  mIio  may  themselves  have  had  acute 
attacks. 

]\Iackcnzie  gives  a  tal)le  showing  that  in  four  successive  years  more 
cases  occurred  in  Sejitendjer  than  in  any  other  month;  in  October  nearly 
as  many,  with  July,  August,  and  Xovember  next.  In  tliis  country  it  seems 
more  prevalent  in  tlie  spring.  So  many  cases  develop  within  a  short  time 
that  the  disease  may  be  almost  epidemic.  It  si)reads  through  a  family  in 
such  a  way  that  it  must  be  regarded  as  contagious. 

An  old  notion  prevails  that  there  is  a  definite  relation  between  tlie 
tonsils  and  the  testes  and  ovaries.  F.  J.  Shepherd  has  called  attention  to 
the  circumstance  that  acute  tonsillitis  is  a  very  common  affection  in  newly 
married  persons.  That  view  is  jirolialjly  correct  which  regards  tonsillitis 
as  a  local  disease  with  severe  constitutional  manifestations,  although  tlie 
fever  is  often  out  of  proportion  to  the  local  symptoms.  The  commonest 
organism  found  in  tonsillitis  is  a  streptococcus.  Staphylococci  also  occur. 
In  some  cases  the  ha  Uits  diphihcrice  of  Loeffler  have  been  found,  but  it 
does  not  always  possess  the  full  virulence  (sec  Atypical  Forms  of  iyi[)\i- 
theria). 

Morbid  Anatomy.— The  lacunar  of  the  tonsils  ])ccome  filled  with 
exudation  i)roducts,  which  form  cheesy-looking  masses,  projecting  from 
the  orifices  of  the  crypts.  Xot  infrequently  the  exudations  from  contiguous 
lacuna;  coalesce.  The  intervening  mucosa  is  usually  swollen,  deep-red  in 
color,  and  may  present  herpetic  vesicles  or,  in  some  instances,  even  mem- 
branous exudation,  in  which  case  it  may  be  difficult  to  distinguish  the  cou- 


i 


^mA 


^-2  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

dition  from  diplitlunia.    Tho  oroainy  c.nt.nts  <.f  tl.e  .•rypt  nro  mn.lo  up  of 
iiiicrooocci  luid  cpitlifliiil  th'liri^.  .       ,  .,,        .      ,  • 

Symptoms.-t 'hilly  fe'olinps  or  ovon  a  dofinito  clull,  and  aelinig  pains 
in  the  back  and  liml.s  n>ay  procedo  the  onset.     The  lever  rises  .■ap.dly,  an.l 
in  the  ease  of  a  young  child  n.ay  reach  105^  on  the  evening  ol  the  l.rst  day. 
The  ..atieiit  coniphiins  of  soreness  of  tlie  throat  and  ditheultyin  swallow- 
ing     On  ex..niiiiatinii,  the  tonsils  are  seen  to  l.e  swollen  and  the  crypts 
present   the   charaeteristh.   creamy   exudate.      The   tongue   is     nrm,   the 
breath  is  heavy  and  foul,  and  the  urine  is  highly  eoh.red  and  loaded  with 
urate>^      In   children   the   respirations  are  usually   very  hurried    and   the 
l.ul-e  is  greatlv  increased  in  rapidity.     Swallowing  is  painful,  and  the  voice 
often  becomes"  nasal.     Slight  swelling  of  the  cervical  glan.ls  is  present.    In 
severe  ca-es  the  ,symi)toms  increase  and  the  tonsils  become  still  more  moWcn. 
The  inilammation  gradually  subsides,  and,  as  a  rule,  within  a  week  the 
fever  departs  and  the  local  condition  greatly  improves,      llie  tonsils   how- 
ever   remain  somewhat  swollen.     The  prostration  and  e<.nstitutional  dis- 
turbance are  often  out  of  proportion  to  the  intensity  of  the  local  disease 

There  are  complications  which  occasionally  excite  uneasiness,  l-ehnle 
albuminuria  is  not  uncmimon,  as  Ilaig-IUown  has  pointed  out.  Cases  o 
emlocarditis  or  pericarditis  have  been  found.  It  is  to  be  borne  m  mim 
that  in  children  an  apex  svstolic  murmur  is  by  no  means  uncommon  at 
the  height  of  any  fever.  The  disease  may  extend  to  the  middle  ear.  The 
develop\nent  of  paralytic  symptoms,  local  or  general,  after  an  attack  winch 
has  been  regarded  as  follicular  tonsillitis  indicates  an  error  m  diagnosis. 
A  diffuse  erythema  mav  develop,  simulating  that  of  scarlet  fever. 

Diagnosis.— It  niay  be  difficult  to  distinguish  follicular  tonsillitis 
from  diphtheria.  It  wouhl  seem,  indeed,  as  if  there  were  intermediate 
forms  between  the  mildest  lacunar  and  the  severer  i..<eudo-menibranous 
tonsillitis.  In  the  follicular  form  the  individual  vcUowisli-gray  masses, 
separated  by  tlie  reddish  tonsillar  tissue,  are  yery  characteristic;  whereas 
in  dii)htheria  the  membrane  is  of  ashy  gray,  and  uniform,  not  patchy.  A 
point  of  the  greatest  imj)ortanee  in  diphtheria  is  that  the  membrane  is  not 
limited  to  the  tonsils,  but  creeps  up  the  pillars  of  the  fauces  or  appears  on 
the  uvula.  The  diphtheritic  membrane  when  removed  leaves  a  bleeding, 
eroded  surface;  whereas  the  exudation  of  lacunar  tonsillitis  is  easily  sepa- 
rated, and  there  is  no  erosion  beneath  it.  In  all  doubtful  cases  cultures 
should  be  made  to  determine  the  presence  or  absence  of  Loelller's  bacillus. 
(2)  Suppurative  Tonsillitis. 

Etiology.— This  arises  under  conditions  very  similar  to  those  men- 
tioned in  the  lacunar  form.  It  may  follow  exposure  to  cold  or  wet,  and  is 
iiarticularly  liable  to  recur.  It  is  most  common  in  adok-scence.  The  in- 
ilammation is  here  more  deeply  seated.  It  inyolves  the  stroma,  and  tends 
to  go  on  to  suppuration. 

Symptoms.— -The  constitutional  disturhanco  is  very  great.  The  tem- 
perature rises  to  104°  or  105°,  and  the  pulse  ranges  from  110  to  130.  Noc- 
turnal delirium  is  not  uncommon.  The  prostration  may  he  extreme.  There 
is  no  local  disease  of  similar  extent  which  so  rapidly  exhausts  the  strength 
of  a  patient.    Soreness  and  dryness  of  the  throat,  with  pain  in  swallowing, 


ACUTE  TONSILLITIS. 


453 


'  nindo  up  of 

aching  pains 
rapidly,  and 
till!  liivt  day. 
,'  ill  swallnw- 
d  the  crypts 
furred,   the 
:  loi'.ded  with 
ied,  and   tlie 
Lind  tiie  voice 
present.    In 
more  SAVoUcn. 
1  a  week  the 
tonsils,  how- 
itutional  dis- 
■al  disease, 
ness.     Febrile 
)ut.     Cases  of 
orne  in  mind 
uncommon  at 
die  car.    Tlie 
attack  whicli 
in  diagnosis. 
:er. 

dar  tonsilUtis 
'  intermediate 
[)-nienibranous 
i-gray  masses, 
ristic;  whereas 
ot  patchy.  A 
!mhrane  is  not 
or  ai)pears  on 
es  a  bleeding, 
is  easily  sepa- 
cases  cultTires 
■nier's  bacillus. 

to  those  mcn- 

or  wet,  and  is 

once.     The  in- 

)ma,  and  tends 

eat.  The  tom- 
»  to  130.  Noc- 
xtreme.  There 
ts  the  strength 
in  swallowing, 


are  the  symptoms  of  which  the  patient  lirst  ( luiiiilains.  One  or  botii  tonsil.s 
may  lie  involvt'd.  They  are  enlarged,  (irni  to  llie  toucli,  dusky  red  and 
o'deniatous,  and  the  contiguous  puts  are  also  mueh  swollen.  The  swelling 
of  the  glands  may  be  so  great  that  they  meet  in  the  middle  line,  or  one 
tonsil  may  even  push  the  uvula  aside  and  almost  touch  the  other  gland, 
'i'lu'  salivary  and  buccal  st'cretions  are  increased.  The  glands  of  (he  neck 
enlarge,  the  lower  jaw  is  lixed,  and  the  patient  is  iinaide  to  open  his  mouth. 
In  from  two  to  four  days  the  eidarged  gland  becomes  s(d'ter,  and  lluctuatiou 
can  be  distinctly  felt  by  |ila(ing  one  linger  (ui  the  tonsil  and  the  other  at 
the  angle  of  the  jaw.  The  abscess  points  usually  toward  the  mouth,  but  in 
some  casi's  toward  the  pharynx-  It  may  burst  spontaneously,  all'ording 
instant  and  great  relief.  Suirocation  has  followed  the  ru|)ture  of  a  largo 
al)scess  and  the  entrance  of  the  juis  into  the  larynx.  When  the  suppura- 
tion is  ])eritonsillar  and  extensive,  the  internal  carotid  artery  may  be 
opened;  liut  these  are,  fortunately,  very  rare  accidents. 

Treatment. — In  the  follicular  form  aconite  may  be  given  in  full  doses. 
It  acts  very  bcnelicially  in  children.  The  salicylatt's,  given  freely  at  the 
outset,  are  regarded  by  some  as  specific,  but  I  have  seen  no  evidence  of 
such  jirompt  and  decisive  action.  At  night,  a  full  dose  of  Dover's  powder 
may  lie  given.  The  use  of  guaiacum,  in  the  form  of  :>-grain  lo/.enges,  is 
warmly  recommended.  Iron  and  ipiinine  should  be  resi'rved  until  the  fever 
has  subsided.  A  jtad  of  spongio-piline  or  tiiick  tlannel  dipped  in  ice-cold 
water  may  be  applied  around  the  neck  aiul  covered  with  oiled  silk.  More 
convenient  still  is  a  small  ice-hag.  Locally  the  tonsils  may  be  treated  with 
the  dry  sodium  bicarbonate.  The  nuhstened  fnigertip  is  dipped  into  the 
soda,  which  is  then  rubbed  gently  on  the  gland  and  repeated  every  houi*. 
Astringent  pre})arations,  such  as  iron  and  glycerin,  alum,  zinc,  and  nitrate 
of  silver,  may  be  tried.  To  cleanse  and  disinfect  the  throat,  solutions  of 
borax  or  thymol  in  glycerin  and  water  may  be  used. 

In  sui)purative  tonsillitis  hot  applications  in  the  form  of  poultices  ami 
fomentations  are  more  comfortable  and  better  than  the  ice-bag.  The 
gland  should  be  felt — it  cannot  always  be  seen — from  time  to  time,  and 
should  be  o]iened  when  fluctuation  is  distinct.  The  jtrogress  of  the  dis- 
ease may  be  shortened  and  the  patient  sjiared  several  days  of  great  suffer- 
ing if  the  gland  is  scarified  early.  The  curved  bistoury,  guarded  nearly 
to  the  point  with  plaster  or  cotton,  is  the  most  satisfactory  instrument. 
The  incision  should  be  made  from  above  downward,  parallel  with  the  an- 
terior ])illar.  There  are  cases  in  which,  ])efore  suppuration  takes  ]>lace,  the 
liarenchymatou,-  swelling  is  so  great  that  the  patient  is  threatened  with 
suffocation.  In  such  instances  the  tonsil  must  either  be  excised  or  trache- 
otomy or,  possibly,  intubation  perforjned.  Delavan  refers  to  two  cases  in 
which  he  states  that  traclieotomy  would,  under  these  circumstances,  have 
saved  life.  Patients  with  this  affection  retiuire  a  nourishing  liquid  diet, 
and  during  convalescence  iron  in  full  doses. 


45i 


DISEASES  OF  TUB  DIGESTIVE  SYSTEM. 


CHRONIC  TONSILLITIS. 

develoimient  of  clnWren.  i„ii<iUu'  slnutnros  is  oooasionally  con- 

genital.  CaM's  are  perhaps  mo.t  ^^  :;\\;  ,^^^  ..lulls,  more  rarely  m 
henu-aocado.  The  cond.  urn  f-  -:/.,,  ,!i^,hthoria  or  the  eruptive 
the  nriddle-a,ed.  The  "^^^f  ^^^^^j  ./  '^l.noid  growths  in  the  naso- 
fevors.  The  frenuency  "'J''!^  /"^^/^^.^  to  .honr  the  profession  is  n>- 
pharynx  has  heen  variously  .tat     .     Mc^  .^^  ^^,,,^^,^  „„,  j,,^ 

ilel.ted  for  calling  attenuon  to  ^'    /'^'      (J'    ,        .^  ,.,„„1  f,,)  cases  in  the 

former.  4,,,  -ll^    kroner    present    a    condition    ot 

Morbid  ^^^"^-T^^'^r^r^-^ZJih.  constituents  <.f  the 
chronic  hypertrophy,  due  to  ";;'^';';^  ",,:,!  y  involved  without  much 
glands.  The  lymplu.id  elements  na  ^  Z^'^';;  ^  j-,„,,,,  ,,,,trix  is  in- 
tlevelopment  of  the  stroma.  ^  ;;^  >;i,  '  fin  and  is  cut  with  nuuh 
creased,  and  the  organ  is  then  hardii,  smalki, 

greater  dithculty.  ,,  ^^   „f  the   pharynx, 

^     The  adenoid  ?^--*'-^ -';!;  ;;!;' "^a '^^  tan  ahnond.     They  may 
form  masses  varying  in  size  l.om  a       ■  '^    |'^  ^^,,1,^1,1,  j,,  color, 

he  sessile,  with  broad  bases,  or  pednncula      .  J  ^^^^  ^^^      .  Abundant, 

of  moderate  firmness,  and  con  am  ""-^^'^^    '^f^^,  i.:,,tachian  tube, 
as  a  rule,  over  the  vault,  on  a  hue  w.  1    tli    fo..v  o^  t^  .^^^  ^^^^^^^^.^^ 

the  growths  may  lie  posterior  to  the  fo...>-na^^^^^  ,,e  parallel  to  the 

as  the  fossa  of  Rosenmuller.  '' ^Zrl^i^t^^^  io  spring  in  the  main 
posterior  wall  of  the  pharynx.    ^ '-^^^^  ^    '^^   lit  "s  where  the  connective 

},om  the  mucons  membrane  ^'-j  '^  ^I  ^f^^  X'^^  "  ("'^"•'^""  ^^^^'"^• 
tissue  fills  in  the  inequalities  of  he  ^^^^^  «  m,;'  j^,,  \  i,niphoid  par- 
The  growths  are  most  frecpient ly  V^^^':^"^^^^-^^^,,,  J^U  vr^^o^ 
ench>'ia.  Hypertrophy  cvf  ^-^^^^i^^^' ^Zc  cirrlAf  the 
without  great  enlargement  of  the  tonsils  propci 

nose  usually  coexists.  ,     ^    .    „f  ,.i,,.nnie  ton-^ilhir  hvportrophy  is 

SymptomS.-The   direct  ^f;-^  of  cuon        m  1  .1^^  ^^^^^^^^^^^^^_ 

the  establishment  of  ^^-^^-^^]'''!'^^^^^l^^Zr^,  sometimes  marked 
tion  of  the  thorax,  changes  in  the  f'^"^/^^!!^^; ;"",,,  stunting  of  the 
alteration  in  the  mental  condition,  '^"J  "  f  J,^  ^^hryologieal  relation 
growth.    Woods  Hutchinson  has  suggested  that  the  cmi)  j      „ 


CnUONIC  TONSILLITIS. 


455 


rosexia.) 

)!'  tlic  adenoid 
110  pharyngeal 
opor 


aiM 


I  Uiis 


n  I'f  groat  iin- 
ital  and  bodily 

:cas!ionally  con- 
ring  tho  tbivd 
more  rarely  in 
or  the  eruptive 
hs  in  the  naso- 
iroi'es^ion  is  in- 
.  about  one  \wv 
GO  cases  in  the 
res  give  a  vcy 
■curs  ecpially  in 
•evalenee  in  the 

a  condition  <d" 
istituents  of  the 
1  \Yithout  nuuU 
us  matrix  is  in- 
.s  cut  with  nuu'U 

of  the  jiharyux, 
ond.     They  may 
rcddisli  in  color, 
,1s.     '■  Aliundant, 
I'aistachian  tul)0, 
depression  known 
re  parallel  to  the 
u'ing  in  the  main 
re  the  connective 
(Harrison  Allen), 
a   lyn\i)hoid   par- 
10  niay  be  present 
;iic  catarrh  of  the 

ar  hypertrophy  is 
Vocts"  are  defornni- 
sometimes  marked 
PS  stunting  of  the 
)ryological  relation 


of  these  structures  with  the  jiituitary  body  may  account  for  the  interfer- 
ence with  development.  Tiu'  estaldisiiment  of  nu)Utli-breatlung  is  the 
symptom  which  lirst  attracts  tlie  attention.  It  is  not  s"  noticeable  by  day, 
altiiougli  the  cliild  may  i)risent  tlie  vacant  expression  cliaractcristic  of  tliis 
condition.  At  night  the  cliild's  sleep  is  greatly  disturlied;  the  respirations! 
are  loud  and  siU)rting,  and  there  are  sometimes  projongrij  pauses,  followed 
by  deep,  noisy  inspirations.  The  jjuIsc  may  vary  stran^^'ly  dnring  these 
attacks,  and  in  the  prolonged  intervals  may  be  slow,  to  increase  gri'atly 
with  the  forcinl  inspirations.  The  ala'  nasi  should  hi'  observeil  during 
the  sleep  of  the  child  as  they  are  sonu'tinus  much  retracted  during  iii- 
sjtiration.  <lue  to  a  laxity  of  the  walls,  a  condition  readily  remedied  by  the 
use  of  a  soft  wire  dilator,  ^'iglit  ternu's  are  conimon.  'J'he  child  jnay  wake 
up  in  a  ]iaroxysm  of  shortness  of  breath.  Some  of  these  nocturnal  attacks 
may  be  due  to  rellex  spasm  of  the  glottis.  During  the  day  there  may  be 
choking  fits  when  eating. 

When  the  mouth-breathing  has  jiersisti'd  for  a  long  time  definite  changes 
arc  brought  about  in  the  face,  mouth,  and  chest.  The  facies  is  so  peculiar 
ami  distinctive  that  the  condition  may  be  evident  at  a  glaiu'c.  The  cx- 
jircssion  is  dull,  heavy,  and  a|)athetic,  i\uv  in  ]iart  to  the  fact  that  the  mouth 
is  habitually  left  ojien.  In  long-standing  casi's  the  child  is  very  stupid- 
looking,  responds  slowly  to  (pu'stions.  and  may  be  sullen  ami  cross,  'i'he 
lijjs  are  thick,  the  nasal  orifices  small  and  ]pimhcd-in  looking,  the  supe- 
rior dental  arch  is  narrowed  ami  the  roof  of  the  mouth  considerably  raised. 

The  remarkable  alterations  in  the  shajie  of  the  chest  in  connection 
with  enlarged  tonsils  were  first  carefully  studied  by  I)n])uytren  (l>l2cS), 
who  evidently  fully  a]ii>reciatcd  the  great  importaiue  of  the  coiulition. 
He  noted  "a  lateral  depression  of  the  parietes  of  the  chest  consisting  of  a 
de])ression,  more  or  less  great,  of  the  ribs  on  each  side,  and  a  proportionati! 
]»rotrusion  of  the  sternum  in  front."  J.  ^lason  Warren  (.Medical  Kxam- 
incr,  ISoD)  gave  an  admirable  descri])tion  of  the  constitutional  symptoms 
and  the  thoracic  deformities  induced  by  enlarged  tonsils.  These,  with 
the  memoir  of  T-ambron  (ISHl).  constitute  the  most  important  contribu- 
tions to  our  knowledge  on  the  subject.  Three  types  of  deformity  may  bo 
recognized: 

{(i)  The  Pigeon  or  Chicken  Breast,  by  far  the  most  common  form,  in 
which  the  sternum  is  prominent  and  there  is  a  circular  depression  in  the 
lateral  zone  (Harrison's  groove),  corrcs])onding  to  the  attachment  of  the 
diajihragm.  The  ribs  are  prominent  anteriorly  and  the  sternum  is  angu- 
lated  forward  at  the  manubrio-gladiolar  junction.  As  a  moutli-l)reather 
is  watched  during  sleep,  one  can  see  the  lower  and  lateral  thoracic  regions 
retracted  during  inspiration  by  tlio  action  of  the  diaphragm. 

(b)  Barrel  Chest. — Some  children,  the  sul)ject  of  chronic  naso-])haryn- 
geal  obstruction,  have  recurring  attacks  of  asthma,  and  the  chest  may  be 
gradually  deformed,  becoming  rounded  and  barrel-shaped,  the  neck  short, 
ami  the  shoulders  and  back  bowed.  A  child  of  ten  or  eleven  may  have  tlie 
thoracic  couformation  of  an  old  man  with  emphysema. 

(r)  The  Funnel  Breast  (Trirhter-hnifif). — This  remarkable  deformity, 
in  which  there  is  a  deep  depression  at  the  lower  sternum,  has  excited  much 


I 


45G 


DISEASES  OP  THE  DICfESTIVE  SYSTEM. 


controversy  as  to  its  inoili'  of  orijrin.  1  bi'licvo  tliat  in  sonu'  instances,  at 
least,  it  is  due  to  the  dhstnieted  breatliinj;;  in  connection  witii  adenoid 
vegetations.  I  have  seen  two  cases  in  children,  in  wiiich  the  condition  was 
in  jirocess  ot  development.  J)iirin<,'  iiu-piration  the  lower  sternum  was 
I'drcildy  retracted,  so  much  so  tiiat  at  tlie  height  the  depression  corresponded 
to  a  well-marked  ''  Iriclitfr-hnisl."  Wliiie  in  repose,  the  lower  sternal  re- 
gion was  ilistinctly  excavated. 

The  voice  is  altered  and  acquires  a  nasal  (luality.  The  jironunciation 
of  certain  letters  is  changed,  and  there  is  inahility  to  pronounce  the  nasal 
consonants  ;;  and  iii.  IMocli  lays  great  stress  upon  the  association  of  mouth- 
breathing  witli  stuttering. 

The  hearing  is  impaired,  usually  owing  to  the  extension  of  inflamma- 
tion along  the  Kustachian  tuhes  and  the  ol)struction  with  mucus  or  the 
narrowing  ot  their  orilices  hy  ])ressure  of  the  adenoid  vegetations.  In  some 
instances'it  may  he  due  to  retraction  of  the  drums,  as  the  upper  pharynx 
is  insniliciently'supplied  with  air.  Naturally  the  senses  of  ta.-te  and  smell 
are  much  impaired.  With  these  symptoms  there  may  he  little  or  no  nasal 
catarrh  or  discharge,  hut  the  i)haryngeal  secretion  of  mucus  is  always  in- 
creased. Children,  however,  do  not  notice  this,  as  the  mucus  is  usually 
swallowed,  hut  older  persons  expectorate  it  with  diiliculty. 

Among  other  symptoms  may  l)e  mentioned  headache,  which  is  hy  no 
means  uncommon,  general  listl'essness,  and  an  indisjiosition  for  j.hysical 
or  nuMital  exertion.  Ilahit-spasm  of  the  face  has  heen  described  in  con- 
nection with  it.  I  have  known  several  instaiu-es  in  which  permanent  relief 
has  heen  all'(/rded  hy  the  removal  of  the  adenoid  vegetations.  Enuresis 
is  occasionally  an  associated  symptom.  The  iniluence  njion  the  mental 
development  is  striking.  Mouth-hreathers  are  usually  ilull,  stupid,  and 
1)ackward.  It  is  inqiossihh'  for  them  to  fix  the  attention  for  long  at  a  time, 
and  to  this  impairnuMit  of  the  mental  function  (iuye,  of  Amsterdam,  has 
given  the  name  iipniscria.  Jleadaches,  forget  fulness,  inal)ility  to  study 
without  discomfort,  are  frecpient  syni]itoms  of  this  condition  in  students. 
There  is  more  than  a  grain  of  truth  in  the  aphorism  shut  umir  iikiuIIi  and 
sdir  your  life,  which  is  found  on  the  title-page  of  Captain  Catlin's  cclc- 
hrated  ])anii>hlet  on  month-hreathing. 

A  symptom  s]iecially  associated  with  enlarged  tonsils  is  fetor  of  the 
breath."  In  the  tonsillar  crypts  the  inspissated  secretion  nndergoes  de- 
comiiosition  and  an  odor  not  unlike  that  oi  Eoquefort  or  Limburger  cheese 
is  produced.  The  little  cheesy  masses  may  sometimes  be  s(|ueezed  from 
the  cryjifs  of  the  tonsils.  Though  the  odor  nuiy  not  a])parently  be  very 
strong,  yet  if  the  mass  be  sciueezed  between  the  fingers  its  intensity  will  at 
once  be  apprt'ciated.  In  some  cases  of  chronic  enlargement  the  cheesy 
masses  may  he  deep  in  the  tonsillar  crypts;  and  if  they  remain  for  a  pro- 
longed ])eriod  lime  .«alts  are  de|)osited  and  a  tonsillar  calculus  in  this  way 
jiroduced. 

Children  with  eulnrfcd  tonsils  arc  csnecially  prone  to  take  cold  and  to 
recurving  attacks  of  follicular  disease.  They  are  also  more  liable  to  diph- 
theria, and  in  them  the  anginal  features  in  scarlet  fever  are  always  more 
serions.     The  ultimate  residts  of  untreated  adenoid  hypertrophy  are  im- 


rii 


cnRONIO  TONSILIJTTH. 


457 


nstanccp,  at 
itii  iulciidid 
mditioii  was 

[(.'11111111     WilS 

()rrc'sj»oii(lf(l 
•  titc'i'iial  10- 

•onuiiciatifin 
CO  the  nasal 
n  of  iiioiitli- 

1'  inllamnia- 
UL'Us  or  tlu' 

is.      Ill  SOlllO 

\)vr  jiliarynx 
to  and  siiioll 
or  no  nasal 
s  always  in- 
is  is  usually 

eh  is  liy  no 
I'or  nhysioal 
ii)od  ill  oon- 
iianont  roliof 
s.  Enuresis 
the  mental 
stuiml,  and 
^*i  at  a  time, 
stordam,  has 
ity  to  study 
in  students. 
/•  iiKiiilh  and 
.'atlin*!"  cole- 
fetor  of  the 
iidorgoes  do- 
nirger  cheese 
[iieezod  from 
ntly  ho  very 
■nsity  will  at 
t  the  cheesy 
in  for  a  pro- 
i  in  this  wav 


portant.  In  some  cases  the  vo<:otations  di-appear,  leaving;  an  atrophic 
condition  id'  the  vault  of  the  pharynx.  Ne<,dect  may  also  load  to  the  so- 
called  'riioriiwaldt's  disease,  in  wiiich  thoio  is  a  cystic  condition  of  the 
pharyiiixoal  tonsil  and  constant  secretion  of  muco-pus. 

Diagnosis.— The  facial  aspect  is  usually  distinctive.  Knlar;j;cd  ton- 
sils arc  readily  seen  on  inspi'ctioii  id'  the  pharynx,  'riiero  may  ho  no  j^roat 
enlar;,romont  of  the  tonsils  and  imthin;.'  appaivnt  at  the  hack  of  the  throat 
even  when  the  naso-pharynx  is  coni|dotely  hlockod  with  adenoid  vc^'ota- 
tions.  In  rliildroii  the  rhinoscoiiic  cxainiiiatioii  is  rarely  prarlicalilo.  Dijri- 
tal  oxamiiiatioii  is  the  most  satisfactory.  The  <;rowtiis  can  tlu'ii  ho  felt 
either  as  small,  ilat   hodics  or,  if  extensive,  as  velvety,  <,MM|ie-like  papillo- 

mata. 

Treatment.  —  If  the  tonsils  arc  larj^^e  and  the  j:enoral  slate  is  evidciilly 
inlliioiiced    hy   them    they   should   1ie   at    once    removed,      .applications   of 
iodine  and  iron,  or  lUMiciilinji;  the  crypts  with  nitrate  of  silver,  arc  of  service 
in  the  milder  <rra(les,  hut  it  is  waste  of  time  to  apply  them  in  very  enlar^i-ed 
ulands.     There  is  a  condition  in  which  the  tonsils  are  not  much  enlarged, 
hut   the  crypts  are  constantly   lillcd   with   cheesy  secretions  and  cause  a 
very  had  odor  in  the  hroatli.     In  such  instances  the  removal  of  the  secre- 
tion and  thorough  pencilling  of  the  crypts  with  chromic  acid  may  he  prac- 
tised.    The  galvano-cautery  is  of  groat  service  in  many  cases  of  enlarged 
tonsils  when  there  is  any  ol)jection  to  the  more  radical  surgical  procedure. 
The  treatment  of  the  adenoid  growths  in  the  pharynx  is  of  the  great- 
est  importance,  and  should  he  thoroughly   carried   out.      Parents  should 
he  frankly  told  that  the  aiVoction  is  serious,  one  which  impairs  the  mental 
not  loss  than  the  hodily  development  of  the  child.     In  spite  of  the  thorough 
ventilation  of  this  suhject  hy  specialists,  ])ractitii)ncrs  do  not  appear  to 
have  grasped  as  yet  the  full  iiujiortanco  of  this  di.<ease.     'Phey  are  far  too 
a])t  to  temporize   and   nnnecessarily  to  iiostpone  radical   measures.     The 
child  must  ho  etherized,  when  the  growths  can  he  removed  either  with  the 
finger-nail,  which  in  most  instances  is  sudiciont,  or  with  a  suitahle  curette. 
Coiisidcralile  lueinorrhage  may  follow,  hut  it  is  usually  checked  ipiickly. 
The  good  oll'octs  of  the  o])oration  are  often  api»aront  within  a  few  days, 
and  the  child  hegins  to  hroathe  through  the  nose.     In  some  instances  the 
hahit  of  mouth-hreathing  ].orsists.     As  soon  as  the  child  goes  to  sleep  the 
lower  jaw  drojis  and  the  air  is  drawn  into  the  mouth.     In  these  ca.ses  a 
chin  strap  can  he  readily  adjnsted.  which  the  child  may  wear  at  night.    In 
severe  cases  it  may  take  months  of  careful  training  before  the  child  can 

speak  iirojiorly. 

Throughout  the  entire  treatment  attention  should  he  paid  to  hygiene 
and  diet,  and  cod-liver  oil  and  the  iodide  of  iron  may  he  administered  with 
houolit. 


>  cold  and  to 

able  to  diph- 

always  more 

)phy  are  im- 


!■■ 


da* 


45S 


DISEASES   OF  THE   DIGESTIVE  SYSTEM. 


V.    DISKASES   OF  THE   (ES()lMIA(irS. 

I.    ACUTE   CESOPHAGITIS. 

Etiology.— Acute  iMlliuiuiialioii  oeriirs  (/()  in  \\\v  (•atiirrlial  processes 
or  tlie  si.ccilic  levers;  more  rarely  as  an  extension  from  catarrh  (.I  the 
i.inrynx  (h)  \s  a  result  of  intense  lueelianieal  or  eheniieal  irritation, 
.rmluee.i  hv  I'orei-n  l.odies,  l.y  very  hot  liquids,  or  l.y  stron-  c.,rrosives 
{(■)  In  the  'form  of  i.scudo-memhranous  intlammation  m  .hphtlu'ria,  ami 
oceasi.mallv  in  pneumonia,  typhoid  fever,  and  i^ya^mia.  (-/)  As  a  juistulav 
inlhnnmation  in  >mall-i.o.x.  and.  ac-rdin-  to  Eaennee,  as  a  result  ol  a  pro- 
L.nKcd  administration  of  tartar  emetic,  (r)  In  connection  with  local  dis- 
ease, partieularlv  cancer  either  of  the  tuhe  itself  or  extension  to  it  from 
vitiiout.  And,  "lastly,  acute  .esophagitis,  occasionally  with  ulceration,  may 
occur  s|iontaiic(Uislv  in  sucklings.  _ 

Morbid  Anatomy.— It  is  extremely  rare  to  see  redness  ol  the 
iiiucosi,  except  when  chemical  irritants  have  been  swallowed.  :\Iore  com- 
iiionlv  the  epithelium  is  thickened  and  has  desipiamated,  so  that  the  siir- 
ue  is  covered  with  a  line  granular  substance.  The  mucous  ('(dlicles  are 
swollen  an<l  occasionally  there  may  lie  seen  small  erosions.  In  the  p>eudn- 
nieml)ianous  inilainmati<.n  there  is  a  grayish  croui)ous  exudate,  usually  lim- 
it.'d  in  extent,  at  the  upi.er  imrtion  of  the  gullet.  This  must  not  he  con- 
founded ^vitll  the  gravish-white  dejiosit  of  thrush  in  children.  The  pus- 
tular disease  is  verv  rare  in  small-i-ox.  In  the  plileginom)us  inllammation 
the  mucous  menihrane  is  greatly  swollen,  and  there  is  ],urulent  mliltration 
in  the  suhmucosa.  This  niav  Ik-  limited  as  about  a  foreign  liody,  or  ex- 
tremely diiVuse.  It  may  even  extend  throughont  a  largo  part  of  the  gullet, 
(lau-rene  occasionally  supervenes.  There  is  a  remarkable  fibrinous  or 
menrhranous  .esophagitis,  which  is  most  frequently  met  with  m  tiie  fevers, 
gometimes  also  in  hvsteria,  in  which  long  casts  of  the  tube  may  be  vomited. 

Symptoms.— 1 'a in  in  deglutition  is  always  i>resent  m  severe  inllam- 
mation of  the  o'sophagus,  and  in  the  fcnun  which  follows  the  swallowing 
of  stron.'  irritants  may  prevent  the  taking  of  food.  A  dull  yarn  beneath 
the  sternum  is  also  present.  In  the  milder  forms  of  catarrhal  inflamma- 
tion there  are  usually  no  symptoms.  The  im>senee  of  a  foreign  h..dy  is 
indicated  by  dysphagia  and  si)asin  with  the  regurgitation  of  portions  of 
the  food,  f.ater.  Idood  and  jms  may  be  ejected.  It  is  surprising  how  ex- 
tensive the  disease  mav  be  in  the  cesopliagus  without  ]iroducing  much  ])ain 
or  great  discomfort,  "except  in  swallowing.  The  intense  inflammation 
which  follows  the  swallowing  of  c(nT<isiyes,  when  nc^t  fatal,  gradually  sub- 
sides, and  often  leads  to  cicatricial  contraction  and  stricture. 

The  hratmeiif  of  acute  innammation  of  the  (vsojiliagus  is  extremely  nn- 
satisfaetorv,  particularly  in  the  severer  forms.  The  slight  catarrhal  cases 
require  no"  special  treatineiit.  When  the  dys,)hagia  is  intense  it  is  best  not 
to  give  food  by  the  mouth,  but  to  feed  entirely  by  enemafa.  "Fragments  of 
ice^inay  bo  given,  and  as  the  pain  and  distress  subside,  demnlccnt  drinks. 
External  applications  of  cold  often  give  relief. 


^ 


SPASM  OP  THE  CESOPIIAGUS. 


4r)y 


rliiil  processes 
■iitiirrli  ol'  tlie 
iciil  initatimi, 
iii^'  eoiTosives. 
i|p|itlieriii,  and 
As  a  ]i\istiilav 
esiilt  111'  a  pro- 
w'lih  loeal  dis- 
ion  to  it  from 
leei'ation.  may 

ciliiess  of  the 
il.  ^lore  c'oni- 
)  tliat  tlie  siir- 
iis  follicles  are 
111  tile  pseiitlo- 
te,  usually  liui- 
ist  not  he  con- 
•cn.  'I'iie  pus- 
s  iuilaiumation 
out  iulillration 
n  body,  or  ex- 
t  of  tlic  fiullot. 
le  fibrinous   or 

I  in  the  fevers, 
lay  be  vomited. 

severe  iullam- 
the  swallowing 

II  pain  beneath 
■rlial  inflamma- 
foreign  liody  is 

of  ])ortions  of 
jirisinp  how  ex- 
jing  much  jiain 
B  inflammation 
,  graduallv  sub- 
e. 
s  extremely  un- 

eatarrha!  oases 
sc  it  is  best  not 
,  T^rafrments  of 
mulcent  drinks. 


A  chrunir  form  of  tesophagitis  is  described,  but  this  results  u-iui'.ly  from 
tlie  prolonged  action  of  the  causes  which  produce  the  acute  f<irm. 

ritrntlion  nf  llir  (Ksdjilidniis. — In  many  cachectic  conditions  catarrhal 
ulceration  is  found.  In  a  lew  rare  instances  ulcers  of  tlie  iesophagii>  arc 
iiiet  witii  in  typhoid  i'evcr.  .\cute  malignant  ulceration  may  pcrfomtc  the 
(esophagus  and  ojien  into  the  aorta. 

Associated  with  idironic  heart-disease  and  nun'e  freiiucntly  with  the 
senile  and  the  cirrhotic  liver,  the  u'sophageal  vi'ins  may  b^  enoriiKnii^ly 
distended  and  varicose,  particularly  toward  the  stomach.  In  t'licse  cases 
tiie  niuc(Uis  membrane  is  in  a  stale  of  chronic  catarrh,  and  the  jiaticnt  has 
freipient  eructations  of  mucus.  Rupture  of  these  (esophitgeai-ji^.'^ins  may 
cause  fatal  luemorrhage.  Two  cases  of  the  kiml  have  occurred  in  my  cx- 
])erienec.  The  blood  may  pass  jier  rectum  alone,  as  in  a  ease  reported  l>y 
Power,  of  JJaltimore,  in  ii<:',\). 


II.    SPASM    OF    THE    (ESOPHAGUS  ((Kmiihayismux). 

This  so-called  sjiasmodie  stricture  of  the  gullet  is  met  with  in  hysterical 
]nitieiits  and  hy])ochou(lriacs,  also  in  chorea,  ejiilepsy,  and  especially  hydro- 
])holiia.  It  is  sometimes  associated  also  with  the  lodgment  (d'  foreign  bodies. 
'JMie  i(lio](alhie  form  is  found  in  females  of  a  marked  neurotic  habit,  hut 
may  also  occur  in  elderly  men.  It  may  be  present  only  during  pregnancy. 
Off  cases  which  have  come  under  my  observation,  2  were  in  men,  one  a 
hypochondriac  over  sixty  years  of  age  who  for  many  months  had  taken 
only  licpiid  food,  and  with  great  dilliculty,  owing  to  a  spasm  which  accom- 
jiaiiied  every  atter.i])t  to  swallow.  The  readiness  with  which  the  bougie 
])assed  and  the  suhsei|Uent  history  showed  the  true  nature  of  the  case.  The 
])atient  eoin})lains  of  inability  to  swallow  solid  food,  and  in  extreme  in- 
stances even  liquids  arc  rejected.  The  attack  may  come  on  abrujitly,  and 
be  associated  with  emotional  disttn-bances  and  with  substernal  pain.  The 
bougie,  when  passed,  may  be  arrested  temjiorarily  at  the  seat  of  the  spasm, 
which  gradually  yields,  or  it  may  slip  through  without  the  slightest  effort. 
The  condition  is  rarely  serious.     Death  has,  however,  followed  it. 

The  (liivinosis  is  not  dillicult,  jiarticularly  in  young  jiersons  with  marked 
nervous  manifestations.  In  elderly  jiersons  (csoiihagism^s  is  almost  always 
connected  with  hyjiochondriasis,  but  great  care  must  be  taken  to  exclude 
cancer. 

Tn  some  cases  a  cure  is  at  once  elTcctcd  by  tlie  ])as)iage  of  a  bougie.  The 
general  neurotic  condition  also  requires  special  attention. 

Pdrnh/sls  of  the  (esophagus  scarcely  demands  separate  consideration. 
It  is  a  very  rare  condition,  due  most  often  to  central  disc^ase,  prir^icularly 
bulbar  ]iaralysis.  It  may  be  peripheral  in  origin,  as  in  dijditheritic  paraly- 
sis. Occasionally  it  occurs  also  in  hystei^.  The  essential  symptom  is 
dysphagia. 


ii* 


f 


460 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


111.    STRICTURE   OF   THE   CESOPHAGUS. 

This  results  from:  (.)  Congenital  narrowing,  (h)  The  --j^JLlX 
traction  of  healed  uleers,  usually  ^-^  ^^  ^^^^^^rV'^T^C^^^i 
to  svnhilis,  and  in  rare  instanees  after  typhoid  fever,  (r)  Ihe  grovstv  ot 
tun' >  in  the  walls,  as  in  the  so-called  cancerous  stricture.  Occas.ona  ly 
X^d  Unnors  pro  ecting  from  th.  mucosa  produce  ^-  narrow. nj,  (J 
External  pressure  hy  aneurism,  enlarged  lymph-glands,  enlaigtd  thjioKl, 
other  tumors,  and  sometimes  hy  pericardial  elhis.on 

The  cicatricial  stricture  may  occur  anywhere  in  the  gullet,  and  in  ex 
trein    cas  s  niav,  indeed,  involve  the  whole  tuhe,  l>ut  in  a  '->.l-ty  «        " 
1  a  c^e.    t  is  folmd  either  high  up  near  the  pharynx  or  low  down  to^^ard 
le    tonuK^    The  narrowing  may  be  extreme,  so  that  only  small  quant, - 
Zti  food  can  trickle  through,  or  the  'f  ^-^^^^  "^J  '^^;;^    ^S 
There  is  usuallv  no  dillicultv  in  making  a  diagnosis  of  the  cica  ricial  strict 
u  e   as  tie  his-torv  of  mechanical  injury  or  the  swallowing  of  a  corrosu 
fluid  ma  es  clear  the  nature  of  the  case.     When  the  stricture  is  low  down 
Si^  cv^M^agus  is  dilated  and  the  walls  are  usually  much  lyP^^trojdued^ 
When  the  obstruction  is  high  in  the  gullet,  the  food  is  usually  rejected  a 
on       V     reas,  if  it  is  low,  it  may  be  retained  and  a  considerable  quant,  j 
coTle'ct    bcfor    it  is  regurgitated.     Any  doubt  as  to  its  having  reached  the 
tniach  is  ren,c>ved  by  thc^ alkalinity  of  the  material  ejected  and  the  absenc 
of  t^^  characteristic  gastric  odor.     Auscultation  of  the  crsophagus  may  be 
1  t  .e     and  is  sometimes  of  service.     The  patient  takes  a  imnithtul  o 
Sr  a  d  the  auscultator  listens  along  the  left  of  the  spme.     The  norma 
;    ph  geal  hruit  may  be  heard  later  than  seven  seconds,  the  normal  t^nne  or 
Vre  .:.y  be  heard  a  loud  splashing,  gurgling  soimd      lie  --J    ^^  -- 
mur,  heard  as  the  iluid  enters  the  stomach,  may  be  f  ^^      P  lo  pa^ag    o 
the  ^.ophageal  bougie  will  determine  more  accurately  the  local  t>.     Con ica 
,";s  a    ached  to^a  flexible  whalebone  stem  are  the  most  -t-sfactory.  but 
hetnim-elastic  stomach  tube  may  be  used;  a  large  one  should  be  tried  fir.t. 
The  patient  should  be  placed  on  a  low  chair  with  the  head  well  thro.n 
b     /    The  index  f.ngei  of  the  left  hand  is  passed  far  into  the  pharynx 
ad  in  some  instances  this  procedure  alone  may  detc.nine    he  presence  o 
a  new  ^nowth.    The  bougie  is  passed  beside  the  finger  until  ,t    ouches  the 
po     rior  wall  of  the  pharvnx,  then  along  it,  more  to  one  side  than  in  the 
midd      line,  and  so  gradually  pushed  into  the  gullet.     It  is  to  be  borne 
'ml  th;t  in  pas^ng  the  cricoid  cartilage  there  is  often  a  shgM  o^>- 
struction.    Creat  gentleness  should  be  used,  as  it  has  happened  more  th  n 
once  that  the  bougie  has  been  passed  through  a  cancerous  ulcer  into  tic 
"liastinum  or  through  a  diverticulum.     I  have  known  t^s  accu  ent    o 
l,,,,p„,  twice-ouce  in  the  case  of  a  distinguished  surgeon,  who  pc  foim  d 
Slu^otomv  and  passed  the  tube,  as  he  thought,  into  the  stomach.    The 
pos   mortem  on  the  next  day  showed  that  the  tube  had  entered  a  diverticu- 
C    and  through  it  the  left  pleura,  in  .hich  the  m,lk  injected  through 
the  tube  was  found.    Tn  the  other  instauce  the  tube  passed    l^rougW  can- 
cerous ulcer  into  the  lung,  which  was  adherent  and  inflamed.    Foitunatelj 


s. 

•icatricial  con- 
s,  occasionally 
riio  growth  of 
Occasionally 
larrov.ing.  ((/) 
largcd  thyroid, 

let,  and  in  ex- 
majority  of  in- 
,v  down  toward 
y  small  qiianti- 
be  (inite  slight, 
icatricial  strict- 
r  of  a  corrosive 
ire  is  low  down 

hypertrophiod. 
tally  rejected  at 
Icrablc  quantity 
ing  reached  the 
and  the  absence 
gphagiis  may  be 
i  a  mouthful  of 
le.     The  normal 

normal  time,  or 

;  secondary  niur- 

Thc  passage  of 

x'ality.     Conical 

satisfactory,  but 
uld  be  tried  first, 
cad  well  thrown 
ito  the  pharynx. 
s  the  presence  of 
til  it  touches  the 

side  than  in  the 
rt  is  to  be  l)ornc 
ften  a  slight  ob- 
ipcned  more  than 
us  ulcer  into  the 
I  this  accident  to 
n,  who  performed 
he  stomach.  The 
itered  a  diverticu- 

injected  through 
pd  through  a  can- 
ned.   Fortunately 


CANCER  OF  THE  CESOPIIAUUS. 


461 


these  accidents,  sometimes  unavoidable,  are  extremely  rare.  It  is  well 
always,  as  a  precautionary  mea.suro  before  passing  the  bougie,  to  examine 
carefully  for  aneurism,  which  may  jiroduce  all  the  symptoms  of  organic 
stricture.  In  cases  in  which  the  narrowing  is  extreme  tlicre  is  always  ema- 
ciation.    For  treatment,  surgical  works  must  bo  consulted. 


IV.    CANCER    OF   THE   CESOPHAGUS. 

This  is  usually  epithelioma.  It  is  not  an  uncommon  disease,  and  occurs 
more  fre(piently  in  males  than  in  females.  The  common  situation  is  in 
the  upper  third  of  the  tube.  At  first  confineil  to  the  mucous  memln'ano, 
the  cancer  gradually  increases  and  soon  ulcerates.  The  lumen  of  the  tube 
is  narrowed,  but  when  ulceration  is  extensive  in  the  later  stages  the  stricture 
may  be  less  marked.  Dilatation  of  the  tube  and  hypertroj)liy  of  the  walls 
usually  take  i)lace  above  the  cancer.  The  cancerous  ulcer  may  ])erforate 
the  trachea  or  a  bronchus,  the  lung,  the  mediastinum,  the  aorta  or  one  of 
its  larger  braiU'hcs,  the  ])ericardium,  or  it  may  erode  the  vertebral  column. 
In  my  experience  jierforation  of  the  lung  has  been  the  most  i'recpient,  [iro- 
ducing,  as  a  rule,  local  gangrene. 

Symptoms. — The  earliest  symi)tom  is  dys])hagia,  which  is  progressive 
and  nuiy  become  extreme,  so  that  the  jiatient  emaciates  rapidly.  Regurgita- 
tion may  take  jilace  at  once;  or,  if  the  cancer  is  situated  near  the  stomach, 
it  may  be  deferred  for  ten  or  fifteen  minutes,  or  even  longer  if  the  tube 
is  much  dilated.  The  rejected  materials  may  be  mixed  wHIi  blood  and  may 
contain  cancerous  fragments.  In  jjcrson.s  over  fifty  years  of  age  persistent 
dilhculty  in  swallowing  acconi])anied  by  rapid  emaciation  usually  indicates 
ceso])hageal  cancer.  The  cervical  ]ym])h-glands  are  freiiuently  enlarged  and 
may  give  early  indication  of  the  nature  of  the  trouble.  Pain  may  l)e  i)er- 
sistent  or  be  jiresent  only  when  food  is  taken.  In  certain  instances  the  pain 
is  very  great.  I  saw  an  autopsy  on  a  case  of  cancer  of  the  trsophagus  in 
which  the  patient  gradually  l)ecame  emaciated,  but  had  no  s])ecial  symp- 
toms to  call  attention  to  the  disease.  These  latent  cases  are,  however,  very 
rare. 

The  profinotiis  is  hopeless;  the  patients  usually  become  ])rogressivoly 
emaciated,  and  die  either  of  asthenia  or  sudden  perforation  of  the  ulcer. 

In  the  (lidfjiiosi.'i  of  the  condition  it  is  important,  in  the  first  ])lace.  to 
exclude  i)ressure  from  without,  as  by  aneurism  or  other  tumor.  The  his- 
tory enables  us  to  exclude  cicatricial  stricture  and  foreign  bodies.  The 
sound  may  1)e  passed  ami  the  ])resence  of  the  stricture  dctermiiuHl.  As 
mentioned  above,  great  care  slioidd  be  exercised.  Fragments  of  carcinom- 
atous tissue  may  in  some  instances  be  removed  with  the  tube.  On  aus- 
cultation along  the  left  side  of  the  spine  the  primary  ar^Jojihageal  murmur 
may  lie  much  altered  in  quality. 

Trcnfmoil. — In  most  cases  milk  and  liquids  can  be  swallowed,  but  su]i- 
plementary  nourishment  should  be  given  by  the  rectum.  It  may  l)e  ad- 
visable in  some  instances  to  pass  a  lube  into  the  stomach  and  attem])t  to 
feed  in  this  way.    When  there  is  dilTiculty  in  feeding  the  patient  it  is  very 


^^ 


4G2 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


i.uKl.  licltor  to  liavo  }ra>tr..t..n,y  luTfornuHl  at  nnco,  as  it  gives  tlie  greatest 
(oinfurt  and  ease,  and  prolongs  the  patieiifs  lii'e. 

V.  RUPTURE    OF   THE   CESOPHACUS. 

Thi'^  mnv  (KH-ur  in  a  l.ealtl.y  organ  as  a  result  of  prolonged  vomiting, 
lioerhaave  (leseril.e.l  the  tirst  ease  in  Uaron  Wassennar,  who  "  broke  a^umder 
the  tnho  of  the  lesophagns  near  the  diaphragm,  so  that  after  the  most  ex- 
erueiating  pain,  the  elements  Nvhieh  he  swallowed  passe.l,  together  with  the 
air  into  tl'e  eavity  of  the  thorax,  and  he  expired  in  twenty-four  hours. 
Fit/,  has  reported  a  ease  and  has  analyzed  the  literature  on  the  ^-'-I'loet  np 
to  IsrT  The  aeeident  has  usually  oeeurred  during  vomiting  alter  a  lull 
meal  or  when  intoxieated.    It  is,  of  course,  invarial)ly  fatal. 

Much  more  common  is  the  post-mortem  digestion  of  the  oesophagus, 
which  was  first  described  by  King,  of  (Juy's  Hospital.  It  is  not  very  in  re- 
nuent  In  one  instance  1  found  the  contents  of  the  stomach  in  the  le  t 
pleura.  The  erosion  is  in  the  posterior  wall,  and  may  be  ot  considerable 
extent. 

VI.  DILATATIONS   AND    DIVERTICULA. 

Stenosis  of  the  gullet  is  followed  by  secondary  dilatation  of  the  tube 
above  the  constriction  and  great  hypertrophy  of  the  walls.  Primary  dila- 
tation is  extremely  rare.  The  tube  may  attain  extraordinary  <  imensions- 
;U)  cm  in  circumference  in  Luschka's  case.  Regurgitation  of  food  is  the 
most  common  symptom.     There  may  also  be  ditlieulty  in  breathing  from 

pressure.  .     ,        ...  , 

Diverticula  are  of  two  f(n-ms:  (a)  Pressure  diverticula,  which  are  most 
common  at  the  Junction  of  the  jtharynx  and  gullet,  on  the  posterior  wall. 
Owincr  to  weakness  of  the  muscles  at  this  spot,  local  bulging  occurs,  which 
i«  araduallv  increased  ])y  the  j^ressure  of  food,  and  finally  forms  a  saccular 
pouch  (h)  The  traction  diverticula  situated  on  the  anterior  wall  near  the 
bifurcation  of  the  trachea,  result,  as  a  rule,  from  the  extension  of  inflam- 
mation from  the  lymph-glands  with  adhesion  and  stdiscquent  cicatricial 
contraction,  by  which  the  wall  of  the  gullet  is  drawn  out.  Diverticula  have 
been  «uccessfu"lly  extirpated  by  von  Bcrgmann  and  by  Mixter. 

\  rare  and 'remarkable  condition,  of  which  a  case  has  been  recorded 
bv  :MacLachlan,  and  of  which  a  second  is  in  attendance  at  my  clinic,  is  the 
(r«opha-o-pleuro-cutaneous  fistula.  In  my  patient  fluids  are  discharged 
at  intervals  through  a  fistula  in  the  right  infra-clavicular  region  which 
appears  to  communicate  with  a  cavity  in  the  upper  part  of  the  pleura  or 
lung.    The  condition  has  persisted  for  more  than  twenty  years. 


-1 


ACUTE   GASTRITIS. 


463 


5  the  greatci^t 


xed  vomitinp. 
broke  a'  iiiuler 
'  tlie  most  ex- 
?tlur  with  the 
^foiir  hours." 
lie  suhjeet  up 
g  after  a  full 

ic  (fsopluifrus. 
lot  very  infre- 
eh  in  the  left 
if  considerable 


m  of  the  tuho 
Primary  dila- 

:  (limeni-ions — 
of  food  is  the 

jreathing  from 

vhieh  arc  most 
posterior  wall. 
r  oceurp,  which 
>rms  a  saccular 
r  wall  near  the 
sion  of  inflam- 
iiont  cicatricial 
)iverticula  have 
r. 

hcen  recorded 
ny  clinic,  is  the 
are  discharfred 
'  region,  which 
if  the  pleura  or 
ears. 


VI.   DISExVSES  OF  THE  STOMACH. 
I.    ACUTE  GASTRITIS. 

{Simple  Gas/ritis;  Acute  Gaxtric  Cutanh;  Acute  Dynpe/ma.) 

Etiology. — Acute  gastric  catarrii,  one  of  the  most  common  of  com- 
plaints, occurs  at  all  ages,  and  is  usually  traceable  to  errors  in  diet.  It  may 
follow  the  ingestion  of  more  food  than  the  stomach  can  digest,  or  it  may 
result  from  taking  uusuitalile  articles,  which  eitiier  themselves  irritate  the 
mucosa  or,  remaining  undigested,  decompose,  and  so  excite  an  acute  dys- 
pei.sia.  A  frecpient  cause  is  the  taking  of  food  which  has  begun  to  decom- 
pose, ])articularly  in  hot  weather.  Jn  children  these  fermentative  processes 
iire  very  apt  to  excite  acute  catarrii  of  tlie  bowels  as  well.  Another  very 
common  cause  is  tlic  abuse  of  alcohol,  and  the  acute  gastritis  which  fol- 
lows a  drinking-bout  is  one  of  the  most  typical  forms  of  the  di.sease.  The 
tendency  to  acute  indigestion  varies  very  much  in  dill'erent  individuals, 
and  indeed  in  families.  We  recognize  this  in  using  the  expressions  a  "  deli- 
cate stomach"  and  a  "strong  stomach."  (loiily  persons  are  generally 
thought  to  be  nun-e  dis])osed  to  acute  dysi)e|)sia  than  others.  Acute  catarrh 
of  the  stomach  occur      t  the  outset  of  many  of  tiic  infectious  fevers. 

LcliiTt  described  a  special  infectious  form  of  gastric  catarrh,  occurring 
in  ei)idcniic  form,  and  only  to  ije  distinguished  from  mild  typhoid  fever  by 
the  ab.<ence  of  ro.«e  spots  and  swelling  of  the  spleen.  Many  practitioners 
still  adhere  to  the  belief  that  there  is  a  form  of  t/astric  fever,  but  the  evidence 
of  its  existence  is  by  no  means  satisfactory,  and  certainly  a  great  majority 
of  all  cases  in  this  country  are  examples  of  mild  typhoid. 

Morbid  Anatomy.— J Jea union t's  study  of  St.  IVrartin's  stomach 
showed  that  in  acute  catarrh  tlie  mucous  membrane  is  red<lened  and  swol- 
len, less  gastric  juice  is  secreted,  and  mucus  covers  the  surface.  Slight 
luTmorrhages  may  occur  or  even  small  erosions.  The  submucosa  may  he 
somewhat  (edematous.  [Microscopically  the  changes  are  chiefly  noticeable 
in  the  mucous  and  i)cptic  cells,  which  are  swollen  and  more  granular,  and 
there  is  an  infiltration  of  the  intertuhular  tissue  with  leucocytes. 

Symptoms. — Tn  mild  cases  the  sym[)toms  are  those  of  slight  "indi- 
gestion " — an  uncomfortable  feeling  in  the  abdomen,  headache,  depression, 
nausea,  eructations,  and  vomiting,  which  usually  gives  relief.  The  tongue 
is  heavily  coated  aiid  the  saliva  is  increased.  In  children  there  arc  intes- 
tinal symptoms — diarrlm>a  and  colicky  pains.  There  is  usually  no  fever. 
The  duration  is  rarely  more  than  twenty-four  hours.  In  the  severer  forms 
the  attack  may  set  in  with  a  chill  and  febrile  reaction,  in  which  the  tem- 
jiorature  rises  to  102'  or  103°.  The  tongue  is  furred,  tlic  breath  heavy,  and 
vomiting  is  freciuent.  The  ejected  substances,  at  first  mixed  will/ food, 
subsequently  contain  much  mucus  and  bile-stained  fluids.  There  may  be 
constipation,  but  very  often  there  is  diarrlnea.  The  urine  presents'  the 
usual  febrile  characteristics,  and  there  is  a  heavy  deposit  of  urates.  The 
abdomen  may  ho  somewhat  distended  and  slightly  tender  in  the  epigastric 
region.  Herpes  may  appear  on  the  lips.  The  attack  may  last  from  one 
29 


■  i 


ii 


,*> 


^Mk 


f 


() 


^^^  DISEASES  OF   THE  DIGESTIVE  SYSTEM. 

to  tl,roo  days,  and  ocoaMonally  lonj^or.  Tl.o  oxan.ination  of  tl>o  vomit  us 
lZ,a.  a  rule,  al.senc.  of  the  hydn.-hlor.c  acul,  presence  .1  lactic  an,l 
f.iHv 'icids  and  marked  increase  in  the  iiuieus. 

Dil^no  is.-nu.  ordinary  afebrile  gastric  catarrh   is  rcaddy  reco,u- 
nix^^°a  nne  febrile  iorn.  I  so  similar  to  tiie  nutud  syn,,ton.  .man, 
the  infec.tious  diseases  that  it  is  impossible    or  a  day  or  two  to    n  k     a 
nlue  <lia,nosis,  particularly  in  the  cases  which  "-->--'-    '  ^^ 
.nnnt'ineouslv  and  indei)endentlv  of  an  error  m  diet.     Some  ot  tnt.e  u 
3  ;^  c   "    y  a    '  .:ute  infection;  the  symptoms  may  be  very  iniense    and 
MUiDit  (losn^  ciii  .  „+t„,.i-  «ot<;  in  with  severe  headache  and  (!.•- 

it,  as  sometimes  happens,  the  attack  sets  in  \\nn  ■^'  .iHlominal 

,  1      .,>;  t.ii-iiii    Inr  iiioniiT'itis.      >>  nen   ine  .inuiuuui.u 

lirium  the  case  may  be  mistaken   loi   "  .^"'"-r' ,        ,    ,,.,„,,„„,.  ,,„iie      I,, 
„..ins  arc  intense  the  attack  may  be  coniounde.l  with  galston.,  ciic.     i 

^^"•T^t;;:^Mild  cases  recover  spontaneously  i^|-"ty-f our  hours 
and^quire  no  treatment  other  than  a  dose  o    castor  oi    in  ^^ /^ ^ 
blue  mass  in  adults.    In  the  severer  lorms,  if  there  is  nui  h  distK>s  i     tn 
re"  orof    he  stomach,  the  vomitino-  should  he  promoted  by  warm  Mt  ■ 
7Z      .     e  emetics.'   A  full  dose  of  calomel,  8  to  10  grains,  sln>idd    . 
;  ve     and      llowed  the  next  morning  by  a  dose  of  Ilnnyadi-Janos  or  lails- 
b  d  wa  there  is  eructation  of  acid  lUiid.  bicarbonate  of  soda  and 

n     1    may  be  given.     The  stomach  should  have,  if  possible,  absolute 
re  1         a  oood  plan  in  the  case  of  strong  persons,  particularly  in  those 

^Wi  "     1    itdiol.  lo  cut  off  all  food  for  a  day  or  two.    The  l-tu^nt  may 
'      lowe,l  soda  water  and  ice  freely.     It  is  well  not  to  attempt  to  ck 
1  e  vomiting  unless  it  is  excessive  and  protracted.     Recovery  is  usua 
completes  though  repeated  attacks  may  lead  to  subacute  gastritis  or  to  the 

establishment  of  chronic  dyspepsia.  rno+rHi«      Tin.  i«  an  ex- 

Phlegnionous  Gastritis;   Acute  Suppurative  Gastrit  s.-T h  s  s  an  ex 
ces^vely  rare  disease,  characterized  by  the  occurrence  of  suppurative     lo- 
ce  ses  in  the  submucosa.     The  atfection  is  more  common  i.  men  th 
^^nien      Leith  has  collected  85  cases,- and  has  given  the  best  accou.     ,n 
1    erati       (l<:dinburgh  Hospital  Reports,  vol.  iv).    l^he  cause  is  seldom 
obvious     It  has  been  met  with  as  an  idiopathic  atfection.  but  ,t  has  occii  r  d 
a    ol  puerperal  fever  and  other  septic  processes,  and  has  occasiom i. 
oUowed  tranma.     Anatomically  there  appear  to  be  two  forms    a  diff    e 
Xit    ifdtration  and  a  localized  abscess  formation,  m  which  case  the 
I         u       ead^^  the  size  of  an  egg,  and  may  burst  into  t^lje  st^omach  or 
nth    peritoneal  cavitv.     In  two  of  the  cases  I  have  seen,  the  abscess  w  s 
n  CO  ncSl  with  cancer  of  the  stomach,  and  it  is  "uteres  in.    o  no  e 
hat  in  both  there  were  recurring  chills.     In  a  third  case,m  a  ditUisc  cai 


ACUTE  GASTUITIS. 


405 


tlio  vomitus 
il'  lactic  ami 

■adily  rocou- 
iMiis  of  many 
■()  to  make  a 
,  so  to  speak, 

of  tlu'se  rc- 

iiiionsc,  ami 
aclic  ami  dc- 
10  al)(lomiiial 
lie  colic.  In 
,ive  forms  of 
^  tom])crat\irc 
more  sudden. 

and  the  rose 
muler  gastric 

gastric  crises 
with  a  simjtle 
nee-jerks  and 

ty-fonr  iKUirs. 
children  or  of 
distress  in  the 
y  warm  water 
ins,  should  he 
I  alios  or  C'arls- 
e  of  soda  and 
sihlo,  ahsolute 
ularly  in  those 
le  ])atient  may 
empt  to  check 
,-ory  is  iisiially 
tritis  or  to  the 

-This  is  an  ex- 
ippurativo  ])ro- 
n  men  than  in 
lest  account  in 
cause  is  seldom 

<it  has  occurred 
las  occasionally 
'orms,  a  diffuse 

which  case  the 
the  stomach  or 

the  abscess  was 
jrcstinc  to  note 
in  a  diffuse  car- 


cinoma, there  was  extensive  jilileguionous  inllammalion  with  vomiting  (»f  a 
liorrihly  I'etid  material. 

The  sijinptditis  are  variable.  There  are  usually  ])aiii  in  the  ahdonion, 
fever,  dry  tongue,  and  symptoms  of  a  severe  infective  process,  delirium 
and  coma  ju'cceding  death.  Jaundice  has  heeu  met  with  in  some  instances. 
Occasionally,  when  the  al).";ce.<s  tumor  is  large,  it  has  been  iAl  externally, 
in  one  case  forming  a  mass  as  large  as  two  ti.-^ts.  Tiiere  are  instances  which 
run  a  more  chronic  course,  witii  pains  in  the  abdomen,  fever,  and  chills. 

'J'he  ilifn/iiiisis  is  rarely  possible,  even  wiieii  with  abscess  ru])ture  occurs, 
and  the  pus  is  vomited,  as  it  is  not  possiide  to  dill'erentiate  this  condition 
from  an  abscess  j)erforatiiig  into  the  stomach  from  without.  It  is  staled, 
liowevcr,  that  I'livostek  made  the  diagnosis  in  one  of  his  cases. 

Toxic  Gastritis. — This  most  intense  form  of  inilammation  of  the  stom- 
ach is  excited  i)y  the  swallowing  of  concentrated  mineral  acids  or  strong 
alkalies,  or  by  such  poisons  as  jiliosphorus,  corrosive  sublimate,  ammonia, 
arsenic,  etc.  In  the  non-corrosive  poisons,  such  as  phosphorus,  arsenic, 
and  antiiiKuiy.  the  process  consists  of  an  acute  degeneration  of  the  glandular 
elements,  and  luemorrhago.  In  the  powerful  concentrated  poisons  the 
mucous  menil)rane  is  extensively  destroyed,  and  may  be  converted  into  a 
bi'ownish-lilack  e.«char.  In  the  less  severe  grades  there  may  be  areas  of 
necrosis  surrounded  by  intlammatory  reaction,  while  the  suhmucosa  is  haMu- 
orrhagic  and  infiltrated.  Tlie  process  is  of  course  more  intense  at  the 
fundus,  but  the  active  ]icristalsis  may  drive  the  poison  through  the  |iylovus 
into  the  intestine. 

The  si/iiijjt()»ts  arc  intense  pain  in  tlu^  mouth,  throaK  and  stoinach, 
salivation,  great  dilUculiy  in  swallowing,  and  constant  vomiting,  the  vom- 
ited materials  being  bloody  and  sometimes  containing  portions  of  the 
mucous  rnemlirane.  The  abdomen  is  tender,  distended,  and  painful  on 
])ressure.  In  the  most  acute  cases  symptoms  of  collapse  su])crvene;  the 
]iulse  is  weak,  the  skin  pale  and  covered  with  sweat;  there  is  restlessness, 
and  sometimes  convulsions.  There  may  be  albumin  or  blood  in  the  urine, 
and  ])otechia'  may  develop  on  the  skin.  When  the  ])oison  is  less  intense, 
the  sloughs  may  so])arate,  leaving  ulcers,  which  too  often  lead,  in  the 
cesojihagus  to  stricture,  in  the  stomach  to  chronic  atrophy,  and  ihially  to 
death  from  exhaustion. 

The  ilidjinosis  of  toxic  gastritis  is  usually  easy,  as  ins])eclioii  of  the 
mouth  and  ])haryiix  shows,  in  many  instances,  corrosive  ed'ects,  whik  the 
examination  of  the  vomit  may  indicate  the  nature  of  the  poison. 

In  ])oisoning  by  acids,  magnesia  should  be  administered  in  milk  or 
with  egg  albumen.  When  strong  alkalies  have  been  taken,  the  dilute  acids 
phonld  bo  adniini.«tered.  If  the  case  is  seen  early,  lavage  should  he  Tised. 
For  the  severe  inflammation  which  follows  the  swallowing  of  the  stronger 
poisons  palliative  treatment  is  alone  available,  and  morjihia  may  bo  freely 
employed  to  allay  the  pain. 

Diphtheritic  or  Membranous  Gastritis. — This  condition  is  met  with 
occasionally  in  diphtheria,  but  more  commonly  as  a  secondary  process  in 
typhus  or  typhoid  fever,  pneumonia,  pyaemia,  small-pox.  and  occasionally 
in  debilitated  children.    An  instance  of  it  came  under  my  notice  in  pneu- 


I! 


^^,(.  DISEASKS  OF  TllH  DldESTlVK  SYSTEM. 

,,,„.lition  is  not  ivn.-niziil.lr  .luring  lilc  uiik>.,  .i>  in  a  i  .i.  l 

^••"i; ';iir;^'''^;s;;L^G:si;ms.--.t  oeca.io..i.y  ,.,>,>.-  that  .,..,1 

,;,;;.!,..  ..f  tlu.  kma  is  that  .-.porfa  l>v  Kun.lrat,  n.  .hxh  tlu.  lasu. 
lun-nis  (lcvrl..lH..l  in  tlie  stomach  and  mtustine 

In  cinrrr  in.l  in  -li'  tation  of  llu'  ^loniacli  tho  sarcma^  an.l  >cast  In     i 
,,.;;,::":•;  ■.  .naintainm,  tin.  ..h,...ni.  .a.n.is.     As  -'>  -^-1^^ 
•   ■       ;■  ,..,,,.,1.1..  of  killin.--  tlu>  ov.lmarv  l)actena.     Oitli   >tat(.s  mar 

iJ^ances  tulK.nnl-.is  an.l  syphilid  attack  the  yastnc  mncosa. 


II.    CHRONIC  GASTRITIS. 

(Chronic  Calurrh  of  ih.  Stumuvh;  Chronic  Dyspevsin.) 
Deflnition.-A  c,m.liti..n  ..f  .listurlu-.l  dij^ostion  associato.l  with  in- 

structure  of  tlic  mucosa.  i.,-<iilr..1   n^  fol- 

EtioloeV -'rhc  causes  of  chronic  gastritis  may  he  .•la>silie(l  as  lo 
loJ  n     n^t'eti...     The  nse  of  unsnitahlc  .>r  improperly  pre,.arcd  food. 
T   ;■,.   •  i'^  eu      se  of  certain  articles  of  diet,  such  as  veiT  hU  suhstanees 
o     o      '  m   aiiiim^  too  much  of  the  oarhohydrates.    Now  England  p.e  and 
the  hot  r.-f  the  Southern  States  arc  res,Kmsihle  for  many  ...ses  ot 

M.i  The  nse  in  excess  of  tea  or  colleo,  and,  ah.ne  all,  of  alc.)- 
;inn-;^v'n:^'fo.  Under  this  heading,  too,  may  he  mentioned  the 
l^L      ot^o  at  irre.nilar  hours  or  too  rapidly  and  imperfectly  chewmg 

ho  W     t  In    0  u   tn'  excess  in  eating  d..es  more  damage  ,han  excess  in 
£  :     A    .unmon  cause  of  chronic-  catarrh  is  drinking  t-.o  iroely  of  ic  - 
er    urim'  meals,  a  practice  which  plays  no  small  part  m  the  prevalence  of 
V  ,?o  I   n     merica.    Another  frequent  cause  is  the  abuse  of  tohacc.,,  par- 
ti^ nrlci^w-^      (^)  Constitutional  causes.     Aniomia,  chlorosis   chronic 
do        i  .  ialiotos,  and  P.right's  disease  are  often  associated  with 
V  ni  t  t;^  cat;,rrh.     C^)  Local  conditions:  (.)  of  the  stomach,  as  in  can- 
'  c,;  and  dilat.,tion,  which,  are  invariably  acc.nnpanied  by  cat.ml,  (  ) 

c  m  IcnVof  tlio  p.>rtal  circulation,  oansing  chronic  engorgement  ol  tho 
Xons  mendw.ane^ls  in  cirrhosis,  ohronio  heart-disease,  and  certain  chroni.. 

'"^iS^"  Anatomy-Anatomically  two  forms  of  chronic  gastritis 
mav  be  recognized,  the  simple  and  the  sclerotic. 

\a)  Simple  Chronic  Gastritis -The   organ  ^^^^^f^   '"/''i ,  Lcn 
nmcois  nu.nbrano  pale  gray  in  color,  and  covered  with  closely  adliercnt, 


„_ «• 


UIIUOXIC  GASTRITIS. 


407 


t.lics.     Tin- 
Idliii  Thom- 

that  fiuij.'i 
lost  rciuiirk- 
h   the  laviis 

I  yi'iist  I'lingi 
,  I'^.o  >,'iiHlric 
tcs  tllilt  tlu' 
1  aiul  iilfi'ia- 
loiis  gastritis 
y  t'xoito  fias- 
i'ls.     In  rare 


I 

nt(Hl  with  in- 
ill  the  gastric 
s  retained  for 
atioiis  in  the 

issilied  as  fol- 
)rei)are<l  food, 
i'at  snl)stances 
ighuid  i)ie  and 
many  eases  of 
ne  all,  of  aleo- 
montioned  the 
f(M-tly  chewing 

than  excess  in 
lO  freely  of  ice- 
0  ])revalence  of 
)f  tohacco,  i)ar- 
lorosis,  clironic 
associated  with 
nacli,  as  in  can- 
hy  catarrh;  (h) 
pifcnient  of  the 

certain  clironic 

hronic  gastritis 

enlarged,    the 
losely  adnercnt, 


tenacious  mucus.  Tin'  veins  are  large,  jiatclics  of  cc(liymo>is  ai'c  not  in- 
fre(}nently  sfcn,  and  in  the  clironic  catarrh  of  jioital  oli>lriiitioii  and  of 
clironic  hi'art-disrasc  small  Inemorihagii-  cni.-iiuis.  Toward  the  pylorus  the 
mucosa  is  not  infrc(|ncntly  irregularly  pigiiK'nted,  and  presents  a  rough, 
wrinkled,  inammillatcd  surface,  the  ihil  huniniii'luiir  of  the  f'l'ench.  a  con- 
dition which  may  sometimes  he  so  prominent  that  writers  have  deserihed 
it  as  i/(islrih's  poUipnsd.  The  luemhrane  may  he  thinner  than  normal,  ami 
much  liriner,  tearing  less  readily  with  the  linger-nail.  I'lwald  thus  de- 
scrihes  the  histological  changt's:  The  minute  anatomy  shows  the  picture 
of  a  imreiichymalons  ami  an  interstitial  inllammatioii.  The  gland  cells 
are  in  part  eroded  or  show  cloudy  granular  swi'lling  or  atiophy.  The  dis- 
tiivtion  hctwcen  the  principal  and  marginal  cells  cannot  he  recognized, 
and  in  many  places,  particularly  in  the  pyloric  region,  the  tuhes  have  lost 
their  regular  form  and  show  in  many  places  an  atypical  hranching,  like 
the  lingers  of  a  glove.  Individual  glands  are  cut  oif  toward  the  fundus, 
hut  a])pi'ar  at  the  horder  of  the  suhnuicosa  as  cysts,  partly  empty,  with  a 
smooth  mcmhrane.  ])artly  filled  with  remnants  of  liyaliiu'  and  refraetile 
epithelium.  An  ahnndant  small-celled  iidiltration  presses  ajiart  the  tuhides 
heing  particularly  marked  toward  the  surface  of  the  mucosa,  and  from 
the  suhmucosa  extensions  of  the  connective  tissue  may  he  seen  passing 
between  the  glands.  The  mucoid  transformiitioii  (d'  the  cells  of  the  tuhiiles 
is  a  striking  feature  in  tlu'  process  and  may  i-xtend  to  the  very  fundus  of 
the  glands. 

{h)  Sclerotic  Gastritis. — .\s  a  final  result  of  the  parenchymat(Uis  and 
interstitial  changes  the  mucous  mcmhrane  may  undergo  com|ilete  atrophy, 
so  that  lint  few  traces  of  secreting  snhstance  remain.  There  appear  to 
he  two  forms  of  this  sclerotic  atrophy — one  with  thinning  of  the  coats  of 
the  stomacli,  plilliisis  rciitrinili,  and  a  retention  or  even  increase  of  the 
size  of  the  organ;  the  other  with  enormous  thickening  of  the  coats  and 
great  reduction  in  the  volume  of  the  organ,  the  condition  which  is  usually 
described  as  cirrhosis  rciitrintli.  Extreme  atrophy  of  the  mucous  mem- 
brane of  the  stomach  has  been  carefully  studied  by  Fenwick,  Kwald,  and 
others,  and  we  now  recognize  the  fact  that  there  may  lie  such  destruction 
and  degeneration  of  the  glandular  elements  liy  a  jirogressive  develo])ment 
of  interstitial  tissue  that  ultimately  scarcely  a  trace  of  secreting  tissue  re- 
mains. Ill  a  characteristic  case,  studied  l)y  IlcTiry  and  myself,  the  greater 
portion  of  the  lining  membrane  of  the  stomach  was  converted  into  a  ])er- 
t'ectly  smooth,  cnticnlar  structure,  showing  no  trace  whatever  of  glandular 
elements,  with  enormous  hy])ertropliy  of  the  inuscularis  mucosa',  and  here 
and  there  formation  of  cysts.  In  the  other  form,  with  identical  atrophy 
and  cyst  formation,  there  is  enornions  increase  in  the  connective  tissue,  and 
the  stomach  may  be  so  contracted  that  it  does  not  hold  more  than  a  cou])lo 
of  ounces.  The  walls  may  measure  from  2  to  3  cm.;  the  greatest  increase 
in  thickness  is  in  the  sulimucosa,  but  the  hy])ertro])hy  also  extemls  to  the 
muscular  layers.  A  similar  atTection  uiay  coexist  in  th(>  caMMiin  and  colon. 
The  condition  may  be  dinicult  to  distinguish  from  dilfuse  carcinoma.  There 
may  bo  also  proliferative  peritonitis,  with  perihepatitis,  ])eris|)lenitis,  and 
ascites.     While  one  is  not  justified  in  saying  that  all  cases  of  cirrhosis  of 


^^ 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


468 

""'svmpS -''n;';  afe.i,.n  ,u.™t,  tor  .n  ,„.loli„i...  ,.c.rio.l.  ..»,    n, 
i.  ,hf  ^f  t"'  .„„.t  ..l,r„„io  ,li..,s«  changes  '-"VZ^  'Z^  go 

Aincii-X  oarly  symptoms  aie  teclint-  ot  (u.  m  i  i 

stomacli  is  empty  there  may  also  l.e  a  p  unlul  tci  l.n 

stomach,  nsnally  '^^  \"^; '"",;, ^.  „,,,,t,,.    The  tip  and  margin  of  tlie 

!:::;:;::!  rtr:^:n;:r'iic^;^a;vith  this  catari^^ai  --t:^;^::; 

mv  he  TH  inci^ase  in  tlie  salivary  and  pharyngeal  secretions.    Nan^ea  is  an 
..raauallv  an  atony  of  the  muscular  walls.     11k  absorption 


l^  ,. 


CIIUONIC  GASTUITIS. 


4(;i» 


catarrh,  it  is 
t'  tlio  gastric 
pcpsia. 
uitc  are  iiu't 
ly  ill  coniuH- 
■irrliosi:*,  ami 

s]iL'cial  coii- 
tlo  srhveds  of 
cl  S'lroness  on 

probably  the 
e,  moro  coiii- 
ny  symptoms. 
■I'ply  Inomor- 
iiy  bo  i)rosent 

do  not  form 

of  profuse  or 

criod,  and,  as 
[o  time.  Till' 
i-s  very  good. 
1  after  eating, 
1.  When  the 
pain  dilVers  in 
A'lien  localized 
it  is  known  as 
ssure  over  the 
DiUed.  and  the 

margin  of  the 
tomatitis  there 
,  Xansea  is  an 
ling  hours.    It 

gastritis  as  in 

may  not  occur 
irs  after  taking 
dent  dysi)epsia, 
I  the  gas,  bitter 
ixHiuent.  occurs 

In  the  chronic 
ion,  in  which  a 
n  various  stages 
ition  sliows  the 
i.  in  addition  to 
cut,  is  much  re- 
am! on  washing 
ions  of  food  are 
on.  the  stomach 
irrh.  may  induce 
ion  is  slow,  and 


iodide  of  potassium,  given  in  capsules,  wliicli  should  normally  reach  the 
saliva  within  tiftcen  miniiti's,  may  not  lie  evident  for  mori'  than  lialf  an 
liuur. 

Constipation  is  usually  present,  but  in  some  instances  there  is  diarrluca, 
and  undigested  food  jmsses  rapidly  through  the  l)owcls.  Tlie  urine  is  often 
scanty,  high-colored,  and  dejtosits  a  heavy  sediment  of  urates. 

Of  oilier  symptoms  headache  is  common,  and  the  patient  feels  constantly 
out  of  sorts,  indisposed  for  exertion,  and  low-spirited,  in  aggravated  cases 
iiielaiuhoiia  may  develop,  'rrousseaii  called  attention  to  the  occurrence 
of  vertigo,  a  marked  feature  in  certain  ca,<es.  'I'lu;  pulse  is  small,  some- 
times slow,  and  there  may  be  palpitation  of  the  heart.  Fever  does  not 
occur.  Cough  is  sometimes  prt'sent,  but  the  so-called  stomach  eongii  of 
chronic  dyspeptics  is  in  all  probability  dependent  n|)()n  pharyngeal  irri- 
tation. 

The  (litstn'r  Cdiilnilx. — The  fasting  stomach  may  be  empty  or  it  may 
contain  nuicli  mucus — ijaslrilis  inucipdni  of  i>oas.  In  the  lest  breakfast, 
withdrawn  in  an  hour,  the  IICL  is  usually  diminished,  though  it  may  be 
normal — naslrilis  aritln.  in  other  cases  the  free  liCl  may  be  absent  — 
gastrins  (nuwidn.  While  in  the  advanced  forms  of  atrophy  of  the  mucosa 
there  may  be  neither  aciils  nor  ferments — (/aslrilis  (ilropliicans. 

The  motor  function  cd'  tlie  .■itomaeh  is  not  usually  much  impaired. 

The  symptoms  of  atrojihy  of  the  mucous  membrane  of  the  stomach,  with 
or  without  contraction  of  the  organ,  are  very  com|dc.\,  and  cannot  be  said 
to  present  a  uniform  picture.  The  majority  of  the  cases  present  the  symp- 
toms of  an  aggravated  chronic  dyspepsia,  often  of  such  severity  that  cancer 
is  suspected.  In  one  of  the  cases  which  I  examined, the  persistent  distress 
after  eating,  the  vomiting,  and  the  gradual  loss  of  llesli  and  strength,  very 
naturally  led  to  this  diagnosis,  but  the  duration  of  the  disease  far  ex- 
ceeded tiiat  of  ordinary  carcinoniii.  In  the  cirrhotic  form  the  tumor  ..lass 
may  sometimes  be  felt.  In  atrophy  of  the  stomach,  whether  associated 
with  cirrhosis  or  not,  the  clinical  picture  may  be  I'  '  of  pernicious  aiuemia. 
As  early  as  18(10,  Flint  called  attention  to  this  connection  between  atrophy 
of  the  gastric  tubules  and  auiemia,  an  observation  which  Fenwiek  and 
others  have  amply  confirmed. 

Diagnosis. — F.wald  distinguishes  three  forms  of  chronic  gastritis:  (1) 
Simjile  gastritis;  (2)  mucous  (sclileiminc)  gastritis;  {'^)  atropine  gastritis. 

In  (1)  the  fasting  stomach  contains  only  a  small  quantity  of  a  slimy 
fluid,  while  after  the  test  breakfast  the  TTCl  is  diminished  in  (piantity  or 
may  be  absent.  Lactic  acid  and  the  fat  acids  may  be  jjreseiit.  After  lioas's 
more  rigid  test  meal  the  organic  acids  are  rarely  found.  The  pepsin  and 
rennet  are  always  present. 

In  (2)  the  acidity  is  always  slight  and  the  condition  is  distinguished 
from  (1)  chiefly  by  the  large  amount  of  mucus  present. 

In  {:])  the  fasting  stomach  is  generally  empty,  while  after  the  test 
breakfast  IlCl,  pepsin,  and  the  curdling  ferment  are  wholly  wanting. 

The  diagnosis  of  cancer  of  the  stomach  from  chronic  gastritis  may  be 
very  difTicult  when  a  tumor  is  not  present.  The  cases  re(|uirc  most  careful 
study,  and  it  may  take  several  months  before  a  decision  can  be  reached. 


u 


470 


DISKASES  OF  TIIK   DIGKSTIVE  SYSTEM. 


Treatment.— WIhmi  possililr  the  canso  in  oiicli  casi'  slioiild  hv  asrcr- 
taiiioil  and  an  attompl  niadi'  In  dctcriHiiic  tli"  sptrial  I'orin  of  indi-ifslioii. 
I'siially  tlKMT  is  no  dillicuity  in  ditrcicntiatin;:  llic  ordinary  catarrhal  and 
tiio  niTVons  varieties.     A  carclid  study  of  tlic  phenonicna  oi'  ilij^'cstion  in 
tiu"  way  already  laid  down,  thou-li  not  e>sential  in  every  instance,  should 
certainly  he  carried  out  in  the  more  oiistinate  and  ohscure  i'ornis.     'i"\vo  nn- 
l)ortant"(inestions  should  he  asked  of  every  dyspeptic— first,  as  to  the  time 
taken  at  his  meals;  and,  second,  as  to  the  quantity  he  eats.      Tractically 
a  larj^'e  majority  of  all  case.'^  of  disturhed  dij,n'stion  come  from  'lasty  an. 
imperfect  mastication  of  the  food   and   from  overeating,      llspecial  ,»^tres^ 
shoidd  he  laid  ni)on  the  former  j.oint.     In  .<ome  instances  it  will  alone  sul- 
lice  to  cure  dysi)ei)sia  if  the  i)atient  will  count  a  certain   nuniher  hetore 
swallowing  each   mouthful.     The  second   point   is  of  even  ^nvater  impor- 
tance.     People  hahituallv  eat  too   much,  and   it   is   prolmbly   true  that   a 
greater  numher  of  mahuiies  ari.<e  from  excess  in  eating  than  from  excess 
in  drinking.     I'artieiilarlv  is  this  the  case  in  America,  where  the  average 
man  is  ah.stemious  in   the  matter  of  alc.hol,  hut   imprudent  to  a  degree 
in  all  matters  relating  to  food.     M(Uvover,  peo|.le  have  not  had  time  to 
learn  the  art  of  cooking,  and  much  of  the  indigestion,  jmrticnlarly  in  the 
country  districts,  may  he  chargt-d  to  the  liarharous  methods  of  preparing 
the  food.    The  treatment  may  he  consi<lereil  under  the  headings  of  dietetic 

and  inedieinal. 

(rt)  General  and  l)ietelir.—\  careful  and  systematically  arranged  di- 
etary is  the  first,  sometimes  the  only  essential  in  the  treatment  of  a  case  of 
chnmie  dyspei)sia.  It  is  imimssihle  to  lay  down  rules  apidicahle  to  all  cases. 
Individuals  differ  extraordinarily  in  their  capahility  of  digesting  dillVrent 
articles  of  food,  and  there  is  much  truth  in  the  old  adage,  "  One  nianV  food 
is  another  man's  poison."  The  individual  preferences  for  diit'erent  articles 
of  food  should  be  permitted  in  the  milder  forms.  Physicians  have  i)rol)aldy 
been  too  arbitrary  in  this  direction,  and  have  not  yielded  sulViciently  to  the 
intimations  given  by  the  ai)petite  and  di'sires  of  the  i)atient. 

A  rigid  milk  diet  may  be  ivm\  in  obstinate  cases.  Much  dei)ends  upon 
whetluMMhe  i)atient  is  able  to  take  and  digest  milk  properly.  In  the  forms 
as.sociated  with  liright's  disease  and  chronic  portal  congestion,  as  well  as  in 
manv  instances  in  which  the  dyspepsia  is  i)art  of  a  neurasthenic  or  hysterical 
tronble,  this  jdan  in  conjunction  with  rest  is  most  efricaeions.  If^niilk 
is  not  digested  well  it  may  be  dilnted  one  third  with  soda  water  or  Vichy, 
or  5  to  fo  grains  of  carbonate  of  soda,  or  a  pinch  of  salt  may  be  added  to 
each  tnniblerfni.  In  many  cases  the  milk  from  which  the  cream  has  been 
taken  is  better  borne.  Uutt(>rmilk  is  particularly  suitable,  Init  can  rarely 
be  taken  for  so  long  a  lime  alono,  as  patients  tire  of  it  much  more  readily 
than  they  do  of  ordinary  milk.  Not  only  can  the  general  nutrition  be 
main-taincd  on  this  diet,  but  patients  sometimes  increase  in  weight,  and  the 
unpleasant  gastric  symptoms  disai>iiear  entirely.  It  should  bo  given  at 
fi.xed  honrs  and  in  definite  quantities.  A  patient  may  take  G  or  8  onnces 
every  three  honrs.  The  amonnt  necessary  varies  a  good  deal,  but  at  least 
3  tof)  pints  shonld  be  given  in  the  twenty-fonr  hours.  This  form  of  diet  is 
not,  as  a  rule,  well  borne  when  there  is  a  tendency  to  dilatation  of  the 


niUONIC  (JASTIMTIS. 


471 


1(1  1)1'  asct'i'- 
iii(li;:i'slii>ii- 
itariiml  ami 
ilijicstioii  ill 
Hill',  slioiilil 
<.  'i'wo  iiii- 
to  till'  tiini' 
Trait  ieally 
II  'lasty  ail' 
|ii'cial  st^l's^ 

II  aliiiu'  siil- 

niliLT  hi't'orc 

'atcr  iiiiiiDi- 

tniL'  thai  a 

from  c'xoL'ss 

tlio  avoraix"' 

to  a  (li'jiri'c 

liad  tiiiu!  to 

ilarly  in  the 

i)t'  prcjiariiig 

rs  oi'  (liftotic 

arran<ro(l  rli- 
ol'  a  case  of 
i;  to  all  cases, 
iiifl  (lilVciviit 
e  iiiaiiV  food 
erent  articles 
ave  i)rol)alily 
•ieiitly  to  tiio 

I('])eii(ls  upon 

III  tiio  forms 
as  well  as  in 

!  (jr  hysterical 

ms.     If  milk 

ter  or  Vichy, 

!  1)c  aildcd  to 

earn  has  been 

\it  can  rarely 

more  readily 

nutrition   be 

'ijiht,  and  the 

be  given  at 

5  or  8  onnces 

1.  but  at  least 

orni  of  diet  is 

itation  of  the 


stomach.     The  milk  may  be  p-wion.ly  ,.e,   oM,...d    bill   it    '^  '  " '<         "^  ^ 

,.. ,    ..hn.,nc   dyspeptic   in   this   way.     TiH.   Mo,.ls   should    b e   cai.t  dl> 

;,^„,,„„l,  „„,  if  „,;„,'  milk  is  takHi  thai,  can  W'  digested  ,t  is  well  to  supple- 
ment iIh'  diet  Willi  eggs  and  dry  lna>t  ..r  hiMiiits  

,,,  ^,  ,^„...,,.     ,„,„,,i„„  of  tiie  cases  of  chronic  in.ligcMio.i  it  is  not  nces- 
sny  to  annoy  the  patient  uitii  such  strict_  dietaries.     It  may  be  .piite  sul- 


jieiunt  t(.  cut  olV  ccrlaiii  artifles  of  biod 


'I'liiis,  if  there  arc  acid  eructations 


ll'le  11  lO  I'Ul  nil   1  11  HUM  "■'  "-  '- .       .      , 

or  llat,ilen<.v,  the  farinaceous  f i<  >lioiild  be  rcstri.t.d,  ,.i.;.-..il;U  v  l-   a- 

,oes  and  the  coarser  vegctal^hs.  A  fruit  lid  source  <d  ""'•^•■"""  ';/  ^ 
hot  bread  which,  in  dilVcivnt  loni.s.  i>  .vgarded  as  an  essential  pa  1  .d  an 
American  breakfast.  This,  as  well  as  the  various  lorms  ..  l'i|>'';'l<'';- .I'''- 
u ul  tarts,  with  heavy  pastry,  and  fri.'d  articles  of  ail  sorts,  sioidd  be  s  ru.  y 
f,.,,„iddcii.  As  a  rule,  white  luead.  toa>tcd,  is  more  readdy  (ligcsf  u 
Inea.l  made  from  the  whole  iiieai.  iVr>o„s.  however,  diller  very  much  n 
this  respect,  ami   tlie  (iraliam  or  brown   bread   is   lor  many   people  mos 

,lioe.tilde.     Sugar  and  vcrv  sweet  articles  of  f 1  should  be  taken  m  g.eat 

.no.h.ration  or  avoided  altogether  by  p.'rsons  with  .hioMic  dyspepsia.  Many 
i„<ta.ic.'s  of  aggravated  indigestion  have  come  to  my  noti-'c  due  to  t  u 
;;..!;a,cnt  pmci^ce  of  eating  largely  of  iee-crcam.  One  of  the  most  ,j.w.r  u 
;,„emie<  of  the  Amerh.an  stomach  in  the  present  <Iay  is  the  -^^^^^^ 
,,„„„i„^  ,,,,ieh  has  u>  'r,.ed  so  im,.ortai,t  a  pla.e  m  the  ^M-'tlu-  '  ^^o  . 
Fats  witli  the  ex(..')tioii  of  a  niod.'rate  amount  ot  good  butti'i,  \.iy 
fat  lueat's.  ami  ihick,  greasy  soups  should  be  avoided.     Uipe  fruit  in  mo.U.ra- 

ti.,„  is  often  advantagcms,  parth^ularly  when kcd.     bananas  an'  no     a. 

a  rule,  well  borne.    Strawberries  are  to  many  jiersons  a  cause  ol  an  annual 
attack  of  indigestion  and  sore  throat  in  the  spring  ni.uiths. 

As  statcl,  in  the  matter  of  special  arti-les  of  iood  it   is  impossible  t 
L,v  down  rigid  rules,  and  it  is  the  couunon  experience  that  one  pa  le 
^vith  indigestion  will  take  with  impunity  the  very  articles  wliu'li  can.e  the 
greatest  distress  to  another.  i   •     u  ■  .    .,.„ 

^  Another  detail  of  importance  which  may  be  mentioned  "i  this  cm - 
uection  is  the  general  hvgienic  management  oi  dyspeptics.  I  hoc  pa- 
tients are  often  introspective,  dwelling  in  a  morbid  manner  on  their  symp- 
t  n  and  nu.ch  inclined  to  take  a  despondent  view  ot  their  cond Hon. 
Y  V 1  le  progress  can  be  made  nnless  the  physician  gams  their  conh.hmce 
f  m  he  outset.  Their  fears  and  whims  should  not  be  nnule  too  light  ot 
or     dnled.     Systematic  exercise,  carefully  regulated    particularly  when 

.watering  places.  It  is  combined  with  a  restricted  diet,  is  of  spe<. 
Srviee     C'lun^a!  of  air  and  occupation,  a  prolonged  sea  yop.ge,  or  a  summer 
'in  the  mountains  will  sc-etimes  cure  the  most  obstinate  ''y^Pn-';!' 

(/.)  .iAv/,Vn,./.-The  sr.eeial  therapeutic  measures  may  ''^l'  ''l^^f^;';; 
tl,o  0  which  attempt  to  replace  in  the  'ligestive  .,n.ces  nnportan  elene 
which  are  lacking  and  those  which  stimulate  the  weakened  action  of  he 
m-an  In  the  first  group  come  the  hydrochloric  acid  and  ferments,  which 
;;";  fm'ly  emplo^d  in  dyspepsia.  The  fornn.r  is  tl-  nu-t  'n,Kn  ant 
It  is  the  ingredient  in  the  gastric  juice  most  commonly  deficient.  It  is  not 
onl  •  ecess;ry  for  its  own  important  actions,  but  its  presence  is  intimately 
a"  oc  ated  with  that  of  the  pepsin,  as  it  is  only  in  the  presence  of  a  sufii- 


iv 


/ 


472  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

,.i».„t  «i..antity  tl.:.t  (h.<  iH.psinu^'.n  in  .■..nvrrtcl  int..  the  a.tiv..  .li^Tstivc 
IVrinrnt  It  is  l-.'st  ^'ivon  as  tlu'  .liliit.'  a.i.l  taken  in  s-mu'what  larK.T  .luan- 
t,ti,..  tluu.  aiv  iisi.allv  a.lvisnl.  Kwal.l  ivr..i.mirn.ls  large  dosos-ot  troiu 
<M)  t..  1(10  .In.l.s-at  'intervals  uf  lilte.n  nnnMt.^s  alter  the  meals.  l.eul,e 
;,„.!  I!ie^..l  advise  smaller  .l-.ses.  l'rnl.al.l.y  tr..n,  i:.  to  •.'.)  ,ln.,.s  i>  snl  le.ent. 
'n,e  prol..njr.'.l  nse  of  it  does  m.t  aiM^'ar  to  he  in  any  way  luirtinl  1  he  n>e. 
however,  shonld  he  restrieted  to  eases  ot  neurosis  and  atrophy  ol  the  nuieoiis 
iiienihrane.     In  aetnal  -astritis  its  value  is  donhtlul.  ,.■ 

Nitrate  of  silver  is  a  j^ood  remedy  in  ^«'«'H'  eases,  used  m  s.dution  m 
the  lavage  (1  to  l.r.UU  or  1  to  •.',0(10),  or  in  pill  h-rm,  one  ei-hth  to  one 
tourth  o?  a  ^^rain  three  times  a  -lay.  For  many  years  Pepper  has  advo.ated 
the  more  extended  nse  of  this  dru-  in  ehronie  f^astritis.  I  have  seen  an 
instanee  of  arjiyria  after  its  protraete.l  use.  ,        ,,       .         .i    . 

Tlu  di'n.stive  ferments:  'I'hese  are  extensively  -mploye.l  to  stren-tiien 
the  vveakene.l  pistrie  and  intestinal  s,..retions.  'I'iu.  use  ot  pepsin  ae- 
cordin-  to  Kwald,  may  ho  limited  to  the  eases  of  advanced  mueous  catarrh 
and  the  instances  .d'  atropl.V  .d'  the  stomach,  in  which  it  should  he  -iven, 
in  .lo<e«  of  from  10  to  \'>  -rains,  with  dilute  hydrochh.rie  aci.l  a  .piartor 
„1-  Mil  hour  affr  meals.  It  may  he  use.l  in  various  .lilVercnt  forms,  either 
as  a  powder  or  in  s..lution  or  pven  with  the  aei<l.  The  P'-wder  is  much 
,nore  certain.  IVpsin  wine  is  jrenerally  inert,  as  there  is  htticol  the  ier- 
ment  taken  up  l.y  alcohol.  It  is  important  to  use  a  reliahle  article.  Mueh 
that  is  in  the  market  is  valueless.  ■         ,,  ■ 

l-aiKMcatin  is  of  e.pial  or  even  greater  value  than  the  i.epsin.  lams 
should  he  taken  to  use-  a  go..d  article,  such  as  that  prepared  hy  Merck.  It 
should  he  given  in  .h.ses  of  from  ir.  to  !>0  grains,  in  comhination  with 
bicari.onate  of  soda.  It  is  converiently  administered  in  tahlets,  each  ot 
which  contains  5  grains  of  the  pancrcatin  and  the  soda,  and  of  these  two 
or  three  may  be  taken  lifteen  or  twenty  minutes  after  each  meal.  1  tyaiin 
and  diastase  are  j.articularly  indicated  when  the  acid  is  excessive,  i  he 
action  of  the  former  continues  in  the  stomach  .luring  normal  digestion. 
The  malt  diastase  is  often  very  serviceable  given  witli  alkalies. 

Of  measures  which  stimulate  the  glandular  activity  in  chronic  dys- 
pepsia lavage  is  by  far  the  most  important,  i.artienlarly  in  the  forms  char- 
acterised by  the  secretion  of  a  large  quantity  of  mucus.  Luke-warm  water 
should  be  used,  or,  if  there  is  much  mucus,  a  1-pcr-cent  salt  solution  or 
a  3-  to  .'-.-per-cent  solution  of  bicarl)onate  of  soda.  If  there  is  much  fer- 
mentation the  8-i)er-cent  solution  of  boric  acid  may  be  used,  or  a  dilute 
solution  of  carbolic  acid.  It  is  best  emph.yed  in  the  morning  on  an  empty 
«tomach,  or  in  the  evening  some  hou."s  after  the  last  meal.  It  is  perhaps 
preferable  in  the  morning,  except  in  those  cases  in  whicli  there  is  much 
nocturnal  distress  and  flatulency.  Once  a  day  is,  as  a  rule,  sufricient,  or, 
in  the  case  of  delicate  persons,  every  second  day.  The  irrigation  may  be 
continued  until  the  water  which  comes  away  is  quite  clear.  It  is  not  neces- 
sary to  remove  all  the  fluid  after  the  irrigation. 

\Yhile  perhans  in  some  hands  this  measure  has  been  carried  to  ex- 
trem"«  it  is  one 'of  such  extraordinary  value  in  certain  cases  that  it  should 
be  more  widely  employed  by  practitioners.    When  there  is  an  insuperable 


J 


CIIUONIC  r.ASTHlTIS. 


473 


ivc  (lificstivc 

liir)fcr  tiiiaii- 

si'w — of  frniii 

H'lll.H.        Ll'llllC 

i  is  siilTicii'iit. 
111.  'riu-  iisi-. 
if  till'  miiciiiis 

II  sollltinll  ii\ 
•i^'litli  Id  iiih' 
ms  lulvdciitcil 
Imvf  si'i'ii  an 

to    stl'l'M^tlR'Il 

.f  pepsin,  ;u'- 
iifoiis  catarrh 
luld  1)1!  ^'ivi'ii, 
icid  a  ([iiartcr 
I'onns,  fitluT 
wdov  is  iiiucli 
:1('  of  the  tVr- 
ntiilo.    Miii'h 

)e])sin.  Pains 
by  Merck.  It 
liinalion  with 
.blots,  each  of 
1  of  these  two 
;noal.  Ptyalin 
xcessive.  The 
nial  (lif^estion. 

'S. 

I  c'lironic  dys- 
lie  forms  char- 
ke-wann  water 
dt  solution,  or 
e  is  nuich  for- 
ed,  or  a  dilute 
g  on  an  eni])ty 
It  is  perhaps 
there  is  much 
',  sufficient,  or, 
i (rat ion  may  be 
it  is  not  neces- 

carried  to  ex- 

5  that  it  shmdd 

an  insuperable 


(ibjcclion  to  lava-:.'  a  Mdi>titutc  may  be  iwid  in  the  fnrm  of  warm  alka- 
line  drinks,    taken    slowly    in    tlic    early    morinn-    or    tlie    la>l    lliin^;    at 

ni^'ht. 

Of  medicines  which  siniudatc  the  ;.'astric  s.crctinii  the  mo>l   inipnitaiit 
arc  the  l.itli'r  tonic.-,  such  as  (piassia,  <.'enlian.  calnmlia.  cnndnranp>,  ipecacu- 
aidui,  strvchnia.  and  cardamoms,     'l'lle^e  are   prol.al.iy  of  more   value  in 
chn.nic  -iistritis  than  the  hydrochloric  add.    Of  these  strychnia  is  the  most 
p<.'Werful,  thou^di  m.nc  of  them  have  prohaliiy  any  very  jrreat  stimulatinn 
action  on  the  secretion,  ami  inlhicnce  rather  the  appetite  than  the  difre.s. 
tion.     Of  stomachics  which  are  I.elieved   to   favoraiily   inllueiice  di-vstion 
the  most  important  are  alcohol  and  common  salt.    The  former  w(.uld  appear 
to  act  in  moderate  quantities  by  increasing,'  the  acid  in  the  f^astric  juice,  and 
with  it  probably  the  pepsin  formation.     Others  hold  that  it  is  not  so  much 
the  secivtory   as   the   motor   fund  ion   of  the   stomach    which    the   alcohol 
stimidatrs.     Ill  moderate  iiuantities  it  has  certainly  no  directly  injurious 
intliience  <m  the  di^restive  processes.     Special  care  slioiihl  be  taken,  how- 
ever, in  ordering'  alcohol  to  dyspeptics.     If  a  patient  has  been  in  the  habit 
(d'  taking'  beer  or  li^dit  wines  or  stimulants  with   his  meals,  the  ]iraetiee 
may  be  (M.nliniied  if  moderate  ipiantities  are  taken.     I'.eer,  as  a  rule,  is  not^ 
well  borne.     A  dry  .>^herry  or  a  class  (d'  claret  is  preferable.     In  the  case  (.f 
women  with  any  "form  <'.f  dysju-psia  stimulants  should  be  employcil  with 
the  jrreatest  caution,  and   the   practitioner  shoiiM   know   his   patient   well 
l)efore  orderini:  alcohol. 

The  importance  of  salt  in  <:astric  di.Lrestion  rests  upon  the  fact  that  its 
presence  is  essential  in  ttie  formation  of  the  hydrochloric  acid.  An  in- 
crease in  its  use  may  be  a.lvised  in  all  cases  of  chronic  dysjiepsia  in  which 
the  acid  is  del'ective. 

Treatment  of  Special  Conditions.— Fermentation  and  ilatn- 
lency.  When  the  dij^estion  is  slow  or  imperfect,  fen  'nlation  jioes  on  in 
the  contents,  with  the  formation  of  pis  and  the  production  <d  lactic,  butyric, 
and  acetic  acids.  For  the  treatment  of  this  condition  careful  dietiu^r  may 
sutlice,  particularly  fcu'biddin.a  such  articles  as  tea,  pastry,  and  the  coarser 
vegetables.  It  is  "usually  combined  with  pyrosis,  in  which  th<'  acid  fhiids 
are  brought  into  the  m"()Uth.  r.ismiilh  and  carbonate  of  soda  sometimes 
suffice  to" relieve  the  condition.  Tliymol.  creasote,  and  carbolic  acid  may 
be  eni])loyed.  For  acid  dysi)epsia  Sir  William  IJoberts  recommends  the 
bismuth  lozenge  of  the  Ih'itish  J'harmacopcria,  the  antacid  pr<x})erties  of 
which  depend  on  chalk  and  bicarl)()nate  of  soda.  It  should  be  taken  an 
hour  or  two  after  meals,  and  only  when  the  jwin  and  uneasiness  are  pres- 
ent. Tlie  burnt  magnesia  is  also  a  good  remedy.  (Ilycerin  in  from  20-  to 
GO-minim  doses,  the  essential  oils,  animal  charcoal  alone  or  in  cond)ination 
with  compound  cinnamon  powder,  may  be  tried.  If  there  is  much  pam, 
chloroform  in  3()-minim  doses  or  a  teaspoonful  of  Ilofl'man's  anodyne  may 
be  used.  In  obstinate  cases  lavage  is  indicated  and  i.s  sometimes  striking  in 
its  effects.     Alkaline  solutions  mav  be  used. 

Vomiting  is  not  a  feature  which  often  calls  for  treatment  in  chron;c 
dyspepsia;  sometimes  in  children  it  is  a  persistent  symptom.  Creasote  and 
carbolic  acid  in  drop  doses,  a  few  drops  of  chloroform  or  of  dilute  hydro- 


^■^ 


474 


DISEASES  OF  TUE  DIGESTIVE  SYSTEM. 


cyanic  acid,  cocaine,  biMiuith,  aiul   cxalatc  of  cerium   may  I)0  uned.     Il 
(,))slinate,  tiio  stouiacii  sliould  he  waslied  out  dady.  „         ,   „  . 

Constiiuition  is  a  fre.iuenl  an.!  tn.ulde.on.e  leaturo  o  mos  forms  ol 
indi-e^^tion.  Occasionally  small  do>es  of  mercury,  podophylliM  the  laxative 
Luneral  waters,  sulplun-  an<l  cascara  may  he  employed,  ^^^y''''^'}'^' 
positories  or  the  injection  of  from  half  a  teaspoontul  to  a  teaspoonlul  of 
"Ivcerin  is  very  ellicacious.  -,  ,      ,,  j. 

"'Ma.y  casiof  chronic  dyspc-sia  arc  greatly  henefited  hy  the  use  of 
mineral  waters,  particularly  a  residence  at  the  springs  with  a  ear-lul  super- 
vision of  the  diet  and  systematic  exercise.  The  stnct  rn/nuc  of  ccrta.n 
(;erman  Spas  is  particularly  advantageous  in  the  cases  in  which  the  chronic 
dy^i-epsia  has  resulted  from  excess  in  eating  and  in  drinking  Kissmgen, 
c4rlshad,  Kms,  and  Wieshaden  are  to  he  specially  recommended. 


III.    DILATATION   OF  THE  STOMACH  (//«a/«c^«s/s). 

Etiology. -This  niav  occur  either  as  an  acute  or  a  chronic  condition. 

Anile  iUlaiaiiuH  is  rarely  seen,  though  it  occurs  whenever  enormous 
quantities  of  food  and  drink  are  (luickly  ingested.  Occasionally  this  lea.  s 
to  extreme  paralytic  dilatation,  and  I'agge  has  described  two  cases  which 
came  on  in  this  wav,  one  of  which  j.roved  fatal.  Allhutt  mentions  a  re- 
markable instance  of  acute  dilatation  of  the  stomach  nnder  the  care  ot 
r.roadhent,  in  which  8  pints  of  iluid  were  siphoned  from  the  stomacli.  '  ^o 
•ever,  was  this  volume  of  fluid  removed  than  the  stomach  began 


sooner,  Iiowev^.,  -  .        ., 

to  refill,  and  was  ra])idly  distended  again  to  its  former  dimensions. 

Chrouk  dUuUilUm  results  from:  (a)  Narrowing  of  the  pylorus  or  ol  the 
duodenum  bv  the  cicatrization  of  an  ulcer,  hypertrophic  stenosis  of  t  le 
pylorus  (whether  cancerous  or  simple),  congenital  stricture,  or  occasionally 
1,V  pressure  from  without  of  a  tumor  or  of  a  tloating  kidney.  \\  ithout  any 
organic  disease  the  ].vlorus  may  be  tilted  up  by  adhcsi.m  to  the  liver  or 
gall-bladder,  or  the  stomach  mav  be  so  dilated  that  the  pylorus  is  dragged 
down  and  kinked,  {h)  Relative  or  absolute  insufficiency  of  the  muscular 
power  of  the  stomach,  due  on  the  one  hand  to  reiieated  overtilling  of  the 
or<am  with  food  and  drink  {l'd)cran.^lirn;iiiuri  di's  Mancnx.  Strumpcll), 
and  on  the  other  to  atony  of  the  coats  induced  by  chronic  inflammation  or 
degeneration  of  im])aire(i  nutrition,  the  result  of  constitutional  allections. 
as  cancer,  tidierculosis,  anannia,  etc. 

It  is  important  to  distinguish  between  a  dilated  stomach  and  a  dis- 
placed or-ran,  which  will  be  considered  under  the  .section  on  entcrojitosis. 

The  most  extreme  forms  are  met  with  in  the  first  group,  and^most 
commonly  as  a  sequence  of  the  cicatricial  contraction  of  an  nicer.  There 
may  be  considerable  stenosis  without  much  dilatation,  the  obstruction  being 
compensated  bv  hvi)ertroi)hv  of  the  muscular  coats.  Considerable  atten- 
tion has  been  'directed  in  Cermany  by  Tatten,  Ewald,  and  others  to  the 
association  of  dilatation  with  dislocation  of  the  right  kidney. 

In  the  seond  grou]).  due  to  atonv  of  the  muscular  coats,  we  must  dis- 
tin<niisli  between  instances  in  which  the  stomach  is  simply  enlarged  and 


DILATATION  OF  THE  STOMACH. 


475 


be  iiHi'd.     Il' 

ost  forms  of 
,  the  laxative 
llycerin  sup- 
laspooiiful  of 

y  the  use  of 
■iU'"fiil  super- 
;/(•  of  eertain 
h  tin;  cliroiiif 
.  Kissingeii, 
lied. 


'xtasis), 

iiic  condition. 
ver  enormous 
illy  this  leads 
o  oases  whieh 
lontions  a  re- 
r  the  care  of 
omacli.  ''  Xo 
foinach  began 
isions."' 
orus  or  of  tlu' 
tcnosis  of  the 
ir  occasionally 
Without  any 

0  the  liver  or 
rus  is  dragged 

the  muscular 
?rli]ling  of  the 
s,  Striimpcll), 
idamniatinn  or 
)nal  alfoctions. 

ich  and  a  dis- 
i  cntcroptosis. 
oup,  and  most 

1  nicer.  There 
struction  being 
;iderable  attcn- 
1  others  to  the 

y. 

s,  we  must  dis- 

y  enlarged  and 


tluwe  '.vith  actual  dilatation,  the  conditions  wbi.ii  Kwald  cliaracterized  as 
mmshk  and  ,,ashrcla.lx  respectively.  'I'lu'  si/.e  ..f  the  sto.nach  vanes 
.rvcatly  in  ditVc'rcnt  iudivi.luals.  and  tlie  ma.vimum  capacity  ol  a  nornuil 
organ' Kwald  places  at  about  \,WW  cc.  ,Mea>urenicnts  above  this  point  in- 
dicate al)solute  dilatation. 

Vtonic  dihitation  of  the  stomach  may  rc>ult  from  \\cai<ness  ot  tlic  coats, 
due  to  repeated  overdistcntion  or  f.  clironic  catarrii  of  the  mucous  mem- 
brane or  to  tlie  general  muscular  cK^bility  wiiich  is  associated  witii  elironic 
wastin"  disorders  of  all  sorts.  Tiic  coinlmiation  of  chronic  gastric  catarrh 
with  <.vcrfccding  and  excessive  drinking  is  one  of  tlic  most  fruitful  sources 
„f  at.mic  dilatation,  as  pointed  out  by  Naunyii.  Tiie  coii.lition  is  Ire- 
.nientlv  seen  in  diabetics,  in  the  insane,  and  in  bcer-drinkers.  In  <H'nnany 
thi<  form  is  very  comuum  in  m.Mi  employed  m  tlic  breweries.  1  ossiiiiy 
muscular  weakness  of  the  coats  may  result  in  some  cases  from  disturbed 
innervation.  Dilatation  of  the  slomacli  is  most  fre.pient  iii  middU-age-l 
or  elderly  i)ersons,  but  the  condition  is  not  uncommon  m  children,  ospe- 
ciallv  in  association  with  rickets. 

Symptoms.— 'J'lK'se  are  vcrv  variable  and  depend  ui)on  the  cause  and 
the  deoree  of  dilatation,  ^■aturally  the  features  in  cancer  of  the  pylorus 
would 'be  verv  dilferent  from  those  met  with  in  an  excessive  drinker.  Dys- 
nei.sia  is  present  in  ncarlv  all  cases,  and  there  are  feelings  ol  distress  and 
unea<iness  in  the  region  -d'  the  stomach.  The  patient  may  comi)lain  nuicli 
of  hun-cr  and  thirst  and  eat  and  drink  frec'ly.  Tlu"  most  characteristic 
.vmiit.un  is  tlie  vomitin-  at  intervals  of  enormous  .piantities  ol  lupud  and 
„"f  food,  amounting  sometimes  to  four  or  more  litivs.  The  material  is  oiten 
of  a  dark-aravish  color,  with  a  characteristic  s(mr  odor  due  to  the  organic 
acids  present."  and  contains  mucus  and  ri'innants  of  f.uxl.  On  standing  it 
separates  into  three  lavers,  the  lowst  consisting  .d'  food,  the  middle  of 
a  turbid,  dark-uriv  fluid,  and  the  upi-crmost  .d'  a  brownish  froth.  Uie 
microscopical  examination  shows  a  large  variety  of  liacteria.  yeast  iungi, 
and  the  sarcina  ventriculi.     There  may  also  be  cherry  stones,  plum  stones, 

and  <rrai>e  seeds.  . 

The  hydrochloric  acid  mav  be  absent,  diminished,  normal,  or  m  execs., 
dejiending  ui-on  the  cause  of  the  dilatation.  The  fermentation  produces 
lactic,  butyric,  and,  ].ossibly,  acetic  acid  and  various  gases. 

In  consecn.enco  of  the  small  amount  of  fluid  whuh  passes  from  the 
stomach  or  is  absorbed  there  are  constipati.m,  scanty  urine,  and  extreme 
dryness  of  the  skin.  The  general  nutrition  of  the  i-alient  sutlers  greatly; 
tlierc  is  loss  of  flesh  and  strength,  and  in  some  cases  the  most  ex  ren.e 
emaciation.  A  yery  remarkable  symidom  which  occurs  occasionally  is 
tetany,  first  described  by  Knssmaul.  . 

Physical  Signs -/'/^«Fr/Km.-Tho  ahdonuui  may  be  large  and  promi- 
nent tho  greatest  lu'oiection  occurring  below  the  mivel  in  the  standing 
nocture  In  some  instances  the  outline  of  the  distended  stomach  can  he 
plainly 'seen,  the  small  euryature  a  couple  of  inches  below  the  ensi form 
carfihirre  and  the  crreater  curvature  i-assing  obli.piely  from  the  tip  ot  the 
tenth  ril.  on  the  left  side,  toward  the  pubes.  and  then  curving  ujiward  to 
the  ri<dit  costal  margin.    Too  much  stress  cannot  be  laid  on  the  importance 


^^Q  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 

„f  in.iKHtioii      In  10  of  i:^  oasos  of  .lilcitod  stomach  in  my  ward,  durino; 
H   viar  the  diajrnosis  was  nuulo  ,le  visu.     A.tiv.  peristalsis  nmy  be  seen 
tl  0  .lihaed  oian,  the  waves  passing  fron.  U.ft  to  r^ht      O-^-alb 
nt  -peristalsis  n.av  bo  seen.     In  cases  of  strietnre    partuularly  of  hjpe,- 
.1       stenosis,  as  the  peristaltic   wave  reaches  the   pylorus    the  t.nnor- 
.       hickenin.r   can   son.etin.es   l)e   distinctly   seen   throuj^h    the  thin   ah- 
dli^r^  To  stinudate  the  peristalsis  the  abdo.uen   .nay  be  1   pped 

V  ha  wet  towel.  Inllation  n)ay  be  practise.l  w.th  carbo.uc-aeH  >:a>. 
\  small  teaspoonful  of  tartaric  acid  dissolved  in  an  ounce  ot  water  is 
ii,.-t  .nven.  then  a  rather  hu-er  (p.antity  of  bicarbonate  "  .--1;>-  1" 
anv  cases,  particularly  in  thin  persons,  the  outhne  ot  the  ddated  ston - 
ach -stands  <mt  with  ^reat   distinctness,  and  waves  of  penstals.s  are  seen 

'"  ']\,l,,alm,.-'rh.  peristalsis   may  be   felt,  and   usually   in   stenosis  tlie 
tumor    s  evi.lent  at  the  pylorus.     Tiu-  resistance  of  a  ddated  slon.ach  >s 

.ecnliar  an.l  has  been  aptlv  compaivd  to  that  <,f  an  a.r  cushion,     l.nuan- 

a  mUon  elicits  a  splasiun,  .,und-W.;./.,.-whieh  ,s.  o,  courscv^  m- 

di4  nc  ive.  as  it  can  be  obtained  whenever  there  .s  n.uch  lupnd  an     a,. 

or.  n,  but  which  cannot  be  elicited  in  a  healthy  pc..;n  two  or  thre 

Zl  af^r  eating.     The  splashing  n.ay  be  very  loud,  and  the  1-  '-t  -^ 

produce  it  hin>self  by  suddenly  depressing  the  d.aphragm,  o     ,     n  a>   b 

eadily  ..btained  by  shaking  bin,.     A  tube  passed  into  the  ^t-nnaeh   m,. 
be  fel    externallv  through  the  skin,  a  ,,rocedure  n  ,  longer  ;-;>'-<""'  f.^'*     > 
Leube.  who  suggested  it.     The  gurgling  of  gas  through  the  j.ylorus  ma> 

^'"^  VcirusswH.-Thi'  note  is  tympanitic   over  the   greater   portion   of  a 
dilated  stomach;  in  the  dependent  part  the  note  is  dull.     Tn  the  upngh 
position  the  percussion  should  be  n.ade  fnun  al>ove  downward,  ,n  the    e  t 
parasternal  Hue,  until  a  change  in  resonance  is  reached.      1  he  l.ne  of  tin. 
hould  l)e  marked,  and  the  patient  exan.ined  in  the  recund.ent  position 
when  it  will  be  found  to  have  altere<l  its  level.     When  tins  is  on  a  hue  w,tl 
the  navel  or  below  it.  dilatation  of  the  stoma.h  nuiy  generally  be  assumed 
to  exist      The  lluid  mav  be  withdrawn  from  the  stomach  with  a  tube,  an.l 
the  dulness  so  made  to  disapi.ear,  ..r  it  mav  be  increased  by  pouring  in  more 
fluid      In  cases  of  doubt  the  organ  should  be  art.hcially  distended  AMth 
carbonie-acid   gas   in   the   manner   described   above.      The    inost    accurate 
method  of  detr.nuining  the  size  of  the  stomach   is  by  inilatum  through  a 
stomach-tube  with  a  Davidson's  syringe.     I'acanowsk,  has  shown  tut  to 
.rreatest  vertical  diameter  of  gastric  reso.iance  in  the  normal  stomach  ^ane^ 
from  10  to  11  em.  in  the  n>ale  and  is  about  10  cm.  in  the  female. 

,,,,,,„//„/,V,„._The  rh,potnne„l  or  succussion  can  be  obtained  rea.  .I>. 
Vrequentlv  a  curious  sizzling  sound  is  present,  not  unlike  tha  heard  when 
the  ear  is"  placed  over  a  soda-water  bottle  when  first  opened.  It_  can  l.e 
heard  natuVallv,  and  is  usually  evident  when  the  artificial  gas  ,s  lH.ng 
generated.  The  heart  sounds  may  sometimes  be  transmitted  with  gnat 
clearness  and  with  a  metallic  quality.  i   •   ,     n, .   -inn,.,,!. 

^hnsnrnlhn  mav  be  used  by  passing  a  hard  sound  into  the  stoni.u  h 
until  the  greater  curvature  is  reache.l.     Normally  it   rarely  passes  more 


DILATATIOX  OF  TIIK  STOMACH. 


47T 


ards  (luriiifr 
iiiiiy  1)L'  «eoii 
Occiisioiiully 
ly  oi'  hypor- 

thc  tiniuir- 
lie  liuii  al>- 
y  ]w  llipiKil 
nic-acid   ^as. 

of  water  i- 
)t'  soda.  In 
lilatr(l  stoin- 
ilsis  arc  soun 

stenosis  the 
d  8tonuK'h  is 
ion.  lUuian- 
)f  course,  not 
i(|uid  and  air 

two  or  throe 
'  patient  may 
or  it  may  l)e 
stomach  in.;y 
;)inmcnded  l)y 

pylorus  may 

]iortion   of  a 
II  the  uprijzht 
•d,  in  tlie  left 
ic  line  of  this 
bent  position, 
oil  a  line  witli 
ly  Ik'  assumed 
h  a  tube,  and 
mrinj:  in  more 
listended   with 
most    accurate 
ion  throu^lh  a 
liown  that  the 
stomach  varies 
male. 

tained  readily, 
at  iieard  wIil'U 
pd.  It  can  he 
1  <ras  is  hein<r 
ted  with   frreat 


than  no  cm.,  measured  from  the  tcctii.  Imt  in  cases  of  dilatation  it   may 
pass  as  mucii  as  TO  cm. 

Diagnosis.— The  diagnosis  can  usually  he  ma<le  witiiout  mucli  dilVi- 
culty.  I  would  like  to  emiiiiasize  a«,'ain  the  great  value  of  insjiection,  partic- 
ularly in  comhination  with  inilation  of  the  stomach  witii  carlionie-at'id  gas. 
Curious  errors,  however,  are  on  record,  one  of  the  most  remarkai)le  id'  which 
was  the  confounding  of  dilated  stomach  witli  an  ovarian  cyst;  even  alter 
ta|)ping  and  the  removal  of  portions  of  food  and  fruit  .seeds,  ahdoininal 
sectioirwas  iierformed  and  tiie  dilated  stomach  opened.  1  notice  tiie  report 
of  a  recent  case  in  which  the  diagnosis  of  ascites  was  made  and  the  al)domen 
was  opened.  The  pmjuosis  is  had  in  ca^e^  in  which  there  is  stenosis  ol  liu; 
jivlorus,  eitlier  simple  or  cancerous. 

Treatment.— In  the  cases  due  to  atony  careful  regulation  of  the 
diet  and  proper  treatment  of  the  associated  catarrh  will  suiUce  to  ell'ect  a 
cure.  Strychnine,  ergot,  and  iron  are  recommended.  Washing  out  tiio 
stomach  is"  of  great  service,  tliough  we  do  not  see  such  striking  and  imme- 
diate results  in  this  form.  In  cases  of  mechanical  obstruction  the  stomach 
should  lie  emptied  and  thoroughly  washed,  either  with  warm  water  or  with 
an  antisejitic  solution.  We  aceomplisii  in  this  way  three  important  things: 
We  remove  the  weight,  which  helps  to  distend  the  organ;  we  remove  tlie 
mucus  and  the  stagnating  and  fermenting  material  which  irritates  and  in- 
llames  the  stomach  and  impedes  digestion;  and  we  cleanse  the  inner  sur- 
face of  the  organ  by  the  application  of  water  and  medicinal  substances, 
'i'iie  imtient  can  nsuallv  be  taught  to  wash  out  his  own  stomach,  and  in  a 
ca^e  of  dilatation  from  sinijile  stricture  I  have  known  the  i)ractice  to  he 
followed  daily  for  three  years  with  great  bcnelit.  The  rapid  reduction  in 
the  size  of  tlie  stomach  is  often  remarkable,  tlie  vomiting  ceases,  the  food 
is  taken  readily,  and  in  many  cases  the  gen.>ral  nutrition  imiiroves  raiudly. 
\<  a  rule.  oncV  a  day  is  sutlicient.  and  it  may  be  jiractiscd  either  the  first 
tiiin.'  in  the  morning  or  before  going  to  bed.  So  soon  as  the  fermentative 
processes  have  been  checked  lukewarm  water  alone  should  be  used. 

The  food  should  be  taken  in  small  (piantities  at  frequent  intervals,  and 
should  consist  of  scraped  beef,  Leubc's  beef  solution,  and  tender  meats 
of  all  sorts.  1-atty  and  starchy  articles  of  diet  are  to  be  avoided.  Lupiids 
should  be  taken  sparingly.  .     . 

When  the  condition  becomes  aggravated  a  resort  to  surgery  is  justili- 
able  Here  may  he  mentioned  the  recent  statistics  of  gastric  surgery. 
Pyloric  stenosis 'is  the  common  condition.  DreydorfT  has  collected  4  1'3 
f..;.o<— 1SS  cases  of  pylorectomv,  mortality  r^'!A  per  cent;  215  gaftro-enter- 
ostomies,  mortality  43.3  ].er  cent;  ,nloro,.lasty.  SH  cases,  mortality  •?0.7 
])er  cent.  On  an  a'verage.  after  |.yloreetoniy  the  patient  remained  tree  irom 
recurrence  for  a  little  over  a  year. 


o  the  stomach 
ly  passes  more 


i> 


478 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


IV. 


THE  PEPTIC  ULCER-GASTRIC  AND   DUODENAL. 


Tlie  round,  iK'rf..vatiii,i,',  or  ^\w\<\v  iiUrr  is  iisuiilly  sin-rlc,  and  occurs 
in  tlio  stonuu'h  and  in  lie' duodoiiuin  as  lar  as  liic  papilla  hiliaria.  It  fol- 
lows nutritional  disturlmnoe  mi  a  limited  re-ion  of  the  mueusa,  \yhieli  re- 
sults in  the  }.n-adnal  dei-tnution  ol'  this  ana  iiy  the  pi^trie  juice.  The  con- 
dition is  usually  associated  with  sii].eraeiility. 

Etiology.— /'"■(</''"'■«'  '■"  //"■  l'i>sl-mi'iini\  Unum.—Xn  the  extensive 
records  collected  l)y  W.  II.  Wi'lch,  ulcer,  cicatrized  or  oi'i'n,  was  present  in 
aljout  -■)  per  cent  of  jiersons  <lyin^-  from  all  causes.  Others  j.rive  percenta-cs 
as  high  as  1(».  The  scars  are  more  frc(iuent  than  the  o|)en  ulcers.  Anuui^' 
the  Ih'st  thousand  autopsies  at  the  dolms  llojikins  Hospital  there  were  '.) 
cases  of  ulcer  of  tliO  stomach. 

Incidence  Cliniciilh/.—'niv  disease  is  much  less  common  in  some  coun- 
tries than  in  others,  niid  in  some  i)arts  of  this  country.  It  is  certainly  less 
fnHpientlv  seen  in  I'.altimorc  than  in  :\rassachusctts  or  in  Canada.  In  nine 
years  there  were  in  my  wards  only  v^■)  instances  with  a  diajruosis  of  ulcer. 

^^,,.._()1'  l^d'i!)  caW's  collected  from  hosjiital  statistics  by  W.  11.  Welch 
and  examined  i-ost  mortem,  1<»  per  cent  were  in  males  and  (10  per  cent  weri' 

in  females. 

,j,^^._In  females  the  larjicst  nuinlier  of  cases  occurs  hetween  twenty 
and  thirty:  in  males  hetween  thirty  and  forty,  it  is  hy  no  means  uncom- 
mon in  ohl  peoph'.  <>'>  the  other  hand,  it  is  not  very  rare  in  children. 
(Joodhart  reported  a  case  in  an  infant  thirty  hours  old;  indeed,  ulcers  of 
the  stomach  have  heen  found  in  the  fietus  and  in  the  new-horn  shortly 
after  hirth.  Of  .'i!H)  autopsies  at  the  (lahy's  IIos|utal  in  New  York,  Martha 
Wollstein  found  o  cases. 

Jlnrilitii  apjiears  to  jilay  a  part  in  some  cases  (Dreschfeld). 
Occnpiiliiiu. — Servant  girls  seem  particularly  proiu'  to  the  disease.  This 
is  to  he  explained  ]>artly  hy  their  careless  habits  in  eating,  partly  in  connec- 
tion with  the  associated  ameniia.  The  special  liability  of  shoemakers,  weav- 
ers, and  tailors  to  ulcer  is  probably  connected,  as  llabershon  suggested,  with 
jiressure  on  the  st<muich. 

TnuuiHt. — ricers  have  heen  known  to  follow  a  blow  in  the  region  of 
the  stomach.  Kasmussen  ludds  that  pressure  of  the  costal  margii'  from 
various  causes  induces  anaunia  and  atrophy  of  the  mucous  membrane,  par- 
ticularly in  the  region  of  the  smaller  curvature. 

Ass'orialfd  Diseases. — Ana'mia  and  chlorosis  jiredisposo  strongly  to  gas- 
tric ulcer,  particularly  in  women  and  in  association  with  menstrual  dis- 
orders. A  very  considerahle  number  of  all  cases  of  gastric  ulcer  occur  in 
chlorotic  girls.  It  has  heen  found  also  in  connection  with  disease  of  the 
'h(>art,  art(MMo-sclerosis,  and  disease  of  the  liver.  The  tuherculous  and  syph- 
ilitic ulcers  of  the  stomach  have  already  been  considered. 

The  duodenal  ulcer  is  less  common  than  the  gastric  ulcer,  and  occurs 
nmst  frccpiently  in  males.  The  combined  statistics  of  Krauss,  C'hvostek, 
T.ehort,  and  Trier  give  TTl  cases  in  males  and  :!!•  in  females.  Tn  9  of  my 
cases  7  were  in  males  and  2  in  females;  one  of  these  was  in  a  lad  of  twelve. 


THE  PKI'TIC  ULCER-OASTUIC  AND  DUODENAL. 


4TU 


ENAL. 

iuxl  ocours 

n:\.     It  lol- 

,  wliicli  ir- 

Tlu'  cdii- 

('  fwk'iisivt' 
-  pri'scnt  in 
|)(.Ti'entiijii's 

lllTC    W'VVV    1) 

!-omo  coun- 
ortiiiiily  Ic'.-s 
la.  Ill  nine 
;  (W  \ilccr. 
'.II.  Wclcli 
iM"  cont  wcrr 

iWll     tWH'lltV 

■;llis  iincnm- 
iii  children. 
(1,  ulcers  di' 
loni  shortly 
ork.  Mnrtlia 


isease.  This 
y  in  eoniu'c- 
lakors,  woav- 
fgostt'd,  with 

ho  r('j,noii  of 
narjiir'  from 
luhrano,  par- 

>nply  to  pas- 
eiistrual  dis- 
Ircr  occur  in 
isoaso  of  the 
us  and  sypli- 

',  and  occurs 

ss,  Chvostck, 

Tn  9  of  !iiy 

lad  of  twelve. 


It  has  hecM  found  in  associalion  with  tuhcrculosis,  and  may  follow  hirj^'o 
su|Hrli(ial  imrns.  Terry  and  Shaw  loimd  it  liv(;  tinu'S  in  II!)  autopsies  in 
cases  of  l)iiins. 

Morbid  Anatomy.— Thou^di  usually  siii<,'le,  the  \deers  nuiy  he  mul- 
tiple. In  none  of  my  eases  were  there  more  than  live,  but  there  is  an  in- 
stance on  record  of  thirty-four.  The  ulcer  is  situated  most  eomnu)nIy  on 
the  posterior  wall  of  the  pyloric  portion  it  or  near  the  le.sser  <Mirvature.  It 
is  not  nearly  so  fre(iuent  on  tiie  anterior  wall.  Of  T!);}  oa«es  collo(!te(l  hy 
Welch  from  hospital  statistics,  ^;.SS  were  on  the  lesser  curvature,  "iW't  on 
the  posterior  wall,  !».")  at  the  pylorus,  (ill  on  the  anterior  wall,  50  at  the 
eardia,  •.".»  at  the  fundus,  "J?  on  the  },'reat«.r  curvature.  The  duodenal  ulcer 
is  usually  situated  just  outside  the  ritig  in  the  first  portion  of  the  ^nit. 

Acute  and  chronic  forms  of  gastric  ulcer  may  l)e  descrihed.  The  former 
is  usually  small,  punched  out,  the  edges  clean-cut,  the  lloor  smooth,  ami 
the  peritoneal  surface  not  thickeiU'd.  The  chronic  ulcer  is  of  larger  size, 
the  margins  arc  no  longer  sharp,  the  edges  are  indurated,  ami  the  honler 
is  sinuous.  The  gastric  ideer  scunctimes  reaches  an  enormmis  size.  The 
largest  of  which  I  have  any  knowledge  is  one  reported  hy  Peahody,  which 
measured  1!'  Iiy  10  cm.  and  involved  all  of  the  lesser  curvature  and  spread 
over  a  large  part  of  the  anterior  ami  posterior  walls.  It  is  often  distinctly 
terraced.  The  floor  is  formed  either  i)y  thi!  suhmucosa,  by  the  nniscular 
layers,  or,  not  infretpiently,  by  the  neighboring  organs,  to  which  the  stom- 
ach has  become  attached.  In  the  healing  of  the  ulcer,  if  the  mucosa  is 
alone  involved,  the  granulation  tissue  develops  from  the  edges  and  the 
floor  aiul  the  newly  formed  tissue  gradually  contracts  and  unites  the  mar- 
gins, leaving  a  smooth  scar.  In  larger  ulcers  which  have  become  deep  and 
involved  the  muscular  coat  the  cicatricial  contraction  nuiy  cause  serious 
changes,  the  most  imiiortant  of  which  is  narrowing  of  the  pyloric  orifice 
ami  consequent  dilatation  of  the  stonuu-h.  In  the  case  of  a  girdle  ulcer, 
hour-glass  ccmtraction  of  the  stomach  nuiy  be  produced.  It  is  |)robablc 
that  large  ulcers  persist  for  years  without  any  attempt  at  healing. 

Among  the  more  seriiuis  changes  which  may  proceed  in  an  ulcer  are 
the  following: 

I'crf(ir(ili(iii.—V<nimy,\U']\,  in  a  majority  of  the  cases,  adhesioxis  form 
between  the  stomach  aiul  ailjacent  organs,  particularly  with  the  pancreas, 
the  left  lobe  of  the  liver,  and  the  omental  tissues.  On  the  anterior  surface 
of  the  stomach  adhesions  do  not  so  readily  form,  hence  the  great  danger 
of  the  ulcer  in  this  situation,  which  more  readily  perforates  and  e.vcitcs  a 
dilfuse  and  fatal  peritonitis.  On  the  jtosterior  wall  the  ulcer  penetrates 
directly  into  the  lesser  ]ieritoncal  cavity,  in  which  case  it  may  produce  an 
air-containing  abscess  with  the  symptoms  of  the  condition  known  as  sub- 
phrenic pyo-pneumothorax.  In  rare  instances  adhesions  and  a  gastro- 
ciitane(uis  fistula  form,  usually  in  the  umbilical  region.  Fistulous  com- 
munication with  the  colon  may  also  occur,  or  a  grtstro-duodcnal  fistula. 
The  pericardium  may  be  iierforated,  and  even  the  left  ventricle.  Terfora- 
tion  into  the  pleura  may  also  occur.  It  is  to  be  noted  that  general  em- 
phvsema  of  the  subcutaneous  tissues  occasionally  follows  perforation  of  a 

gastric  ulcer. 

30 


480 


DISKASES  OF  TilE  DIGESTIVE  SYSTEM. 


Fro.lo,,  of  lllood-,rssfls.-'VU'  iKvn.nrrhap.  may  .nrur  m  t  ..■  a.ut.ly 

f..,,^         '  ,.  or  in  ,lu.  nlH-nUioM  wln-l.  tak.s  pla.c  at  tl,.  has.  oi  .h-  chn. m. 

.    t  is  in  tlu.  latt.T  n.n.ihinn  that  tlu.  l.lmlit,,'  .s  must  conunnn.    11      > 

'   ;;     .st.rinr  ...11  may  .n.!.  ti..  s,.i..m.  a.t.ry    but  .cfhaps  mo      1     - 

0      V  tho  l.loclinK  l.rmvcls  Imm  tlu.  art.fy  oi  the  lessor  curve.       n  th. 

1  uon     al  ukrr  the  ,,a,u.r.ati.o-.hm.U.nal  artery  .nay  he  ero.le.l  o,- 

i      ,  .  y  eases)  fatal  luen.orrha.e  n,ay  result  front  the  o,.en,n,^  ol 

'''^;;;t;:^!;;:-Superfi..ial  mee,.  oftet.  heal   withoni   leavin,  any  seri- 

on.  .    m"'       Stenosii  ..f  the  pyloric  orifice  not   infrequently   1-,  lows    he 

",1    1"  Fan  ulcer  in  its  neij,hhorhoo.l.     In  other  tnstances  the  lar,e       - 

M.lcer  n>av  eanse  in  its  cicatrizati.m  an  honr-lass  contra<t,on  ol  tl  e 

;  a         'n  e  a.lhesion  of  the  nicer  to  nei.hhorin,  parts  n.ay  -— M-'''  .|, 

il;;,;;,  ;!;,„se  of  nn-cl,  pain.    The  parts  of  the  nuu-osa  tn  the  ne„hhorhood  ol 

flic  nicer  freduently  show  si^nis  of  chronic  pistritis. 

Tl  0  or  <,  of  (he  peptic^  nicer  is  still  ol.scure.  Vlcers  have  been  pro- 
dncec  "n  .nals  in  many  ways,  hoth  hy  artilicial  -"'••>•'  -'^'y^- 
.Lncal  an.l  nu>chanical  irritants  applied  to  *•-  -';';'-  '-,;'- ^^^^ 
pro.luee.1  heal  with  great  rapidity  i.nlcss  the  ^''''l'^, '^^,  ^'"  J^™ 
. nvemic  hv  re,.eated  abstraction  of  blood.  A  irehow  s  view  that  t lie  piocess 
r"  J  1  n.n>  pln.,in.  the  nutrient  artery  of  the  part,  either  by  a.^ 
™  L  ^s  by  a  thrombuCand  that  the  infarct  so  produced  ,s  ^-t,;oyed  by 
h  '  .astric  iuice,  has  gain-d  .eneral  acceptance.     It  .s  ,n  .onlornu  h 

v^"    well-known  experiments  and  with  the  anatomical  lacts  already  nen- 
il  u-d     ,a  t  e  larly  with  the  funnel-like  shape  of  the  ulcer,  and  the  actua 
rit^tion,  inlme  eases,  of  the  plugged  ;^f-^^^^\;^^:^:''^, 
„u.ets  all  the  eases,  in  many  of  which  the  e  >olo,7  is  sfll  ohM  ne     M    t 
„K,..,,anical  injury  to  the  mucous  membrane  is,  '-^-^^^^-^I'^^^'Z. 
.ullicient  cause  for  an  ulcer,  for  normally  the  stomach  is  peii.   tlj   allc 
t      .        tand   such    insults.      Kwald    concludes   that   certain    P'-l-POS^n, 
•nnJ  play  an  im,K.rtant  role  in  its  development.     He  points  to  its  fu- 
,^,^y  in  conditions  of  amenorrluva.  chlorosis.  an,einia  after  ^:o-Un.u.^ 
r    Jhere  one  may  assume  that  the  condition  of  the  Idood  is  not  .hi 
u;rmal.  and  also  to  the  fact  that  in  the  majority  of  case.  <'Hlns  at  c. 
tlHM-e  is  a  snperacidity  of  the  pastric  juue.     One  or  both  "^^''^^'-^  '     \'^ 
win.^  facto  s  seem  to  be  present  in  most  cases,  and  i    has  l.een  recent  y 
^  o^n  that  in  the  various 'an.,nia>  there  is  an  appreciable  dim.nutu. 
the  normal  alkalinity  of  the  blood,  a  fact  winch  tends  to  ^-1  -'.--; 
tl,..  pivdisposiuK  causes  in  these  affections,  and  which  is  m  aecoid  mH.  tlu, 
' '   11  .,lesc.enee  theory  "  of  Cohiiheim.     Of  late  the  yiew  has  been  advaneed. 
p.      iuWW  by  T.etnlle  and  by  Sydney  Martin    U.at  the  ^.l--^-"  ^     ;;;; 
lo  a  bacterial  necrosis  of  the  gastric  mucosa,  and  the  h.  t.^  -^-!;^^^^ 
frcpiency  of  the  t.teer  at  the  pyloric  region  is  associated  mI    tho  .    s  nee 
of  the  criands  at  this  part,  which  form  the  hydrochloric  acid.     J  he  duo 


TIIH   I'KPTIC  ULCER-GASTHIU  ANI>  DIODKNAI.. 


48i 


the  iiclltily 
1'  ilu'  c'linuiic 
nini\.  riccrs 
ips  more  I'l'c- 
irvr.  Ill  till' 
1)0  eroded  or 
If  oiioniug  ol' 
■hangos  occur 
I'd  region  liii- 
■ritis.  Small 
u^las  rowcll. 

ing  any  scri- 
y  riiUowrf  the 

tlu'  largo  an- 
raction  of  tlio 
,•  siil)so(iiicntl".' 
iirhhorhood  ol' 

lavo  boon  i)ro- 
and  by  direct 
'lie  nlcors  thus 
been  rondere<l 
lat  the  process 
,  either  by  an 
is  destroyed  by 
)ni'orniity  with 
s  already  nion- 
ai\il  the  actual 
IS  view  scarcely 
obscure.  ^lero 
most  cases,  in- 

pert'octly  able 
n  jjrodisposing 
ints  to  its  fro- 
r  confinements, 
il  is  not  wholly 
)f  this  atTection 
of  these  prodis- 
s  been  recently 
)  diminution  in 

explain  one  of 
accord  witli  the 

been  advanced; 
Iceration  is  due 
uggests  that  the 
iilh  the  absence 
acid.     The  duo- 


denal ulcer  has  an  identical  origin,  but  a  few  cases  of  acute  nicer,  as 
already  mentioned,  have  a  curious  relalion  with  su|ierlicial  burns.  Vuu- 
doeii's  researches  upon  tlu-  necroses  in  the  viscera  following  e\Icii>ivo  luirns 
tlu'ow  ail  important  light  upon  these  eases,  showing  especially  bow  the 
gastro-intestinal  mucous  meiiibrano  is  implicated  in  the  toxic  elVecls.  In 
one  of  my  cases  there  was  an  ulcer  in  the  po>torior  wall  of  the  duodenum, 
l..">  (111.  in  (liamoler,  with  o\crlappiiig  edges  and  not  far  fnuu  it  was  a 
cyst-lilso  cavity  in  the  subimicosa  associated  with  IW'uniier's  glands,  and  it 
is  possible  that  the  opi'U  ulcer,  with  undoriuiiied  vi\'^v^,  resulted  from  the 
riii>turo  of  one  of  these  cysts. 

Symptoms. — 'i"he  condition  may  bo  met  with  accidentally,  jiost  nmr- 
ieni.  Tlie  lirst  .symptoms  may  bo  those  of  |ierl'oration.  Jn  other  cases  again, 
for  months  and  years,  the  patient  has  had  dyspepsia,  and  iho  ulcer  may 
not  have  been  suspected  until  the  occurronco  of  a  sudden  hieinorrhago. 

The  synii>t<)iiis  suggestive  of  iie])tic  ulcer  arc:  {a)  Di/.spcjixid,  which  may 
be  slight  and  trilling  or  of  a  most  aggravated  character.  In  a  considciable 
proportion  of  all  cases  nausea  and  vnitiHuKj  occur,  the  latter  not  for  two 
or  more  hours  after  eating.  The  vomitus  usually  contains  a  large  amount 
of  JlCl. 

(/))  Ihi iiKirrJiiiiir  is  ]iresont  in  at  least  one  half  of  all  cases.  It  may  bo 
slight,  but  more  comiiionly  is  ]irofuso,  and  may  be  in  such  (piantilios  and 
brought  up  so  (piickly  that  it  is  fluid,  liriglit  red  in  color,  and  (luito  un- 
altered. When  the  blood  remains  for  some  time  in  the  stomach  and  is 
mixed  with  food  it  may  bo  greatly  changed,  but  the  vomiting  of  a  largo 
(piantitv  of  niialiorod  blood  is  very  characteristic  of  ulcer.  Syncope  or  con- 
vulsions may  follow,  or  death  may  directly  result  from  the  liu'inorihago.  .\. 
most  extreme  grade  of  aiKomia  may  be  ]ir(i(biced.  1  have  known  liemi- 
]ilegia  to  develop  after  a  sorii'S  of  jirofuso  luomorrhagos.  In  cither  the  gas- 
tric or  duodenal  nicer,  more  ciuiimonly  in  the  latter,  the  blood  may  bo 
jiassod  in  the  stools  and  not  bo  vomited.  This  may  occur  when  the  liaMii- 
orrhage  is  slight,  but  also  when  it  is  jirofuso  enough  to  ]iro(liice  colla|)S(! 
and  extreme  anivmia.  I'rofuse.  even  fatal,  hannorrhago  may  come  from 
small,  superficial  nlcers.  or  oven  from  tlio  h.Tnmrrliagic  erosions.  Prob- 
ably it  is  from  such  that  in  t'lderly  persons  ])rofuso  lueiiiorrhago  occurs 
witliont  previons  gastric  symptoms. 

(r)  Pdiii  is  ])crha]is  the  most  constant  and  distinctive  feature  of  ulcer. 
It  varies  greatly  in  characti'r:  it  may  be  only  a  gnawing  or  burning  sensa- 
tion, which  is  particularly  felt  when  the  stomacli  is  omjity,  and  is  relieved 
by  taking  food,  bnt  the  nun'o  characteristio  form  conies  on  in  iiaroxysms 
of  the  most  intense  gastralgia,  in  whicli  the  iiain  is  not  only  felt  in  the 
epigastrium,  but  radiates  to  the  back  and  to  the  sides.  In  many  cases  the 
two  jioints  of  oi)igastric  pain  and  dorsal  pain,  aliont  the  level  of  the  tontb 
dorsal  vertebra,  are  very  well  marked.  These  attacks  are  most  frequently 
induced  by  taking  food,  and  they  may  recur  at  a  variable  ])oriod  after  eat- 
ing, sometimes  within  liftoon  or  twenty  minutes,  at  others  as  late  as  two 
or  three  hours.  It  is  nsually  stated  that  when  the  nicer  is  near  the  cardia 
the  ]iain  i.e  apt  to  set  in  earlier,  bnt  there  is  no  certainty  on  this  point.  In 
s(Mne  cases  it  comes  on  in  the  early  morning  hours.      The  attack;^  may 


4^2  DISEASES  OF  THE   DKJESTTVR  SYSTEM. 

,„..,,r  nt  interval^  witli  groat  int..nsily  fur  wcrks  .,r  n.ontl.s  at  a  tinu'.  so  tl.at 

''""l!'/l'"7V„,f,Tm-,<  „„  ,.ro...iri.  i.  a  oon.mr.,,  sy,„|.l...n  in  ,,U-..«nJ  |,»lin.l. 
„.t    1,'  ■     ...    iry  low.     .■.■..«..ro  .l.m.l.l  l„.  ...»*•  wMl.  ?.«.t  .,uo. 

l"n„     ,c  of  »..  ..l.or  1...;  !,«,>  in.l.,c.u.l  l.y  ....vl..*  ...a,.io„l,..,o.,. 

(,!)  In  oUI  nU-cr.  will,  tl.i.k.niHl  l»,se,  an  in.lnra,..!  ...a.*  .-an  n.nall)  1.0 
c.U  in  tlio  iii.i"-lil)(>rlio(i(l  ol'  the  pvloni;*. 

'"'rr/d!! :/'i'.-This  occurs  in  about  Ci  per  cut  of  all  oa.os.  Tl. 
aou  0  ,t  .iing  for.ns  is  ,nuch  .novo  oonnuon  in  ...non  -  -j;  ; 
Sc  V^.pton.s  ^0  those  of  porfovativo  por.ton.t.s.  ^'^^'^^t^ J^^^ 
,„ust  1.0  nvon  to  this  accident  since  it  has  con>e  so  snc<;ossfull>  ^  '  'i"  the 
s  lulo  ot  t  0  su,-eon.     As  already  mentioned,  perlorat.on  may  take  place 

0  t  ler  into    he    esser  ,,eritona..m  or  into  the  general  peritoneal  cav.ty,  u. 

1  o  "  d,i  h  cases  operation  is  indicated;  in  rare  i.istances  the  ulcer  may 
l;:ll^:;It:lhe  pericardium.     This  was  the  case  in  10  oi  2S  cases  u.  wlueh  the 

''"'l  ::5;^cr;:;"^^|ull!v  thphrenic,  al.coss  may  follow  perforation. 

Th;  c      s    of  the  disease:  i,,  iJ.  the  n^ajority  of  cases,  chronu..     (  n  y  a 
few  i   -t  nces  run  a  very  acute  course.     The  follow.n,  group  oi   clnucal 
orms  d  scrihed  hv  Welch,  indicate  the  diversity  ol  t  us  atlecfon: 

"1  Latent  ul'cers,  with  entire  ahsence  of  symptoms,  and   rcNoaled  as 
onon  ulcers  or  as  cicatrices  at  the  autopsy.  .    i     p,    •  f  „.,. 

^    "i     \eute  perforating  idcers.     With  or  without  a  por,od  of  hr.of  ga.- 
trip  di-turhance,  perforation  occurs  and  causes  speedy  death. 

"V  Acu  ri V.-morrhagic  form  of  gastric  ulcer.     After  a  latent  or  a 
hrief  cour        f  the  ulcer,^.rofuse  gastrorrhagia  occurs,  wluchn^.y  term,- 
r f' tallv  or  mav  he  followed  hy  the  symptoms  of  chrome  ulcr. 

"  ;  nMrahnc-dvspe,>tic  form.  In  this,  which  is  the  umst  common 
form  If  nitric  ^Ice.  gairalgia,  dyspc,.sia^  and  v.>miting  are  t  ;-y;;;P  -- 
Somotimo«  one  of  the  svmj.toms  pred.miinates  greatly  .ne  tlie  otlKK,  .o 
^^^L^rt  distinguishes  separately  a  gastralgie,  a  dyspept.c,  and  a  vomit- 
ive variety.    Gastralgia  is  the  most  frequent  symptom. 


THE  PEPTIC  ULCER-GASTRIC  AND  nL'onEN'AL. 


483 


lime,  so  thut 
ay  (lisiipiH'iii' 
usuiiUy  lii'iil 
iVLiioii;  out' 
lair;  another 
uut'ii.  Vv>- 
liiiv  af^suiuftl 
this  i>  very 

and  ]iati('iits 
li  <:ivat  ciii'o, 

>M. 

an  usually  ho 

rolon.ai'il  (lys- 
tcnosis  of  llie 
\<riiii(t  may  he 
L'd,  the  hlood- 
s,  sucli  as  the 
nuMuia  cannot 
cases  ])arotitis 
iitation  oi'  the 

11  eases.  Tlie 
tlian  in  men. 
ular  attention 
illy  within  the 
nay  take  ])lace 
neal  eavity,  in 
tlie  uleer  may 
es  in  which  the 

■  ])\>rf  oration. 

ironic.     Only  a 

oil])  of  clinical 

'ction: 

111(1   revealed  as 

.d  of  hriof  gas- 

h. 

r  a  latent  or  a 

lich  may  termi- 

ic  ulcer. 

>  most  common 

c  the  symi)toms. 

■r  the  others,  so 

ic,  and  a  vomit- 


"5.  Clironic  ha'morrha},'ic  form,  (lastrorrlia'^'ia  is  a  marked  symptom, 
and  occurs  usually  in  comhination  with  the  symptoms  jii>i  nienlitnicd. 

"  (;.  Caclu.li.'  form.  This  usually  corresjionds  only  to  the  linal  fclajio 
of  one  of  the  precedin-j  forms.  l)ut  the  caciiexia  may  develop  so  rapidly 
and  heconie  .<o  marked  that  the  course  of  tlie  disease  clo.-ely  rer-cnil)Kri  that 

of  gastric  cancer. 

"  T.  liecurrent  form.  In  lliis  the  symptoms  of  ga^llic  uKer  di>api)ear, 
and  then  follow  intervals,  often  of  considerable  duration,  in  which  llioro 
is  apparent  cure,  hut  the  sympt.)ms  return,  especially  after  some  indiscre- 
tion in  the  jnode  of  living.  This  interniitteiii  e(.urse  may  continue  for 
many  years.  In  these  cases  it  is  prohahle  cither  that  frc^h  ulcers  form  or 
that'tlie  cicatrix  of  an  old  ulcer  heconu's  ulcerated. 

"  H.  Stenotic  form.  Uy  the  formation  of  cicatricial  tis>ue  in  and  around 
the  ulcer,  the  pvloric  oriiice  l)ecomes  ohstructed  and  the  symptoms  of  dila- 
tation of  the  stomach  develop."  And  to  this  may  he  added  the  form  in 
which  cancer  develops,  which  will  he  referred  to  later. 

The  course  may  he  very  protracted,  and  tiiere  are  cases  in  which  the 
disease  has  persisted  for  ovi>r  twenty  years.  1  have  reported  two  instances 
of  i)ei>tic  ulcer,  i-rohahly  duodenal,  in  which  well-marked  symptoms  were 
present,  in  one  case  for  "eighteen,  and  in  the  other  for  twelve  year.s.  JJoth 
were  of  the  chronic  luvmorrhagic  form. 

Diagnosis.— The  recognition  of  gastric  ulcer  is  in  many  cases  easy, 
as  the  coml-ination  of  dyspepsia,  gastralgie  attacks,  and  hainatemesis  is 
very  characteristic.  Of  the  symptoms,  luvmorrhage  with  the  gastralgie. 
attack  is  the  most  characteristic.  The  distinctions  hetween  nicer  and  can- 
cer will  he  given  later.  The  greatest  diHiculty  is  oil'ered  hy  certain  cases 
of  gastral-ia,  which  may  resemble  nicer  very  closely,  as.  with  the  excejition 
of  the  hamiorrhage,  there  is  no  single  syin]>tom  which  may  not  lie  jireseiit. 
A  dilliciilty  also  results  from  the  fact  that  in  many  instances  gastralgia  is 
one  of  the  syini)tonis  of  nervous  dyspej.sia,  and   may  exist  with   marked 

emaciation.  .       ,    .  .i         x 

The  following  points  are  of  value  in  discriminating  hetween  these  two 

conditions:  .    ,•..,,  i  •       j-     i 

(a)  In  ulcer  the  pain  is  more  definitely  connected  with  taking  lood, 
thoucrh  this  is  not  alwavs  the  case,  as  in  the  duodenal  form  the  gastralgie 
attacks  may  occur  at  night  when  the  stomach  is  empty.  ]{eliet  of  pain 
after  eatin^r  i<  certainly  less  common  in  ulcer  than  in  gastralgia,  though  it 
is  a  very  uncertain  feature,  and  in  certain  cases  the  i)ain  in  ulcer  is  nhrai/s 

relieved  hv  taking  food.  ,   •     ,i 

(/;)  In  ulcer  dvsiiejitic  svmptoms  are  almost  invariahly  present  m  t he 
intervals  hetween 'the  attacks,  and  even  when  pain  is  absent  there  is  slight 

distress.  •       i  • 

(c)  Local  sensitiveness  over  a  particular  spot  in  the  epigastrium  is  sug- 
<re«tive  of  ulcer.  External  pressure  usually  aggravates  the  i)ain  in  ulcer, 
and  often  relieves  it  in  gastralgia.  This  is,  however,  a  very  uncertain  fea- 
ture, as  iiatients  writhing  with  the  pains  of  ulcer  may  press  the  ahdomen 
over' the  hack  of  a  chair  or  place  a  hard  pillow  under  it. 

(d)  The  general  condition  and  history  of  the  piticnt  often  give  the 


md 


daA 


DISKASHS  OK  TIIK   DUlKSTIVK  SYSTKM. 
45-T 

,„n.t  triKtworthy  inf<.r.ni.li..n.    Tlw  nutritim,  is  impaircl  inovc  fmiuontly 

,  .   UunorHw-a  a.ul  d.lun.is  .1,11.  in  the  la„.r  .h-.n;  are  assun- 

:;;:;, ;;.v.;us  ,h..nonu.na^-hv...n.al  ,nanilV..a,iun.  or  mMual^a.  .n  ntlu., 

"■^'iTon  .Na.ninatinn  ..f  Ih.  al.-lumrM.  nut  <mly  i<  l-ain  on  pressniv  nuuh 
,,o,vll!!nnui;  in  uU.  r,  Imt  tlu.v  n.ay  als..  1.  tlm.k.nin,  al.unt  th.  py-..n,. 
.,,,,1    in  nnnv  ca^.s,  si-ns  ..f  dilatation  of  the  stoniacli. 
■'•''';;•;  Sn"n>H;lity  and  oit.n  .uia.rs.c.>.Hion  of  tlu-  gastric  junv  ..s,.  w„h 

"'"tIh.  <i.slrlr  rrlscs  vvl.ioh  oocnr  in  alTodions  of  the  spinal  ..onU  padi.u- 
,,,.lv    n  'Lon,..tor  ataxia,  n.ay  sin.ulat.  v.ry  closdy  the  gastra  gu'  att     k. 

'    ,,  !     ,„.l  as  thov  so  off.n  oxist  in  the  preataxR.  stajro  tlu-.r  trno  natn,. 

,,:,•  Hooked ;"l.nt  tlu-  o.rur.vn.r  of  li.'l.tnin,.  pan.s,  the  oenlar  syn.p- 
;:;•  s!  and  ll.o  al-snu.  of  the  knee  rellex  are  ind.eat.ons  usually  snlhe.ent 

to  ivnder  the  diai:'i"sis  clear.  ■  ,     i     i-    •     ii,.v       \ 

'  „  ,1,,  ..,<tne  and  duodenal  uleer  ho  d.st,n,.nnshed  .Imuallv  -  A^ 
a„.e  d V  ^  ted.  thev  originate  in  the  snn.e  way  and  present  the  same  ana- 
t  n  e,l  ehara.ters."  In  the  g,-eat  majority  of  eases  they  eannot  l)e  s,  pa- 
n  i/lif,.  n^  the  <vnn>ton.s  pro.lneed  are  identu-al.  r.ue.pioy  has 
:;;  i^  1  h;  dnildenal  lleer  L  he  dis.in.nished  hy  the  follo.,n, 
nnite  hara<.ters:  (.)  Sndden  intestinal  luenmrrhage  ,n  an  apparently 
h  V     'on.  .hieh   tends  to  reeur  and   produce  a   pndo.njd   an,enna. 

1  «rha,e  fron,  the  ston.ach   u,ay  precede  or  --"M-"^;  ^  '^   ^     ! 
(/,)  I'ain  in  the  ri-ht  hypochondriac  n.o,on.  eonnng  on  two  or  tlnee  ho  n> 

a  no    h  '^  is  nore  apt  to  occur.      Certainly  the  occurrence  of  sudden 
^    Sl,aMnorrha.e'vith  gastralgie  attacks  is  extrenu.ly  su-estive  ot 
;:,;:::;  nhc.      W.    ^^.   .lohnston    m.   reported    an    -^J-    'IJ J  ^  j 
,„  „„ie  the  diagnosis  on  these  symptoms,  an.l  m  one  of  the  Mon      a 
Ls    I'ahner    Howard    suggested    correctly    the    l"-ence    of    a    duod     a 
ulcer  on   sinnlar  grounds.      A   patient   undc.  n.y   -^  ;1-   ';;;^;,: '"^^ 
ohditcon    vcars.    fre.,uent    attacks    of    ImMnateuu.s.s    w.th    ga>t,alg  .     had 
w  vna    nreatedlv    without   vomiting  hlood;    hut    as   a    rule   ,n    the   at- 
tacks the  hlood  was  vonnted  llrst.  and  did  not  appear  ,n  the  stools  un- 
til  later       Occasionallv   this   symptom   will   he    found   an    important    aid 
in   dia.HKwis       The   situation   of   the   pain    is  too   uncertain    a    tactor   on 
xvhich'to    lay    much   stress,   and    the   character   of   the   crises    is   usually 

'''uall-ton..  colic  mav  occasionally  simulate  the  pains  of  gastric  ulcer. 
The  sudden  onset  and  as  sudden  termination,  the  swelling  and  enderness 
of  the  liyer.  the  enlaraement  of  the  gall-ldadder,  if  present,  and  he  occur- 
rence of  iaundico  aro']."i"ts  to  be  considered.  The  experience  of  surgeons 
has  tauLd.t  us  that  a  number  of  cases  in  Avhich  the  pains  were  regarded  a> 
gastralgia  haye  in  reality  been  duo  to  gall-stones,  with  which,  as  ,s  now  well 
known,  iaundico  is  not  necessarily  connected. 

Treatment. -Post-mortem  observations  sllo^y  that  a  very  largo  num- 
ber of  ulcers  heal  completely,  but  tl.o  process  is  slow  and  tedious,  ottcn 


TllK   PKPTIC  ULCEIl— GASTUIC   AND   DlODHNAli. 


485 


(•  fi'diiuMitly 
iiminiily  (ill 
L'  iiro  nssoci- 
[iiis  in  (itluT 

cssui'c  niiiili 
ihc  py'iii'ii;: 

('  ("vist-^  with 

(inU  iiarticii- 
■iil;.Mc  attacks 
1"  tnio  iiatiirt' 
ocular  symp- 
lUy  siiilicii'iit 

nically':'  A> 
lie  siiiiic  ana- 
niiit  lit'  s('|ia- 
l>iic(|Uoy  lias 
:1h'  i'dllipwi nu- 
ll aiijiai'i'iitly 
und   ana'iiiia. 

the  incla-'iia. 
r  three  hours 
Iff  which  the 
ICC  of  sudden 
sufiiiestivc  of 
ice   in    whith 

the  ^lontreal 
f  a  duodenal 
1  had.  durin;; 
:astral;j;ia  had 
Ic  in  the  at- 
the  stools  un- 
iinportant  aid 
1  a  factor  on 
sc's    is    n-ually 

(rastric  ulcer, 
md  tenderness 
and  the  occnr- 
ce  of  surgeons 
■re  rejrarded  as 

as  is  now  well 

:^ry  larfro  n uni- 
ted ions,  often 


requiring  m.mths.  or.  in  severe  .ascs,  years.     The  following  arc  tlu-  im- 
portant points  in  trcatineiit: 
((1)  Aiisolute  rest  in  hed. 

(/,)  \  carcfullv  and  sy.-teniatically  re<:iilate(l  did.  \Vliile  theoretically 
it  i.lK.ttertofiivJthestonmchcoiiipieterest  l.y  rectal  feeling,  yet  iii  prac- 
ti,.,-  thi^  strict  limitation  is  not  found  satisfactory.  The  food  should  he 
l,l,,id  ca-ilv  di-.-t.'d,  and  given  at  staled  intervals.  The  foUowing  dietary 
will  lie  iniind  us.ftil:  .\t  S  A.M.  give  V'dO  cc.  of  Leuhe's  h.vi  soi.ili..n;  at 
1-'  M  ;?ii(i  ,c  of  milk  gruel  ov  peptonized  milk.  The  gruel  slioird  he  made 
with  ordinary  Ih.ur  or  arrowroot,  and  is  mi.Ncd  with  an  equal  (luantity  of 
iMilk  if  necessary  it  luav  he  peptoni/.ed,  I'.ultermilk  is  very  well  horue 
hy  these  patients.  .\t  I  V.  M.  ihc  h.rf  .solution  again,  ami  at  H  i-.  .\i.  the 
iiiilk  gruel  or  the  huttermilk. 

The  stomach  in  some  cases  is  so  irritahlc  that  the  >imallcst  amount  ol 
food  is  not  well  horne.  In  such  cases  lavage  may  he  practised,  if  necessary, 
every  morning,  with  mildly  alkaline  water,  after  which  the  heel  solution 
i.  .nVcn  and  the  feeding  supplemented  hy  tlu"  rectal  injections  111  elects 
ranlv  fallow  the  careful  um'  of  the  stoma.di  tiihe  m  ga.stnc  ulcer.  1  here 
iiv  <ome  (Mses  which  do  well  from  the  outset  on  a  milk  diet,  given  at  regu- 
lar intervals,  :5  or  4  ounces  every  two  hours.  When  milk  is  not  well  horne 
cmr  alhunien  may  he  suhstituted,  or  the  whiles  <d'  eight  eggs  may  he  alter- 
naUMl  with  Leiihe-s  heef  s..lution.  At  the  eml  of  a  month,  if  the  condition 
has  improved,  the  i.atient  may  he  allowed  scrai.ed  heef  or  young  chicken 
l„afeetlv  fresh  sweet-hrea.l,  and  farinaceous  puddings  made  with  milk  an.l 
CM...  i.ocal  aiudications,  such  as  warm  fonientati..ns,  over  the  alidoiuen 
are' very  useful.  The  patient  should  he  told  that  the  treatment  wil  take 
at  least  three  months,  and  for  the  greater  portion  of  the  time  he  slumld 

he  in  heih  ,       .  .  •       i  i  ^l,.^ 

(r)  Medicinal  measures  are  of  very  litle  vame  in  gastric  ulcer,  and  the 
remedies  employed  do  not  ,.rohahly  henefit  the  ulcer,  hut  the  gastric  ca- 
tarrh The  Carlshad  salts  aiv  warmly  recommended  hy  von  /lemssen..  1  lie 
artificial  i.re].iration  (sulphate  of  sodium,  HO;  hicarbonate  ol  sodium  <.; 
chl.nide  of  sodium,  :5)  mav  he  suhstituted,  of  which  a  teaspoonful  is  taken 
overv  morning.  I'.ismnth,  in  doses  of  W  to  (!<)  grains  three  limes  a  day, 
and  "nitrate  of  silver  may  he  given,  hut  they  inlluence  the  associated  con- 
ditions rather  than  the  ulcer.  ,,•••< 

The  ..ain,  if  severe,  re(,uires  opium.  Unless  the  gastralgia  is  intense 
,,iorphia  should  not  he  given  hypodermically,  as  there  is  a  very  serious 
dan'er  in  these  cases  of  estahlishing  the  morphia  habit  T>;f^'«/f  J" 
oioirth  of  a  grain,  with  the  bicarbonate  of  soda  and  bismuth,  wdl  allay  the 
mild  attacks,  but  the  very  severe  ones  require  tlie  hypodermic  injection  <.t 
a  quarter  or  often  half  a  grain.  Antipyrin  and  antifcbrin  may  he  tried, 
but.  as  a  rule,  arc  quite  inelfectual.  Tn  tlu  milder  attacks  Hoffman  s  ano- 
dvne  or  20  or  30  drops  of  chloror<u'm,  or  the  spirits  of  camphor  will  give 
relief.    Counter-irritation  over  the  stomach  with  mustard  or  cantliandes  is 

''^^  When  tlie  stomach  is  intractable,  the  patient  should  he  fed  per  roctum. 
ITe  will  sometimes  retain  food  which  is  passed  into  the  stomach  through  the 


*A 


480 


DISKASKS  OF  TIIK   DKlKSTIVK  SYSTHM. 


t„l„.  nn.l  1.(m,1k.'h  Lccf  ^<..lnli..n  or  milk  n,.,v  1...  j:ivni  in  tins  way.    (  rack.;,] 

,,   ;.,,,„n.lor.u.  ..xalah.  ..l  .vrinn,,  l.iM-u.th.  l,y.lrn.,vani.  a.H     a.ul  ,m,1uv,m 

,„av  lu"  <n«-l-     WluM,  l.a.nH.rrl.aj;,.  .un.r.  tl.r  pali-nt  s1..m.M  b.  l-ut  nnHr, 

u.  intlm.n.r  of  opin,,.  as  n.pi.lly  as  pnssihl...     No  attnn,.t  sl.nuhl  Ik-  ma.l.. 

U      Lk  tlu.  l,a.nu,.Tl.a,c.  I.y  a.lnnMi.t..r.iM,  n....li.ims  l.y  tho  .noutl,:  as 

,;  '  ofuso  Llrnlin,'  is  always   ITun.   an  .to,!..!  art.Ty.   livM>u.n.lv    Inun 

„„,  ;,r  .onsi,u..ai.u.  si...  it  is  .loui.t f-i  if  a.Hat.  ..f  u.ui  '"-'■;;:;;";' ,^;';, 

a.i.ls,  an.l  tl.r  ..snal  mn...li.-s  hav.  ll.-  si,.i,t.sl  in  I.mmhv  1 1  .■  .■^M'nl  al 
'in  is  to  Kivo  rc-sl,  wl.ic-l.  is  l.csl  ohtainnl  l.y  ..punn  Kr^ot.n  n,av  .. 
,lninistm.,l  hypoclonnically  in  two-^rain  .los...  Notlnn^;  sl.m.M  ho 
"in  l.y  tlu.  n.ontl.  .xn-pt  snn.ll  qnantiti.s  oi'  i...  In  pn  us.  l.l.....l,n« 
a  li.ratnr..  n.ay  l.o  applir.l  aron.wl  a  k'it,  -r  a  h-  and  arn..  Not  ,nlnM,uc.ntly 
h7ll  of  l.lL.i  is  HO  groat  that  tho  ,.ationt  faints.  A  latal  ro^nlt  ,s  no  . 
l,„wovor.  vory  o..n.n.on  Iron,  lKon.orrl.a;ro.  'rran>tuHon  n.ay  ho  nooossaiy, 
or.  still  hottor,  tho  sniu  ntanoons  infusion  ol  salino  solution. 

T;.o  pationts  nsuallv  rcoovor  rai.i.lly  from  tho  iKoniorrha-o  an<    ro.pi.r.. 
iron  in  full  .losos,  wliid,  may.  if  no<.ossary.  lu-  givon  ':>'i;'."'7";.";'  'f'...,  ,„ 

Surgioal  intorforonoo  in  nhor  of  tho  stonm.-h  ,s  ,n.  lioato.!:  (.        in 
porforati<.n  has  takon  ,.laeo.    Tho  statistios  oollooto.l  hy  I^ar lin^'  aiul      ,     - 
licz  indioato  how  suooossful  this  oporathu.   has  hooonio.     (/-     In  ^oI\    in- 
traotahlo  oasos  whioh   have  rosisto.l  all   tivatmont.  a.ul   whioh  nro  aooom- 
naniod  l.y  attacks  of  vory  sovoro  i.ain  and  ivurrin-.  almost  latal  luomor- 
ihagc,  the  uloor  may  ho  oxois.Ml.    (r)  Kor  iK-matoiuosis.     A  nninhor  ol  oasos 
hnvo  now  boon  snooossfullv  oporatod  upon  for  tho  ro.Mirnn-  hlo...l,ii-.        \u 
„n-oon  must  hoar  in  min.l  that  tho  vory  sovoro,  profnso    Komorrha-o  doos 
not'always  oomo  from  tlio  largo  round  nloors,  hut,  as  Dioulalov  has  r.rontly 
pointed  mil,  from  (inito  small  orosions.     In  a  oaso  of  this  kmd  th..  opvialion 
las  porformod  suooossfully.      b'or  a  full  oonsi.loratioi,  o    this  .|iiostion      lo 
roa.lir  is  roforrod   to   Ko.-n's  Cartwright  Lo.turos  on   tho  ^'-'^''''T''    tho 
Stomaol).  in  tho  IMiiladolidiia  Mo.lioal  Journal  lor  :May  and  Juno,  18J». 


V.    CANCER  OF  THE  STOMACH. 

•Etio\ogy.-I >irul('„rr.—\u  an  analysis  of  30,000  oasos  of  cancer,  V7. 
II  Woloh  found  tho  stomaoh  involved  in  'i^A  per  cent,  this  organ  thus 
standing  next  to  the  utorus  in  onUr  of  fre-inonoy.  Among  S.KM  oases  ad- 
mitted lo  mv  wards,  there  wrro  1^0  cases  of  oanoer  of  the  stomach.  1  hero 
wore  39  cases  among  the  first  1.000  autoi)sies  in  tho  lutst-mort.'in  room  ot 
the  Johns  Hopkins  Hospital.  The  disease  is  more  oommon  m  some  coun- 
tries.    Figures  indicate  that  canoer  of  the  stomach,  as  ol  other  organs,  is 

increasing  in  frequency.  wi    + 

Scx—'V  Mot^rae  has  analyzed  IT.O  eases  from  my  wards  and  tound  that 
there  were  12(1  males  and  2\  females.    Welch  gives  the  ratio  as  r,  to  4. 

^np—Oi  our  mo  cases  the  ages  were  as  follows:  Between  twenty  an<l 
thirty-,  v.;  from  thirtv  to  forty.  17:  forty  to  fifty,  3S:  fifty  to  sixty,  4!): 
sixty  to  seventy,  30; "seventy  to  eighty,  4.  Fifty-eight  per  cent  occurred 
between  the  ages  of  forty  and  sixty.     Oi  the  G  cases  oecnrring  under  the 


CANCKR  OF  TIIK  STOMACn. 


487 


iiy,  Crackt'il 
1111(1  in<;liiviii 
H-  juit  mult  r 
iiild  Ik>  iiiihIi' 
If  iiuiiitli;  as 
jiu'iilly  lii'iii 
lie  niul  ^Tiillii' 
Tlic  essential 
lotiii  may  1»' 

<r      sliolllll      1)0 

I'lisc  Idccdiiif^ 

inl'rcMiiu'iitly 

result  is  not, 

he  necessary, 

e  an<l  retinire 
iiiiealiy. 
.(1:  ((/)  When 
n;,'  and  Mikii- 
)   In  very   in- 
•h  iir(!  aecoMi- 
I'atal  lia-inor- 
indier  of  eases 
llee(lin;.^     The 
iiinrrl\a,t;'e  does 
ly  has  recently 
I  the  o|ieratiiMi 
s  qnestion  the 
iiuirery  of  the 
Juno,"  18118. 


of  oanoor,  V7. 
his  or;ran  thus 
S.KM  cases  ad- 
onujch.  There 
orteni  room  of 

in  some  coun- 
)thor  or<jans,  is 

and  found  that 
as  T)  to  4. 
?on  twenty  and 
y  to  sixty,  40; 
r  cent  occurred 
rrinp:  under  the 


thirtieth  year,  the  younirest  was  twenty-two.  Of  the  Iar;.'e  niimher  of  cases 
analyzed  hy  Wi'Icli,  three  fourths  occurred  hetweeii  the  lortieih  and  seviMi- 
tielh  years.  ( 'on,i:cnilal  eaiieer  of  the  .-loniaeh  has  lieeii  dexrihed,  .md 
cases  have  heeii  met  with  in  children. 

Jlaif, — Anionj,'  our  1">0  cases,  i;il  were  white;   lit  were  ncfirocs. 

Ilcnillhi. — Of  the  l."ii)  cases  in  only  11  was  there  a  jiositive  history  of 
cancer  in  the  family.  In  some  families,  as  the  r.ona|iartes,  the  disease  seems 
to  prevail.  In  our  series  n  very  much  larjicr  nuniher — iiS— had  a  family 
iiistory  of  tnherculosis. 

J'rfviiius  Dist'dsrs,  llnhih,  vlr. — A  history  of  (lyspepsia  was  present  in 
only  n:{  cases;  of  these,  17  had  had  attacks  at  intervals,  11  had  had  chroiiie 
stomach  troidde,  and  5  had  had  dys])epsia  for  oiu'  or  two  years  heforo  the 
symptoms  of  cancer  developed.  Napoleon,  discussiti;,'  thi.s  interestini,'  point 
with  his  |ihysician  Autoinmarchi,  said  that  he  had  always  had  a  stoniaih 
of  iron  and  felt  no  iiuonvenieuce  until  the  onset  of  what  proved  to  he 
his  fatal  illiu'ss. 

Alidlii'l. — Seventy-seven  of  our  ])atients  hail  used  it  re;,ndarly,  (1.")  of 
these  moderately  (?),  8  excessively.  Tnuniui. — Oidy  one  case  pave  a  posi- 
tive hi^lorv.  In  a  recent  case  the  cancer  developed  rapidly  afti.'r  a  hlow  on 
the  stomach,  and  the  patii'ut  lost  sixty  pounds  in  weight  in  threi'  months. 
(Idstrir  I'lrvr. — Four  cases  ^mve  a  history  ])ointin^'  to  ulcer,  hut  there  was 
no  instance  of  ulcus  earcinomatosum  anu)n,u:  the  autopsies. 

Mental  worry  and  strain  were  <,Mven  occasionally  as  causes  of  tlu'  illness. 

Morbid  Anatomy. — The  most  common  varieties  of  pastrie  caiucr 
are  the  cylindrical-celled  adeiuvearcinonia  ami  the  encephaloid  or  nu'dul- 
lary  carcinoma;  mwt  in  fretpu'ney  is  scirrhous,  and  then  colloid  cancer. 
With  reference  to  the  situation  of  the  tumor,  Welch  analyzed  1,;3()0  eases, 
in  which  the  distrihntion  was  as  follows:  i'yloric  re<iion,  7!)1;  lesser  curva- 
ture, 1  IS;  cardia,  10  1;  ]),)sterior  wall.  (!S;  the  whole  or  <rreater  i)art  of  the 
.stomach,  (il;  multiple  tumors,  l."i;  frreater  curvature,  ;5l;  anterior  wall,  30; 

fundus,  1!). 

The  medullary  cancer  occurs  in  soft  masses,  which  involve  all  the  coats 
of  the  stomach  and  usually  ulcerate  early.  The  tumor  may  form  vilhuis 
projections  or  caidiflower-like  out^n-owths.  It  is  soft,  grayish  while  in 
color,  and  contains  miudi  hlood.  Microsco])ically  it  shows  a  scanty  stroma, 
enclosin,ir  alveoli  which  contain  irrcirular  polyhedral  and  cylindrical  cells. 
The  cylindrical-celled  epithelioma  may  also  form  larpe  irregular  masses, 
hut  the  consistence  is  usually  flrnu-r,  iiarticularly  at  the  edges  of  the  can- 
cerous ulcers.  ]\Iierosco])ically  the  section  shows  elongated  tuhular  spaces 
filled  with  columnar  epithelium,  and  the  intervening  stroma  is  ahundant. 
Cysts  are  not  uncommon  in  this  form.  Tiic  scirrhous  variety  is  character- 
ized hv  great  hardiu'ss,  due  to  the  ahnndance  of  the  stroma  and  the  limited 
amount  of  alveolar  structures.  It  is  seen  most  Imjuently  at  the  ^lylorus, 
Mhere  it  is  a  common  cause  of  stenosis.  It  may  he  comhined  with  the 
medullary  form.  It  may  he  diffuse,  involving  all  parts  of  the  organ,  and 
leading  to  a  condition  which  cannot  he  recognized  macroscoi)ically  from 
cirrhosis.  This  form  has  also  heen  seen  in  the  stomach  secondary  to  cancer 
of  the  ovaries.     The  colloid  cancer  is  peculiar  in  its  widespread  invasion 


d^ 


488  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

of  ..11  tlio  coat..    It  al.o  spreads  with  greater  frequepoy  to  the  mMghboring 

1;  .11    oecasicnally  causes  extensive  see.Mulary  growths  o    the  suue 

'    ii'e        other  or-mns.     The  appearance  on  section  is  very  d.st.netue, 

d      e   \  HhVi;,;.kea  eye  largl  alveoU  can  he  seen  filled  -th  the  ^.n.- 

uent  colloid  material.    The  term  alveolar  cancer  ,s  olten  applicnl  to  this 

:       •    ;l;ion  is  not  constantly  present,  and  tl.ere  arc  n^  an.es  -n 

whieh    with  most  extensive  disease,  digestion  has  been  bu    ^hgh  In   d 

l'  T  lere  is  a  .specimen  in  the  Warren  Museun),  at  the  larvard  Med  - 
l:i  sl-d!  or  the  nlost  widespread  colloid  cancer  in  winch  tho  stomach 
eontained  after  death  Lirgc  pieces  of  undigested  beef-steak. 

Seondaru  Cancer  of  the  Shmach-Oi  37  cases  collected  by  ^^elch,  1. 
.-ore  ZSlio  can/er  of  the  breast.  Among  tlu3  first  f,0(.0  autopsies 
^t    he  Iohn«  Hopkins  Hospital  there  were  3  cases  of  secondary  cancel. 

'  ;;      "i,  /^':S/.H«.^^-('ancer  at  the  cardia  is  usually  assocUed  w,  h 
^vac  i       of  the  organ  and  reduction  in  its  six.e.     The  c.sophagus  above  th 

hslnld:!  n,ay  be  greatly  dilated.     <>'V^'7  ^^'^^^^^r^^.^lir'lT';:: 
at  the  pvlorus  causes  stenosis  with  great  ddatatum  of  the  oigan.     I"  '^^^^ 
rax.    nuances  the  pylorus  has  been  extremely  narrowed  w.thm.t  any  in- 
^  a.    h    the  size  o   Ihe  stomach.     In  diffuse  scirrlmus  cancer  the  stoinacl 

vn-  b  vcrv  greatly  thickened  and  contracted.  H  may  be  displaced  or 
"  r  d  in  hape  bv\he  weight  of  the  tumor,  particularly  in  c^incer  of  the 
;  Ions  in  sudi  cases  it  has  been  found  in  every  region  of  the  abdomen,  and 
[. ven  in' the  true  pelvis.  The  mobility  of  the  tumors  is  at  times  extraord.- 
mry  and  verv  deceptive,  and  they  may  be  pushed  into  he  righ  hypocho  - 
iui,  or  into  the  splenic  region,  entirely  beneath  the  nbs.  Adhesions  veiy 
Cuently  occur,  particularly  to  the  colon,  the  liver,  and  the  anterior 

"''";mda^f 'ancerons  growths  in  other  organs  are  very^  frecp-ent,  as 
.hown  by  th^  following  analysis  by  Welch  ;.f  1  5T4  -^-.^'j^^;^-;-; 
eurred  in  the  lymphatic  glands  in  5.^1;  in  the  liver  in  4.o    •       '<^    ' 
tcnKvum,  omentum,  and  intestine  in  ;5:.T;  in  the  pancreas  in  U„  m  th 
pleura  and  lung  in  <)S;  in  the  spleen  in  20;  in  the  brain  and  meninges 
I;  i„  other  parts  in  D3.     The  lymph-gland^  affected  are  usually  thos    of 
tl  e  abd.nnen,  but  the  cervical  and  inguinal  glands  are  not  -nfrecp      tly 
attacked,  and  give  an  important  clue  in  diagnosis.     Secondary  metastatic 
growtlis  occur ^subcutaneously,  either  at  the  navel  or  beneath  the  skin  in 
til.  vicinitv,  and  are  of  great  value  in  diagnosis.    In  one  instance  'U^^tiu  t 
th  jaundice,  which  had  developed  somewhat  suddenly  and  was  bolievec    o 
b    ca  arrhal,  presented  no  signs  of  enlargement  of  the  liver  or  tumor  of  the 
stomach,  but\a  nodular  body  appeared  at  the  navel,  whic  i  on  remov.1 
proved    o  be  typical  scirrluis.     A  second  case  in  the  ward  at  the  same 
lime,  with  an  obscure  doubtful  tumor  in  the  h^ft  lypochondrium.  develo 
a  painful  nodular  subcutaneous  growth  midway  between  the  navel  and  the 

left  margin  of  the  ribs.  ^      ^;,  „  „f 

P„.forafwn.-\n  the  extensive  ulceration  which  occurs  perforation  ot 
the  stomach  is  not  uncommon.    It  occurred  into  the  peritonrrum  m  17  o 
te  507  cases  of  cancer  of  the  stomach  collected  by  r.nnton.    In  our  serie 
perforation  is  recorded  in  4  cases.    When  adhesions  form,  the  most  extensive 


J 


CANCER  OF  THE  STOMACH. 


4S9 


lu'igliboring 
:)1'  tho  yaiiiL' 
distinelivo, 
li  tlio  tvaiis- 
iliod  to  this 
instances  in 
sliglitlv  ilis- 
irvanl  Modi- 
tlio  stomach 

•y  Welch,  ir 
100  autopriics 
y  cancer, 
■iociated  witli 
us  aljovo  the 
innlar  cancer 
n.     In  a  few 
liout  any  in- 
the  stomach 
displaced  or 
cancer  of  the 
[ibdomcn,  and 
lies  extraordi- 
ht  hyi)oclu)n- 
.dhcsions  very 
the  anterior 

frecpicnt,  as 
Metastasis  oc- 
;  in  the  peri- 
n  122;  in  the 
[1  meninges  in 
ually  tlios'!  of 
t  infrequently 
nry  metastatic 
th  tho  skin  in 
;dnce  a  patient 
was  believed  to 
ir  tumor  of  the 
:di  on  removal 
d  at  the  same 
ium.  developed 
I  navel  and  the 

perforation  of 
nn?um  in  17  of 
.  Tn  our  scries 
'  most  extensive 


destruction  of  the  walls  may  take  iilacc  witliout  perforation  into  tlie  peri- 
toneal cavity.  In  one  instance  wliich  came  umk'r  my  ol)scrvation  a  large 
]iortion  of  the  h'ft  hihc  of  tiie  liver  lay  witliin  the  stomacii.  Occasionally 
a  gastro-ciitaneous  li>tula  is  cstalilislicd.  IVrforation  may  occur  into  tlic 
(.■(don.  the  small  liowcl,  the  pleura,  the  lung,  or  into  the  pericardium. 

Symptoms.— /.'//(■«/  Vinrinowa. — The  cases  are  not  very  inlre(iueiit. 
There  may  lie  no  symptoms  pointing  to  tlie  stdiuaeh,  and  tiie  tumor  may 
be  dis(H)vere(l  accidentally  after  death,  in  a  .mvoikI  group  tiie  symptoms 
of  carcinoma  are  present,  not  of  the  stomach,  but  of  the  liver  or  some  otlier 
organ,  or  there  are  subcutaneous  nodules,  or,  as  in  one  of  our  cases,  sccon(l- 
ary  masses  on  the  rilis  and  vertebra'.  In  a  third  group,  seen  jiarticularly  in 
(!(lerly  persona  in  institutions,  there  is  gradual  asthenia,  without  nausea, 
vomiting,  or  other  local  synqitoms. 

Frtiliiirs  (if  Oiiscl. — Of  the  ITjO  cases  in  our  series,  IS  complained  of 
pain,  44  of  dyspepsia,  21  of  vomiting,  1:5  of  loss  in  weight,  :5  of  dilliculty 
in  swallowing,  1  of  tumor.  In  7  the  features  of  onset  suggested  pernicious 
anu'inia.     in  ;57  cases  there  was  a  history  of  sudden  onset. 

General  Symptoms.— 7. c^.s-  of  ll'r/;//;/.— Progressive  emaciation  is  one 
of  the  most  c(mstant  features  of  the  disease.  In  1!t  of  our  cases  in  which 
exact  figures  were  taken:  To  ;M»  iiounds,  ;?2  cases;  oO  to  50  pounds,  ;3(;  cases; 
50  to  (To  pounds,  5  cases;  (U)  to  70  pounds,  4;  over  70  piuinds,  f;  100 
jiounds,  a  caso  of  cancer  at  tlie  cardiac  end  with  obstruction  to  swallowing. 
The  loss  in  weight  is  not  always  progressive.  We  see  increase  in  w(Mglit 
under  three  conclitions:  (a)  Proper  dieting,  with  treatment  of  the  associated 
catarrh  of  the  stomach;  (/;)  in  cases  of  cancer  of  the  jiyloriis  after  relief  of  the 
dilatation  of  the  organ  by  lavage,  etc.;  (r)  after  a  profound  mental  impres- 
sion. 1  have  known  a  train  of  ten  pounds  to  follow  the  visit  of  an  optimistic 
consultant.  In  Keen  and  D.  D.  Stewart's  case  there  was  a  gain  of  seventy 
pounds  after  an  exploratory  operation! 

Loss  in  strcnuIJi  is  usually  proporti(niate  to  the  loss  in  weight. ^  One  sees 
sometimes  remarkable  vigor  almo.st  to  the  close,  but  this  is  excejitional. 

Atirrniia  is  present  in  a  large  proportion  (d'  all  cases,  and  with  the  emaci- 
ation gives  the  picture  of  cachexia.  There  is  often  a  yellow  or  lemon  tint 
of  thc'~skin.  In  59  cases  careful  blood-counts  were  made,  in  ;i  the  red  cor- 
imscles  were  above  fi/>00,000  per  cubic  millimetre.  This  occurs  in  the 
concentrated  condition  of  the  blood  in  certain  cases  of  cancer  of  the  ])ylorus 
with  dilatation  of  tho  stomach.  The  average  count  in  the  5!»  cases  was 
3,712,180  ])er  cubic  millimetre.  Tn  only  S  cases  was  the  count  below  2,000,- 
000,  and  in  none  below  1,000.000.  Tho  average  of  the  luuinoglobin  was 
44.0  per  cent.  In  only  !)  was  it  below  30  per  cent.  In  C>2  cases  in  which 
the  leucocytes  wore  counted  there  were  only  18  cases  in  which  they  were 
above  12.000  ]wv  cubic  millinu'tre;  in  only  3  cases  were  they  above  20,000. 
As  mentioned,  there  were  7  cases  in  wh\h  the  features  of  onset  suggested 
a  primary  anrcinia.     To  this  (|uestion  we  shall  return  under  diagnosis. 

Among  other  general  svmptonis  may  be  nieiiti(me(l  frror.  Of  our  150 
oases,  74  showed  some  fever.  In  only  13  of  these  was  tho  temperature 
above  101°.  In  2  it  was  above  103°.  Fifteen  presented  fairly  constant 
elevation  of  temperature.     Eight  presented  sudden  rises.     Two  cases  had 


490 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


fhiU,  with  elevation  to  mi°  and  104°.    ( 'lulls  may  l.e  associate.l  with  ?u]<- 
nuration  at  the  hase  of  the  eanoer. 

;-,./„^_Tiiere  may  he  no  ehaiiixes  throii^rhont;  m  ('.5  ol  our  eases  there 
were  no  alterations,  in'  :5(;  alhnmin  was  loun.l.  and  in  :i  1  all.umin  with  tul)e- 
easts.    (ilyeosnria.  pci>tonuria.  and  aeetonuria  have  heen  desenhed.     in.liean 

is  eonimon.  ,   ., 

^,V,„,„ —Swelling'  of  the  ankles  is  of  impient  oeeurrenee  towanl  the 
elose'  In  some  eases  there  is  even  early  a  jieneral  anasarca,  nsually  in  eoni- 
hination  with  extreme  ana'mia.     Tlie  eaneer  is  nsually  overlook  .L 

'I'lR.  bowels  are  often  eonstipated.  In  only  Vi  cases  m  our  series  was 
diarrh.ra  present.  In  2  eases  l.lood  was  pa>s,,!  per  reelum.  There  arc  no 
special  cardiac  stiwphms;  tiie  pulse  l.ec.mcs  pro-rcssively  weaker.  1  hrom- 
hosis  (.!■  one  femoral  v..in  may  occur  or.  as  in  .me  of  ..ur  cases,  widesi.rea.l 
thromhosis  in  the  suiuMlicial  veins  of  the  ho.iy. 

Svmi.toms  on  tlie  part  of  the  nervous  system  are  rare;  conscumsness 
is  often  retainc.l  to  the  end.  Cuma  nu.y  develop-viz.,  similar  to  that  seen 
in  diahetes,  and  is  helieved  to  he  due  to  an  acid  intoxication. 

Funotional  Disturbances.— . I /(.-mrfVf,  loss  of  desire  tor  tood.  is  a  re- 
fluent and  valual)le  svmptom,  more  constant  i.erhaps  than  any  other. 
Nausea  is  a  strikiuj,^  feature  in  many  cases;  there  is  often  a  smhlen  re- 
pulsion at  the  sigiit  of  food.     In  cxcepti.^nal  cases  the  appetite  is  retame.l 

tlirouj^diout.  .      , 

Vnmilin,!  mav  come  on  earlv,  or  only  after  tlie  dyspepsia  has  persisted 
for  some  time,  it  occurred  in  f.'S  eases  in  our  series.  At  first  it  is  tit  long 
intervals,  hut  suliseqnentlv  it  is  more  impient,  and  may  recur  several  times 
in  the  day  There  are  cases  in  wiii.li  it  comes  (ui  in  paroxysms  and  then 
subsides; 'in  other  cases,  it  sets  in  early,  iiersists  with  -reat  violence,  and 
mav  cause  a  fatal  termination  within  a  f.'W  weeks.  Vomit in}r  is  more  ire- 
,,uent  when  the  cancer  involves  the  orifices,  particularly  the  i>ylorus.  m 
wliich  case  it  is  usuallv  delayed  f(n-  an  hour  or  more  after  takm-  the  loo.  . 
When  the  cardiac  (U'ifice  is  involved  it  may  follow  at  a  shorter  interval. 
Fxtensive  disease  of  the  fundus  or  of  the  anterior  or  posterior  wall  may 
1)('  present  without  the  occurrence  of  vomitin.u.  The  food  is  sometimes  very 
little  chan-icd,  even  after  it  has  remained  in  the  stcnnach  for  twenty-four 

hours.  ,111  11 

Ilannorrhuie  occurred  in  aO  <,f  our  loO  eases;  in  32  the  blood  was  diirk 
and  altered,  in  15  it  was  liri-ht  red.  fn  2  cases  vomitin-  of  blood  was  tlie 
first  syniiit.nn.  The  bleedinji  is  rarely  i.rofuse;  more  commonly  there  is 
slhdit'oozinfZ,  and  the  blood  is  mixed  with,  or  altered  by  the  secretions 
and  when  vomited,  the  material  is  dark  brown  or  black,  the  so-called 
"  c.)fTee--n'.nind  "  vomit.  The  blood  can  he  reco-nized  by  the  microscope  as 
shadows  of  the  red  hlood-corimseles  and  irrejrular  masses  of  altered  blood 
pifrment.     In  eases  of  doubt  the  spectroscope  may  be  cini-h^yed  .n'  luemm 

crystals  obtained.  .     -,,„!. 

■  Vain,  an  early  and  important  symptom,  was  y.resent  m  i;iO  oi  our  eases. 
It  is  very  variable  in  situation,  and  while  most  eomition  in  the  e|)iirastrium. 
it  may  he  referred  to  the  shonlders,  the  back,  or  the  loins.  The  ])ain  is 
described  as  draggin-,  burning,  or  gnawing  in  character,  and  very  rarely 


CANCKU  OP  THE  STOMACH. 


4<J1 


ted  with  puji- 

iir  ciisi's  there 
lin  witli  tulx'- 
l)eil.     iiulieaii 

[^e  towiu'd  tlie 
«iiiilly  hi  eoiii- 
)iik  (h 

our  Korics  was 

'Phero  are  iid 

iker.    Throiii- 

cs,  widoi-pread 

eoiiseimisncss 
ir  to  that  seen 

'Odd.  is  a   fre- 

iin   any    otlier. 

a  sii(l(U'n  ro- 

lite  is  retained 

a  lias  jiersisted 
rst  it  is  at  hmji 
ir  several  times 
ysnis  and  then 
t  violenee,  and 
iiff  is  more  t're- 
he  ]>ylorns.  in 
ikinjf  the  food, 
lorter  interval, 
erior  wall  may 
soinetimos  very 
for  twenty-four 

l)lood  was  dnrk 
I'  hlood  was  the 
imonly  there  is 
the  secretions, 
k,  the  so-called 
le  inierosco))e  as 
if  altered  IiIoihI 
Idved  or  luvmin 

IliO  of  our  cases, 
the  e|)iirastriuni, 
IS.  The  ])ain  is 
and  very  rarely 


occurs  in  severe  parowMus  ..f  jra>tral<:ia.  as  in  -rastrie  ulcer.  As  a  rule,  the 
pain  is  ajxu'ravate.l  l)v"takin^^  fond.  'I'iiere  is  nsually  marked  tenderness  on 
pressure  ?n  the  epipistric  region.  The  areas  of  skin  tenderness  are  referred, 
iis  Head  has  shown,  to  the  re;.'ion  hetueeii  tiie  nipi>le  and  the  umhilieiis 
in  frnnt  and  heliind  from  tlie  iifth  to  the  twelfth  thoracic  spine. 

Examination  of  the  Stomach  Contents.— 'i"he  vomit  us  in  su^pei  ted  cases 
should  l.'c  carefully  studied,  jiarticularly  as  to  (piantity  and  character  of 
injiredients.  Larjre  amounts  hrou^ht  iii;  at  intervals  of  a  few  days,  with 
the  apiiearances  alrea<ly  descrihed,  are  characteristic  of  dilatation  of  the 
stomacii.  Some  of  the  material  should  he  spread  in  a  larjie  ^\ii>^>^  plate  aiul 
any  susi)icious  portions  picked  out  for  examination.  I'.acteria  in  lar-j;e  nuni- 
hei-s  occur,  one,  tlie  Oppler-i'.oas  hacilhis— an  unusnally  lon<;  non-niol)ile 
f,„.,u— is  supposed  to  he  of  diaj,niostic  value,  and  to  he  largely  responsilile 
I'or  the  formation  of  lactic  acid.  The  yeast  funj,nis  is  very  coiunu)nly  found, 
sarcina'  less  frequently  tlian  in  dilatation  from  stricture.  I'.hiod  is  a  most 
important  inj^redient;  the  jiersistent  presence  microscopically  of  red  cor- 
])uscles  in  the  early  morning  washin<rs  is  always  very  suspicious.  Later, 
when  coil'ee-fxround"  voniitin<r  takes  place,  tiu'  macroscoi)ic  evidciu'c  is  suf- 
ficient. In  cases  of  donht  the  spectroscope  may  he  used  or  the  test  made 
for  hicmin  crystals.  Frafrments  of  tlie  new  jrrowth  may  he  vomite<l  ur  may 
apjiear  in  the"  wash injj;s.     Positive  evidence  of  cancer  may  he  olitaiiicd  from 

them.  . 

E.mminalUm  «f  the  Tcsl  Iimtl,-fasl.—T\u'  Ewald  t(>st  mi'al,  consisting 
of  a  slice  of  stale  hrcad  and  a  larjre  cup  of  weak  tia  witiu.ut  cream  or  sujrar, 
is  jriven  at  7  a.  m.  and  withdrawn  at  S  a.  m.  The  lioas  test  meal,  consistuif,' 
of^'a  pniel  made  of  a  talilopoonful  of  oatmeal  Hour  in  a  litre  of  water,  is 
used '"in  tiie  estimation  of  lactic  acid.  As  an  outcome  of  the  en<u-mous 
mimher  of  ohservations  made  of  late  years,  it  may  he  said  that  free  llCl 
is  ahsent  in  a  laro;e  jiroporticni  of  all  cases  of  cancer  of  the  stomach.  Of 
<)4'cases  in  which  the  contents  were  examined  in  SI  free  IlCl  was  ahsent. 
In  T)  undouhted  cases  the  reaction  was  f,'ood;  in  2  of  these  the  history  sug- 
•re^ed  previous  ulcer.  IK'l  may  he  ahsent  in  chronic  gastritis  ami  in 
atrophy  of  the  gastric  mucosa.  (For  a  good  discussion  of  hydroehloric-acid 
determinations  see  .T.  S.  Thatcher.  I'rcshyterian  Hospital  Keiiorts,  vol.  iii  ) 
The  presence  of  lactic  acid  after  Boas'  test  meal  is  regarded  as  a  valuable 
<vm  It  is  rarely  present  in  chronic  catarrhal  conditions,  hut,  as  Stockton 
and  Jones  conclude,  it  is  hy  no  means  positive  evidence  of  carcinoma  veii- 

'"physical  Examination.— (rf)  ///.s'/^rr/m/L- After  a  iireliminary  sur- 
vev  emhracinir  the  fades,  state  of  nutrition,  etc.,  jiarticular  direction  is 
.nven  to  the  ahd(mien.  An  all-imi)ortant  matter  is  to  have  the  j-atient  in 
a  <'ood  li'dit.  Fulness  in  the  epigastric  region,  inecpiality  in  the  miracostal 
'grooves,  "the  existence  of  peristalsis,  a  wide  area  of  aortic  pulsati.m,  the 
nre^ence  of  suhcutaneous  nodules  or  small  masses  ahout  the  navel,  and. 
lastlv,  a  well-deliiied  tumor  mass— these,  togetiier  or  singly,  may  he  seen 
on  careful  inspection.  I  cannot  emphasize  too  .strongly  th."  value  of  this 
method  of  examination.  In  C'?.  of  the  ir.O  cases  a  p.,sitive  tumor  could  he 
seen.     In  52  the  tumor  descended  with  inspiration;  in  3G  peristalsis  was 


^fj2  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

vi.il.lo;  in  :5  case.  inovonu>nls  w.ro  vi.il.lc  in  tlu'  tmu.u-  itself.    In  10  oa.o. 

i  1    V  sihlo  peristalsis  n..  tumor  was  soon,  l.vu  c-uhl  he  lelt  on  palpa  ,on. 

>    ainn  with  earhonie-aeid  gas  n.ay  he  tried,  exc.ept  when  ha.norrha,.e 

has  profuse  or  tl>e  eanecr  is  very  extensive.     Tl.e  d.hUat.on  olten  ren- 

.  evi.lent  ti>e  peristalsis  or  n.ay  hring  a  tumor  into  v.ew.      I  -  1-- 
of  .uheutaneous  and  nndjilieal  nodules  is  sometnnes  a  very  great  help.     1  h  > 
t;"    ound  in  5  of  our  series.     Palpaiion.-ln  115  cases  a  tujnor  could  l.e 
0    ■  in  -IS  in  the  epigastric  region,  in  2.-i  in  the  und.d.cal,  m  Is  ,u  the   el 
hvnochondriac   in  IT  in  the  right  hypochondriac  region,  while  m  .  ca^^^  a 
el  in  deep  inspiration  from  heneath  the  left  cos  t.d  margin 
Tl  ;<(  lionres  illustrate  in  how  large  a  pn.portion  of  the  cases  the  tumor  i    m 
oviden.;.     In  rare  cases  examination  in  the  ki-.-elhow  position  is  ot  value. 
MohUU,,  in  gastric  tumor  is  a  point  of  much  importance.    1  irst,  the  diange 
will,  Inspiration,  already  referred  to;  a  mass  may  descend  .5  oi   4  u      es 
n  deep  inspiration:  secondly,  the  communicated  pulsatu.n  troin  the  aorta, 
"^u'h  is  often  in  its  extent  suggestive;  thirdly    the  intrnis,e  movemen  s 
in  the  hvpcrtrophied  muscularis  in  the  neighhorhood  ol  the  cancer      ihi. 
aav  give  a  renulrkahle  character  to  the  mass,  causing  it  to  appear  and  disap- 
pear   lifting  the  ahdominal   uall  in  the  epigastric  region;  and,  louithlj, 
E,anic.al  nH.vemen^■,   with   intlation,  with   change  of   posture,  or  com- 
inicated  with  the  hand.     Tumors  of  the  pylorus  arc  the  most  niovahU 
Zl  in  extreme  cases  can  he  displaced  to  either  l'yP'f--l'''-;;;;  l'^  ^f 
far  down  helow  the  navel  (see  illustrative  cases  in  my  Lectures  on  the  Diag- 
nosis of  Ahdominal  Tumors).     I'ain  on  palpation  is  common;  the  ma..    . 
usually  hard,  sometimes  nodular.    Gas  can  at  times  he  lelt  gurgling  through 
the  tumor  at  the  pyloric  region. 

Pncuxsiuu  give;  less  important  indieations-the  note  over  n  tun  or  i> 
rarely  Hat,  more  often  a  flat  tympany.  .l«.r»//«/»o»  may  reveal  the 
ffur-ling  through  the  pylorus;  sometimes  a  systolic  hruit  is  transmitted 
from  tht'  aorta,  and  when  a  local  peritonitis  exists  a  friction  may  he  heard. 
CompUcations.— .^C(om/(//7/  iirouih><  are  common.  In  44  autopsies  in 
our  series  there  were  metastases  in  38;  in  29  the  lymph-glands  were  m- 
volved-  in  n  the  liver,  in  11  the  peritonanim.  in  8  the  pancreas  in  8  the 
howel.'in  4  the  lung,  in  ;5  the  pleura,  in  4  the  kidneys,  and  in  3  the  spleen. 
In  8  no  deposits  were  found. 

rerfomiwu  mav  lead  to  peritonitis,  hut  in  3  of  our  4  cases  there  was 
no  general  involvement.  Cancerous  ascites  is  not  very  ""conimon._  Dock 
has  called  attenti.m  to  the  value  of  the  examination  of  the  fluid  in  such 
cases  as  a  help  to  diagnosis.  The  cells  show  mitoses  and  arc  verv  charac- 
teri^^tic'  Secondary  cancer  of  the  Uver  is  very  common;  the  enlargemc-nt 
may  he  very  great,  and  such  cases  are  not  infrequently  mistaken  lor 
primary  cancer  of  the  organ.  Involvement  of  the  himph-ijhunh  may  givo 
valuahie  indications.  There  may  he  early  enlargement  oi  a  gland  at  tli-> 
i.o^terior  horder  of  the  left  sterno-clcido-mastoid  muscle;  later  adjacent 
'.hinds  may  hec(une  alVected.  This  occurs  also  in  uterine  cancer.  Accord- 
hi.'  to  AVilliams.  Trosier  was  the  first  to  descrihc  this  condition,  which  must 
no't  he  conf.)unded  with  the  p^rmh-lipomc  sus-chivinilam  of  Yerneuil. 
\  very  remarkahle  picture  is  presented  when  the  cancer  sloughs  or  be- 


^ 


CAXCEIl   OF  TIIK  STOMACH. 


idi 


In  10  cases: 
111  iKilpation. 
liiviiiorrlmiic 
111  ultou  I'on- 
riio  preseiiec 

1  lu'lp.    Thry 
mur  cmilil  \)v 
18  in  tlu'  Iflt 
:  in  7  Cii:^os  a 
os'tal  margin. 
10  tnnior  it^  in 
111  is  of  valiR'. 
!t,  the  change 
i  or  1  inclies 
oiii  the  aorta, 
ic  movements 
cancer.     This 
car  aiul  disap- 
111(1,  I'ourtlily, 
lure,  or  com- 
iiost  niovahU'. 
nin  or  pushed 
i  on  the  Diag- 
i;  the  mass  is 
•gling  througli 

er  a  tumor  is 
ay  reveal  the 
is  transmitted 
may  l)e  heard. 
14  autopsies  in 
hinds  were  in- 
creas,  in  8  the 
n  2  tlie  spleen. 

■ases  tlicrc  was 
minion.     Dock 

2  fluid  in  such 
re  very  charac- 
10  enlargement 
•  mistaken  for 
'atulx  may  give 
a  gland  at  the 

later  adjacent 
nicer.     Accord- 
on,  whicli  must 
£  Vcrnouil. 
r  sloughs  or  be- 


comes gangrenous;  the  v.unitiw  hiis  a  fuiil  o.h.r,  often  of  a  penetrating  na- 
ture, to  l)c  perceived  tlirougli..ut  the  room,  in  .ascs  m  which  the  uhir 
perforates  the  colon,  the  vomiting  may  he  faral.  I  iiave,  Imwcvcr.  met  with 
the  faval  odor  in  a  case  witii  incessant  vomiting;  tliere  was  no  pcrloralKHi  of 

ihi^  colnii  at  autopsv. 

Course.— While  usually  rhniiiir  and  lasting  fmni  a  year  to  cightLrii 
months,  acute  cancer  of  tlie  stomach  is  hy  no  means  infrrtpiciit.  Of  the 
(i!)  cases  in  wliich  we  could  determine  accurately  the  (hiialK.n,  1.)  lasted 
under  tiiree  months,  K;  from  three  to  six  months,  11  from  six  to  twelve 
months— a  total  of  -ir,  under  one  year.  Four  cases  lasted  fur  two  years  or 
over.     One  case  lived  for  at  least  two  years  and  a  half. 

Diagnosis.— In  11")  of  (Uir  loO  cases  a  tumor  existed,  and  with  this 
the  recognition  is  rarely  in  douht.  Tractically  the  chief  dilllcidty  is  in 
those  ca^es  whi.-h  ])resent  gastric  symptoms  or  ameinia,  or  both,  without 
the  presence  of  tumor.  In  the  one  a  chronic  gastritis  is  suspicted;  in  the 
other  a  primary  ana'inia.  in  clironir  nastrilis  the  history  of  long-standing 
dyspeiisia,  the  "absence  of  cachexia,  the  absence  of  lactic  acid  in  the  test 
meal,  and  the  less  striking  bh.od  changes  are  the  important  iH.ints  for  con- 
sideration. The  cases  with  grave  amvmin  without  tumor  oll'er  the  greatest 
ditliculty.  The  blood-count  is  rarely  so  low  as  in  pernicious  aiKcinia.  a 
point  oi'i  which  F.  r.  Henry  has  laid  special  stress.  In  only  S  of  our  o!» 
cases  with  careful  blood  examination  was  the  number  below  -^OOO.OOU 
per  cubic  millimetre.  The  lower  coh)r  index,  as  in  secondary  ana'iiiia,  the 
absence  of  megaloblasts,  and  a  lencocytosis  speak  for  cancer.  Some  lay 
stress  on  the  dilTercntial  count  of  the  leucocytes.  l)ut  there  is  not  evidence 
enough  to  enable  us  to  speak  positively  on  this  point.  The  digestion  lenco- 
cytosis might  be  a  help  in  some  cases.  The  chemical  findings  are  of  greater 
value  The  constant  presence  of  lactic  acid  and  the  absence  of  IK'l  have 
in  several  of  our  cases  suggested  the  diagnosis  of  cancer,  which  has  licen 
verified  later  on  I)y  the  development  of  a  tumor. 

From  iilrcr  of'ihe  stomach  malignant  disease  is,  as  a  rule,  readily  recog- 
nized. Tlie  iilcus  carcinouialosum  usually  iiresents  a  wi'll-uiarked  history  ()f 
nicer  for  years.  Ilemmetor  has  given  a  good  account  of  this  rare  condi- 
tion in  his  recent  work  on  the  stomach.  The  greatest  dilliculty  is  olVered 
when  there  is  nicer  with  tumor  due  to  cicatricial  contraction  about  the 
pylorus  In  3  such  cases  we  mistook  the  mass  for  cancer,  and  even  at 
operation  it  mav  (as  in  one  of  them)  be  imjiossililo  to  say  whether  a  neo- 
plasm is  present.  The  persistent  hyiierchlorhydria  is  the  most  iiuimrtant 
single  feature  of  ulcer,  and,  taken  with  the  gastralgie  attacks  and  the  laem- 
orrhagcs,  rarely  leave  donbt  as  to  the  condition. 

Nowadays,"  when  exidoratory  laparotomy  may  be  advised  with  such 
«afetv   the  surgeon  often  makes  the  diagnosis. 

The  practitioner  should  recognize  the  fact  that  there  are  cases  of  cancer 
of  the  stomach  in  which  a  positive  diagnosis  Ciinnot  be  readied  for  weeks 
or  months  by  iny  known  means  at  onr  command. 

Treatmert".— The  disease  is  incurable  and  iialliative  measures  are 
alone  indicated.  The  diet  shmdd  consist  of  readily  digested  snbstiinces  of 
all  sorts.     Many  patients  do  best  on  milk  alone.     Washing  out  of  tlio 


M* 


491 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


stoiiiacli,  wliicli  iiiiiy  lie  done  with  a  soft  liila'  witliout  any  \-i>k,  is  partiiu- 
larly  advaiitafrcoiis  "wlicii  tlifir  is  ()i>striR-ti(»n  at  tlio  itylonis,  and  is  by  iar 
till'  most  satislactorv  means  of  (■oml)attiii','  tiu'  vomitinfi.  Tin.'  excessivo 
tVrmnitalion  is  also"  host  troatcd  l.y  lava-v.  When  tliu  pain  bocomos  se- 
vere, partienlarly  if  it  distnrl.s  tlie  vest  at  nijiiit,  morphia  must  1)0  <;iven. 
One  eifihtii  of  a"  f:rain,  eondiined  witli  earlionate  of  soihi  (-^r.  v),  hismntli 
(<:r.  v-x),  iisuaiiy  ^nves  prompt  relief,  and  the  dose  does  not  always  re(piire 
to  i.e  ine'reased."  Creasoto  (mj-ij)  "ii'l  carholie  aeid  are  very  useful.  Tiio 
bleeding  in  pistric  eaneer  is  rarely  amenable  to  treatment.  Operative 
measures  have  been  advised  and  praetised,  and  in  excei.tional  mstanees 
there  are  eases  in  whieli  the  limited  eaneer  or  even  the  entire  organ  has 

been  reseeteil. 

Other  Forms  of  Tumor. — Xdii-idncinius  liimors  of  the  stomach  rarely 
cause  inconvenience.  I'dlnpi  (polyadeiiomata)  are  ecmimon  and  they  may 
l)e  numerous;  as  nuuiy  as  150  have  been  reported  in  one  case.  There  is  a 
form  in  which  the  adenoma  exists  as  an  extensive  area  slightly  raised  above 
the  level  of  the  mucosa— /'o///r/r/c;(o//(f'  ni  iiapiic  of  the  V'rench.  11.  B.  An- 
derson has  described  a  case  (if  remarkai)le  multiple  ci/sis  in  the  walls  of  the 
stomach  and  small  intestine.  ."^iinviiKila  are  very  rare.  Fibromala  and 
Ujnniiala  have  been  described. 

Foreign  hadtcs  occasionally  produce  remarkable  tumors  of  the  stomach. 
The  most  extraordinary  is  the  Innr  liniior,  of  which  there  are  li;  cases  in  the 
literathre.  The  cases  occur  in  hysterical  women  who  have  been  in  the  habit 
of  eating  their  own  hair.  A  spceimen  in  the  inedical  museum  of  Mc(;ill 
I'nivcrsity  is  in  two  sections,  which  form  an  exact  mould  of  the  stcunach. 
'IMie  tumors  arc  large,  very  ])uzzling,  and  are  usually  mi.staken  for  eaneer. 
Of  r  cases  operated  ujion,  0  recovered;  in  1»  eases  the  condition  was  found 
post  mortem  (Schulten). 


VI.    HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS. 

(a)  In  Adults.— A^^y  one  with  a  large  post-mortem  experience  has  met 
with  instances  of  dilated  stomaclis  in  connection  with  thickening  or  hyper- 
tropliy  of  the  pylorus,  sometimes  forming  a  tumor  large  enough  to  be  felt, 
and  suggesting  the  presence  of  a  new  growth.  .Microscopically,  however, 
the  condition  is  found  to  be  very  largely  hypertrophy  of  the  muscularis  and 
submueosa  of  the  jiylorus.  It  was  well  described  by  the  older  writers.  The 
symptoms  are  tho.«e  of  dilatation  of  the  stomach.  The  condition  has  been 
fully  discussed  recently  by  lloas  (Archiv  fiir  Verdannngskrankheitcn,  Bd.  4, 
1),  who  re|)()rts  two  interesting  cases  with  successful  gastro-enterostomy. 
The  (piestion  is  whether  some  of  these  eases  may  not  really  be  congen.ital, 
as  there  have  been  instances  reported  in  girls  as  early  as  the  twelfth  and 
sixteenth  years. 

(h)  Co'ininiitdl  Unpfrlrnphu  of  ihc  Piihinis.—To  this  interesting  condi- 
tion much  attention  has  been  ])aid  of  late.  John  Thomson,  of  Kdin- 
burjih,  Rolleston  and  llayne,  :\leltzer  and  I.  Adler,  of  New  York,  have 
recently  reported  cases.     The  average  age  in   17  cases  was  five  months. 


ILEMOUHHAGI']  FROM  TIIP:  STOMACH. 


49." 


,  is  particu- 
11(1  is  by  lar 
he  excessive 
becomes  sc- 
st  be  <;ivcii. 
v),  bisiimth 
ivays  rc(iiiiro 
iisel'ul.  riic 
OpiTative 
al  instances 
•e  organ  has 

miacli  rarely 

1(1  tliev  may 

Tliere  is  a 

raised  al)()VO 

11.  ]'..  .\n- 

walls  ol'  the 

hroiiiata  and 

the  stomaeli. 
!  cases  in  tlic 
.  in  tlie  lialiit 
111  of  McCJill 
tlie  stomach, 
n  for  cancer, 
ni  was  found 


-ORUS. 

ence  lias  met 
inj:  or  liyper- 
crli  to  lie'  felt, 
lly.  however, 
nscularis  and 
writers.  The 
lion  has  been 
heiten,  lid.  4, 
i-enterostoiiiy. 
)e  congenital, 
.'  twelfth  and 

't'.sting  condi- 

on,  of  Kdin- 

V  York,  have 

five  inontlis. 


Three  cases  have  lieeii  met  with  in  one  family.  Thninsoii  siigi:e>ts  tlie  name 
cuiiijciiihil  ijnslrir  sjnisni,  and  thinks  it  is  due  to  nervous  incorinlination, 
but"  the  olistruclion  is  usually  thought  tn  be  mechanical.  lli>l()logically 
the  changes  appear  to  be  similar  to  those  in  the  adult.  In  iioth  Meltzer's 
and  J.  .Vdlcr's  case  gastro-ciitcrostoniy  was  i)crforined,  but  in  neither  in- 
stance with  success. 

VII.     H>E!VIORRHAGE   FROM  THE  STOMACH  (/I(imatemesis). 

Etiology. — (Jastrorrhagia,  as  this  symptom  is  called,  may  result  fnuii 
many  conditions,  >^oun'  of  which  are  local,  others  general. 

1.  In  local  disease  in  the  stomach  itself:  {ti)  cancer:  (h)  ulcer:  (r) 
disease  of  the  blood-vessels,  such  as  miliary  aneurisms  of  the  smaller  arte- 
ries, and  occasionally  vai'icose  veins;  (d)  acute  congestion,  as  in  gastritis, 
and  possibly  in  vicarious  lueinorrliage,  l»ut  both  of  these  are  extremely 
rare  causes. 

•i.  Passive  congestion  due  to  obstruction  in  the  ])ortal  system.  This 
may  be  either  (d)  hepatic,  as  in  cirrhosis  of  the  liver,  thnnnbosis  of  the 
portal  vein,  or  iiressure  upiui  the  portal  vein  by  tumor,  and  secondarily  in 
cases  of  chronic  disease  of  the  heart  and  lungs:  {//)  sjilenic.  (iastrorrhagia 
is  by  no  means  an  uncommon  syin|)tom  in  enlarged  spleen,  and  is  ex- 
plained by  the  intimate  relations  which  exist  between  the  vasa  brevia  and 
the  splenic  circulation. 

;•).  Toxic:  (d)  The  poisons  of  the  specific  fevers,  sniall-p"X,  meiish-s, 
vellow  fever;  (/))  poisons  of  unknown  origin,  as  in  acute  yellow  atrophy 
and  in  purpura;  {<)  phosphorus. 

4.  Traumatism:  ('/)  Mechaniciil  injuries,  sutli  as  blows  and  wounds, 
and  occasiomilly  by  the  stomach-tulie;  (h)   the   rcsulf  of  severe  corrosive 

])oisons. 

r>.  Certain  constituti(nial  diseases:  (a)  llaMiioi.hilia;  (/')  jirofoiind  ansr- 
iiiias,  whether  idiopathic  (U-  due  to  splenic  enlargements  or  to  malaria;  {<) 

chohi'inia. 

fi.  !n  certain  nervous  aifections.  iiarticularly  hysteria,  and  occasionally 
in  lu'ogressive  paralvsis  of  the  insane  and  ejiilepsy. 

7.  The  blood  mav  not  come  from  the  stomach,  but  How  into  it.  .Thus 
it  mav  i«ass  from  tlie  nose  or  the  pharynx.  In  iKcmoiit.Vsis  some  of  the 
blood"  mav  find  its  wav  into  the  st(Uiiacli.  The  bleeding  may  take  ])lace 
from  the  "(esophagus  and  trickle  into  the  stomach,  from  which  it  is  ejected. 
Tl)i>  occurs  in  the  case  of  rniiture  of  aneurism  and  of  the  (esophageal  varices. 
A  cr.ild  may  draw  blood  with  the  milk  from  the  mother's  breast  oven  in 
considerable  (piantities  and  then  vomit  it. 

5.  Miscellaneous  causes:  .\neurisni  of  the  aorta  or  of  its  branches  may 
rupture  into  the  stomach.  There  are  instances  in  which  a  i.atient  has  vom- 
ited blood  once  without  evir  having  a  ivcurrence  or  without  developing 
symptoms  ])ointing  to  disease  of  the  stomach. 

In  new-born  infants  liirmatomesis  may  occur  alone  or  in  connection 
with  bleeding  from  other  mucous  membranes. 
31 


/  ! 


490  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

I„  „K.,lin,l  pra.ticis  iKvn.orrhnj,..  from  tl.o  stnnmrli  ..ccnrs  most  fro- 
"  „  ,,„„J,.,ion  witl.  .irrhos,s  ul'  th.  liv.r  ami  uUor  ol  tl.o  stonuK.h 
iTi", ,;.>,''  imiu.nt  in  sunn.n  than  in  nuM,,  ..wing  to  the  greater  invvalence 

of  r<)iin<l  nicer  in  th.'  I'orm.T.  i    c,.  .,„   ti,.,   Ivi'iu'ite- 

Morbid  Anatomy.— When   .leath   has  (u.urre.l    liom   the   lia  mat. 
„u.^°hen    a^  ^t^ns  -^  intense  ana.n.ia.     The  e..n.liti..n  ..t  the  stonmeh 
vu    <  e     vn;..lv.    TIh-  lesion  is  evi.lent  in  ean.er  an.l  in  »!..,■  .,1  the  st.nu- 
a  It  is  t..  I..'  home  in  n.in.l  that  iatal  Lenmrrhage  may  eo„,e    r..m   i 

nail  miliary  aneurisn,  eonMunni.ating  ^vith  the  surface  by  a  i-n-hole  per- 
rn  :  or'the  hl.v.ling  n.ay  he  .lu..  to  the  rnptnre  „  a  -'""-■'--- 
l.Hl  the  er..si..n  in  the  nuu-.s:,  n.ay  he  sn.all  an.l  read.ly  "v;'''l...;ko  1.     1 

av   re.mi,v  a   carefnl  an.l   pn.l.n^ge.l   sear..],   to   ayo..     .>verh,..k,ng  s uel 
Tion'        n  the  large  gronp  associat...!   with   p..rtal  ..hstrn,-t...n,  whethe 

;  to'lu  t  ..  ..r  s,;^eni;.  .lileas.-.  th..  nu,..,.sa  is  usually  pah;,  snwu.th.  an^ 
ZJ^Z    ra.e  .>f  al.y  lesion,     l.t  ..irrhosis,  fatal  hy  haMuon^hage,  one  nu^y 

;!     etinu.  search  in\ain  f..r  any  fo.-al  '--'VV'^'n't h"     H  m^    u  ^ 
rha.na.  an.l  we  n.nst  c.-neln.le  that  it  is  possible  f..r  ev,;n  tin   "''"-^    ""^ 
!<:;,..  to  ...■.ur  hv  .liapch'sis.    The  st..n,ach  n.ay  he  .hsten.l...!  w.tl    hl..o. 
n    1       ''the  source  .'.f  the  haMuorrhage  be  not  apparent  either  m  the  stonuteh 
::!n;i;.  portal  systen..     In  such  cases  the  .s.,phagus  sh.n.hl    ----;;; 
as  the  hlecling  may  erne  from  that  s..urce.     In  t..x.c  ca.e.  theic  a.c  m 
v.ri'ihlv  haMn.)rrhages  in  the  mucous  membrane  itselt. 

Sympionxs.-ln  rare  instances  fatal  syncope  n.ay  occttr  w,thot,t  any 
v...,.iUn.^      In  a  ease  of  the  kin.l,  in  which  the  woman  l.a.t  lallen  over  a...l 
11  ra  f..w   n.in..tes,   the  st.>,.,ach   co..tai,.e.l  betweet.   three  an.l   iour 

p„„n,ls  of  blo.,<l.  The  su.l.le,.  profuse  blee.lh.gs  rapi.lly  l-'/"!';;;;  ':";;; 
i„aM..ia.  When  .b.e  t.)  t.l.'er  <.r  cir.-h<.sis  the  blecMbng  ..sually  .ecu.>  f . u 
sevral  .lavs.  Fatal  h;eu...rrl.age  fi'on.  the  st.^n.ach  is  n.et  with  m  ulcer. 
,irrh..sis,  ;.nlarg.>ment  ..f  the  si.lcen,  an.l  in  instances  in  which  an  aneurism 
ruptures  int..  ^hc  st.una.h  or  ,.so,.l.agus.  (iastrorrl.ag.a  may  oc^cur  m 
sphMiic  ana....ia  ..r  in  leuka-mia  before  tbe  con.l.t.on  has  aroused  the  at- 
tenti.tn  of  friends  or  physician.  „     ,    i    •       ,  i  ,^ 

The  v..niited  blood  may  be  fluid  or  clotted;  it  ,s  usually  dark  m  col.  r, 
but  in  the  basin  the  out.'r  part  rapidly  becomes  red  from  the  actu.n  ol  the 
air.    The  longer  bloo.l  remains  in  the  stomach  the  more  altered  is  it  when 

^'■''''T^.e  amount  ..f  bl...)d  lost  is  very  variable,  and  in  the  course  of  a  day 
i,,,  patient  may  bring  up  three  or  four  pounds  or  even  more.  In  a  case 
undir  the  care  of  George  Ross,  in  the  Montreal  (icneral  Uosi>.tal.  the  pa- 
tient lost  during  seven  days  ten  pounds,  by  measurement.  .if  b  oo.l  1  h e 
usual  sympt..nis  of  ana.uia  deveh.p  rapi.lly,  and  there  may  be  sl.gbt  fever, 
and  sui.se.  uently  o>denia  may  occur.  Syncope,  conyulsions,  and  oeeas.o  " 
,llv  bemipU'gia  occur  after  very  profuse  ha-morrbage.  An  interesting  c.r- 
;llmslanci  .-.^nuH-ted  with  gastro-intestinal  haMuorrhage  is  the  development 
„f  amaurosis,  the  m.Mle  of  production  of  which  is  still  under  discussion. 

Diagnosis. -In  a  Tnaj..rity  of  instances  there  is  no  question  as  to 

the  oricrhi  of  the  blood.    Occasionally  it  is  difficult,  par  icularly  if  the  caje 

as  n..t  been  seen  during  the  attack.     Examination  of  the  vomit  readily 


'1 


NEUROSES  OF  THE  STOMACH. 


407 


rs  most  frc- 
tlu'  stDinach. 
■r  pivviik'iKO 

tlic  liii'iiiiito- 

tlic   stnllliU'll 

ol'  till'  stoiu- 
coiiu'  from  ;i 
liinliok'  iior- 
iiiiucKiis  vrin 
I'l'liinkod.  It 
lookiuji  siuli 

ion,  wlu'tluT 

smootli,  and 
iifjo,  oni'  may 
r  tlu'  pistror- 

most  |)rot'iisi' 
(■(1  with  l)loo(l 
n  tliL'  stomach 

he  examini'il. 

there  are  in- 

r  without  any 
\\\vn  over  and 
iree  and  four 
d  to  profound 
illy  recurs  for 
with  in  ulcer, 
h  an  aneurism 
may  occur  in 
roused  the  at- 

dark  in  color, 
e  action  of  the 
Bred  is  it  when 

'ourse  of  a  day 
ore.     In  a  case 
i)si)ital,  the  pa- 
of  hlood.     The 
be  slight  fever, 
1,  and  occasion- 
interesting  cir- 
he  devclo]iment 
r  discussion, 
question  as  to 
larly  if  the  ease 
e  vomit  readily 


delermines  whether  hlooil  is  present  or  not,  The  materials  vomited  may 
ht'  stained  hy  wine,  the  ,iui(c  of  strawhcrries.  raspherries.  or  craiiherries, 
which  give  a  color  very  clo.-ely  resemi)liiig  that  of  fresh  hlood,  while  iron 
and  hismiitii  and  bile  may  produce  the  hlacki.-h  color  of  altered  Idood.  in 
such  cases  the  micro,<cope  will  show  clearly  the  presence  of  the  shadowy 
outlines  of  the  red  lilood-corpuscles,  and,  if  necessary,  spectrosco[iic  and 
chemical  tests  may  he  applied. 

Dcceiitioii  is  sometimes  jiractised  hy  hysterical  imtients,  who  swallow 
and  then  vomit  hlood  or  colored  liipiids.  With  a  little  care  such  cases  can 
usuallv  he  detected.  The  cases  must  he  excluded  in  which  the  hlood  passes 
from  the  luise  or  pharynx,  or  in  which  infants  swallow  it  with  the  milk. 

There  is  not  often  diUlciilty  in  distinguishing  hctween  ha-moptysis  and 
ha-matemesis,  though  the  c(Uighiiig  and  the  vomiting  are  not  infre([uently 
eomhined.     The  following  are  points  to  he  home  in  mind  in  the  diagnosis: 

II.ICM.VTEMESIS.  II.K  MOl'TYSIS. 

1.  Trevious  history  ])oints  to  gas-  1.  Coiigh  or  signs  of  some  pul- 
tric,  hepatic,  or  splenic  disease.               nioiiiiry  or  cardiac  disease  ])reccdes, 

in  many  cases,  the  ha'morrhage. 

2.  The  hlood  is  brought  up  hy  ■.'.  'i'he  l)lood  is  coughed  up, 
vomiting,  ju'ior  to  which  the  jiatient  and  is  usually  precedeil  hy  a  scusa- 
may  experience  a  feeling  of  giddiness  tion  of  tickling  in  Ihe  throat.  If 
or  faintness.                                               vomiting     occurs,     it     follows     the 

coughing. 
'^.  The  hlood    is  usually  clotted,  '.l  'I'lie    l>lood    is    frothy,   bright 

mixed  with  paiticles  of  food,  and  red  in  color,  alkaline  in  reaction, 
has  an  acid  reaction.  It  may  be  if  clotted,  rarely  in  such  large  co- 
dark,  grunious,  and  lluid.  agula,  and  imico-pus  may  he  mi.ved 

with  it. 

4.  Sul)se(iuent  to  the  attack  the         4.    The   cough    persists,   ])hysical 

patient  passes  tarry  stools,  and  signs   signs   of   local   disease   in   the   chest 

of  disease  of  the  abdominal  viscera   may   usually   be   detected,    and    the 

mav  he  detected.  sjiuta  may  he  blood-stained  for  many 

days. 

Prognosis. — Except  in  the  case  of  rujiture  of  an  aneurism  or  of  largo 
veins,  lurniatemesis  rarely  proves  fatal.  In  my  experience  death  has  fol- 
lowed more  frecpiently  in  cases  of  cirrhosis  and  splenic  enlargement  than 
in  ulcer  or  cancer.  Tn  ulcer  it  is  to  he  remembered  that  in  the  chronic 
ha-morrhagic  form  the  lileeding  may  recur  for  years.  The  treatment  of 
ha?nuitemesis  is  considered  under  gastric  ulcer. 


VIII.     NEUROSES   OF  THE   STOMACH  (Nervous  Di/sprpsin). 

The  studies  of  Leuhe,  Ewald,  Oser,  'Rosenhach.  and  many  others  have 
shown  that  serious  functional  disturhances  of  the  stomach  may  occur  with- 
out anv  discoverahle  anatomical  basis.     The  cases  are  met  with  most  fro- 


DISEASKS  OP  TIIK   DKiHSTIVK  SYSTEM. 

„„,„tlv  in  tl.'w..  who  iK.v.  nthor  inl.orito.l  a  nervou.  const  it  m1  inn  or  uho 
a    u    V,  tl>n.u,h  iM.li>c.n.,ions.  l.n.u.l.t  al.out  a  condUiou  ol  .utvo 
.r    i,  Not  inlmnu.ntlv.  hourvcr,  Ww  ixnAvW  syn.pl.m.s  stan'!  «..  lai 

U  \,i.  nlis  notice.     Sonu.liMHS  tlu-  j^aslri.   nuuuU.staiions  l.avo  a  -  -a  - 
;';;;!;.  Inlx  o,„in  <U,.c.n.iin,  on  ov,anu.  .li.lurSan.r.  ,n  .vn...l.  part,  ol 

^'"T;;:!'n.no„s  .l..nn„c.,n<.nts  of  .Ih-  ston.,.!,  n.ay  l.o  .livid..!  into  „.o,,.. 

r::, ■■;,::  h-': . '. ;,;  ::.;n..i,„.,i  ..,„.  t,,..  ..i ■..,,.,.  ,,.„„ 

tli(\  aic  luu.  ny  nfuroscs  is  known  as  iirrmns  ,hispqisin. 

""Ti;:'.;^"'-'?;;^.  n..rv.n.s  .lyspcpsia  pros.nts  a  va,,in,  Vi;'<-"-     All 
,,n.l       .u-  uv     inun    ti.o    nnaciato.l    sk..k.t..n-liko    pat.cnt    w>lh    anorcx  a 
t    t.   t.;  \ho   wc.il-n.uu-islK.l,   lK.altlu-l...kin,,  ircsh-.^ 
vi.iual  wh..s(.  onlv  (..niplaint  is  .list.vss  an.l  unoasuH'ss  aft  ■.  cm  .n-.     \     .n 
It;;!^:^  Hio^d-;  elasineatiou  as  giv.n  in  his  roccnt  oxhausUvo  w.uk  on 

tho  n..rn,al  nu.t..r  activity  of  the  st.unac.h  rosnlts  u.    ...>  -"'>      '       ''    ^  , 
llu.  in^u.ta  inl..  Ih..  intostin...     It  is  more  r..nunon  y  a  scr..n.la.y  nc     <  > 
;    ulonl  up..n  superacidity  ur  .uporsocrotion  of  tlio  gaslru..  ju.co    b   t 
u   xrnr  ,  rinn^rilv,  p..ssil.lv  fn.n.  rellox  causes.     The  .l.a^n,..s,s  i>  t..  l)e 
I'l^hcll  onlv  hv  n.^inl  ..f  the  st.nnach-tube.     It  ^ives  r.se  t.>  n..  charac- 

'-'t  ;!:-;:;*'';t;:;:-This  cndition,  as  descrihd  l>y  Kussn^m    . 
an     V  rcn.elv  conun..n  and  distressin,^  syn.pt.nn  in  neurastlK.ua.     Sh.>r tlv 
.  ter  catin.Mhe  peristaltic  n...ven,ents  of  the  st.>nu,ch  are  nicro^ed,  and 
hllh..:;  nu  andUli"^  -ay  he  hear.1    even   at   a  <l-tance.        he  s>  >- 
iectivesl.nsations  are  nu-st  ann.niuK,  and  it  w.)uld  appear  as  ,f  n  Hh"  I'M 
S  Ictic  c.ndition  of  the  nerv.n.s  syste.n  the  patient  felt  n.uMnal  per.stals  s, 
iu!    a'  in  these  states  the  usual  beating,  .d'  the  lu^rt  n>ay  l.e  perceptdde 
,  ,n      A  further  anal.>oy  is  aiT..rded  hy  the  fa.^t  that  ...n..  u.n  increases 
Ins  "ristalsis.     It  may  extend  t..  the  intestines   varticnlarly  t..  the  duod  - 
„„,„'  ,„i  ,„  palpation  over  this  ve,L^i.n,  the  ouroln.o-  ,s  n...st  n,a.k...L     U 
;;,ov:n.ent  nuly  be  anti-peristalsis,  in  ^^dHeb  the  ^va^.  F--,  -^.^^^^^ 
loft    a  .■..uditi..n  ^vhi.•il  may  also  exteud  t.>  the  int.'st.ues.      1  Ik'U  ai     ca.c.^ 
;;,;';,;;,„,,  ;„  ,,,i,i,  c.,.l..red  enemata  or  even  soybala  have  been  discharged 

"'"T.i'':v;™s-/^n././;...-Tn  this  conditi.>n  severe,  attacks  of  uoi.y 
eructations,  f..ll..^vincr  one  auother  often  in  rapid  success.ou,  occur.  A\  \mi 
V  lent  th..v  last  for  hours  or  days.  At  other  times  they  occur  .n  paroxyMU>, 
d  .in,/oftcn  upon  meutal  excitement.  The,'  rr^"^%":"r""  !  't 
sc  ved  in  hvstcrical  women  and  neurasthenics,  but  a  so,  .ot  infro.juc  t^ 
in  children:  The  hysterical  nature  ..f  the  afTo.'t.ou  is  some  nues  test.liocl 
to  by  th..  occurrence,  especially  in  children,  of  several  instances  m  one 
househ.dd. 


NEUUOSKS   OF  TIIK   STOMACH. 


4!>'J 


tion  or  who 

II  of  lUTVollS 

stand  so  far 

tlu'  patient 

liavt'  appar- 

loti'  parts  ol' 

into  motor, 
u'cnr  sin^'ly; 
ill  lire  ri'Siilt- 

IIS    (hlSjIfj)^!!!. 

lally  iilay  tlic 

picture.  All 
itli  anorexia 
I'xiolled  il\ili- 
tin^r.  1  liiive 
itive  work  on 

Vn  IntToaso  in 

II  (lischarjte  of 
idary  neurosis 
'  juice;  but  it 
:!iosis  is  to  be 
to  no  cbarac- 

Kussmaid,  is 
enia.  Shortly 
increased,  and 
ce.  The  sub- 
1'  in  the  hyper- 
nud  peristalsis, 

be  perce]ttible 
otion  increases 
:  to  the  dnode- 

niarl<ed.  The 
;  from  right  to 
There  are  cases 
leen  discharged 

tacks  of  noisy 
,  occur.  AViien 
ir  in  i)aro.\ysnis, 
'  ciunionly  ob- 
nt  infrcciuontly, 
letinies  testified 
nstances  in  one 


'I'he  c\|)cllcd  fxas  in  these  cases  is  aininsphrric  air,  which  is  swallowed 
or  aspirated  from  without.  Sonu'times  the  wliolc  proci'ss  may  l»e  clearly 
(ih,<crved,  hut   in  other  instances  the  act   of  swallowing'  niay  lie  almost  or 

iputi'  impcrceptilile.      i'MUiveret  considers  the  conditi lue  to  a  ^pa^m  of 

the  pharynx  which  causes  involuntary  swallowin>:.  Oser  has  suggested  that 
the  air  may  enter  liy  aspiration,  the  stomach  acting  like  an  ela>lic  ridiher 
hag  which  tends  to  iill  again  after  the  air  is  expressed.  It  is  ipiite  possible 
that  in  .some  instances  the  eructations  cun.sist  of  gas  winch  has  lu'ver  actually 
rcai'hed  the  stomach,  l)nt  is  brought  uj)  from  the  u'sophagns. 

((/)  ycrriiiis  \'(iniiliii(i. — A  condition  which  is  not  associated  with  ana- 
tomical changes  in  the  stomach  or  with  any  stale  of  the  contents,  hut  is  A\u'. 
to  nervous  inlluences  acting  cither  directly  or  imlirectly  upon  the  centre!* 
presiding  over  the  act  of  vomiting.  The  patients  are,  as  a  rule,  women — 
usually  iirunettes — and  the  s\diject  of  more  or  less  marked  hysterical  luani- 
h'stations.  A  special  feature  of  this  form  is  thi'  absence  of  tin'  prelindnary 
nausea  and  of  the  straining  elTorts  of  the  ordinary  act  of  voiiutiug.  It  is 
rather  a  regurgitation,  and  without  visible  eil'ort  and  without  gagging  the 
month  is  filled  with  the  conti'Uts  of  the  stomach,  which  are  then  sjiat  out. 
It  comes  on,  as  a  rule,  after  eating,  but  may  occur  at  irregular  intervals. 
In  some  cases  the  nutrition  is  not  impaired,  a  feature  which  may  give  a 
clew  to  the  true  nature  of  the  disease,  as  there  may  be  uo  other  hysterical 
manifestation  i)rcsent.  As  noted  by  Tuckwcll,  it  may  occur  in  children. 
Nervous  vonnting  is  rarely  serious. 

A  tyiH'  of  vonnting  is  that  a.ssociated  with  certain  disea.ses  of  the  nerv- 
ous system — i)articnlarly  locomotor  ataxia — fornung  part  of  the  gastric 
crises.  Leyden  has  reported  cases  of  lu'imary  periodic  vonnting,  which  ho 
regards  as  a  neurosis. 

{(■)  nintiiiKtlidii ;  ^fn•!|(^isl)lllli. — In  this  remarkable  and  rare  c<mdition 
the  iiati<'nts  regurgitate  and  chew  the  cud  like  runnnants.  It  occurs  in 
lu'urasthenic  or  hysteri^-d  persons,  ei)il"|)iics,  and  idiots.  In  some  ]iatients 
it  is  hereditary.  There  is  an  instance  in  which  a  governess  taught  it  to  two 
childrt'U.    The  habit  may  persist  lor  yeais,  and  does  not  necessarily  impair 

the  health. 

if)  Spasm  of  llif  Cardin. — Si»asmodic,  usually  jiainful  contraction  (d'  the 
circidar  muscle  fibres  at  the  cardiac  orifice  may  follow  the  introduction  of 
a  sound,  hasty  eating,  or  the  taking  of  too  hot  or  too  cold  food.  It  may 
occur  in  tetanus  and  also  in  hysterical  and  neurasthenic  individuals,  espe- 
ciallv  in  air  swallowers,  in  whom,  if  it  be  cond)ined  with  pyloric  ;pasm.  it 
may  result  in  i)ainfu1  gastric  distention— '' pneun\ato,sis."  Here  the  spasm 
may  l)e  of  considerable  duration.  The  condition  is  rare  and  practically 
not  of  nnich  iuonunit. 

(fl)  Pi/hn-ir  Spas))}.— Thh  is  usually  a  secondary  occurrence,  following 
superacidity,  supersecretion,  ulcer,  or  the  introduction  into  the  stomach 
of  irritating  substances.  The  spasm  often  causes  pain  in  the  region  of  the 
pylorus  and  increased  gastric  peristalsis.  Tn  cases  where  the  spasm  is  com- 
bined with  superacidity  and  supersecreticm  marked  dilatation  with  atony 
may  follow:  it  is  questionable,  however,  whether  a  primary  nervous  pyloric 
■  spasm  ever  gives  rise  to  serious  results.     I  have  already  referred  to  John 


% 


J 


d^AmIb 


DISKASKS  OF  TllH   DUlKSTlVK  SYSTKM. 


5m) 

■r ,„„„V  vi..»s  ,.(  ,yl..ric  -,.«™.  in  n*.«.ti....  will,  Ih.  c .-...it.l  f"™, 

'"";;„„„  ,„,,,.  „„„,  ,„.  ,.l..„  i„  ilu.  ,lia,n,«.  ...  r„l all  Ml,..v  ,.os,iU.. 

causes.  f  /;,„  /',,/,,r(/s'— 'Phis  ciiiulit ion  was  di'- 

, '-l,,.  „r,,,i,l  to  o»t  «„  ».r.nn,t  ot  tl,c  „„l,<.,,,«Unl  I-".;— "•"'"" 
„,,,,  „,,,r  l,„,  l,,,.n  rororrcrt  I...    TI,.TO  ,s  cnnnonl,     ,T'  I  ■'',:,„  „,  ,,,,. 

i)('i)si!i  whicli  has  noen  long  11(0^,1  i/-<-   '  n-n«(ri<.  iuico  mav  1)0 


NKL'UOSKS  (•!•'   Tin;  STOMACH. 


5(1 1 


rciiitiil  form 

iniiU'l)  itself, 
idividiiiilt  ol' 

|K>sMiltly  (If- 
isiially  thosi- 

sensory  tlis- 
lioiis,  ami  so 

itlicv  i>ossililt' 

it  ion  was  df- 
.■ni/.i'(l  liy  lli'^ 
iiipts  at  inlla- 
linal  I'onti'iits 

reiojinizi'tl  l>y 

lihl  :  llnr'^r- 
Lrastrii-  juici'S. 
(1  iiastric  jui»-o 

in  yoiniff  and 
il)k'  l'n'(i\R'ncy 

not,  as  a  r>de, 
vv  liours  later, 
iressnre,  sonie- 
th  acid  erueta- 
is  usually  rela- 
rli  the  sulterer 

Its  association 
ation. 

a  form  of  dys- 
pcc'ially  studied 
,c  juice  may  lie 
ircumslancos  is 
■riodical  form — 
of  the  time  of 
nay  he  secreted 

especially  asso- 
[)v  ataxia.  The 
lawiufi,  unpleas- 
ifter  the  patient 
iroat  is  irritated 
'  he  (piitc  inde- 
mon.  The  con- 
..  ])yloric  spasm, 
;id  gastric  juice, 


are  foljoweil  liy  a  mnie  or  le^s  e\teiisivr  (hljitnlion.  I»i;restion  <,\'  the  starchcri 
is  retanh'd,  and  tliere  are  eriielations  of  niid  llind  and  ;;astric  ilistress. 
This  secret  ion  of  hi^ddy  acid  <:astric  juice  may  continue  ulini  the  ,«toniach  is 
fr«r  from  food.  In  tiiese  cases  pain,  luirnin;;  acid  eruetatioii>.  ami  even 
voniitinj:,  occurring,'  during'  the  ni^dit  auil  early  in  the  nuuuin^:.  aiv  rather 
characteristic. 

(r)  XfiTDiis  SiilKiiiilihi  iir  liKK  iilihi:  Achjilid  (l(i.'<lrl((t  Xirinsit. --\Auk  of 
tlie  normal  amount  of  acid  is  found  in  chronic  catarrh,  and  paitieularly  in 
cancer.  As  Lciihe  has  shown,  a  reduction  in  the  normal  amount  of  acid 
nuiv  exist  with  the  most  pnuKUineed  symptoms  of  nervous  dyspepsia  and 
yetthe  >toniaeh  will  he  free  fnmi  food  within  the  re^Milar  time.  A  condi- 
tion in  which  fre<'  acid  is  al)sent  in  tlie  ;.Mstric  juice  may  occur  in  cancer, 
in  extreme  seleiosis  of  the  m\ieous  nu'iuiirane.  as  a  nervous  manifotation  of 
hysteria,  and  occasionally  of  tahcs.  In  most  of  tiiese  cases,  tii(Uij,di  there 
bo  no  free  acid,  yet  the  other  di^restivc  feiniciits — pepsin  and  the  ciirdllnj,' 
f,,,.„i,,„ts — or  their  /ymof^ens  are  to  he  demonstrated  in  the  <rastric  juice. 
There  may,  howt'Ver,  he  a  complete  iihsence  of  the  ;rjistric  secretion.  To 
these  cases  i'linhorn  has  given  the  name  of  nchjiHn  (jitslricd.  This  condition 
was  at  iir.4  tlionj;ht  to  occur  only  in  cases  of  total  atrojiliy  of  the  pistric 
mucosa,  hilt  recent  ohservations  iiave  shown  that  it  may  occur  as  a  neurosis. 
In  a  case  of  Kinhurn's  the  gastric  secretions  returned  after  live  years  of  total 
acln/lid  tjaslrica. 

The'  symy)toms  of  suhacidity,  or  even  of  arhijlln  f/nslrini.  vary  greatly 
in  intensity;  they  niay  he  almost  or  (luite  ahsent  in  cases  of  advanced  atro- 
phy of  the  mucosa,  and,  as  a  rule,  are  not  marked  so  long  as  the  motor 
activity  of  the  stomach  remains  good.  If  atony,  however,  develop  and  ah- 
norniai  fermentative  processes  arise,  severe  gastric  and  intestinal  symptoms 
may  follow.  In  the  cases  associated  with  hysteria  and  neurasthenia,  even 
tJKmgh  the  food  may  he  well  taken  care  of  hy  the  intestines,  there  are  very 
commonly  grave  sensory  disturliaiices  in  the  region  of  the  stomach,  in  ad- 
dition to  "the  generTd  nervous  symptoms. 

III.  Sensory  Neuroses. — («)  Ih/prnrslhcsid.—ln  this  condition  the  pa- 
tients conqdain  of  fulness,  pressure,  weight,  burning,  and  so  forth,  during 
digestion,  just  such  symptoms  as  accompany  a  variety  of  organic  diseases  of 
tlie  stomach,  and  yetin  all  other  respects  the  gastric  functions  appear  (piite 
normal.  Sometimes  these  distressing  sensations  are  present  even  when  the 
stomach  is  empty.  These  symi)t(mis  are  usually  associated  with  other  mani- 
festations of  hysteria  and  neurasthenia.  The  jiain  often  follows  particular 
articles  of  food.  An  hysterical  patient  may  ai)iiarently  suffer  excruciating 
pain  after  taking  the  smallest  amount  of  food  of  any  sort,  while  anything 
prcscril)ed  as  a  medicine  may  he  well  borne.  In  severe  cases  the  jiatient 
may  be  reduced  to  an  extreme  degree  of  starvation. 

"(?;)  ridslrah/ia;  (hi.'^lniilt/ina.—^cycre  i)ains  in  the  epigastrium,  parox- 
ysmal in  character,  occur  (a)  as  a  manifestation  of  a  functional  neurosis, 
independent  of  organic  di.'Jease.  and  usually  associated  with  other  nervous 
symptoms  (it  is  this  form  which  will  here  be  described);  (h)  in  chronic 
disease  of  the  nervous  system,  forming  the  so-called  gastric  crises;  and  (c) 
in  ortranic  disease  of  the  stomach,  such  as  ulcer  or  cancer. 


.02  DlSEASIiS  OF  THE  DIGESTIVE  SYSTEM. 

^,lcer.     Tlu^y  frequently  eonio  on  a    n.^ht      ^;nn  m  ^^^ 

,  „  the  taUin.  ^'^  ^^i^^^—  ^^  ^^  ,t  n^rcJiZ^  gives  relief, 
striking  exceptions.     1  .e..inc,  n  on  t ' u-       -  necessary  to  separate 

but  .leep  pressure  niay  be  ["""^"^-^^^.^^Xe^ml  depressive,  as  the  cases 
the  forms,  as  some  have  done,  '"^;/'",*:  ^'^  ^J  \,^;' ,,,,,  the  occ.rrenee 
insensihly  merge  into  each  other.  Stress  ha.  ^'"^  ;  "^  "  ',  \;,,t  very  little 
of  painful  iH>ints,  but  they  are  so  common  in  neina.tlun.a  that        > 

^"%;:'2;::Jr:nV Jstn'Slti..  organic  ai.ase  either  of  ^u- 
.olurorif  the  nervous  ^f^^V^^^^^  ^jtZZ'^^^Z 
,jot<,r  ata.a,  -^^  e  e.c  m^^  ^  -^i;-  ^J^^,^^,,  ,.,,,  ,,,  ,ton.ach  is 
always  ea>j.     » ^.'^^   '  ^       '^  '^^^  ,^f  f„,,i  ;,  ,,„„times  regarded  as  pathog- 

cr„l  ».vm|  I"    ■■»''-'■■;  "^>^',  ^„,;^.  ,,„„„,;„  i,  ,„,,„onl)y  absent.  ,„ul  ,n 

„„n' a'lly  ox,,...ivc  l,„nso.  co„,ins  m,  often  ,n  V»™>;;'    ,'";;;  ,;'     '- 
e-,n<e  tie  nntient  to  r..mniit  e^trnol■.l,nun■  en-esses  m  e,i  ing.      '"  "  '»    ' 

rn,',;,Ice„r  in  .liat.etes  n.ellitns  „„,!  ''•^J^^"""''';J^:^::^';^'Z- 
tieiilnrly  tln.se  assoriated  with  siiperseeretnin.     II  is.  lio»e%er    ■'  »'<■  <^ 
nSv  ^«n  in  hysteria  an.l  in  psychoses.    It  nn,y  oeenr  ,n  eetvhral  tnmo.s, 

f„,I':„f  laiLtess  an,t  i^ain,  ..jf.;,;'™-'';';*  ^:X  '^^'^^^JZy 

i;::Si:;o  ;;rr  ;::;w:;;;:Ko;t:^,*:n:,^:jhe.  ti„,e=  e„o™ons ,.,.- 


NEUROSES  OF  THE  STOMACH. 


503 


mly  in  con- 
1  liystorii'ul 

it  is  llinl'l' 
\iivo  wovrii'S 
)ri'  t'roiiUL'ut 
[•  in  r()l)ust, 
1  of  general 
sia  in  whieh 

I   am   very 
origin, 
(lenly  peizo<l 
lie  haek  and 
1'  the  talcing 
[■h  has  given 
.>  to  malaria. 
;ic  attaeks  of 
i;  more  com- 
er, there  are 
y'  gives  relief, 
■y  to  sejiarate 
,  as  the  eases 
he  oeeurrenue 
Kit  very  little 

either  of  the 
M'ises  of  loco- 
:'er  this  is  not 
he  stomach  is 
led  as  pathog- 
\ce])tions,  and 
nged  intervals 
irtant  features 
than  the  gen- 
nosis.     It  is  to 
absent,  and  in 
nir  at  intervals 
d. 

Biiliiiiin. — Ab- 
attaeks,  which 
r.  This  condi- 
■  disorders,  par- 
ver,  more  com- 
•erebral  tumors, 

waking  with  a 
or  food.  Sonie- 
The  attack  may 
enormous  quan- 


tities mav  be  taken,  lu  obstinate  cases  gastritis,  atony,  and  dilatation  fre- 
ouentlv  result  from  the  al)use  of  the  stomach. 

^11^ A, -An  absence  of  the  sense  of  satiety.  Tins  eo„d>t,on  .s  nnn- 
,nonlv  associate.1  with  bulimia  and  i-olyphagia,  but  not  always.  1  he  pa  lent 
ahvaj-s  feels  "  en.pty."    There  are  usually  other  well-marked  man,lestatH.n> 

of  hvsleria  or  neurasthenia.  ...    .   i-  ,■    , 

Lrcria   A>,v.,s...-This   condition,    which    is    a    num.testat.on    ol    a 

„,„„,,„  i,  tenMH.ran>ent,  is  .liseussed  subse.iuently  under  the  general  head- 

'''^Tr!!tn!^Zf  Neuroses  of  the  Shmach.-Tho  n.ost  in>purta..t  part  of  tl>e 
featnunt  of  nervous  dyspepsia  is  often  that  directe.l  ^^^^^ ^^^ ^^^''^^^ 
inent  of  the  -eneral  phvsical  and  mental  condition  ol   tiie  i-atieit.      1  1  u 
;      >mtv  Ui^t  the  s^ml-toms  may  be  of  rcilex  origin  should     e  l.rne  m 
„ind      A  large  proporti<.n  <.f  cases  of  nervous  .lyspepsia  are  depen.lent  upon 
ental  and  ph  sicld  exhaustion  or  worry,  and  a  vacation  or  a  change  o 
"!ene  will  often  accomplish  what  years  of  treatiuent  at  home  have  laded 
to  do.     The  manner  of  life  of  the  patient  should   l)e  investigated  am. 
,„,„„  „„.,„„t  of  physical  exercise  in  the  open  air  insisted   '•l/--  - 

ilone  will  in  some  cases  be  sulVicient  to  cause  the  .lisappean.nce  ol  the  sjmp 

^""Manv  cases  of  nervous  dvspepsia  with  marked  neurasthenic  <n-  hysterical 
.vuM>toms  do  well  on  the  Weir-Mitchell  treatment  and  m  ''''^t'";;^;;  l:;"";; 
it  should  be  given  a  thorough  trial.  The  most  striking  results  a,e  pe.  aj^ 
seen  in  the  cl^se  of  atiorexia  nervosa,  which  will  be  relerred  to  subsecp.ently. 
It  is  also  of  value  in  nervous  vomiting.  ,      ,      ,  ■^    „..,ii,.„. 

In  canlinr  spasn>  care  should  be  taken  to  cat  slowly,  o  avoid  ^u  11  - 
ing  too  large  morsels  or  irritating  substances.    The  methodical  introduction 

of  thick  s(uinds  may  be  of  value.  .wlonted 

The  treatment  in  aton,,  ..f  the  stomach  should  lie  similar  t  th  ad  ted 
in  moderate  dilatation-the  administration  ot  small  .pian  i  le.  ol  iood  at 
^m^n  n  er^al  ;  the  lituitation  of  the  fluids,  which  shoud  also  be  aken 
{"snuln  lunonnts  at  a  time;  lavage.     Stryclnune  in  full  doses  may  be  of 

''' "n  the  distressing  eases  of  lniperari.lil„  in  addition  t-'^Ju^^-^l^^'-^"^ 
the  .rouerd  neurotic  condition,  alkalies  must  be  i'luidoyed  either  m  the 
nf  In  s  t  or  bicarbonate  of  soda.  These  should  be  g|ven  n.  large 
Ws  n  d  the  heu,M  of  ^u,e.iron.  The  burning  acid  enu-tations  n.ay  b 
J^;:^  1  h  wav'  The  .liet  should  be  tnainly  alluiinmous  and  sb<M,  d 
be  all  i  iltered  in  a  non-irritating  form.  Stimttlatmg  con.liments  and 
ah^oh!;;  Ildd  be  avoided.    Starches  should  be  sparingly  allowed,  and  only 

^^"t;: i^i^r;;;"^  ;:^:i:i::;ru;f  s -s  a ..... ..cedu. 

shJitlv  CO  .1    d      It  is  best  given  finely  minced  or  grated  on  s  ale  bread 
K;p;rd:;tary  is  H  outtc^s  (10.)  grammes)  of  meat,  two  rm.hum  s  u^ 
of  stale  bread,  and  an  ounce  (:?0  grammes)  of  butter.     1  lu    may  be  t  Ken 
Jhree  times  a  day  with  a  glass  of  Apollinaris  water,  soda  watei,  or,  what 


jm 


5Q4,  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

is  iu.t  .«  sUi«factorv,  sprin,'  water.  The  lliml  slu.uM  imt  ho  taken  too  coUl 
S,  "^d  ■•;  ^  <  m  Ml  0  akcu  in  the  ex.nninaliun  ui  the  meat  to  guani  agam.t 
'  "  ;  .  i;  e  ion,  hnt  .uitahle  in.trnctions  on  this  point  can  be  ,.vjm,. 
T  .  iieient  fo  an  a.luh  n.an,  an.l  n,any  ohst.nate  cases  y.dd  s,  ^- 
.'  orii;  a  n.onth  or  six  ueeks  of  this  treatnK.nt,  after  uuch  tunc  ho 
;  e  11  V  .1  -n.ste.l  articles  of  food  n>ay  be  ^rradnally  added  to  the  d.etai). 
''-'^Zr^^rcUon  the  use  of  the  st.nach-tube  is  of  j  «  f^-  ;;;^  ^^^j- 

:;ir1  ri^o::^V^^^^r.  tms  is  in,practicable  the  takin.  of 

were  alleviate.l.    Alkalies  in  large  doses  are  also  in.liealed 

]n  ca«es  of  continued  supcrsenrlwu  there  is  usually  aton>  and  data 

ti.,„      m>  diet  here  shonl/l  be  much  as  in  superacd.ty,  but  should  be 
ninii  mi    in    sn.aller   nuantities   at    fre<iuent   intervals.      La^.gc   w. 

alkaline  solutions  or  with  nitrate  of  silver  ,s  ol  great  value      Jj'  -^   -/'  - 

large  .luantities  of  bicarbonate  of  soda  or  magnesia  should  be  guen  at 

'^^n  ;;LS;lv  a  "earefully  regulated,  easily  digestible  mixed  diet.  n<.  too 

.ic.h  h.  aulun.inoids,  is  advisable.     Bitter  tonics  befon^  meals  are  .une  ,m  . 

of  value.     In  arlniUa  (,aslnca  the  use  of  pred.gested  foods  and  of  hvd.o 

plilnric  acid  in  full  doses  may  be  of  assistance. 

^''r,;";t:d  A,..../^..  Jbeslde  the  treatment^f  *!-  |^"^;^;-  ,; ^^ 

nitrate  of  silver  in  doses  of  gr.  H-  taken  m  5  uj-.l  ^v  of  water  on  an  empty 

stomach,  is  advised  by  Rosenheim. 

n  scnue  instances  rectal  feeding  may  have  to  be  -sortod  to 
The  gastralgia,  if  very  severe,  rennires  morphia,  which  is  b  >    .dm m 
i.tered  subcntaneously  in  combination  with  atropia.    In  the  milder  attacks 
,    'Combination  of  ,i,rphia  (gr.  i)  with  cocaine  ,vnd  ^f  ^^j;;;-  ^  .^^    ; 
1  A  l>v  Vwnld      The  «n-eatest  canton  should,  however,  be  exercised  m 
r  :  s^     ;  t  ^nse  ol  thrhypodermic  syringe.    It  is  preferable,  if  opium 
n  ce  s  rv,  to  give  it  by  the  numth.  and  not  to  let  the  patient  know    lie 
c  nnc^er  of  the  drug.     Chloroform,  in  from  10-  to  '.'U-drop  d..ses,  or  Ho  f- 
^;;:^::;4n:  wilUometinies  allay  the  severe  1--  .[^'-^--^  ^^  ); 
tion  should  receive  careful  attention,  and  in  many  cases  the  attacks  recur 
;;;m't  health  is  restored  by  change  of  air  ^ith  the^j.n^mged  use  .d 
•uvonic     If  there  is  anaMuia  iron  may  he  given  freely.    ^dIatc  oi  silver  1 
doses  of  gr  I  to  i  in  a  large  claret-glass  of  water  taken  on  an  empty  stomach 

''  "^I'^riorm^^d'nervous  dyspepsia  occurring  in  women  who  are  often 
.velU  i  1-1  and  with  a  good  color,  yet  who  suffer-particularly  at  night 
!^wi  h  ilatulcncv  and  abdominal  distress.  The  sleep  may  be  quie  and  un- 
di  b  d  for  two  or  three  hours,  after  which  they  are  aroused  with  painful 
^^  llns  in  the  abdomen  and  eructations.  The  appot  to  -^f  ^-  -^^^ 
nnneir  to  be  normal.  Constipation  is,  however,  usually  present  In  many 
o  C  pa  i  nts  the  condition  seems  mther  intestinal  dyspepsia,  and  the 
d  .    c"  ir  due  to  the  aecunudation  of  gases,  the  result  of  excessive  putre- 


Hk 


con  too  coUl. 
;iiard  against 
iin  1)0  givon. 
;  yiold  sitis- 
icli  time  the 
1  the  (liotavy. 
■oatost  vahie. 
hogins.    'riio 
of  nitrate  of 
tlio  taking  of 
to  have  two 
nrnal  attacks 

y  and  dihita- 
ut  shoidd  he 
Lavage  with 
'o  rohove  pain 
>  given  at  the 

I  diet,  not  too 
are  somotinios 
:ind  of  hydro- 

t-ral  condition, 
r  on  an  eniiity 

,  to. 

is  host  admin- 
niihh'i-  attacks 
[»nna  is  roconi- 
1)0  exorcised  in 
ral)h'.  if  oi)ium 
tiont  know  the 
dosos,  or  Holf- 
general  condi- 
0  attacks  rocnr 
(dongod  tisc  of 
•ate  of  silver  in 
empty  stomach 

n  who  are  often 
cnhirly  at  night 
0  quiet  aitd  nn- 
!od  with  painfnl 
d  digestion  may 
^sont.  Tn  many 
Jltepsia.  and  the 
excessive  pntre- 


DISEASES  OF  TIIK   INTESTINES  ASSOCIATED   WITH    DIAlUUia^A.     5u5 

faction.  The  fats,  starches,  and  sugars  should  be  restricted.  A  diastase 
ferment  is  sometimes  ns..r.d.  The  ilat..h.n.y  may  l)o  treated  hy  the  mctho.ls 
ahovo  montione.1.  Naphthalin,  sali.'ylate  of  i,i>nmth.  an<l  sah)  have  hccn 
roconnnon.h.d.  Some  of  these  cases  obtain  relief  from  thorough  irrigation 
of  the  colon  at  bedtime. 

The  treatment  of  anurcvia  nervosa  is  described  subsequently. 


YII.    DISEASES  OF  THE   INTESTINES. 

1      DISEASES    OF    THE    INTESTINES     ASSOCIATED    WITH 

DIARRHCEA. 

CATARRHAL  ENTERITIS;   DIAURIUEA. 

In  the  classification  of  catarrhal  enteritis  tlie  anatomical  divisions  of 
tlio  bowel  have  been  too  closely  followed,  and  a  duodenitis,  jejiinitis,  ilei- 
tis tvi.hlitis,  colitis,  and  proctitis  have  l)een  recognized;  whereas  in  a 
ma'ioritv  of  cases  the  entire  intestinal  tract,  to  a  greater  or  lesser  extent,  is 
involved,  sometimes  the  small  most  intensely,  sometimes  the  large  bowel; 
but  during  life  it  may  be  .luite  impossible  to  say  which  portion  is  specially 

^Etiology.— The  causes  mav  be  either  primarii  or  scrowJan/.     Among 
the  causes  of  nrimani  catarrhal  enteritis  are:  (a)  lm]n-o\n'V  food,  one  ot 
the  most  Impioiit,  especially  in  children,  in  whom  it  folh.ws  overeating 
or  the  ingestion  of  unripe  fruit.     In  some  individuals  specia    articles  ot 
diet  u^ill  alwavs  produce  a  slight  diarrh.ea,  wliic^h  may  not  be  due  to  u 
catarrh  of  the  mucsa,  but  to  increased  peristalsis  induced  liy  the  otTonding 
material      (h)  Various  toxic  substances.     i\Iany  of  tlie  organic  p(.isons,  such 
ns  tho<^e  produced  in  the  decomposition  of  milk  and  articles  ot  food,  excite 
the  most  intense  intestinal  catarrh.    Certain  inorganic  substances,  as  arsenic 
and  niercurv,  act  in  the  same  way.    (r)  Changes  in  tlie  wea  her.    A  fall  in 
the  temperature  of  from  twenty  to  thirty  degrees,  particularly  in  the  spring 
or  autumn,  may  induce-how,  it  is  diibcult  to  say-an  '^••'♦^l';'';''-''^-       ^ 
cnoak  of  this  as  a  catarrlial  process,  the  result  of  cold  or  of  chill.    On  the 
other  hand,  the  diarrheal  diseases  of  children  are  associated  m  a  very  spe- 
cial wav  with  the  excessive  heat  of  summer  ni.uiths.     {<!)  (  hanges  in    he 
constitution  of  the  intestinal  secretions.     We  know  too  little  about  the 
surrus  enterirus  to  be  able  t(^  speak  of  influences  induced  by  change  in  its 
quantity  or  (,uiilitv.    It  has  long  been  held  that  an  increase  in  the  amount 
of  liile'poured  into  the  bowel  might  excite  a  diarrhrea;  I'^f  ^    '^-^  Z;^"" 
bilious  diarrlura,  so  frequently  used  by  the  older  writers.     Possiby  theie 
are  conditions  in  which  an  excessive  amount  of  bile  is  poured  into   he  intes- 
tine increasing  the  peristalsis,  and  hurrying  on  the  contents;  but  the  oppo- 
site state,  a  scanty  secretion,  by  fayoring  the  natural  ferrnentative  processes, 
much  more  commonly  causes  an  intestinal  catarrh.     Absence  of  the  pan- 
creatic secretion  from" the  intestine  has  been  associated  m  certain  cases  with 


«i 


in* 


506  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

.,  f.,ttv  (liarrlm'a.     {,')  Xcrvm.s  innuonoos.     It  is  l.y  no  moans  clear  how 
; ncn  s  act  upon  the  bowels,  and  yet  it  is  an  oUl  and  Iru.tworl  ,y  ob- 

X  at  ion    which  even-day  experience  cunlinns,  that  the  .uental  state  may 
^  ^m"h  a     't    he^nti^  canal.     These  iniluenccs  should  not  prop- 

eonsidercd  under  cUarriud  processes,  as  they  roult  sunply  from  m- 
,1  peristalsis  or  increased  secretion,  and  are  usually  descnbed  unde.- 
"hiding  ,n:rous  cliarrl.ra.     In  children  it  /-l-";;'^    ;;   ^^  ^^[^    ; 
It  i.  common,  too,  in  adults  as  a  result  oi  emol.onal  di^tuil.ancc^.     tan 
,  t    ni'ntion;  a  burgeon  who  always  before  an  in.portaut  <;i;-  -;    ;;^ 
\vUerv  diarrh.ca.     In  hysterical  women  it  is  seen  as  an  occaMon  d  occur- 
n;;!:;?.!'!;    to  transient  excitement,  or  as  a  chronic,  protracted  diarrlnca, 
whicii  may  last  tor  months  or  even  years.  ,•        i. 

\  n  .;''  the  srnuulani  causes  of  intestinal  catarrh  may  he  nKMitunud: 
(.)  InfcctTous  diseases.   -Dysentery,  cholera,  typhoi.l  fever,  pyamiia,  sep  .- 
,uia    tuberculosis,  and  pneumonia  are  occasionally  associated  with  inte.- 
'in  1  ;.at  r  h.     In  dvsentery  and  typhoid  fever  the  nlccration   >s  m  par 
"     n:;ble  for  the  catarrhal  condition,  hut  in  c.holera  it  is  V-^f^^^^ 
iniiuence  of  the  bacilli  or  of  the  toxic  materials  l'-<"l-ed  by  the         (h) 
The  extension  of  inilammatory  processes  from  a.ljacent  pait>.      1  hu.    m 
PC  itonitis,  catarrhal  swelling  and  increased  secretion  are  always  present  in 
[ins       In  cases  of  invagination,  hernia,  tub..rculous  or  cancerous  nl- 
^l™  •;;.   catarrhal   processes   are   common.     (0    ^'i-"'f' Tj-tu^.nces 
cause  a  catarrhal  enteritis,  nsually  of  a  very  chrome  character.     Tl i. 
common  in  diseases  of  the  liver,  such  as  cirrhosis,  and  in  chronic  alTection 
o  heart  and  lungs-all  conditions,  in  fact,  which  produce  engorgement 

o  the  terminal  brandies  of  the  portal  vessels.  (./)  In  the  ..achecic  condi- 
tions met  with  in  cancer,  profound  amvmia,  Addison  s  disease,  and  J.nght  , 
disease  intestinal  catarrh  may  develop,  and  may  terminate  lite. 

Morbid  Anatomy.-Changos  in  the  mucous  membrane  arc  not  al- 
ways visible,  and  in  cases  in  which,  during  life,  the  symi.toms  of  intestinal 
catarrh  have  been  marked,  neither  redness,  swelling,  nor  increased  secre- 
tion—the three  signs  usually  laid  down  as  characteristic  of  catarrhal  inflam- 
mation-may he  present  post  mortem.     It  is  rare  to  see  the  mucous  mem- 
hrane  iniected;    more  commonly  it  is  i^ale  and  covered  with  mucus.      Jn 
the  ni.per  part  of  the  small  intestine  the  tips  of  the  valvuUy  conn.ventes 
,uav  lie  deeply  injected.     Even  in  extreme  grades  of  portal  obstruction  in- 
tense livpera>niia  is  not  often  seen.     The  entire  mucosa  may  he  softened  and 
infiltrated,  the  lining  epithelium  swollen,  or  even  shed,  and  appearing  as 
large  l^.akes  among  the  intestinal  contents.     This  is,  no  doubt,  a  P-'ft-mor- 
tem  chan-e.     The  Ivmph  follicles  are  almost  always  swollen,  inirticnhii  ly 
in  chil.livn.     The  r'ever's  ])atclies  may  ho  prominent  and  the  solitary  loi- 
licles  in  the  largo  and  small  bowel  may  stand  out  \vitli  distinctness  and 
present  in  the  centres  little  erosions,  the  so-called  follicular  n  cers.      Ijiis 
Inav  he  a  striking  feature  in  the  intestine  in  all  forms  of  catarrhal  enteritis 
in  children,  quite  irrespective  of  the  intensity  of  the  diarrh.ra.       _ 

When  the  process  is  more  chronic  the  mucosa  is  firmer,  m  some  instances 
thickened,  in  others  distinctly  thinned,  and  the  villi  and  follicles  present  a 
slaty  pigmentation. 


I 


IS  clear  how 
ftwoilliy  ol)- 
al  sttito  iiuiy 
Id  nut  prnp- 
ij)ly  from  in- 
criljc'd  xindt'i' 
)ll()\vs  i'l'iglit. 
liiiu'os.  t'au- 
jieration  liad 
isiional  occur- 
X'd  diavrluL-a, 

0  mciitioiipd: 
lyaMiiia,  t^opti- 
■d  with  intos- 
1)11  is  in  i)art 
l)al)ly  a  direct 
\)y  tiiein.  (h) 
•ts.  Tiiiis,  in 
ays  ])resent  in 

cancerous  nl- 
disturhances 
ctcr.  This  is 
onic  alTections 
>  onfforgement 
ichectic  condi- 
',  and  Jirighfs 
'c. 

ne  arc  not  al- 
ls of  intestinal 
icrcased  secre- 
tarrhal  inflam- 

nuicoiis  mein- 
h  nuicus.  In 
hv  connivcntes 
obstruction  in- 
)c  softened  and 
[1  aiti)carin<i  as 
ht,  a  ])ost-mor- 
■n,  ]iarticularly 
he  solitary  fol- 
istinctness  and 
r  ulcers.  This 
arrhal  enteritis 
pa. 

some  instances 
Hides  present  a 


DISEASES  OP  THE  INTESTINES  ASSOCIATED  WITH  DIAUKIUEA.     50? 

QvmTitoms  -\cut.'  ami  clironic  forms  may  lie  recu-ni/.e.l      The  im- 

.orSuH;  of  iMh  is  diarrluea,  whi.-h,  n,  the  maj.n.y  n,  instance. 

e  ^.le  indication  of  this  condition,     it  is  not  t.>  1m.  >u,M--1  "at  dia  - 

u      ;      nvariahlv  caused  hy,  or  associated  with,  catarrhal  cnt-n Us,  a. 

n   tc'  imxluccd  hv   ...mvous  and  other  inilueiiccs.     It    is   p ml.  14c   tha 

"L       01     he  icjunum  may  exist  without  any  diarriuea;  n.dcc  ,  it   is  a 

,•  h    veil         or  even  ..f  a  gravish-white  tint.     The  eonM>tencc  is 

pho.phate  of  lime,  oxalate  of  .ina^  and  occasionally  chole.tenn  and  (  har 

nr;"in  hI,'  r.,ur.o  ,.t  .1.0  ,l.y.     Tin.  «U«-k  1,,-..  U.  ,.„  or  .h,..  .!«,>. 

„„,„,y.opro.„„,.i  '•-=;;-;;. -'™fS,,,„,  ,„„  „,.,„„  r,„™,  ..,■  „.>•  .1.- 

„,.V;^;i^^-  !f :  0,,.  ,^^^^^^^ 

.liarrh.ca  is  of  a  lienteric  character    and      hen   *'^;^  '  .  ,,„, 

stools  are  thin  and  mixed  w  tli  much  --'-,  "^^  "  J  ^  „i  in  the.. 
diarriuea  will  be  -^-'ir^.'  -•'•;:;.  ,  ^  i;";;:;',/ loss  <,f  ilcsh  an.l 
ohronic  c:wes  is  greatly  di>tuib(d  <"";"..  .  ^  ^  j^i^,,  „,  hvpo- 
oreat  pah-r.     The  patients  are  inclined  to  .uilei  iioni  low  •  I  .1 

ohondriasis  may  develop.  determine,  if  i-os- 

DiagnosiS.-lt   .s  importa   t.  .n  <''",'       ^    ^    ^^      ^^  ,.„t„,,,„  of 
sible,  whether  the  large  or  sun.  1  bowc     s  '       '  ^      ^^  ,^  ^.^,„.,^^.  ,,,„,. 

the  small  bnw..l  the  diarrl.ea  ,s  less  m  ik  .1.  ''     '  ;^  .,,     ;„,,.„„ 

acter,  borborygmi  are  not  so    requent,  '^l^^'^^^;^  'LLi  aiul 

of  food,  and  are  moiv  y^^^^^-^;;-  l^U^^t^U^^t  li  fault  there 
do  not  contain  much  mucu>      \\  hen  tne  i.u  ■.,,^^.,^u,^  nssociatcd 


1', 


mmm 


.J 


«■* 


r 


508 


DISEASKS  OF  THE   DIGEISTIVE  SYSTEM. 


iiiarkod  tcncsimis.  'I'lu'  s^tools  liavo  a  uniform  soupy  consistoiioo;  tlioy  arc 
grayisli  in  rolor  an.l  -laniilar  tliron-liout,  witli  Iuto  and  tluTu  ilakcs  of 
liiucns,  or  thcv  niav  contain  vory  largo  quantities  of  niueus. 

There  aro'no  positive  svuiiitonis  l)y  wliieli  tiie  diagnosis  of  duodenitis 
ean  ])e  mndo.  It  is  usually  associated  with  acute  gastritis  and,  if  tlie  process 
extends  into  the  hile-duct',  with  jaundice.  Neither  jejunitis  nor  deitis  can 
Ijc  separated  from  general  intestinal  catarrh. 

ENTEHITIS   IN   CIIILUIIEX. 

We  mav  recognize  three  forms:  (1)  The  acute  dysi.eptic  diarrluea;  {-i) 
cholera  infantum;  and  (;?)  acute  entero-colitis. 

General  Etiology  of  the  Diarrhoeas  of  Children.— 1  he  dis- 
ease is  must   frecpient  in  artiliciaily  led  cliildren,  and  the  greatest  numl)er 
of  cases  occur  hetween  tiie  ages  of  six  and  eighteen  months.     A  ])opular  and 
well-founded  helief  ascrihes  si)ecial  danger  to  the  second  summer  of  the  in- 
fant.    Infantile  diarrluea  is  very  ])revalent  among  the  poorer  classes  in  the 
large  cities.      It  attacl<s,  however,  children  with  the  most  favorable  sur- 
roimdings.     Two  factors  inlluence  the  disease,  diet  and  temperature.     An 
immense  majority  of  all  fatal  cases  are  artificially  fed.     Of  1,!»4;5  fatal  cases 
in  Ilolfs  statistics,  only  three  i)er  cent  were  exclusively  breast  fed.     Among 
the  ])oor  the  bowel  coin])laint  in  children  begins  with  the  artificial  feeding. 
Tl;e  relation  of  temperature  to  the  prevalence  of  diarrlural  diseases  in  chil- 
dren has  long  been   recognized.     The  mortality  curve   begins  to   rise  in 
]May,  increases  in  June,  reaches  the  maximum  in  July,  and  gradually  sinks 
through  August  and  Septenil)er.     The  maximum  ccuTcsponds  closely  with 
the  Idghest  nu'an  temperature;  yet  we  cannot  regard  tiie  heat  itself  as  the 
direct  "agent,  but  only  as  one  of  several  factors.     Thus  the  mean  temper- 
ature of'~Juuo  is  only  four  or  five  degrees  lower  than  that  of  July,  and  yet 
the  mortality  is  not 'more  than  one  third.     yeil)ert,  who  has  carefully  ana- 
lyzed the  mortality  and  the  temperature,  month  by  month,  in  New  York, 
for  ten  years,  fails  to  liud  a  constant  relation  between  the  degree  of  heat 
and  the  number  of  cases  of  diarrluea.     Neither  barometric  pressure  nor 
luimiditv  a])])cars  to  have  any  inlluence. 

Eelation  of  Bacteria.— The  healthy  fa-  <  of  suckhngs  contain  a 
number  of  bacteria  and  micrococci,  the  most  iniiK)rtant  of  which  are  the 
ladcriinn  hirtis  acrofii'iirs  and  the  harlrrltiui  coli  rommuiif.  The  former  is 
only  present  in  the  intestine  after  a  milk  dit't,  the  milk  sugar  appearing  to 
furnish  the  materials  necessary  for  its  growth.  It  occurs  rather  in  the 
u])]»er  portion  of  the  bowel,  and  in  this  region  excites  the  fermeutativo 
])rocesses  in  the  milk.  The  hartcriiim  coli  commune  is  found  more  abun- 
dantly in  the  lower  portion  of  the  small  intestine  and  in  the  colon,  and  ex- 
cites fermentative  changes  which  are  probably  associated  with  certain  i»hases 
of  digestion.  The  oliservations  of  Escherich  show  the  remarkable  sim])lic- 
ity  of  this  bacterial  vegetation  in  the  healthy  fa  res  of  milk-fed  children,  as 
tlu'se  two  organisms  alone  develop  and  are  constant.  In  infantile  diarrluva 
tlie  number  of  l)acteria  which  may  be  isolated  from  the  stools  is  remarkable. 
Booker  has  discriminated  forty  varieties,  the  greatest  number  of  which  were 


ico;  tlioy  are 
ere  tlakcs  ul' 

)1'  (luodt'iiitis 
il'  tlu'  proct'ss 
lor  ileitis  can 


liarrluea;  {'i) 

n.— The  dis- 
atcst  iuiinl)t'r 
L  ])oi)ular  and 
nor  ol'  the  iii- 
classes  in  the 
avorable  sur- 
)erature.     An 
4;)  i'atal  eaa's 
fed.     Among 
ficial  feeding, 
ceases  in  chil- 
ns  to  rise  in 
radnally  sinks 
s  closely  with 
t  itselfas  the 
mean  temper- 
July,  and  yet 
carel'iilly  ana- 
in  New  York, 
legree  of  heat 
pressure  nor 

ngs  contain  a 
which  are  the 
The  former  is 
r  apjiearing  to 
rather  in  the 
^  fermentative 
id  more  ahun- 
colon.  and  ex- 
certain  i>liases 
•kahle  sim])lic- 
ed  (hildren,  as 
intile  diarrhrea 
is  remarkal)le. 
of  which  were 


DISEASES  OF  THE   INTESTINES  ASSOCIATED   WITH    DIAIMMKEA.     5ui» 

found  in  the  cases  of  cholera  infantum.  The  two  constant  forms  noted 
al,ove  do  not  dis.pi.ear  in  the  ,liarrlueal  .<tools.  No  for.us  have  l.een  louml 
to  l)ear  a  constant  or  speciiic  relation  to  the  .liarrh.ral  lares,  such  as  the 
two  ahove  mentioned  (h.  to  the  lu.ilthy  milk  luH-es.  1  he  bacteria  ot 
Ihe  pruln,.^  group  are  most  frcpient,  and  pos>ess  i.athogemc  i.roperties. 
Ml  the  varieties  develop  and  produce  important  changes  ui  the  milk,  winch 
have  been  dealt   with  verv  fully  by  looker  iu  his  exhaustive  mon..grai;h 

(Johns  lloi.kius  Hospital  l{ep<>''t^  ^"l-  ^■''-  '^''''^  ""^'""'  <""'  ''."'"^  "';'.^  \" 
the  diarrh.ea  of  infauts  "  m.t  one  specific  kiml.  but  many  .bllercnt  kinds 
of  bacteria  are  c..iuerned,  and  that  their  action  is  manifested  more  m  the 
alteration  ..f  the  food  ami  intestinal  contents  and  in  the  i.ro.iuction  ol  m- 
iurious  products  than  in  a  direct  irritati<.n  upon  the  intestinal  wal  .  W  ith 
these  agree  the  conclusions  of  Jeltrics  and  I'.aginsky  regarding  cholera  m- 

Morbid  Anatomy.— We  find  most  frc.,uently  a  catarrhal  sNU'lliug 
of  the  mucosi  of  both  small  and  large  bowel  with  enlargement  oi  the  ymph 
follicles.  ]n  more  chronic  cases  the  latter  show  small  erosions  or  follicular 
uhrrs;  more  rarely  there  is  croupous  enteritis  affecting  the  lower  j-art  ot 
the  ileum  and  tlu>  cdon.  The  changes  in  the  other  organs  are  neitlier 
numerous  nor  characteristic,  {'.roncho-pncumonia  occurs  in  many  cases 
The  si.leen  niav  be  swollen.  I'.rain  lesions  are  rare;  the  membranes  an<l 
substance  are  often  anamiic,  but  meningitis  or  thrombosis  is  very  un- 
common. ,  „,        ,  ., , 

ClinicalForms.— Acute  Dyspeptic  Diarrhoea.— Ihe  child  may  ap- 
pear in  its  usual  health,  but  has  an  increase  iu  the  number  of  stools,  with- 
out fever  or  special  disturbance  except  slight  restlessness  at  nigh  .     After 
l)ersi«tin.'  for  a  day  or  two  the  stools  become  m.>re  fretiuent  and  contain 
nndi.n>sted  food  and  curds,  and  are  very  offensive.     In  other  cases  the  dis- 
ease "ets  in  abrui.tlv  with  vomiting,  griping  jmins,  and  fever,  which  may  rise 
rapidly  and  reach  "104°  or  10.5°.     There  may  be  convulsions  at  the  outset. 
The  ai.domen  is  sensitive,  and  the  child  lies  with  tiie    egs  drawn  up.      J  he 
.tools  c.nsist  of  grayish  or  greenish-yellow  beccs  nnxed  with  gas,  curds,  and 
portions  of  food.     In  children  over  two  years  ot  age  sue  .  attacks  not  ,n  u- 
Iiuentlv  follow  c'ating  freely  of  unripe  fruit  or  the  drinking  ol  milk  ^^l  uh 
1  as  been  tainted.     With  judicious  treatment  the  ch.  dren  '-'r'--;;  ^^^  »    ';?; 
days;  but  relapses  are  not  uneon.mon,  and  in  the  lH>t  weather  the  attak 
niay  be  the  starting  point  of  a  severe  entero-colitis      In  a  debihfated  child 
a  mild  attack  may  prove  fatal.     This  dyspeptic  diarrluea  is  dis  inguished 
sharply  fnnn  choleri  infantum  by  the  character  of  the  stools,  wb.ch  ne  e 
have  a  watery,  serous  character.     In  many  instances  this  f..nn  prece.le^  the 
on-^ct  of  the  specific  fevers,  imrticuhirly  during  the  hot  weather 

Cholera  Infantuin.-This  is  by  no  means  so  common  as  the  onl. nary 
dyspeptic,  diarrh.ea  of  children,  and,  according  to  n..lt,  occurs  only  m  wo 
or  three  per  cent  of  the  cases  of  summer  diarrho-a.  Tt  i^revails  ,n  the  hot 
weather  and  in  children  artificially  fed  or  who  have  had  previously  some 
sli-d.t  dyspeptic  derano-ement.  It  is  characterized  by  vomiting,  uncon- 
tndlable  dian-luea,  and  collapse.  The  disease  set.  in  with  vomiting,  which 
i«  incessant  and  is  excited  by  an  attempt  to  take  food  or  drink.     1  ho  .tool. 


*i* 


f 


510 


DISEASES  OP  THE  DUiESTlVE  SYST)  M. 


are  i.rofuso  iiiul  frciiuMit;  at  first  fiwal  in  cliara.t.T,  Im.wn  ..r  vHluw  iii 
c.lcr,  aiul  linallv  thin,  s^nuis,  aiul  vvatciy.     '1'!..  st....ls  lirst  imssnl  air  very 
..llViisive;  siibsfqiiHitiv  tiicv  aiv  ..dorU'ss.     Tiu'  ti.in,  hmuus  sI.h.I.  are  alUa- 
lin,.      Tiiore  is  IVvit.  hut  the  axilhiry  tcinpcnitinv  may  r(•^nsl.■r  tluw  or 
MHMV  (Ic-rces  l)ol..\v  that  ..ftlu'  rectum.      Kn.m  the  <.ut-et  there  is  marke.l 
pn.stratmu;  the  eyes  are  sunisen.  the  IVaturrs  i.iiu'iie.l,  tlic  Inutaiu'lle  de- 
pressed, and  the  skin  lias  a  pecniliar  asiiy  l-alhu-.     At  lir>t  .vsth'ss  an.'  ex- 
cited, tiie  cliild  suhsequently  hec.nies  lieavy,  (hill,  aiul  li>tless.      1  he  tungue 
i.  coaled  at  the  onset,  hut  sul)se(inently  becomes  red  and  dry.     As  m  all 
choleraic  conditions,  the  thirst  is  insatiahle:  the  |nilse  is  rapid  ami  ieehl.s 
iuid   towar.l   the   end    hecmies   irregular   an.l   imi-erccptihle.       D.'ath    ma\ 
oc.iir  within  twentv-l'.mr  hours,  with  symptoms  .d'  coUaj-se  aiul  givat  eleva- 
tion or  the  internal  temi-erature.      IVfore  the  end  the  diarrluea  and  vom- 
itiiP'  mav  cease.      In  other  instances  the  intense  symptoms  suliMde,  hut  the 
child  renmins  torphl  aiul  semi-comatose  with  lingers  clutched,  and  there 
may  he  convulsions.     The  head  may  he  retracted  and  the  respirations  in- 
terrupted, irregular,  and  of  the  Cheyne-Stokes  type.     The  child  may  re- 
,nain  in  this  eon.lition  for  ,nnw  days  without  any  signs  of  nni-rovement 
Jt  was  to  this  group  of  symptoms  in  infantile  diarrluea  that  Marshall  Hall 
.rave  the  term  "  hvdreucephaloid  "  or  spurious  hydrocephalus.     As  a  rule, 
no  changes  in  the'hrain  or  other  organs  are  lound,  and  the  condition  is  no 
douht  caused  hy  the  toxic  agents  absorbed  from  the  intestine.     A  remark- 
able eonditioi/of  sclerema  is  described  as  a  secpiel  of  cholera   mlantum. 
The  skin  and  suhcutanefuis  tissues  become  hard  and  lirm  and  the  appear- 
ance has  been  compared  to  that  of  a  half-frozen  cadaver. 

No  constant  organism  has  been  found  in  these  eases.  P.aginsky  con- 
siders the  disease  the  result  of  the  action  on  the  system  of  the  poisonous 
])roducts  of  decomiiosition  encouraged  by  the  various  bacteria  i>resent— a 
Fuuhiixs  disease.  The  clinical  i.icture  is  that  produced  by  an  acute  bac- 
terial infection,  as  in  Asiatic  cludera. 

The  diaqiinsis  is  readily  made.  There  is  no  other  intestinal  allVction  m 
children  for  which  it  can  be  mistaken.  The  constant  vomiting,  the  fre- 
iinent  watery  discharges,  the  collapse  symptoms,  and  the  elevated  temper- 
ature make  an  unmistakable  clinical  picture.  The  outlook  in  the  majority 
of  oases  is  bad,  particularly  in  children  artificially  fed.  liyiierpyrexia,  ex- 
treme eollai)se,  and  incessant  vomiting  are  the  most  serious  symptoms. 

Acute  Entero-COlitis.— Tn  this  form  the  ileum  and  colon  are  most  af- 
fected, chietly  in  the  lymph  f(dlicles,  hence  the  term  follicular  enteritis  or 
follicular  dysentery.  Catarrhal  ulceration  is  a  common  secnu'iue.  it  oc- 
curs most  freciuentlv  in  warm  weather,  in  artificially  fed  diildren;  but  it 
may  set  in  at  any  season  of  the  year,  and  is  the  form  of  enteritis  most 
cou'imon  as  a  secondary  eomiilication  in  the  specific  fevers  of  childhood. 

The  attack  may  fcillow  the  ordinary  dyspei)tic  diarrhii>a.  The  temper- 
ature increases,  the  stools  cliange  in  cliaracter  and  contain  traces  of  blood 
and  mucus,  the  former  usually  only  in  streaks.  The  fu'ces  are  passed  with- 
out any  pain.  The  abdomen  is  distended  and  tender  along  the  line  of  the 
colon.'  Vomiting  mav  be  ])resent  at  the  outset,  but  is  not  a  characteristic 
feature,  as  in  cholera  "infantum.     The  diarrha-a  may  be  gradually  checked 


DISEASES  OF  THE  INTESTINES  ASSOCIATED  WITH    DIAKHIKEA.    511 


)V  yt'lliiw  in 
scd  ail'  very 
ml-  arc  alUa- 
l,T  tlircc  or 
IV  is  iiiarkt'il 
•ntaiu'llo  (ie- 
llfss  aiK^  ox- 

'I'lic  Uinjine 
'.  As  ill  all 
1  ami  IVt'lil<', 

Dratii  may 
1  ^rcat  cli'va- 
vu  and  vmii- 
i>ii!(',  l>ut  tiic 
(I,  ami  Ihoiv 
-|>i^ation^<  in- 
liild  may  ro- 
mjirovi'inont. 
ilarsliall  Hall 
.  As  a  rule, 
iiiditioii  is  110 
.  A  rcmarl^- 
■ra  inl'antnm. 
1  the  appoar- 

^agiiisky  con- 
die  poisonous 
ia  ])resent — ^a 
an  acute  bac- 

al  alVection  in 
itinjr,  tlio  fre- 
vated  tem])er- 
1  tile  majority 
lerpyrexia,  ex- 
yinptonis. 
1  are  most  af- 
ar enteritis  or 
ueiice.  it  oc- 
lildren;  Imt  it 
enteritis  most 
fliildhood. 

The  teniper- 
:races  of  blood 
ro  passed  wit  li- 
the line  of  the 
1  chaiacteristic 
duallv  checked 


iuid  convalcMence  is  establishe<l  in  t\v(.  or  three  weeks;  in  other  instances 
'till,  dis-aso  becomes  subacute,  the  fever  subsides,  Imt  the  diarrluea  persists 
and  the  general  health  of  the  (•hild  rapidly  deteriorates.  The  case  may 
drag  on  for  iivo  or  six  weeks,  when  improvement  grailually  occurs  or  the 
ehifd  '\^  carried  oil"  liy  a  severe  iuteicurrcnt  attack.  In  a  third  form  (d' 
acute  eiitero-colitis,  in  which  analomically  the  lesions  are  tho.^e  already 
i,„,,i,i,,m,,l_„amelv,  an  intense  follicular  inllammation— the  symiitoms  are 
of  a  more  severe  character,  and  the  atl'ection  is  .sometimes  spoken  of  as  acute 
dvseiitcry.  It  attacks  children  up  to  the  third  or  fourth  year  or  even  older. 
'I'he  on>ct  is  sudden,  with  high  fever,  vomiting,  freipieiit  stools,  which  at 
tiist  contain  remnants  of  food  and  fares  and  subseiiuently  much  mucus  and 
some  blood.  There  is  inccssai  >ain,  which  may  be  more  severe  than  in 
auy  intestinal  all'cction  of  childliood.  The  j.rostration  is  very  great  and 
the  fatal  terminatiou  may  occur  within  forty-eight  hours.  More  commonly 
till'  case  lasts  for  a  week  or  longer. 

The  CoBliac  Affection.— ruder  this  lica<ling  (ice  has  described  an  intes- 
tinal disorder,  most  com-.ioiily  met  with  in  children  between  tlu'  ages  of 
one  and  live,  characterized  by  the  occurrence  of  pale,  loose  stools,  not  un- 
like gruel  or  oatmeal  jiorridge.  They  arc  bulky,  not  watery,  yeasty,  frothy, 
and  extremely  olTcnsive.  The  alVection  has  received  various  names,  such  as 
lUarrhmi  alha  or  diarrhm  chi/losa.  It  is  not  associated  with  tubcrciiluus 
or  other  hereditary  disease.  It  begins  insidiously  and  there  are  progressive 
wasting,  weakness,  and  pallor.  The  In'lly  becomes  doughy  and  inelastic. 
There  is  often  flatulency.  Fever  is  usually  absent.  The  disease  is  lingcr- 
uv  and  a  fatal  termination  is  common.  So  far  nothing  is  known  of  the 
paThidogy  of  the  disease.  Ulceration  of  the  intestines  has  been  met  with, 
liut  it  is  not  constant. 

Sprue  or  Psilosis.— A  rcmarkalile  disease  of  the  tropics,  character- 
ized by  "a  jicculiar,  inllamcd,  superlicially  ulcerated,  exceedingly  sensitive 
condition  of  the  mucous  membrane  of  the  tongue  and  mouth;  great  wast- 
ing and  ana>mia;  pale,  copious,  and  often  loose,  fre.picnt,  and  frothy  fer- 
menting stofds;  very  generally  by  more  or  less  diarrhaui;  and  also  by  a 

marked  tendency  to  relapse"  (Mii"^"")-  -,  ^   .,     • 

It  is  very  iirevalent  in  India,  China,  and  Java.     Nothing  definite  is 

known  as  to  its  cause. 

When  fully  established  the  chief  symptoms  are  a  disturbed  condition  of 
the  bowels,  iiale,  veasty-looking  stools,  a  raw,  bare,  sore  condition  of  the 
tongue,  mouth,  and  gullet,  sometimes  with  actual  siiiicrficial  ulceration 
With  these  gastro-intestinal  symptoms  there  are  associated  ana-mia  ami 
general  wa.sting.  It  is  very  chronic,  with  numerous  relapses.  There  are 
no  characteristic  anatomical  changes.  There  are  usually  ulcers  in  the 
colon,  and  the  French  think  it  is  a  form  of  (Ij-sentery. 

:Manson  recommends  rest  and  a  milk  diet  as  curative  in  a  large  propor- 
tion of  the  cases.  The  recent  monograidi  by  Thin  and  the  article  by  Man- 
gon  in  Allbutt's  System  give  very  full  descriptions  of  the  disease. 


82 


J 


51 -2 


DISKASKS  OF  THK   DUiESTlVE  SYriTKM. 


DllMlTIlEKITir  OH  CROITOUS  ENTEIUTIS. 
viilvemml  "I  H"'  i"Im>    in"  >i     .i„uit,,l  ii|«>n  hjl«nwin. 

„,„„v..,.,.iv  „,■,,,„,,..  ";;■":-;,•;;,•■,. ,.:     mvlo ,.  laW.  ,«.■•■ 

""^Tir;;xs:?:i;u"s:r.;::i;r ,.. ...  o,,,^  a  .en.,,,.,  eve,. 

ill  these  diphtheritie  procosses. 

pnLEGMOXOUS  ENTERITIS. 

t:;ir  wll^i;:;^  o.  in;:;..u.eeption  the  a.ec.i      cannot  he  diagnosed. 

The  symptoms  usually  rescmhle  those  of  peritonitis. 

ULCERATIVE  ENTERITIS. 
Tn  addition  to  the  specific  ulcers  of  tuherculosis   syphilis,  and  typhoid 

fovor  the  folloAvini:  forms  of  ulceration  occur  m  the  howel..      _ 

J\  VnlZlnr  Ulcerntion.-As  previously  mentioned,  tins  ,s  met  ^Mth 
(,)  ^""'  "  '  /   ^7^^  dUases  of  children,  and  also  in  the  sec- 

S:^rC!ni:d  hifl^^l^io-  m  .any  fevers  and  constitutional  disor- 


DISRASKS  OF   TIIK   IXTKSTIXKS   ASSOCIATFl)  WITH    DIAKHIKKA.     :,\:\ 


of  tho  finall 
|)i'()c('ss  in  tlir 
and  typlioitl 
■li  as  l>i'if:ht"s 
it  ciTtain  i">i- 

V()ll|l  of  oas-oa 
i-ycllow  diph- 
somo  cuses  all 
.'fi'osis  and  in- 

i'olon  similar 
on  liypora-niii' 
■0  a  lar-;L>  por- 
iiation  without 
1  bowel. 
pouH  c'liaraetor. 
nitcd.  jHThaps, 
^  ot  pnt'Uiiionia 
DrminjJ!  patidics 
iipia  cnistfi. 
ritis,  involvinj: 
I  ari'a  of  diph- 
ulocrs  aiv  coin- 

iiny  syniptonis, 
in  other  in- 
•  the  passaj^e  of 
iiptonis  may  he 
if  constitutional 

terminal  event 


en  less  frequent 
ly  in  connection 
truction.  Apart 
lenum,  and  leads 
.  ]':xcept  when 
lot  he  diagnosed. 


ilis,  and  typhoid 

Is: 

this  is  met  M'ith 

1  also  in  the  sec- 

istitutional  disor- 


ders, 'i'lie  ulcers  are  small,  piinclicd  out.  uitti  sharply  i  ut  vi\^s*'^.  and  they 
are  usually  limiteil  to  the  follicles.  With  this  form  may  he  jilaccd  the 
catarrhal  ulci'rs  of  some  writers. 

(//)  Slrrranil  iilfcrs,  which  occur  in  loii^'  i-tandiu^'  cases  of  const ipat inn. 
Very  rcmarkal)le  indeed  arc  the  cases  in  which  the  saccidi  (A  the  colon  lie- 
come  tilled  with  roundcil  small  scyhala,  some  of  which  prodiKc  distinct 
ulcers  in  the  mucous  mendirane.  The  fa'cal  masses  may  have  liuui  salts 
deposited  in  them,  and  thus  form  little  enteroliths. 

(r)  Siiiiiik  rircrolirc  Ciililix. — 'I'his  alVcction,  which  clinically  is  char- 
acterized hy  diarrluca,  is  often  rcirarded  wrongly  as  a  form  of  dysentery, 
it  is  not  a  very  uncmnmon  alVection,  and  is  most  frequently  met  with  in 
men  ahove  the  middle  period  of  life.  Tiie  ulceration  may  lie  very  exten- 
sive, so  that  a  large  ]iroportion  of  the  mucosa  is  removed.  The  lumen  of 
the  colon  is  sometimes  greatly  increased,  and  the  muscular  walls  hy]ier- 
tro|ihicd.  '{'here  are  instances  in  which  the  howcl  is  contracted.  Fre- 
(picntly  the  remnants  of  the  mtU'osa  are  very  dark,  even  hlack,  and  there 
may  l)e  polypoid  outgrowths  hetwecn  the  ulcers. 

These  cases  rarely  come  under  observation  at  the  outset,  and  it  is  dilVi- 
cult  to  speak  of  the  mode  of  origin.  They  are  characterized  hy  diarrlnea 
of  a  lienteric  rather  than  of  a  dysenteric  character.  There  is  rarely  Idood  or 
pus  in  the  stools.  Constipation  may  alternate  with  the  diarrluea.  There 
is  usually  great  impairment  of  nutrition,  ami  the  patients  get  weak  ami 
sallow.      Perforation  occasionally  occurs. 

The  disease  Tuay  j)rove  fatal,  or  it  may  pass  on  and  hecome  chronic. 
The  atl'cction  was  not  very  iufreipient  at  the  Philadel|»hia  Hospital,  and 
though  the  disease  hears  some  resendilance  to  dysentery,  it  is  to  he  sepa- 
rated from  it.  Some  of  the  cases  which  we  have  learned  to  recognize  as 
anuvhie  dysentery  reseud)le  this  form  very  closi'ly.  An  excellent  descrip- 
tion of  it  is  given  hy  Hale  White  in  Allhutt's  System.  The  ulcerative 
colitis  nu't  with  in  institutions,  such  as  that  <lescrihed  hy  (iemmel,  of  the 
Lancaster  Asylum,  in  a  recent  monograph,  seems  to  he  a  trm-  dysentery. 
Dickinson  has  deserilu'd  what  he  calls  allmminuric  ulceration  of  the  howels 
in  cases  of  contracted  kidney. 

((/)  rirnvlion  from  E.rlrrnal  Perforalidii. — This  nuiy  result  from  the 
erosion  of  new  growths  or,  more  commonly,  from  localized  jieritonitis 
with  abscess  formation  and  perforation  of  the  bowel.  This  is  met  with 
most  frequently  in  tuberculous  peritcmitis,  but  it  may  occur  in  the 
abscess  which  follows  perforation  of  the  appendix  or  .su])purativo  or 
gangrenous  pancreatitis.     Fatal  ha'inorrhage  may  residt  from  the  ])erfora- 

tion. 

((')  Cnnronmt^  Tlrrrs. — In  very  rare  instances  of  multiple  cancer  or  sar- 
coma the  submucous  nodules  break  down  and  ulcerate.  In  one  case  the 
ileum  contained  eight  or  ten  sarcomatous  ulcers  secondary  to  an  extensive 
sarcoma  in  the  neighborhood  of  the  shoulder-joint. 

(f)  Occasionally  a  solUary  vlrrr  is  met  with  in  the  caecum  or  colon,  \\liich 
mnv  lead  to  )ierforation.  Two  instances  of  ulcer  of  the  ca^'um,  both  with 
lerforation.  have  come  under  my  observation,  and  in  one  instance  a  simple 
nicer  of  the  colon  perforated  and  led  to  fatal  peritonitis. 


5U 


DISKASKS  OF  TIIH   DUiKSTIVK  SYSTEM. 


DiaenoBis  of  Intestinal  Ulcers.-As  a  rule  .lianlH.;a  i.  prm.,! 
liL'ial  absii^N  <>i  m  \\^'>"^'i  '  '      i..„,...i   „r  it  iiiav  lu'  aiu'  to  local  disease  in 
'''''';v;.'.n,™'ll''l:f  li-...K'  «n-  ..-ari"..ally  '™"'l  '"  'I"  ^'"'*  '"  "''■'"■•  '""- 

splo'ic  flexure  of  the  colon  .ith  an  ahscos.  contauung  a.r  and  pu.-a  con- 
tlition  of  sul.i'ln-onic  pyo-pncumothorax. 

Treatment  of  the  Previous  Conditions. 

tl  i     he  patient  has  been  freely  purged.     If  the  pam  is  severe,  20 

;  r,  c    or  lar-o  .l..«.>.  of  l.ismull.  (SO  to  hO  prnms)  miiy  be  pivon.     A  .ma 
l-^tof  r;.|,  (-2  o„„cc.)  wi.l.  20  <lro,.  ot  l»ml»m,m.  every  s,.  lun.r.,  ,. 

"  '■';;:;  SSdSSk  ineU,,.,,,  ^romc  e...n„  n,,.,  --t'™  ™;- 
iti.     Tl  if  imi.orl».,t,  ill  tl,e  flrsl  iJaco,  to  necertam,  ,f  posB.ble,  the  ea.i.e 


i«Jl  i:<  jircsciit 
idii.  piirliLii- 
ralinii  ill  tli" 
of  till'  (Irjii- 
>\\V  llu'  Uinr-t 

M  w  itli  uU'ors 
lie  iiiiiiiimt  i> 
an  iiiilicalioii 
lire  of  a  pcri- 
ut.     I'lis  may 
ical  (lisoase  iti 
cases  ut  uli'i'i". 
ro-likc  masses 
ulceration  are 
ant  and  valu- 
se.      It   oec Ill's 
ecially  si<iiiiti- 
losl  imiiurtant 

in  nicer,  par- 
erie  iirocesses. 
(1  even  bits  of 
i08,  either  of  a 
olon,  very  lini- 

iilcer  extends 
■nil  peritonitis. 
•  if  perforation 
ling  colon,  the 
nil.  In  a  case 
foration  at  the 
nd  pns — a  con- 


10  withhold.  If 
f  milk  and  soda 
t  of  large  quan- 
;a1)le,  hut  is  not 
lin  is  severe,  20 
lay  he  given,  or, 
rain  of  morphia, 
it  usually  stops 
'  aromatic  chalk 
civen.  A  small 
ery  six  hours,  is 

nlcorative  entcr- 
issible,  the  cause 


I)I.SE.\SF,S  OF  TllM   INTESTINES   ASSOCIATED  WITH    DIAKKIUEA.     :,\:, 

,„„l  whether  ul.vration  is  pivscnl  or  not.  So  niurh  in  livalnu'iil  depends 
„,„,„  ,|„.  ..Mvfid  ..xaminalion  ol'  tli..  .to.ds-as  to  the  amount  o|  mucis. 
the  presence  of  pus,  the  oc.nrrence  of  parasil.s.  and,  ahosc  all.  the  stale  nl 
.li.rcstion  ..f  Ihe  food- that  the  pra.l itioiier  should  i-ay  si-ccial  attcMliun 
t.rthem.  Manv  cases  simply  re.piire  rest  in  l.d  and  a  rcslridcd  .lid. 
Chronic  .liarrh.ea  of  nianv  months-  or  even  of  several  years  duralinii  may 
he  sometimes  cured  hy  strict  confinement  to  hed  and  a  diet  ol  hoded  milk 
and  alhiimen  water. 

|„  iiiat  form  in  which  immediately  after  eating  there  is  a  tendency  to 
loose  evacuations  it  is  usually  found  that  sume  on.'  article  .d'  diet  is  at 
fiinlt.  The  [latienl  should  rest  for  an  hour  or  more  after  meals.  Sonie- 
limes  this  alone  is  sutrieient  to   prevent  the  ..ecurrenee  of  the  diarrli,ea. 

in  tho>e  forms  which  dciu'iid  upon  ahiiornial  c litions  in  the  small  intes- 

,i,„,,  ,.|,h,.r  too  rapid  peri>lalsis  or  faulty  fermentative  processes,  hisnuilli 
i.  indicated.  It  must  he  given  in  large  doses— from  half  a  drachm  to  a 
,l,,H.hm  three  lim.'s  a  .lav.  The  smaller  .loses  are  ..f  little  us.'.  Naphthalm 
prcnarati.ms  h.'re  .h.  miuh  i,'o.i.l,  given  in  .h.ses  of  fr.nn  10  t..  \:>  grains  (in 
capsul.')  f.)iir  or  live  times  a  .lay.  Larger  .loses  may  he  ncede.l.  Sal.il  an.l 
tlie  salicylate  .d'  hismiith  may  li.'  tri.'d. 

An  extrenielv  ohstinate  and  intra,  taide  f.)rm  is  the  .liarrh.ea  .)f  hyst.'r- 
ical  women.  A'svstematic  rest  cure  will  he  louiid  most  advantageous,  ami 
if  a  milk  diet  is  not  well  h..riie  the  patient  may  he  fe.l  exclusively  ..n  egg 
alhumen.  The  conditi.m  seems  t..  he  ass.u'iat.'d  in  s.nne  cases  with  in- 
eiva-ed  peri«taNis,  and  in  such  th.'  hronii.h'S  may  .1.)  goo.l.  or  prejiarations 
of  oiiium  mav  h..  necssarv.  There  are  instances  which  lU'ov..  most  ohsti- 
nat.'  and  resist  all  f..rnis  ..f  treatment,  and  the  patient  may  h.'  greatly  re- 
duced     A  change  of  air  and  surroundings  may  .!.>  iidiv  than  medicines. 

In  a  lar--e  'M'oiip  of  the  chr.)nic  diarrh.eas  the  mischief  is  seated  in  the 
colon  and  is  due  t..  id.vrati..n.     Medi.'ines  hy  the  nmuth  are  here  ..f  little 
vilue      The  sto.ds  should  he  .  aivfully  vvatched  and  a  diet  arranged  whudi 
<hill  leave  the  smallest  possible  resi.iue.      I'.oiled  ..r  peptonixed   milk  may 
he'  "iven    hut  the  st.mls  should  he  examined    t..  s.'C  whether  then-  is  an 
excess  of  food  oa-  of  curds.     Meat  is,  as  a  rule,  ha.lly  horne  m  th.'se  cas.'s 
The  diarrh.i-a  is  best  treated  by  cnemata.     The  starch  ami  lau.lanum  shoiihl 
bo  tried,  but  when  ulceration  is  present  it  is  bett.^r  to  use  astringvnt  iiije.- 
tions      From  2  to  4  jdnts  oi  warm  water,  cmtaining  fr.nn  hall  a  .h'a.iim 
t,i  a   dra.hin   of  nitrate   of  silver,   may   bo   iise.l.      In    the   .hroni.-   diar- 
rho'a  which  tollows  dvsenterv  this  is  parti.Milarly  advantag.M.ns.      In  giving 
lar-n-  injc-tions  the  patient  should  bo  in  the  d..rsal  i.ositi.m.  with  the  hil-s 
elevat.'d    and  it  is  host  to  allow  the  injecti.m  to  tlow  in  gradually  Irom  a 
Mphon  lia.^      In  tliis  wav  the  entire  colon  can  he  irrigated  and  the  \y,\twnt 
can  n.tain  the  in  je.ti.m  "for  some  time.     The  silver  inje.dions  may  he  very 
paMilul    Init  th.'V  are  invaluable  in  all  forms  of  ulcerative  cditis.     Acotat.' 
of  lead,  boracic  acid,  sulphate  of  cojipor,  snlidiate  of  zinc,  and  salicylic  aci.l 
mav  bo  used  in  l-jier-cent  s.dutions.  •  ,    i      •,, 

"in  the  int.msef.irms  of  choleraic  diarrh.ea  m  adults  assoeiat.'d  with 
constant  v.nniting  and  fre.,iient  watery  discharges  the  patient  should  be 
criven  at  once  a  hvpodermic  of  a  .piartcr  of  a  grain  of  morphia,  which  shonhl 


h 
'i 


Ji 


^^ 


r" 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


l 


town  U.  the  mountains  or  the  .ev  ..  '  ,   ,^i^,,,i  co.ulition. 

tl>o  nun.bor  oi  .UnA.  and  a  rapul  ' »>P  '  ^^ '  \l  1<    into  the  parks  or 

Kvon  in  cities  niucli  "-y^;  ;-  ^'  ,  ^^^  tlv^.e  the  condition,  irosh 

air  IS  indicated.  ^  «-  '  .  ;  j  ,^^.,  .jjiinren  too  hoavdy.  I'.athing  .. 
oven  in  the  warm  ^^eathel,  ^^"^'^^  "  *;  ,      ^         ^.j^^g  j,,,ove  l(f^.5°  the 

of  value  in  infantile  diarrhcea,  and  "  ^'^  j;;^/,^,,,,,  ^f  which  may  be 
child  should  be  placed  in  a  -;""  ?-  ^'j,  '^ J^Ki  r  twenty  minutes,  by 
oraduallv  reduced,  or  the  child  »  kept  in     ic  oar  ^^^  ^^.^^^^^^ 

;.hich  lime  the  water  ^^ -f  ^^^^  >;;';;ttei  he  Iwigation 

the  a,  :    ication  of  ice-c<.l.l  clotlis  or  of  the  '^^  j,  ,,,,  ,,,t  the 

^,^  ^J.  ,.,,,  ,,itu  ice-cold  .^ater  ,s  -"^  I^^^;'^;!';  ,\     ',  ,,,„,  not  only 

-s-d;;i:^n^f^:r;:;;;p:^ 
-■^;^rr;;:;i:::-inth^.se<d.a^h^ 

-fdiXSd;:;^r^^^^^ 
;s-;:'ls".:.r,=;::,f =:;;£  ;B 

;.nns  of  intestinal  fermentathm-lhc  ^-<Vt  ^e  "tb^  ^no  s  a^los 

,vl,ic.h  this  author  relies,  is  a  suibnent  te.t  of  ^  ^^^  M  infants  it  is 
.         forn>entation.     In  the  dyspe,.,c  dnirrluvas  of  "^    ^na  b   ^^J  -   J 

best,  as  a  rule,  to  withhold  mdk  ami  to  f-'^^tlu  ch  R^      the  ^^^^^ 

on  egg  albumen,  broths,  and  beef  juices.     To  picpaio  tnc  e,^ 


DISEASES  OF  THE   INTESTINES   ASSOCIATED   WITH    DIAIMMKEA.     517 


I  tlio  attack. 
n^-  iri  allayed 

of  the  first 
losplu've  of  a 

reduelion  in 
;al  coiulition. 

t!ie  parks'  '>r 
:i(liti<in,  iresh 
laiiy  mothers, 
.  loathing  is 
vo  102.0°  the 
,vhieh  may  be 
y  minutes,  by 
-  ()l)taiiu'(l  by 
d.  Irrigation 
it  has  not  the 

seen,  not  only 
ulation  ot  the 

^  important,  if 
ill  is  sure  to  be 
•ted.  If  water 
tion  of  food  so 
not  to  attempt 
he  water  wlieu- 

,lu)le  treatment 
in  niedieine  on 
The  studies  of 
'ding  of  infants, 
111  various  cities 
Jo  d<nil)t  within 

II  the  intestines 
om  his  observa- 
two  well-defined 
line:  If  there  is 
uminous  articles 
iOn,  such  as  dex- 
'.  ranks  with  the 
t  not  fetid  stools, 
albumen.     It   is, 
the  stools,  npnn 
of  the  intestinal 
fod  infants  it  is 
the  time  at  least, 
eo-ff  albumen,  the 


xdiite-  of  two  or  three  eggs  may  be  stirred  in  a  pint  of  water  and  a  tea- 
spoonful  of  hran.lv  an.l  a  little  salt  mixed  with  it.     The  child  will  usually 
take  this  freelv,  aiul  it  is  both  stimulating  and  nourishing,     it   is  some- 
times remarkable  with  what  rai.idity  a  <hild  whirh  has  been  fed  on  artihcial 
food  and  milk  will  pick  up  ami  improve  on  this  diet  alone,      i'.ccl-juice  is 
<,htained  by  pressing  with  a  Innon-stpurxer  fresh  steak,  previously  mmce.l 
,n,d  eitlier  uncooked  or  slightly  broiled.     This  may  be  givni  alternately 
with  tlie  egg  albumen  or  it  may  be  given  alone.     Mutt..n  or  chicken  bn.tli 
will  be  found  e.piallv  serviceable,  but  it  is  prepared  with  greater  dilhcuity 
•uid  contains  more  fat.     In  the  preparation,  a  pound  of  mutton,  ducken,  ur 
iR.cf   carefullv  fr.rd  from  fat,  is  minced  and  placed  in  a  pint  of  cold  water 
a,„l  allowc.l  to  stand  in  a  glass  jar  on  ice  for  three  or  four  hours.     It  should 
then  be  cooked  over  a  slow  lire  for  at  least  three  hours,  and,  alter  being 
«t rained,  allowc.l  t..  col;  the  fat  is  then  skimmed  olf  an.l  sulh.ient  salt 
a.l.lc.l-  it  mav  then  be  unven  either  warm  or  c.l.l.     These  naturally  prcpare.l 
';,lluimin  foolls  are  very  much  to  be  luvferrcl  t.)  the  vari.ms  artificial  sub- 
stances.    There  is  no  form  of  nourishment  so  readily  assimdated  and  apt  t.) 
caii^e  so  little  disturbance  as  egg  albumen  or  the  simple  beef  juices.     The 
child  should  be  fed  every  two  hours,  and  in  the  intervals  water  may  he  freely 
-dven      It  cannot  be  expected  that,  with  the  .ligesti.ui  seriously  unpaired, 
as  much  f.)od  can  be  taken  as  in  health,  an.l  in  many  instanc.'s  we  see  the 
diarrh.ea  aggravated  by  persistent  over  feeding.     When  the  child  s  stoma<'h 
is  duieted  and  the  .liarrluea  checked  there  may  ho  a  gradual  return  to  the 
milk  diet      The  milk  should  be  sterilized,  and  in  institutmns  an.l  m  cities 
thi-  simple  prophvlactic  measure  is  of  the  very   lirst   importance  and   is 
readily  carried  <.ut   by  means  of  the  Arn..ld  steam  sterilizer  he  milk 

shoul'l  be  at  first  freely  dilnted-four  parts  of  water  t..  one  ..i  milk,  whicli 
is  perhaiis  the  ,.referable  way-or  it  may  be  pept..nized.  1  he  st.^.ls  should 
he  examined  daily,  as  imp.-rtant  indicati.nis  may  be  obtainc  trom  them. 
Alilk-whey  and  f.u'ms  of  fermented  milk  are  s.)metimes  uselul  an.l  may  he 
omploved  when  the  stomach  is  very  irritable.  These  general  directions  as 
to  fo.)d  also  h.dd  g.)od  in  cholera  infantum.  ,.      v      > 

Mtullrinal  Tmilwenl.—'Vhe  first  indicath.n  in  the  dyspeptic  diarrh.ea 
of  children  is  to  get  rid  of  the  dccoiniH.sing  matter  in  the  st..mach  an.l  in- 
te<tine^  The  diarrh.ea  and  v.)niiting  partially  elVect  this,  but  it  may  be 
n,.n-e  thor.)UL.dilv  a.'comi.tished,  so  far  as  the  shunach  is  coiu'erm..l,  by  irri- 
cration.  It  mav  s..em  a  harsh  procedure  in  the  case  of  young  m hints,  but  in 
realitv.  with  a"larg.-sized  soft-rnbher  catheter,  it  is  imu'tised  with..ut  any 
dillicultv  r.v  means  ..f  a  funnel,  lukewarni  water  is  allowed  to  pass  m  an.l 
out  until  it  comes  away  .^uite  clear.  1  can  s].eak  in  the  very  warnu'st  man- 
ner of  the  g.M.d  results  ..l.taimHl  by  this  sim|.le  j-nH^ediire  in  .'ases  ol  he 
most  <d,stinate  gastr.)-intestinal  catarrh  in  children.  In  nu.st  cases  tho 
warm  water  is  sulficient.  Tn  s..me  hands  this  method  has  pr..bably  hern 
carried  to  excess,  but  that  d.u's  n..t  d.'tract  fn.ni  its  great  value  in  suitable 
cases  To  remove  the  fermenting  substan.rs  rr..m  the  intestines,  doses  ol 
calomel  or  grav  powder  may  be  administer.'d.  The  cast..r  oil  is  e.iually 
efficacious,  but'is  more  apt  to  be  vomited.  Irrigati.m  of  the  large  b.nvel  is 
useful,  and  not  only  thoroughly  removes  fermenting  substances,  but  cleanses 


tl 

I' 
il! 


?ii 


J 


«■* 


518  DISEASES  OF  TUE  DIGESTIVE  SYSTEM. 

tl.e  mucosa.     Th.o  child  should  bo  placed  on  the  hack  ^vith  the  hips  elo- 
e        A  tloxihle  catheter  is  passed  lor  from  0  to  8  juches  and  from 
;     int  to  2  pints  of  water  allowed  to  th>w  in  from  a  lonntam  syr.ngo. 
V      t  will  thoroughly  irrigate  the  colon  of  a  chihl  of  six  months  and  a 
t  r     im    of  a  child  of  two  years.     Tlie  water  , nay  be  lukowarn.   l.ut  when 
.  WvrU  fever  i..-cold  water  nu.y  be  used.     In  cases  ot  entero-col.t  > 
n.     be  injections  with  borax,  a  drachm  to  the  p.nt,  or  <  ;l"to  n.  ra  c 
ivr  "which  may  be  either  oiven  in  large  injections   as  in    he  ad.lt,  m 
i   ;  4ions  of  3  or  4  ouncs  with  3  grains  of  nitrate  o   silver   <,   he  ounce. 
'    ,e:i^ ;.fton  cause  very  great  pain,  and  it  is  well  in  such  cases    o    olio,  the 
silver  injection  with  irrigations  ..f  salt  s-duti-m,  a  drachm  to  a  pint. 

\v    are  still  without  a  reliable  intestinal  antiseptic.     ^e>  her  naphtha- 

lin    salol,  resorcin,  the  salicylates,  nor  mercury  meets  the  indications.     A, 

'tl      d  arrluea  of  adults,  bismuth  in  large  doses  is  olten  very  eilectne, 

;     .acUtioners  are  in  the  habit  ot  giving  it  in  do^s  -Im^h  are  qur^e  in- 

ouiV.cient      'Po  be  of  any  service  it  must  l)e  used  ui  larg.;  dose.,  s      hat  an 

"  n"a 'vear  old  will  take  as  much  as  2  drachms  in  the  day      Ihe  gray 

wdei  has  long  been  a  favorite  in  this  condition  and  may  be  given  m 

fiain  dose; every  hour.     It  is  perhaps  preferable  to  calomel,  which 

b"    ed  in  small  doses  of  from  one  tenth  to  one  fourth  of  a  gram  evejr 

ur  at  the  onset  of  the  tn.uble.     The  sodium  salicylate  (in  doses  o    2  oi 

3    nin^  every  two  hours  to  a  child  a  year  old)  has  been  recommended 

'  I    cholenl  infantum  serious  symptoms  may  develop  with  great  rap.ddy, 
nnd  bore  the  incessant  vomiting  and  the  fre.pient  purging  render    he  ad- 
iii  t,  tion  of  remedies  extremely  dilbcult.     Irrigation  .>      ho  stomach 
it  bowel  is  ot  great  service,  and  when  the  fever  is  high  ice-watei 
"   c  t  ms  may  be  used  or  a  graduated  bath.     As  in  the  acute  dioleraic 
hrr  a      of  adults,  morphia  hypodermically  is  the  remedy  which  gives 
i:  nt^  r^^        and  ii  the  conditions  of  extreme  vomiting  and  purging,  with 
SSS.,       a,  d  collaiise  symptoms,  this  drug  alone  commands  tlie  situatiom 
T     il    of  one  vear  may  l.e  given  from  ^i,to  ^  of  a  gntin,  to  be  rep  at.^ 
^^In  hour,  and  again'  if  not  better.     When  the  -- ;;;f  ^ ^;;^'^;^;  ^; 
tenu.ts  may  be  made  to  give  gray  powder  in  half-gra in  do.es  witli    ,^ 
^c-s  powder.     StarcirC^  ij)  and  laudanum  (^  iH-.,)  infections  if  re- 
ined   are  soothing  and  beneficial.     The  combination  of  bisim  th  ^^,t  i 
D  ye  's  1^-der  wiUalso  be  found  beneficial.     Xo  attempt  should  be  made 
derive  food      Water  may  be  allowc.!  fre.ly.  even  when  ejected  at  once  by 
V  mi    n  "     Sma     doses  of  brandy  or  cluunpagne,  frequently  repeated  and 
i  e     cold,  are  sometimes  retained.     When  the  collapse  is  extreme,  hypo- 
da     icnjctions  of  1-pci-ceiit  saline  solution  may  be  used  as  recommended 
h  T  a   c  c'l-l--^  "-^  ..ypodermic  injections  of  ether  and  brandy  may  be 
ioVl      The  convaescence  requires  very  careful  management,  as  many    aso> 
son        o  the  condition  of  entero-colitis.     When  tlje  intense  syniptoms 
a  0  subsided,  the  food  should  be  gradually  given    begmmng  with  tei- 
oonf  1  do.e    of  egg  allmmen  or  beef-juice.     It  is  best  to  wdhl.old  m.lk 
r"  enil  lavs,  and^vhen  used  it  should  be  at  first  complete  y  peptonize 
;;:  diluted  wiil.  gmel.     A  teaspoonful  of  raw,  scraped  meat  three  or  four 
times  a  day  is  often  well  borne. 


jj 


APPENDICITIS. 


510 


Lhc  hips  clo- 
L's  and  from 
lain  syringe, 
lonths  and  a 
•m,  l)ul  whun 
cntero-i'iilitis 
:liluto  nitrate 
tho  adult,  or 
to  tlio  onnce. 

to  follow  the 

pint. 

her  naphtha- 
lications.  As 
very  eiVectivo, 

are  quite  in- 
os,  80  that  an 
ly.  Tlie  gray 
y  he  }j;iven  in 
ah)nu'l,  whieli 
['  a  grain  every 

doses  of  'i  or 
nunended. 
great  ra])idity, 
render  the  ad- 
f  the  stoniaeli 
high  ice-water 
unite  eh<deraic 
y  wliicli  gives 
I  ])urging,  with 
s  tlie  situation. 

to  1)0  re])oated 

is  allayed,  at- 

doses  with  jV 
njeetions,  if  re- 
'  bismuth  with 
sliould  1)0  made 
cted  at  onoo  by 
ly  repeated  and 

extreme,  hyi)0- 
\s  rcconnnended 

])randy  may  bo 
t,  as  many  cases 
tense  sym])toms 
lining  with  tca- 
)  withliold  milk 
etely  i)eptonized 
at  three  or  four 


U.     APPENDJCITIS. 

Inflammation  of  the  vermiform  appendix  is  the  most  important  of  acute 
intestinal  disorders.  Formerly  the  "  iliac  phlegmon"  was  thought  to  he 
due  to  disease  of  the  caHnim— ////'////V/n— and  (.f  the  peritoiueum  covering 
it_pn7 )//'/' /'//.s%-  1)nt  we  now  know  that  with  rare  exceptions  the  caruni 
itself  is  not  all'ected,  and  even  tho  condition  formerly  described  as  stercoral 
tvi)hlitis  is  in  reality  a])pendicitis.  The  recognition  of  the  importance  of 
appendicitis  is  due  largely  to  tho  work  of  the  American  ])bysieians  and  sur- 
geons—to Pepper,  who 'described  in  18S;}  tho  relapsing  form;  to  Fitz, 
whose  cxlianstive  article  in  ISSd  served  to  i>ut  the  whole  (luestion  on  a 
rational  basis;  to  Willard  I'arki-r,  who  was  the  first  to  advocate  early  oper- 
ation; and  to  Sands,  lUill,  McBurney,  Weir,  Morton,  Keen,  Sunn,  .).  \\\\- 
liam  White,  Deaver,  and  others,  who  have  <lone  so  much  to  improve  the  o])- 
erative  measures  for  its  relief.  Treves,  of  London,  has  been  foremost  m 
advocating  the  ])roper  surgical  treatment  of  the  disease.  'Jlie  interest  at- 
tached to'tho  sul)ject  is  manifest  from  the  ai)pearance  within  a  few  years  of 
a  number  of  s])ecial  monograi)hs  l)y  Kelynack,  Talamon,  Fowler,  Soniien- 
borg,  Hawkins,  Deaver,  and  :\Iyntor. 

Anatomy.— Tho  ai)pcndix  veriformis  is  a  fnnctionless  relic  of  a  largo 
ancestral  ca'cuni.  It  measures  usually  about  3  inches  in  leijgtli.  i)ut 
it  may  he  scarcely  an  inch.  Tho  diameter  is  about  one  fourth  of  an  inch. 
In  a  majority  of  instances  it  has  a  triangular-shaiied  meso-ai)pendix,  usually 
shorter 'than  tho  tube,  which  thus  becomes  a  little  curled  or  bent  upon 
itself.  There  is  often  a  small  lynii)h-gland  just  at  tho  root  of  its  mesentery. 
Tho  position  of  tho  appendix  "is  very  varialilo.  Tlie  most  common  direc- 
tion it  assumes  is  upward  and  inward,  tho  tip  pointing  toward  tho  spleen. 
The  position  next  in  frociuency  is  behind  tho  cwcum,  and  next  ])assing  over 
the  pelvic  l)rim.  It  may  bo  mot  with,  however,  in  almost  every  region  of 
the  abdomen,  and  adherent  to  almost  every  organ  in  it.  T  have  seen  it  in 
close  contact  with  the  bladder,  adherent  to  one  ovary  and  the  broad  liga- 
ment; in  the  central  portion  of  tho  abdomen  close  to  the  navel;  in  contact 
with  the  gall-l)ladder,  i)assing  out  at  right  angles  and  adherent  to  the  sig- 
moid flexure  to  tho  left  of  the  middle  lino  of  the  abdomen;  and  in  one  case 
it  entered  with  tho  cax'um  the  inguinal  canal,  curved  upon  itself,  I'e-entoied 
the  abdomen,  and  was  adherent  to  the  wall  of  an  abscess  cavity  just  to  the 
right  of  the  proinontorv  of  tho  sacrum.  The  structure  of  tho  appendix  is 
almost  identical  with  tliat  of  the  cwcum;  it  is  particularly  rich  in  lytnphoid 
tissue.  Tho  blood  supply  is  derived  from  a  small  artery  whii'h  passes 
along  tlie  fn^e  ediie  of  its  mosonterv. 

Morbid  Anatomy  and  Etiology.— The  following  are  the  most 
common  morliid  conditions: 

(a)  Fsecal  Concretions,— The  lumen  of  the  appendix  may  contain  a 
mould  of  fa>cos,  which  can  readily  bo  s(picezed  out.  F'vcn  while  soft  tlie 
contents  of  tho  tube  may  be  mmdded  in  two  or  three  sections  with  rounded 
ends.  Concretions— onterolitlis,  coiiroliths- are  also  common.  The  mode 
of  formation  is  not  verv  clear.     Tossibly,  as  with  gall-stones,  tlie  micro- 


j; 
J 


520  DISEASES  OF  THE  DIGESTIVE  SYSTEM. 

organisms  niay  luno  a  favoring,  iniluonco.  Th.y  ^v...•o  pvoM.nl  ^^^^J^^^^ 
i  r.l(.(.  nutup  ios  (Kil.l..rt),  and  in  IVJ  of  -15-J  autop.R..  .n  lu.ntjpl  1  = 
colletoa  1,/K.nvcM-s.  The  enteroliths  often  resen>l.le  "i  .hape  d  e- 
o  es.  'Vi  iMM...rtanee  of  these  eoneretion.  >.  shown  hy  the  gre  t  i  e- 
,j,K,ney  Nvith  which  they  are  found  in  all  aente  mthunnuUu.ns  of  the  ap- 

^""(/I)  Foreign  bodies  are  hy  no  n.eans  so  frequently  met  with-only  Vi 
per  nt  in  i:.->  eases  of  appenclieitis  eoUeeted  by  Fitz.  Only  two  u.stanee. 
r:n.e  Inni^r  n.y  ohsenation  in  ten  years'  patholc>,ieal  work  in  Montreal;  m 
one  there  were  eij,d.t  snipe-shot  and  in  another  hve  api-le-pUs  iht  stmc^ 
'  d  .ee.1s  of  various  fruits,  bits  of  bone,  and  p.ns  have  been  lound.  It  i» 
"uto  bear  in  nund  that  son.e  of  the  coneretions  bear  a  very  strdang  re- 
semblance  to  cherry  and  date  stones.  mi.,,,!    tlw  ,,oTi- 

{r)  Obliterative  Appendicitis.-The  entn-e  tube  is  tuekened,  the 
ton  a    surface  snuH.th  or  injected,  an-l  either  w,th  adhesions  ironi  sh^l  t 
ei    u  uscribed  peritonitis,  or  perfectly  free.     The  mucosa  may  show  noti- 
ng    ore  than  a  she.ldin-^  of  epithelium  with  iniiltrat.on  oi  leucocytes  m 
Z  Xu  osa,  while  in  more  Jhronie  .ases  there  is  ahnost  con.p lete  den- 
u^.ti  n    f  the   nucosa,  which  is  repk.ea  by  granulation  t.ssue.     The  nu.^ 
coats  are  thickened  throughout,  and  the  entire  tubes  i,rm  and  st.tt, 
as  i"  in  a  state  of  erection.     When  laid  open  longitudinally  n  at  once  as- 
sume- a  rolled  form  in  the  reverse  direction.  _ 
"•"!:,,;;  ,,„„  ,,u„.rI.aK  which  has  been  applied  to  this  con.l.tion.  is  scarce  y 
appropriate,  since  the  changes  are  dilVuse  throughout  the  who  e  t^u^..     Ii 
the  naiority  of  instances  the  term  appauhcih.  ohhterans     ^..d  b>  bcnn 
^n      alitv  more  appropriate.  -As  Hawkins  remarks,  this  eonddion  is 
rodlv  a  fertile  soiree  of  local  peritonitis,  and  one  may  see  ,n  this  stage 
r    lb  <  ons  on  the  peritoneal  surface  or  more  extensive  circumscribed 
er  to               t  may,  however,  be,  as  he  says,  the  precursor  of  complete  im- 

source  oi  (  isease  tlien  ceases  lo  l.\i.  i.     -m  ^  >  ,,       .,  i      i         i  „  ,,i' 

m  en      n,  ot  take  place  on  account  of  the  rigid  incoUaps.ble  diaracter  o 
\  .1  1       i^  this  condition  of  chronic  appendicitis  winch  may  lead 

lo  r:c:ul^n;;s  of  attacks  of  colic  and  local  symptoms  in  the  right  ihae 

^"''McBurney  lavs  great  stress  upon  the  narrowing  of  the  lumen  as  pre- 
venting  norn'al  drainage  of  the  tube  and  establishing  conditions  favorable 

^^•^:!;:iit:nU;r:;;!e;2'Srin::?:^th  m  about  .  per  cent  of  an  sub- 
ject^ ^^Ih-tricture  occurs  at  the  c.cal  end  of  the  tr^je  Uie  lumen 
nay  become  greatlv  dilated,  forming  a  cystic  appendix  winch  ^^J^ 
Z  «i/e  of  the  thumb,  or  even  that  of  an  ordinary  sausage        Ihc  en- 
:;:      t t    it    re  either  clear  fluid  or  pus.     Ulceration  and  perforatmn 
n  e  vcU  ant  to  occur.     Obliterative  a,)pendicitis  may  go  on  as  an  on  inaiy 
nv.d  t^on  p    eess  without  causing  any  symptoms,  Irut  in  many  .nstanc 
e  a  tacks  of  pain-appendicular  colic;  in  others,  exacerbations  of 


APPENDICITIS. 


521 


in  38  cases 
H'l'ityphlitis 
ihape  dato- 
i  great  I'ro- 
,  ol'  the  ap- 

h — only  I'v 
Yo  instances 
lontmil;  in 

The  stones 
omul.     It  is 

striking  re- 

■d.  tlie  ])eri- 
i'roni  slight 
'  show  noth- 
leucocytes  in 
jnipiete  den- 
'.  Tlie  nms- 
rni  and  still", 
t  at  once  as- 

)n.  is  scarcely 
Ilk'  tiil)e.     In 
sed  l>y  Senn, 
condition  is 
in  this  stage 
circumscribed 
comitlete  ini- 
!  surrounding 
,ct,  and  if  the 
a])i)endix  as  a 
M-ation  of  the 
e  character  of 
lich  may  lead 
he  riglit  iliac 

hnnen  as  pre- 
ions  favorable 

nt  of  all  sub- 
Ill  )e  the  lumen 
ich  may  reach 
ic.  The  con- 
nd  perforation 
as  an  ordinary 
nany  instances 
<acerbations  of 


fever  with  pain  and  swelling;  while  in  others  again  ulceration  nn.l  j.erfora- 

tiou  may  tal<e  place.  ...  i      ■     .     , 

(r/)  Ulcerative  Appendicitis.-Local   nUeratmn   m  tlie  appendix   is  met 

witii  as  a  result  of  tlie  i-resence  of  cncretions  or  ot  foreign  l-odu's.  or  as 
the  result  of  the  action  of  certain  micro-orgauisiiis,  cither  those  imrmally 
inhabiting  the  ca'cum  or,  under  certain  circumstances,  the  tyi-hoid  ami 
tubercle  bacilli.  I'a'cal  concretions  and  foreign  bodies  are  met  with  lu  tUe 
apnendi.v  without  anuarently  causing  the  slightest  ain'asi.m  ol  its  mucosa. 
In  other  cases  the  enterolith  has  caused  atrophy  of  tiie  nnicous  membrane 
^vith  which  it  is  in  e.mtact.  In  other  cases  again,  the  concretion  ..r  l..re,gn 
body  may  be  po<leted  in  an  ulcer  at  the  ti].  of  the  appendix,  tn.m  wliu-ii 
it  may  be  shelled  out.  Tiiese  conditions  may  be  present  wniu.ut  adiie- 
sions  and  without  reddening  of  tiie  serous  surface,  but  one  not  mlrequently 
«.cs  thickening  of  the  peritomeum  with  adhesions  I.,  the  adjacent  parts  in 
ulcerative  ai)pendicitis. 

Tuberculosis  of  the  appendix  is  by  no  means  uncommon.  I  Iceiation 
in  tyi.hoid  fever  is  also  frequently  met  with;  in  a  series  ol  S(»  autopsies 
there  were  3  instances  of  i.erforati.>n  of  the  aiM-endix  by  a  typhoid  ulcer. 
An  actinomycotic  ulcer  has  also  been  described.  ,  ,    ^.       .  ,. 

(e)  Necrosis  and  Sloughing  of  tlie  Appendix-Acute  Infective  Appendi- 
citis—Following upon  the  conditions  described  under  (c)  and  {d).  necrosis 
and  sh.u.diing  may  take  place  either  in  a  limited  portion  of  the  appendix 
with  perf(n'ati(m,  or  en  vku^sc  without  perforation,  m  both  cases  leading  to 
the  most  intense  peritonitis,  localized  or  general.  .Alost  commonly  the  gan- 
grene is  localized  to  (me  spot,  either  at  the  tip  or  in  some  porli.m  of  the 
tube  Usually  tlie  organ  is  swollen;  the  color  may  be  reddish  brown,  black, 
or  greenish  yellow.  Necrosis  may  occur  en  masse,  and  the  entire  appendix 
may  indeed 'slough  olf  from  the  ca'cum  and  lie  free  in  an  aliseess  cavity. 
In  one  remarkable  case  operated  ui-on  by  my  colleague,  Halsted,  the  appen- 
dix between  4  and  5  inches  in  length,  was  shrunken,  lilackisli  brown  in 
color,  s])hacelated  throughout,  and  looked  like  a  desiccated  earthworm. 

These  active  processes  leading  to  ulceration  and  necrosis  are  due  to  the 
action  of  micro-organisms,  and  much  work  has  l)een  done  to  determine 
their  character.  Ilodcni)yl  showed  that  the  l)aeillus  coli  cummunis  was 
])resent  in  a  verv  large  number  of  cases  of  ai)pcndieitis.  Tn  (il  cases  of 
i)eritoncal  inflanlmation  conseiiuent  upon  disease  of  the  appendix  tlie  ba- 
cillus coli  communis  was  found  in  57,  and  in  50  of  these  it  was  the  only 
or.^uiism  iiresent.  The  streptococcus  ])yogenes  and  the  staphylococcus 
pvo-rcnes  aureus,  the  ])roteus  and  bacillus  ])yocyaneus  have  also  l)cen  found, 
fhe'^streptococcus  infection  is  the  most  virulent.  Probably  too  much  stress 
has  been  laid  upon  the  bacillus  coli  communis  as  a  cause  of  infective  pro- 
cesses in  and  about  the  appendix.  In  many  cases,  with  slight  fresh  adhe- 
sion and  a  little  sero-fibriu,  the  cultures  are  negative.  As  \\elch  remarks, 
"There  is  reason  to  believe  that  the  highly  resistant  colon  bacillus  may 
survive  in  an  inflamed  ]iart  after  the  primary  organism  whieii  started  the 
trouble  has  died  out.  or  has  been  crowded  out  by  the  invader.  1  he  prone- 
ness  of  the  appendix  to  infective  inflammation  of  this  sort  lies  "  in  that 
subtle  structure  which  determines  the  degree  of  resistance  of  a  tissue  to  dis- 


J 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


522 
!L1  !,°,,t„;r,s,  tlu,n  from  «lcnAm  ..1  iu».mn„a.,o„  In.m  »  lo„,l  l,ou-.,l- 

''"tlirLlltorPeritoBiti.  with  Absces.,-Iv.lo...i..n  1« 

''■">™tn.^i".;i;™;r;;:;:ut,;'::r'ii;r:;;;:;i::':^?i;r^;^i;<":" 

varies  m  «tii.itKm  »""  '       I       ,  j  ,,„„„,„„  ,it„alirai  is  on  llic  jKoaa 

miisclc,  just  , It    IK  ."V"  I  ,  J  ,„  „,p  ,„.„raontory 

'f;  r'':;"'™ '„ 'r:^  ™  -to. ..'.an .,»-ci ■'„ .i.c ,„.i.i,i>ori,™,a 

„t  llie  su'iiim,  or  lit  uluncl  „      ,|     |         fircuni^onljed  intra- 

"< "-  "","""""'■,  i;\r;:r;,  c  t  ,0  -^^^^     "-  -'">  -^ «"' 

'''■:'";:■  ntr.  ^        »   »n,  „clho«ve'l,crito„rtis,  an,!  tl,o  |,ro<l„c- 

ti,„  of  .  localixoa  abscess  nmy  l'"^^^  ;,^^^, .;;,^,, suited  from'acci- 
tou.,  an.l  tl,e  cond.t.on  n.ay    -/<:  -  .^^^'^  t1      e     tonts  of  the  abscess 

.vHv  Pvoi,  ^vhen  larcro  is  iiitra-poritoucal,  there  may  be— 
""".  "*^  •;  '"o"'  I^  tlK.VS-s       o'at  n„°vo  ,10  „ot  »  oft,.,,  soc  the  «- 


APPENniClTIS. 


5215 


o;  tlip  more 
iniuuu'r,  oi\o 
>  art'  (lealiii!; 
to  hif^t,  anil 
)lhL'r  way  uf 

oso-appcndix 
tliu  c.vcuui, 
•vsidU  anil  in- 
I'lling  of  tlio 
of  its  tissuL'S. 
omc  of  those 
irani'li. 

Peritonitis.— 

(T  lead  at  onco 
in  vinilonce, 
orst  cases  arc 
ral  peritonitis 
e  otlior  forms. 
•  .sloiijlhing  of 
local  i)ori-ap- 

(Is   usually   to 

cavity,  wliicli 
in  size  from  a 
is  on  the  psoas 
1.  The  perfo- 
he  promontory 
!  uciglihorhootl 
nscril)C'd  intra- 

uavol  and  the 
nd  the  produc- 
,'  serious  symii- 
Ited  from  acei- 

of  the  abscess 
fivcal  odor;  but 

color,  and  hor- 
icalized  abscess; 
ry  exudaic  that 
nces  the  abscess 

appendix  perfo- 
•itonanim;  if  on 
m,  the  adhesion 
;  into  the  retro- 
uften  see  the  ex- 
The  pus  may 
iment,  in  which 


Mtnation  external  perforation  may  occur  and  recovery  take  place,  [lie 
■„i,<  may  be  chiellv  in  the  retro-peritoneal  tissue  in  the  Hank.  t"n>""i,"V 
.„.;,  pcrincphritic"ahs..c>s.  In  a  case  under  the  care  of  (lardner.  i.l  Mont- 
,,al,  an  enorn.ons  ahsee.s  cavity  developed  in  this  situat.on,  winch  con- 
fiined  air,  pushed  up  the  diaphrafrm  nearly  to  the  second  rd.,  and  produced 
,1,0  svmi.ton.s  of  pneuuH.lhorax.  Perforation  of  the  pleura  n.ay  occur  in 
,he<c"  cases,  forniinj:  a  fa'cal  pleural  listiila.  The  pus  may  extend  a loi^ 
tiio  ixoas  muscle  and  mav  perforate  the  liil.  joint,  or  pass  to  tlie  nei-hhor- 
lH,o.l  of  tlie  rectuin,  or  produce  multiple  abscesses  of  the  scrotum;  or,  pass- 
in.  ,i,n.u-h  the  obturator  foramen,  form  a  lai-e  oluteal  abscess  !';>  1^, 
i„U-a-  an,r extra-peritoneal  aiMuMidix  abscess  may  perlorate  into  the  b  adder 
or  into  the  bowel,  and  recovery  may  follow,  thou.di  there  is  f^reater  danger 
in   perforation   into   the   latter.     The  api-cndix   has   been   dis..hai-ed   per 

"""ReinoteEffects.-The  remote  elfects  of  perforative  appendicitis  are  in- 
teresting     iia^morrhaoe  mav  occur.     In  one  of  my  cases  the  appendix  was 
adlu'ient  to  the  i.n.montorv  of  the  sacrum,  and  the  abscess  cavity  had  per- 
forated in  two  places  into  the  ileum.      Death  resulted  from  proluse    uenior- 
rha^e      Cases  are  on  reconl  in  which  the  internal  iliac  arti'ry  or  the  deep 
cir(^imllex  iliac  arterv  has  luru  oi-cmd.     Suppurative   pylephlebitis   may 
result  from  inllammation  of  the  mesenteric  veins  near  the  pcriorateil  ap- 
pendix     Two  instances  of  it  have  come  under  my   notice;  in   one  tliere 
was  a  small  locali/.ed  abscess  which  had  resulted  from  the  perforation  o    a 
tynlioid  ulcer  of  the  ai.pendix.     In  the  other  case,  which   I  saw  with  -Ma- 
chell   of  Toronto,  the  svmptoms  were  those  of  septicumua  and  oi  suppura- 
tion of  the  liver.     The  abscess  of  the  ai.pendix  was  small  and  had  not  pro- 
duced symptoms.     In  the  healinix  of  extensive  inllammation  about  the  mar- 
.nn  of  the  pelvis  the  iliac  veins  may  be  -rcatly  compressed,  and  one  of  iny 
patients  had  b.r  months  (edema  of  the  ri-lit  leg,  whieli  is  now  permanently 

enlarged.  ,  .     ,  ^  ^^  ■ 

The  appendix  may  ].erforate  in  a  hernial  sac.  Several  instances  ol  this 
have  been  recorded.  In  a  case  which  came  under  my  care  at  the  I  lu- 
vn'sity  Hospital,  IMiiladelphia,  there  was  a  hernia  of  the  ca'cum  in  tlie 
in>nnnal  canal.  The  proximal  orifice  of  the  appendix  was  at  the  extreme 
en?l  of  the  hernia  in  the  inguinal  canal.  The  tube  then  curved  upon  itself 
pa^-^od  into  the  alulomen,  and  the  terminal  three  fourths  of  an  inch  hai 
sloughed  in  a  small  circumscribed  sac  situated  close  to  the  promontory  of 

the  sacrum.  .        •,    ,       •  n       *■ 

The  following  additional  facts  may  be  mentioned,  bearing  on  tiie  eti- 
ology: .  T  ,       ,-•;    . 

Age.— Apjicndicitis  is  a  disease  of  young  persons.  According  to  Mtz^ 
«tati*tics,  more  than  50  per  cent  of  the  cases  occur  before  the  twentieth 
year-  according  to  Einhorn's,  GO  per  cent  between  the  sixteenth  and  thir- 
tieth years.  It  has  been  met  with  as  early  as  the  seventh  week,  but  it  is 
rarely  seen  prior  to  the  third  year. 

Sex— It  is  much  more  common  in  males  than  in  b'niales,  80  per  cent 
of  the  former  in  the  table  of  Fitz.  In  Hawkins'  series.  V\l  were  males 
and  03  females.     Contrary  to  the  general  experience,  the  :Munich  figures 


J 


dn* 


tl 


I)ISE\SES  OF  THE  DIGESTIVE  SYSTEM, 
^.ivon   l.y    Kinhorn    in.li.at.   a    ivlativoly   gm.tor   nu.nl.er   ..f   womon    at- 

,v..,?  r^'  r;nno  i.nnu.  tu  .h.  disoaso.     Traun.a  plays  a  vory  .U.h.n  o  ,W. 
:;;f!n  a  mun!:;.  on.a..s  tl.o  sy,n,.t.....  hav.  follow..!  vovy  clos.ly  a  fall  o, 

"  '''r'li  .n.tioMs  in  .THt  aiv  v..rv  pn.no  to  l-rin-  on  an  attack,  parti.-.larly 
in  t      '  :      nn^  J-':  '^^  the  .li.i.  in  whi.l.  j.in  in  t,.o  a,.,.n,Ux  ,....n 
"t  iMfmiurntlv  follows  tho  oating  of  in.liji.sfl.K.  arfolos  ot  to.-l  h.    c 

lloJn  h!M'n'-.i:  too,  with  the  nnn>her  of  cases  .n  hoys  .n  whu.h  there  ha. 
K.wiii  .1  lii^toi'v  of  cors'inir  with  i)eannts.  . 

ivmBtims  -In  a  lar.e  proportion  of  all  cases  of  a.ute  appon.liot.s 
,,H.S  °^'npt'  -  -.e^resen't:  (1)  Sn.l.lon  pain  in  the  alnlomon,  nsn- 
V      t  r     1  to  the  riKht  iliac  fossa;  C^)  fever,  often  oin.o.h.ra  e  ^vad. 
-^     M  Itestinal  .li^turhance-nansea,  vomitin..  and  frequent  y  const. 
f "...  (4^  t.Mi<lerne<s  or  imin  on  prcssnro  in  the  appendix  re{,non. 
^"' Sud  l^J;^  P  ";  ^y,;  tL.  m  ^young  person,  particularly  foll.ns.n,  an 
indiscretion  in  diet  o?  an  injnry  or  strain,  in  the  absence  ol  s.gns  ot  hen  a, 
a  0  tl"    xistence  of  appendicitis;  they  do  not  suggest  .n  any  way  t  e 
r..    the  lesion,  whether  olditerative,  nlcerative,  or  an  acute  necrotic 
;pl;;mllcitL.     ^\e  n>ay  tirst  consider  n.ore  fully  these  general  syn-pton^s  ot 

""S-A  sudden,  violent  pain  in  the  ahdon^en  is,  according  to  Fit. 
.,  ;  ..,vHnt    first    decided  svnn.t..n,  of  perforating  intlannnat.on  ot 

'"'l.t^V^^^\yml<^<^  within  Ihirty-six  or  forty-oight  honrs      It. 

and  colic-likc,  ana  case,    nut  intense  pain— serons-mem- 

colic.     S.mie  patients  speak  of  it  as  a  slia  p,  nucn.c 

,  .;^.  Mhors  IS  a  dull  ache— connective-tissue  pam.     \Miiie  a  Aer\ 

li"a"  i^;  of  the  circnlar  and  longitudinal  nuiscles  in  the  expulsion  of  the 
"'"Fever  -  \  ri^e  in  the  temperature  follows  rapidly  upon  the  pain,  and  is 


APPRNPiriTIS. 


525 


women    at- 

ig  of  heavy 
(lelinite  rolr, 
sely  a  iall  or 

,  iiartio'ilarly 
H'lidix  legioii 
'oo.l.  1  liavo 
icli  there  \u\i 

'  appendicitis 
iMlonion,  usu- 
iderate  f^rade; 
neatly  eonsti- 
eginn. 

,'  i'ollowinji  an 
i;ns  of  hernia, 
1  any  way  tlio 
acute  iieerotic 
1  symptoms  of 

rding  to  Fitz, 
itlanimation  of 
ilyzed  by  him. 
liac  fossa,  but 
I  of  tlio  ahdo- 
1  the  a])pendix 
ght  hours.     It. 
mes  very  sharp 
;  or  for  biliary 
1 — porous-mem- 
While  a  very 
lost  misleading, 
egion  Talamon 
I  to  he  due  to 
•egnlar  peristal- 
>x])ulsion  of  the 

the  pain,  and  is 
age  of  appendi- 
moderate,  from 
lie  thermometer 
the  most  trust- 
ipendicidar  colic 
lized  abscess  has 
;tis,  the  tempera- 
iptoms  which  in- 


dicate the  gravity  of  the  situation.     The  jndse  is  (piickened  in  proi.orti^m 

to  the  fever. 

Gastro-intestinal  Disturbance.- -The  tongue  is  usually  lurred  an<l  moist, 
seldom  dry.  .Nausea  and  vomiting  arc  symptoms  which  may  be  aiisent, 
l,ut  which'are  comnmnly  present  in  the  acute  perforative  cases.  The  vom- 
ilin''  rarely  persists  bevond  the  second  day  in  favorable  cases.  ('onstii>a- 
tioiris  til.'  rule,  but  the  attack  may  set  in  with  diarrlufa.  particularly  m 

children. 

Local  Signs.— Inspection  of  the  abdomen  is  at  first  negative;  there  is  no 
distention,  and  the  iliac  fossa-  l<.<.k  alike.  On  pali-ation  there  are  usually 
from  the  outset  two  inipoitant  signs— namely,  great  tension  oi  the  right 
rectus  muscle,  and  tenderness  or  actual  imin  on  deep  pressure.  The  mus- 
cular ri-ndity  may  be  so  great  that  a  satisfactory  examination  cannot  be 
made  whliout  an  ana-sthetic.  :MeIiurney  has  called  attenti.m  to  the  value 
of  a  localized  point  of  tenderness  on  deep  pressure,  which  is  situated  at  tlie 
intersection  of  a  line  drawn  from  the  navel  to  the  anterior  superior  spim> 
of  the  ilium,  with  a  second,  vertically  placed,  corresi)onding  to  the  outer 
edge  of  the  right  rectus  muscle.  Firm,  deep,  continuous  pressure  with 
one  finger  at  this  spot  causes  pain,  often  of  the  most  extpiisite  character. 
In  addition  to  the  tenderness,  rigidity,  and  actual  pain  on  deep  pressure, 
there  is  to  be  felt,  in  a  majority  of  the  cases,  an  induration  or  swelling. 
In  some  cases  this  is  a  boggv,  ill-defined  mass  in  the  situation  of  the 
ca<cum:  more  commonly  the  .swelling  is  circumscribed  and  delinite.  situated 
in  the  iliac  fossa,  two  or  three  fingers'  breadth  above  Pouparfs  ligament. 
Some  have  been  able  to  feel  and  roll  beneath  the  fingers  the  thickened  ap- 
pendix. The  later  the  case  comes  under  observation  the  greater  the  ])roba- 
bility  of  tlie  existence  of  a  well-marked  tumor  mass.  It  is  not  to  be  for- 
gotten that  there  may  be  neither  tumor  mass  nor  imluration  to  be  felt  in 
some  of  the  most  intensely  virulent  cases  of  perforative  appendicitis. 

In  addition  nuiy  he  mentioned  great  irritability  of  the  bladder,  which 
I  have  known  to  li-ad  to  the  diagnosis  of  cystitis.  It  may  Ijc  a  very  early 
cvmiitom.  The  urine  is  scanty  and  often  ccmtains  albumin  and  indican. 
Peptonuria  is  of  no  moment.  The  attitude  is  somewhat  suggestive,  the 
decubitis  is  dorsal,  and  the  riglit  leg  is  semi-flexed.  Kxamination  per 
reclum  in  the  early  stages  rarely  gives  any  information  of  value,  unless  the 
a]i])endix  lies  well" over  the  brim  of  the  pelvis,  or  unless  there  is  a  large  ab- 
scess cavity.  .  -■       4.1 

There 'are  three  possibilities  in  any  case  of  aitpendicitis  presenting  tlie 
above  symptoms:  (1)  (Jradual  recovery,  (2)  the  formation  of  a  local  abscess, 
and  (3)  the  development  of  a  general  peritonitis. 

•  Recovery  is  the  rule.  Out  of  li'A  cases  at  St.  Thomas's  irosiutal  witii 
the  above-mentioned  clinical  characters,  100  recovered.  In  one  instance 
the  appendix  was  removed,  and  in  two,  attempts  were  made  to  remove  it 
(Hawkins).  There  are  surgeons  who  claim  that  the  getting  well  in  these 
eases  does  not  mean  much;  that  the  patients  have  recurrences  and  are  con- 
stantly liable  to  the  graver  accidents  of  the  disease.  This,  I  feel  sure,  is 
an  unduly  dark  picture. 

In  a  case  which  is  proceeding  to  recovery  the  pain  lessens  at  the  end  ot 


J 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


520 

„K.  .i,;,-.i  n,.  ,w,rth  .i,,v.  ,!..■  '■■ ■';..""■  '»'';'-,":,;;:;;i;;!;i  ':;:,r;i:;lr:;; 

;:?tt:;::;,,::;;:r:;rr:::;;:;;::i-'™- -- -'- 

:;!:;;  :-:;;;;:!:l:^l"ors^  j;;:^.  r.  a.,,. ,.- ..■. 

Local  Abscess  Formation.- As  a  rc.ul    <  "      the  diiVuse  ap- 

.,„u.tinu.s  following  tlu.  -^'^f ' /'"'^^  J"  ;  .^  'Xvo  l-sc.riluMl;  but  at 
,a.n.1ic-itis,  the  patient  has  1^«/™VV  . ''  ^n  Wt  ^ L  on>o  ao-.ravatod. 
„o  end  of  tlu.  llrst  week  tho  ^ ■'fT:.'^^^ ^J^^^^^^  ->'^  "^  ^'-^ 
Tho  course  ot  the  disease  n.ay  '^^y;^^^'^^^^^^^^-  -^  ^'-  ^'^^'^ 
fourth  or  iii'tli  day  there  ,s  an  ^'^^^or^C^^hly^  shown  that  even  at 
iliac  fossa,  uith  ^n-eat  tendc.rness,  and  '  1  "  '  .'"^^j^;;  ^  ,n,ou,d,  as  a  rule 
,IUs  very  early  date  an  abscess  --  y  ->^^  ^  ^^1  iurationrthis  is  not 
,.  fever  '----|;|:-;:;  t.:^,^  ,  "i  elcnienti' in  the  d.agnosis  of 
always  the  case.     1  he  two  "  '  .^  ^   ,     i,,^,.^!  tumor  and  the  aggra- 

abscess  formation  are  the  gradual  ina  ,       •    t^c  1  .^  ^^^  ^,  ,^_^^^^^^^^^ 

vation  of  the  general  syn.ptoms.    ^^^^  '^^  ^^^^^^^^^^  stages  of  develop- 

we  bave  opportunities  of  see.ng  t       ^^^^^^^^^^^  ,1^  tho  coils  of 

,„ont.     (^Hte  early  the  pus  ".>        ^  ,^     ;  '^j  ' ;  tn.rin,  or  there  is  a  sero- 

tbe  ileum,  uith  the  general  1'^^'^'^"'^  '"  f "  ^  ,twoen  the  bnver  coils  of  the 
nbrinous  exudate  with  a  sbght  amoni    us  ..oc  ^^^^^^^^^^  ^^^ 

•    ileunu     Tlie  abscess  -^-ty  n..y  bo  -m       ^^  J.^,,^^.,,  ,^     .i,,i,i, 

at  tho  edge  of  the  P^'"'^"^*"'^  f ,  ^\'„,  /"  'i  y  the  small  bowel  and  pro- 
size.     The  sac,  when  larger,  may  1     roof  ^^^y..y  ^.^^^^.^^^^_     i„ 

.ent  irregular  processes  a.u  V^J^r;^  ^^.^^  farmed  by  the  ab- 
larger  collections  m  the  .1  ac  ^^^^^^^'^^  ^^^  ^^^^  i,„,ii,ed  abscesses  are 
dominal  wall.     Some  o    ^1-  "J-         -^^^^^^  Tho  various  directions 

those  which  are  situaedeiUn^eh  ^^^lnnK  F  ^^^^.^^^^,  ,^^^^.^,  ^^^^,,^, 

and  positions  into  which  ^I'^f  ^^^'^  "^  >  ^^  j^  ,,^,,.  i,,.  ,„re  mentioned 
l,,,n\eferred  t<,  under  morbid  ana  omy,  ^^^^^^^  :^,H.urrow  in  various 
again  that,  loft  alone,  they  "^''^V  ^       ectum  '"  nna.  or  bladder.     Death 

^^:^z^;:f^^^:^  t^.:^^^^..... .. ...  or  by 

x;;::^t-?isrj;n^^^3 

Si^;::::rL;tlvrr:S^^^^      eases  a  locali.d  focus  of 


»i 


iiu's  cleaner, 
tl\o  howeU 
isi.led.  The 
liinci's  ^liglit 
^aU'secnce  i^* 
rom  the  size 
■li  leaves  the    _ 

t  lei'l'oratiou 
t)l'  ihe  peri- 
unis   exudate 
with  a  well- 
's (lus  I'nniia- 

1  ]ni  loration, 
le  (litVuse  ap- 
■rihed;  but  at 
le  a^-,iiravate(l. 
he  end  of  the 
I  in  the  right 
1  that  even  at 
[Righ  as  a  rule 
111.  (his  is  not 
e  diagnosis  of 
and  the  aggra- 
is  so  i"re<iuent, 
res  oi  develop- 
id  the  coils  of 
there  is  a  sero- 
wer  eoils  of  the 
soas  niuscie,  or 
>aeli  a  ])ali)al)lo 
liowel  and  pre- 
diveetions^     In 
med  by  the  ab- 
lmI  abscesses  are 
irious  directions 
te  have  already 
here  mentioned 
irrow  in  various 
bladder.     Death 
■y  or  vein,  or  by 

^rforation  of  the 
[!  any  delimiting 
?  has  been  an  at- 
the  general  peri- 
ocalized  focns  of 


Ari'KNDlclTIS.  5'27 

Mippuralinii  exi>ts  aix.ut  an  iullam-'d  ;.ppendi\,  and  rnuu  thi^  perfnratinii 

talu'S  plact'.  ... 

jtcath  ill  appendicitis  i-  due  usually  to  general  |ienl(iuitis. 

\Vi.  >ee  at  ciperaticu-  all  grades  of  tlu-  alVe.ticui.  In.m  the  mildest,  in 
uhic.h  th.'  MTous  Miriaee  is  injirted,  tinlud.  and  >tuky.  Imt  uitlinut  lymi-h 
Ml-  elVu-inu,  e.vcept  in  the  immediate  neiglil.urh.M.d  of  the  piTlurated  ap- 
,H.|,dix.  in  other  eases  there  is  a  lil.rin.uis  exudate  gluing  the  eods  lo- 
,,,.ther  and  a  varial.ie  aiuouui  of  turhid  serous  lluid.  In  other  in.-tanees, 
'^-  the  ah.lomeii  is  opened,  pus  wells  out.  and  there  is  a  dilfuse  purulent  m- 
ll;,Mnnation  of  the  i)eritonieum.  it  is  intere>ting.  houvver.  to  note  the  eom- 
|,;native  ra^il^•  of  lalal  peritonitis  from  appendix  di,<ea>e  m  general  uiedieal 
work,  in  l.Vi  consecutive  autopsies  on  jiaticnls  dead  in  my  wards  there 
wa<  not  a  sin-le  instance  of  general  peritonitis  from  appendix  disease.  On 
,he  ^in-ical  Hde  there  have  hceii  admitted  during  the  same  period  ID  cases 
,,r  .liiVuM.  peritonitis  from  this  cau-e.  Kigiit  were  operated  upon;  all  died. 
1„  !i  ea^e«  there  was  found  a  iierforated  and  more  or  h'ss  gangrenous  a])- 

l„.ndix.   with    little  or   no  attempt   at   localization;    in    1   case   ruptur 

an  alisccss  caused  the  ecneral  peritmiitis. 

Thr  'irnrlhl  »f  ,iri>rH.li.v  ,llsn,sr  lirs  in  llir  furl  Ihdt  (mm  Ihr  rrrii  nuhd 
Ihr  nrrllnHnum  ninii  hv  Infrrtnl:  llir  InilinI  siimploius  uf  pain,  inlh  ininsra 
,ni,l  rnnnlin>i,  frrrr,  nn,l  Innil  Irnilmirss.  pn'scnl  in  all  atsvs.  wan  ni^lmtlra 
,ri,ks,,vni,l  'infrrtinn  of  this  wcwhnnir.  The  onset  is  usually  sudden,  ihe 
unin  dilVuse.  n  .t  alwav^  localized  iu  the  right  iliac  fossa,  hut  it  is  nut  so 
inuch  the  character  as  the  greater  intensity  of  the  symptoms  Irom  th.'  (uit- 
>et  that  makes  (Uic  susi.icious  of  a  general  perit.mitis.  Aiidominal  diMen- 
tion.  (lilVuse  tendcriu'ss.  and  absence  (.f  abdominal  movements  are  the  most 
tru-tworthv  local  >igns.  hut  they  are  not  really  so  trustworthy  as  the  gen- 
eral svmptoms.  'riie  initial  nausea  and  vomiting  iiersist.  the  ].ulse  i)e- 
rumv<  more  rapid,  the  ton,irue  is  dry.  the  urine  scanty.  In  very  acute 
,a>es.  hv  the  cud  of  tweiitv-foiir  hours  the  ahdomeii  may  Ik'  distended.  15y 
ih,.  third  and  huirth  days  the  classical  picture  of  a  general  peritonitis  is 
well  estahlished— a  distended  and  motionless  abdomen,  a  rapid  pul.<e.  a  dry 
tongue,  dorsal  decuhitus  with  the  knees  drawn  up.  and  an  anxious,  pinched, 

llippocratic  facies.  ,•,•.! 

Fever  is  an  uncertain  clement.  It  is  usually  present  at  first.  I)ut  it  tiie 
|,hv<iciau  doe-  not  see  the  case  until  the  third  nv  fourth  day  he  should 
not  be  dc.rivi'd  bv  a  temperature  helow  l(H)..-,°.  The  pul<e  is  really  a 
Letter  iudicathm  than  the  temperature.  One  rarely  has  any  doubt  .m  tin- 
third  or  fourth  dav  whether  or  not  peritonitis  exists,  hut  it  must  bo  ac- 
kuowlcd-cd  that  tiiere  are  excepthms  which  trouble  the  judgment  not  a 
httie  While  on  the  one  hand,  witluuit  >uggestive  symptom.-^,  a  laiiarotomy 
has  disclosed  an  unexpected  general  peritonitis,  on  the  other,  with  severe 
constitutional  symptoms  and  apparently  characteristic  local  signs,  the  peri- 
toniX'um  has  lieen  buind  smooth. 

Relapsing  Appendicitis.- IVpiKM-.  in  IS.^r,.  called  attention  to  the  re- 
arkable  liability  to  rclai-se  in  perityphlitis.     The  patient  gets  well  and 


II 


1,11  trace  of  induration  and  tenderness  disappears:  then  in  three  or  four 
months,  or  earlier,  he  again  has  fever,  pain,  and  local  signs  of  trouble. 


^a^ 


ggg  DISKASKS  OF  Till'.   DKiKSTIVK  SYSTKM. 

Tl,.-  ntta.k.  M„.v  mm-  for  y.nrs.     Th.  ......  whi-1.  .v.nv.T  j^'tl'  the  P-r 

^     .,       ..!■  an  i.Hh.n,ti..n  -r  tun.-.r  nu..s  an-  nx-st  ,..•..„.•  to  n.lap.o.     1  .  • 

a,.  n.  ..vcv  n,s.s  i,.  wind.  th.  nU.Tvals  l.tw^M  ,1.-  at.ark.  an     .  > 

,.        n,l  .1...  ,.a.i.....  l..-nu.s  a  .Umu.^  ...val.-l.     Alt..'  iviu.atM  a.  mV 

""'\      \       Vl./  ..l-.n-  i    at   I  I  \>vv  .rnt.  Hawkins  at  ■-':•..«;  |...'  .rut.      Uw 

t  '  Lw  ~nn  nu>st   1..  tl.is  ty,..  ot  th.  .1,.....,        nil  has  .olLvM 
•>     p,.ratiuns  in  .l-.'oni..  .vla,.si,„'  a,.,-n.lint>s  l.y  n,'hty  m,.,...,,.,    .  .1 
aUtality  oiM>  p.- ..nl  J.ut  iuMlunks  ,lKU  :>  o,.  .;  ,..•  .H.t  wouM 

''m^t:;lniln.n.lhH.,,  intln.  l...aisn,lH.,-as^ 

„.„,      tis  will,  o,.  witl.unt  a,liu.sions.  ..,■  an  adiu.n.nt.  ,..ri,a,.s  ,u..ln    t.. 

^'''Diaen08i8.-A!.i-n.licitis  is  l.y  fa.'  the  n.ust  ......n.nn  inllan.n.ato.y 

,„.,suns  un.l..-  thi..tv.     Th.'  su.-vnns  hav.  ta,.-ht  .  >  that,  ''»•'■'; 
x...,.ti..n,  sn.l.h...  pain  i.,  th.  ...ht  ilia,  h.ssa,  -^'^  '--'V-'!,  j       ':^;^^      !  ] 
,1,,,.„U    with  or  without  tu.n..f.  m.ans  a|.i.rn.lix  .lis...>c       Hum.    a..   ... 
H u     U;^    '.!•  tlH'  al,.lo„,inal  ...•,a..s  ..ha-a.!......-!  l,y  ,.a>..  wlu..h  a,v  a  .. 

";:'c:.;;.-..un.i..,i  with  a,.,..n.iioitis  i;iiia.-y  ...li..,  i-;;-y,,;;^- -t; 

cliekv  pains  at  th..  .uenstmal  p.rio.l  -n  won,....  hav.  ...  ^'•••> '    '      /    ,    , 
°"'T,;;,pi:.U-s  cvi..s  m  ll..a.m,  ki.l,u,v  lK,v.  l.o..n  ,ni.,.,k..„  f.r  a|,,..n,li- 

r^ni"  ™::r  ;;':s  a^r:;;™ ..,..  .,i.o.y  i.  oo,.. ,..  ,„i.ako, 

,h„:e  rf  aiii'cmlioitis  ,v'.l,  gcc-d  ,.ovito„iti..    Ty,.1>o,a  i.vcr  .,as  loon 


t„ 


Al'I'KN'DH  ITrs. 


.■|'J!> 


witli  tliL'  [iir- 
clapsf.  Tlifiv 
itiU'krf  nro  vi  r_v 

|K'llt('(l   lltt!lrk«. 
ciHc  is  (lillifuli 

|IC1'  <'t'llt.       Tlir 

11.1  iitlicrs  iiiili- 

II   Ims  collivt.'.l 

>m\<:fi'iis.  wltli 

•(•111  wiiuld  1)1'  a 

ulilitl'lMtivC    ilp- 

liai>s  iicri'tivatnl 
y    dense   lilimid 

m  iiilliiiiunntDvy 
u'li  jit'iu'ially  ill 

almost  \villi"iit 
nd  localizt'd  ti'ii- 

TluTc  art'  (•<'i'- 
ti  which  aiv  apt 
y  colic,  and  the 
sDinc  cases  to  lie 
;•(■  (d'  either  renal 
ut  a  jiatient  was 
i'{  of  severe  pain 
anil  with  an  ill- 
k',  she  was  trans- 
condition  iiroved 
lost  on  tiie  point 
■red. 

iilate  appendicitis 
nder  ether  should 
isis.  I  have  seen 
iroved  to  he  tuho- 

iken  I'or  appendi- 

prosont  very  sim- 
later  stajzes,  when 
res  may  he  almost 
tion.  is  never  seen 
and  liloody  stools 
ditFicnlt  to  decide 
elear,  but  mistakes 

ymiitoms  very  like 
)id  i'evcr  has  Ijoon 


IMI 


... ..-taken  for  appemlieitis.  I  ua>  told  of  a  ca-e  recently  in  one  of  the  Iar;;e 
|lo>pitals  of  this  country  in  uiiich  the  fe\er.  the  prcMiiee  of  a  tender  indu- 
ration in  the  ri;:iit  iliiie  fo>sa.  seemeil  to  indicate  -o  dearly  appeiniiN  dis- 
ease that  an  operation  was  performed.  Imt  the  induration  wa<  ioiind  to  \<v 
tiie  swidleii  ileum  and  adjacent  filaiids.  In  a  pei>oii  who  had  had  previous 
appendicitis  tiie  dia-rnosis  mi^rlit  l>e  e.\tivniely  dilheiilt.  as  in  a  ca>e  m.'ii- 
tioned  liy  l>a  Costa.  Late  in  the  c(mvale.«ceiiee  of  typhoid  fever  syinptonis 
,,r  appendicitis  may  develoi..  due  to  the  perforation  of  an  unhealed  iih  er. 

There  is  a  well-mark. 'd  a|>pi'iidicuiar  hypo.hon.lriasis.  'I'hr..u-h  tin- 
pernicious  inllueiice  .d'  the  daily  press,  appcmlicitis  has  l..vom.'  a  Mirt  ..f 
fa.l.  iind  the  phvsician  has  (dt.-ii  to  deal  with  pati.'nt>  who  hav.'  a  s..rt 
,,f  lix.'.l  idea  that  they  hav.'  the  disease.  The  worst  eases  of  this  class 
whi.h  I  have  seen  have  heeii  in  memhers  <>\'  our  profession,  and  I  know  .d' 
at  least  one  instance  in  which  a  perfectly  normal  appendix  was  reniov.'.l. 
The  .piestion  reallv  has  its  lu.licrous  side.  A  well-known  physician  in  a 
Western  city  having'  on.>  ni^rht  a  hellyache.  and  f.'elin,ir  convineecl  that  his 
appendix  had  perforated,  sumnioui'd  a  surgeon,  who  (luickly  reim.ved  the 

tiupposed  oiVender! 

Jlysteria  may  of  course  simulate  appendicitis  very  clo>ely,  and  it  may 
reiiuire  a  verv  keen  jndjjment  to  make  a  diagnosis. 

Mucous  colitis  with  enteralgia  in  nervous  women  is  s.)m. ■times  mis- 
taken f.n-  anpendicitis.  In  two  instances  of  the  kind  I  have  pivveiit.'d 
propose.l  operation,  and  I  have  heard  nt  cases  in  which  the  appendix  has 

heeii  removed. 

I'.Tin.'phritic  and  i-ericivcal  ahsccss  from  perforation  of  ulcer,  either 
simide  or  cancerous,  ami  cireumscrilied  peritonitis  in  this  region  from  other 
caus.'s.  can  rarely  he  dill'ereiitiated  until  an  exjiloratory  incision  is  made. 

Chr.mic  ohliterative  api»endicitis  canimt  always  he  diil'erentiated  from 
the  perf.M'ative  ioriii,  and  in  intensity  of  i)ain.  severity  of  symi»toms.  and.  in 
rare  instances,  even  in  the  production  of  peritonitis,  the  two  may  be  iden- 


tic; 


al. 


Briefly  stated,  localized  jiain  in  the  right  iliac  fossa,  with  or  without 
induration  or  tumor,  tlie  existence  of  ^IdUirney's  tender  iMunt.  fever, 
furred  timgue.  vomiting,  with  constipation  or  diarrh.i'a.  indi.ale  appeii. Il- 
eitis. The  occurrence  of  general  peritonitis  is  sugg.'sted  hy  increas.'  and 
dilVusion  of  the  alidoininal  jiain.  tymimnites  (as  a  rule),  mark.'d  aggrava- 
tion of  the  c.mstitutional  sympt(mis.  particularly  tdevation  .d'  fever  and  in- 
creased rajiidity  (d'  the  ]n'ils.'.  Obliteration  of  hepati.'  diilness  is  rarely 
pres.'iit,  as  fh.'  peritona'um  in  these  cas.s  does  not  often  contain  gas. 

Prognosis. — While  we  cannot  overestimate  the  gravity  of  certain 
f.irnis  of  ajipendicitis.  it  is  well  to  recognize  that  a  large  proportion  of  all 
cases  recover.  It  is  the  clement  of  iinrn-lniiitii  in  individual  cases  which 
has  given  such  an  imp(>tiis  to  the  surgical  treatment  of  the  disease.  That 
an  inllamed  apjiendix  may  heal  perfectly,  even  after  p.^rforation.  is  shown 
by  instances  (jiost  mortem)  of  obliterated  tubc-s  liriidy  imbedded  in  old 
s.'ar  tissue.  Formerlv  we  had  n.it  a  full  knowl.Mlge  of  the  natural  history  of 
the  dis.>ase.  As  J.  AVilliam  White  remarked  in  an  addivss  at  th.>  Colleg.' 
of  rhvsicians,  riiiladelphia.  "  We  are  in  special  need  of  reliable  medical 


riiA 


r^ 


» 


DISEASES  (^E  THE  DIGESTIVE  SYSTEM. 


530 

'■^''■^ -'■•'I"  ■'' .'''\;:;;Hi  -t:  u  m  !l;.;  Tu'  -..■u  „  ,„  v.  .„■„- 

nisfs  at  St.  Tlunua.>  ile^l'Ual,  ."  ^j^^  stau.lpoini 

BU.ndea  particularly  to  sur^ons   s    c.^      ^^^^  ^^^  ^^.^^  ^^^  ^^^^  ^^,,.^.^,^, 

.,^.  „,.  physician  >u,a  l'"^'>';'"f'^^',  ;„  "  ;-,e  to  the  uork  of  American 
,.,.,..,s  ot  the  d.sea.0,  an.l  ^^^\;^^^\^^^,,^^,^,^  linuted  to  the  right 
•"'^'■■''^:>'-^-     ^'TS^;^.^I-an'     r    iJ   ron^^  ot   pu.    1.0   case.    n„ 

.piH.ndix  dmnug  the  attack    I'  •      '    /^!        ^^^^^i,,-,,  ,f  indindual  opera- 

,i,„  „,  „.„„„„i.i„,  ,vi,l,  certain  .,.,„»,.....     '.t^^    ,^ 
hoq.ital  ...rk.  .o  l.avc  H'O  "'■•I"-  "'I  '«;         '  l^  ;  ,,    ,_„:|,„|,„  hi,  1.,,,,- 

trollin;:  the  .■•."vsc  oi  tl„.  .hs.aM-.     'i'        >        '        ;    .,„,      .i-,,,,.,  „,.«  two 

""■'■"1 '"  "",".'•,"";  """!'"i~"!r .  -v  m    i  i:i.'.i.  "--IV,  ti.o  .-•  •»■ 

,,„i„„  „„  »li,ol,  tlH.  I"'"''''""  ,;;,',,  „[  „ivi„,,  ,.|,i,„„  in  »nno  Uma 
"'  "I''"""''"*  ;■;"'  r'r'hnrtl;;;  ;  r^  '    "".'nu,'  ,in.  ,aa,.,i...  a. 

-1 -t;;  ;!;x';:ri;:;;^-'s\;rUuLt  ,„ ...  ,c.i,tent  „. 

„f  i.o  h.cally  to  relieve  the  pain.        _  advocated  hy 

,ive  intlannnatmn   is  .et    '•;"';  \      ,^  ^^.^^^  throughout  its  extent  i< 


INTESTINAL  OBSTRUCTION. 


r)p.i 


1  in  iho  atlini- 
as  iUialyzod  ihr 

C    i:i   ti)    111-'    Cillll- 

the  stauilpiHiii 
to  the  suru'iinl 
•k  of  Ainoricaii 
:l'(1  to  llio  riglii 
1!J0   case^,   ii" 
iho   I'orinatinn 
(■)  gi'ueval  peri- 
tality  ol;  1 1  P'T 
ore  previous  at- 
vorcd;  o£  T  witli 
liod.'     Tho^^e  ivs- 
■tor:  Ui'inoval  "I' 
ision  and  drain- 
indi-idual  opera- 
;ay  that  in  acute 
appendicular  ali- 
:eons  is  now  very 

,•0  physicians  lose 
tliat  'l  prefer,  in 
ly  to  the  sureical 
whether  his  Iimh- 
l"  treatment — tliat 

here  are  remedies 
1  any  way  ot  con- 
diet,  measures  di- 
h     Tliere  are  two 
lamely,  the  use  o< 
inm  iu  some  form 
^ihy^icians.     Sar- 
in tiie  practic  '.  as 
e  sense  ol'  seciu'ity. 
— deferrin.ii:  in  thi- 
^  tlio  persistent  use 

eh  is  advocated  hy 
In  any  .uiven  e.ise 
ation  oi'  the  appen- 
lor  a  limiting  adhe- 
ices,  anythin.ff  that 
iicrhout  its  extent  is 
s'that  the  csrcum  is 
reallv  on  theoretical 
}  howel.     I  nm  glad 


t„  H'C    too,  that  some  surgeons  of  the  largest  experience,  as  ^^UBurney 
.tate  that  tiiev  never  employ  purgatives.     They  are  also  contra-mdicated. 
think    when  there  are  signs  of  the  formation  of  a  local  al)scess.     If  useful 
■,t  all    it  is  when  general  peritiuiitis  has  lu'cn  c-tabli.-hed.  hut   then,  as  a 
rule,  the  mischief  is  done,  and  purgatives  cannot  inlhieuce  the  rcMdt. 

Uperation  is  indicated  in  all  cases  of  aeute  inllamuiat<.ry  trouble  m  the 
recal  region,  whether  tumor  is  present  or  not,  when  tli.'  general  symptoms 
are  -evere,  and  when  l»i  the  third  daij  Ihv  fculurc.^  of  the  casr  point  lo  a  pm- 
,,n's^hr  lesion.  The  mortality  from  early  oi)eration  uniler  these  circum- 
stances is  verv  slight.  .        ,  -^  i 

Jn  recurring  appendicitis,  wiien  the  attacks  are  of  such  seventy  and 
fre.iuency  as  seriouslv  to  interruiit  the  patient's  occui.ation,  the  figures  al- 
ivadv  "iven  show  Imw  slight  the  m<,rtalily  is  in  the  hands  of  ca!)able  oper- 
ators. ^I'nfortunatelv.  in  hospital  jiractice  too  many  cases  are  brought  in 
with  -eneral  peritonitis— a  condition  in  which  operation  is  rarely  successful. 

rust-operative  fealnres  in  A ppemlieit is.-V nUmXmv.MvU;  the  operation 
d.,c<  not  alwavs  finish  the  victim's  trouble^.  I  have  been  cuisulted  by  sev- 
eral imtients  with  severe  jiain  following  the  operation,  and  the  literature  con- 
tains a  number  of  reports  of  recurrence  of  the  pain  in  the  right  iliac  fossa. 
There  have  been  instances,  indeed,  in  which  an  indurated  eonl  has  been 
f..lt  and  might  have  readilv  been  mistaken  for  the  api-emlix  had  it  not  been 
previouslv  removed.  In  .<ome  instances  a  second  oi.eration  has  been  suc- 
ecssf-d  in  freeing  the  adhesions  which  have  cau.sed  the  pain. 


111. 


INTESTINAL  OBSTRUCTION. 


Intestinal  obstruction  may  lie  caused  by  strangulation,  intussusception, 
twi^t-  and  knots,  strictures  and  tumors,  and  by  almormal  contents. 

Etiology  and  Pathology.— (^/)  Strangulation.— This  is  the  most 
Irequent  cause  of  acute  obstruction,  and  occurred  in  ;U  jier  cent  of  the  •.'!»•> 
eases  analvzed  1)V  Fitz,*  and  in  35  j.er  cent  of  the  l.i:U  cases  of  Leiehteii- 
stern.-l  (>f  the  iul  cases  of  .■strangulation  in  Fitz's  table,  which  has  the  spe- 
cial value  of  having  heen  carefully  selected  from  the  literature  since  ISSO. 
the  followini,'  were  the  causes:  Adhesions.  <!3;  vitelline  remains,  '>1 :  adher- 
ent ani.endix.  (i:  mesenteric  and  omental  slits,  i\;  peritoneal  pouches  and 
opeiiiniTs,  3:  adherent  tube,  1:  ].eduncnlar  tumor,  1.  The  bands  and  adhe- 
sions result,  in  a  majority  of  cases,  frmn  former  peritonitis.  A  number 
of  instances  have  been  reported  following  operations  upon  the  pelvic  or- 
gans in  women.  The  strangulation  may  be  recent  and  due  to  adhesion  of 
the  bowel  to  the  abdominal  w(nind  or  a  coil  may  be  caught  between  the 
p,.,li(le  of  a  tumor  and  the  pelvic  wall.  Sucli  cases  are  only  too  common. 
Late  occlusion  after  recovery  from  the  operatiiui  -■  due  to  liands  and  ad- 
hesions. 


*  Transactions  of  the  f'on^'ress  of  American  PhysiiMims  and  Surgeons,  v, 
Th'-  pprcentajjos  of  his  tables  are  nscd  thronpliout  tfiis  section. 
+  Von  Zieinsscn's  Encyelopa>clia  of  Practical  Medicine. 


i.  is^t). 


532  DISEASES  OF  TDE  DIGESTIVE  SYSTEM. 

;,';;„;,;;l!;;,rw.n':;:»'.lu. ,..., .,. ...  .1.. -*•...  .,,,.1 .,  ,■„„. ,. ^ 

;i;;;.';;:'';:„.  '     .  .... ...■  .i.- >-- -< "'-""■'-» ;:'-;" '"«° "m 

;!;;,,;„;,  :L  i„  ,1,..  .1.1..  »■»,.  f.,.., ;,. ..:  :..■.■  -...  -^  ^^^  -«-.  »"■'  "■  >'" 

(/,)  Intussusception.-ln  this  .ond.t.ou  one  portion  of  tl'^^n  u-    nc  .1. 
into  Vn  a.limrnt  portion,  lorniinj:  an  invagination  or  intus.u«;o  tion.      Ik 
"rot  n.alo  a  cvlindrical  tumor,  winch  varies  m  length  lr..in  a  hall- 
'  ,„      r  nu.rJ      The  ...ndition  is  always  a  doscending  mtiissuscep- 

1         1  -  nroced^   tlH-  nii.l.llc  and  inner  layers  increase  at 

;;;r;^  :  :o    th    ;:;er  i::  ;;.     a,,  intnssnsception  consists  of  three  hiyers 
1   'c^'    the  outermost,  known  as  tiio  intnssnscp.ens,  or  receiving  laye 
\      ,  le  or  returning  layer;  ami  the  innermost  or  entering  layer      1  he 
.  p.,     o  t  lin  •!  clnu-  idea  of  the  arrangement  by  making  the  end  oi  a 

:  W^  i!;iin  tho  post-mortLi  invaginations  which  are -common  nt 

"snail   lunvel  of  chihlren.     In  the  statistics  of   ^' '    "     ;^;\;'*;;      ^ 

of  .uute  intestinal  obstruction  were  duo  to  this  cause.     Of  the.( .  o.  ^^>^^lo  m 

1    ,-  in  f,.nv,le<      The  cases  are  most  common  m  early  hie.    -4 

;rctt;ih  d;:r;!n:::;^;^^^^^^ 

;!nhe  ;;ce;vL  laver  by  contn.ction  of  the  longitudinal  coat.     Invagma- 

ti„n  mav  follow  any  limited,  sudden,  and  severe  V^^^^^^^^         intussu^cep- 

l„  the  post-mortem  examinati.m.  in  a  case  of  death  fion    '"^'>-"^^^l' 

ti.n     t Icndition  is  verv  characteristic.     Peritonitis  n.ay  be  present  or 

"acm^    injection  of  the  Serous  membrane.     When  death  occurs  eat  ja 

t,  av  do    rom  shock,  there  is  little  to  he  seen.     The  portion  of  bo^^cl 


INTESTINAL   ORSTRUCTION. 


533 


iculum,  which 
ithin  eighttvii 
lalo-nu'seutfrit' 
iiuiiioalt'il  with 
ttaehfd  to  tho 
a  ring  is  thus 

igulatiiiii  occur 
s  of  iiitoon  ami 
)m  tlios^e  causes 
he  s;traiigulatt'(l 
iscs,  anil  in  the 

e  intestine  slips 
.isce])tion.     Tlie 
;th  I'l'oni  a  half- 
ing  intussuscep- 
yei's  increase  at 
s  of  tliree  layers 
receiving  layer; 
ing  layer.     Tho 
ing  the  end  of  a 
tion  can  he  very 
•e  so  common  in 
i):5   of  2!).")  cases 
these,  5'^  were  in 
in  early  lilV.   ''it 
h  year.'     Of   ,.';5 
1,  tit'th,  and  sixth 
1  i-.'  of  the  cases; 
1. 

'  (1)  an  iko-nfC(il 
lere  are  cases  in 
er  rectum.  This 
r  of  AViggin's  col- 
m  jiasses  through 
is  alone  involved. 
'.     And  (1)  colico- 

hsception.  Xoth- 
railic  current  that 
it  the  drawing  up 
1  coat.     Invagiua- 

from  intussuscep- 
nay  he  i)rcsent  or 
th  occurs  early,  as 
!  portion  of  bowel 


nirectcd  is  large  and  thick,  and  forms  an  elongated  tumor  with  a  curved 
u  li  u.  The  ,. arts  are  swollen  and  congested,  owing  to  the  constriction 
:;\h,  ii.c.nterv  hetween  the  layers.  The  entire  mass  may  l;e  ol  a 
.^  ,i,j,,.,,„,  ,.,i,„,  1„  very  recent  processes  there  is  only  .■ongest.on,  and 
n.rhai>s  a  thin  laver  ot  lymph,  an.l  the  intussusception  can  he  rcduce.l, 
1,,^  J|,,„  it  has  lasted  lor  a  lew  days,  lymph  is  thrown  uut.  the  layers 
,,v  -dued  together,  and  the  entering  portion  of  the  gut   cannot   he  with- 

'"'"Vhe  anatomi.-al  condition  aecunt^  Inr  the  pivsence  of  th."  tunmr.  which 
,xi.ts  in  two  thinls  ..f  all  cases;  and  the  cng..rgeinent.  whuli  re^dts  Inun 
„,;  compression  of  the  mesenteric  vessels,  explains  the  iivquent  oc-urreiire 
„1'  hlood  in  the  discharges,  which  has  so  important  a  .liagno.tic  value.  11 
, I,,  patient  survives,  necro.is  an.l  sluughing  -d  the  mvagmated  portion  may 
„^,,,;,,.  „„i  if  union  has  taken  i^lace  iulween  the  mi.ldle  and  outer  la  e, 
tho  calihre  of  the  gut  uniy  he  restored  and  a  cure  m  this  -'V  ;"  -  ;;''• 
Many  cases  of  the  kind  are  on  record.  In  the  Museum  ol  the  .Me  lie  d  1  a> - 
iiltv'of  MctiiU  l-niversity  are  IT  inches  of  small  i-'t-fne,  which  were 
,,as"sed  hy  a  lad  who  had  had  symptoms  of  internal  strangulation,  and  who 

made  a  comjilete  recovery.  i    •       ,.,      <•  tLn  -xr. 

(r)  Twists  and  Knots.-Volvulus  or  twist  oc.mrred  m  1-  oi  lie  ..D 
cases.  Sixtv-eight  per  cent  were  in  males.  It  is  most  fmp.ent  hetween 
tlie  a>^es  of'thirtv  and  fortv.  In  the  great  maj.u'ity  ot  all  cases  the  twist 
is  axial  ami  ass.u-iated  with  an  unusuaily  long  mes..ntery.  In  ..0  per  cent 
„r  the  cases  it  was  in  the  sigmoid  ilexure.  The  next  most  common  situa- 
tion is  ahout  the  ca'cum,  which  may  he  twisted  upon  its  axis  or  hent  upon 
it^df  \s  a  rule,  in  volvulus  the  loo])  of  bowel  is  simply  twisted  upon  ds 
Icn.r  axis,  and  the  portions  at  the  end  of  the  loop  cross  each  other  and  so 
,ause  the  strangulati.m.  It  occasionally  happens  that  one  portion  ol  tho 
h(.wel  is  twisted  about  another.  _ 

(d)  Strictures  and  Tumors.— These  arc  very  much  less  important  causes 
of  acute  ohstruction,  as  may  he  judged  hy  the  fact  that  there  are  only  !•> 
instances  out  of  the  'i'.K,  cases,  in  14  of  which  the  ohstruction  occurred  m 
the  large  intestine.     On  the  other  hand,  they  are  cmmon  causes  ol  chronic 

ohstruction.  .    ,     ,   •  ,  m 

The  obstruction  mav  result  from:  (1)  roiuinnhi]  strirhnr.  1  hese  a  c 
rxce.'din.dy  rare.  :Much  more  commonly  the  condition  is  that  of  completo 
occlusion,  "either  forming  the  imperforate  anus  or  the  ongeiiital  detect  by 
which  the  du..denum  is  not  united  to  the  i-ylorus.  {■')  Sniiplr  nmlnnnl 
.Irmisi..  which  results  from  ulceration,  tuberculous  or  syi-hditic,  more 
varelv  from  dvsenterv,  and  most  rarely  of  all  from  tyi-hoid  ulceration.  (.5) 
\rir\iro,rlh>^.'  The  maliuiumt  strictures  are  duo  chietly  to  cylmdru'al  epi- 
thcli.mia,  which  forms  an  annular  tumor,  most  commonly  met  with  m  ho 
lar-e  bowel,  ab.mt  the  si-moid  Ilexure.  or  tho  descending  colon.  Ol  1)0- 
ni'ni  -n'owths,  papillomata,  adenomata,  lipomata,  and  tibromata  occasion- 
ally induce  obstruction.  (4)  Co,i,prr..wn  and  irndum.  Tumors  ot  neigh- 
boring^ organs,  particularly  of  the  i-elvic  viscera,  may  causeobstruc  lion  by 
adhesion  and  traction;  more  rarely,  a  coil,  such  as  the  sigmoid  flexure, 
filled  with  fa^cos,  compresses  and  obstructs  a  neighboring  coil.     In  tho  heai- 


-    - 


DISEASES   OF  THE   DIGESTIVE  SYSTEM. 


534 

.„.  ,,  ,,,ereulou.  ventonitis  the  eontvactp  of  U.  tlueR  exuaa.  u.y 

(,)  Abnormal  Contents.- l-..ni.nuche...  ,^,,^^,i|,,  „,  ,„■  Uiua- 

"-^'-  -  ^^":  ^i:;;r™;r  n:  ^ .:;::-  ^'>^->  '-•  =>■  -^"^i  ---^ 

,,n,l  cause  .,l,.tt mtion.  n^n  ,      ehihlren,  eau.e  no  nieun- 

barley  ear  may  n'ach  the  "'^■^■^»"7\|-         ,,    ,,,,,  ,„„i  kn.nvn  to  aceunui- 
McUeines.  sueh  as  nuuniesui  o      H>n  ut    .    ^^^^^    ^  ,.„.;,,.  „^. 

,,,  in  the  lH>wel.  and  P-^-'^"  ^  ;;^™    ^^  ^t   n       o^  enten.lhh^. '   <.r 
the  eases  the  oondmon  is  ^!^-^,;'  J*  ^  \-2:\  ,  i  ,  ,,-  ......  and  in   > 

44  cases,  in  -^l?  tiu-  ohstruct.on  .a.  ^'\^2.T^nJn  .i  anv   period  .(  lile. 
by  enteroliths.     Ohstrnctn.n  hy  l.eee>  n.a     ''  1  1^^^  •    \,^^,,  „.,,„  i„ 

is  mentioned  .hen  speakmg  ot  ddatatnu    o      la  •        >  ^^;  ^,,^,  ,^ 

vonn.  children  and  persist  lor  week.   /       '    j^^^  "^  J",^,^,,,,,  ,,,,.  hanl. 
l-vel   n>ay  reach  an   --••--„;;X;' I.  '^.:  Amities  of  .^^^^^^ 
The  retained  nuisses  may  he  ;'"""^\'     ; '"  '  '   ,„„,  ,  ,,,,1  canses  ohstruction. 

?:.-tr^.;vrr,;;r™:r^:,E,: .,«. ..-^^- 

,,„,„  llH.  hot  tl,»t  23  ««.  .ore  "1»  '"I    "    '  ,  '"     "^     ,„„,„„„  ,;,  ,1,0 
cses  It  on-.iv.T.l  a  tcr     '<•     ""       ■  ,,„,„l,iHun.     Tla-st  larfie  ™l.tavy 

p,ll-.l"..os  >.liHrato    '""  '^'  2    -  ,„  „„  |„„or  tnso  tlwy  ran-ly  «u,«  ul,. 
,i,„..  ....pasionally  mi«  tW  '""■"'         ,„  ,„  „„  ii,„,,,t„re. 

.„„..lio„      (■■.m-v,,,.,™  ha-  '•"'«;;'':^4.";  ■,,,,,.,  „„„,,  ,„„„„„„ly  of  tl.v 
Knt>..n.mh-  may  1...  '""";''';;'■;  ,,°  ,1     .  fonnod  of  a  (oioign  V.ly 

■;'■  'i'  ''t,  ::;' ■;  ,         -  .'  ;:Ion  u.  ...»  as  m  ro.,,i„,uu,.  a,„l  a,  nKhcaa,. 


,„onlv.  dnrin^^  the  verlonnance  of  ^''^"^  ^  ;  ^^  ^  ^^  ^.^,,.,  .,„,„,,     Von>- 

.•!n>raeter.  hnt  suhsequently  it  '--"^  ^"^^^^^^^  ^  i„,  .vmvto.n.  At 
it-,  iollows  M-;l<^y  -  ^^^^--i"'^,;'  is  ^;,1  then  greenish,  hile- 
fiM   the   contents  o     the  ^^  "'^^  J^  J.  ^,„,i  ponnanent  obstntction. 

.tained  nfaterial.  and  soon,  m  case  " ;'      ^^        ^^,^  ^^   ^ii,ti„,tlv  fa-cal 

,,„  ,,,,  ,u  votnited  ,s  ;>  -;•-  ;^  tt  finallv.  stercoraceons  votnit- 
odor.     This  so.itipnco  of  pastiic,  ""    ";  ;      ^  ^^,,,te  ol.  truction. 


IXTESTINAT.  OBSTRUCTION. 


535 


L'Xiuliue  may 

r;.  (■iiin>.  iiiiis. 
,  (ii-  liv  luiia- 
taii.ulcd   nia>s 

i>(j  no  incuii- 
1~.  Ot-easiiiu- 
i\lj\>  and  ^\  ill 
Valiody).  or  a 

,11  tn  iu-i-iunu- 
it  majority  of 
ilcrolilli>.     <>1' 
jvci'^.  and  in  'J 
period  of  lil'i'. 
mav  oeciir  in 
Ltion  thf  larue 
ime  very  hard, 
of  fa'cal  matlir 
^0^;  obf^truetion. 
Liorni'  for  wr.'ks 

i;iy  111'  uiUlK'ri-'il 
in  ciuhl  ywuv. 
sevenths  of  the 
s  usually  in  the 
ic  larue  s(ditary 
the  small  intes- 
rarely  eause  ob- 
it u  re. 

ommonly  of  the 
i  a  foreign  body 
peeimens  of  this 
and,  as  indicated 

nrin  in  the  alido- 
Viin  sets  in  early 
li'  or,  more  eom- 
t  lirst  e(dieky  in 
y  intense.     Vom- 
iii  svmi'tom.     At 
n   greenish,  hile- 
nent  obstrtietion. 
1  distinctly  fa'cal 
reoraceons  vomit- 
acute  ob  truction. 
re  of  either  fa-ces 


or  fM<.  Verv  often  the  contents  of  the  b(puel  below  the  stricliire  are  dis- 
eluu'"vd  Distention  of  the  alidomen  usually  occurs,  and  when  the  large 
b(Av"l  IS  involved  it  is  extreme.  On  the  otlu'r  haml,  if  the  obstruct  ion  is 
hj.di  up  in  the  small  intestine,  there  may  be  very  slight  tympany.  At 
lirst  the  abdomen  is  not  painful,  but  sub>e.pieutly  it  may  becoiuc  anitcly 

The  constittitional  svmptoms  from  the  o^lt^et  are  severe.  The  face  is 
pallid  and  anxious,  and  linally  collapse  symptoin>  superveiu'.  I  he  eyes 
luHoiue  sunken,  the  features  pinched,  and  the  skin  is  covcicl  with  a  col,!, 
clammv  sweat.  The  pulse  becomes  rapid  and  feeble.  There  may  be  no 
fcv.^r:  \he  axillary  temperature  is  often  suliuorjual.  '1  he  tongue  i>  .h'> 
and  parched  and  the  thirst  is  incessant.  The  urine  is  high-colored,  scanty. 
,11,1  there  mav  be  suj.i.ression,  particularly  when  the  (,bst ruction  is  ugh 
HP  in  the  Imwel.  This  is  proiiably  due  t.,  the  constant  vomiting  and  the 
<,uall  amount  of  liquid  which  is  absorbed.  The  case  terminates  as  a  rule 
in  from  three  to  six  days.     In  some  instances  the  patient  dies  from  shock 

or  sinks  into  coma.  ,.       ,   ■ 

(/A  Symptoms  of  Chronic  Obstruction.— When  due  to  fa'cal  impac  ion, 
there  is  a  historv  of  long-standing  constipation.  There  may  have  been 
diM-har-n'  <d'  mucus,  or  in  some  instances  the  fa'cal  masses  have  been  chan- 
neled, and  so  have  allowed  the  contents  of  the  upper  ].orti<m  of  the  bowel 
to  pa<<  throu-di.  In  elderlv  ].ersons  this  is  not  infre.pient;  but  examina- 
tion either  per  nrhnn  or  externally,  in  the  course  of  the  colon,  will  reveal 
the  ])resence  of  hard  scybalous  masses.  There  may  be  retention  of  heces 
fur  weeks  without  exciting  serious  sympt(uns.  In  (.ther  instances  there  are 
vomiting,  i.ain  in  the  al)domen,  gradual  distention,  and  linally  the  ejecta 
l)eeome  fa'cal.     The  hardened  masses  may  excite  an  intense  colitis  or  even 

peritonitis. 

In  stricture,  whether  cicatricial  or  cancerous,  the  symptoms  ot  obstruc- 
tion are  verv  diverse.  Constiiiation  gradually  comes  on,  is  extremely  van- 
able,  and  it'mav  l)e  months  or  even  years  before  there  is  complete  obstruc- 
tion' There  are  transient  attacks,  in  which  from  some  eause  the  ia'Ct'S 
accumulate  above  the  stricture,  the  intestine  becomes  greatly  distended, 
and  in  the  swollen  abdomen  the  coils  can  i)e  seen  in  active  iieristalsis.  In 
-uch  attacks  there  mav  be  vomiting,  Imt  it  is  very  rarely  of  a  fa'cal  charac- 
ter. In  the  majoritv  of  these  cases  the  general  health  is  seriously  im- 
paired: the  iiatient  gradually  becomes  ana'uiic  and  emaciated,  and  imally. 
in  an  attack  in  which  the  obstruction  is  complete,  deatli  occurs  with  all 
the  features  of  acute  occlusion  or  the  case  may  be  prolonged  for  ten  or 

"'Diagn'osis.-(^0  The  Situation  of  the  Obstruction.— Hernia  must 
1„>  excluded,  which  is  bv  no  means  alway.  easy,  as  fatal  obstruction  may 
occur  irom  tlm  involvement  of  a  very  limited  portion  of  the  gut  in  the 
external  ring  or  in  the  obturator  foramen.  :Mistakes  from  botli  of  these 
cau-es  have  "come  under  mv  observation:  they  were  cases  in  which  it  was 
iiupo^-^ible  to  make  a  <liao-nosis  other  than  acute  obstruction.  Timely  op- 
eration would  have  saved  both  lives.  A  thorough  rectal  and.  in  women,  a 
va-inal  examination  slnnild  be  made,  which  will  give  important  information 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


536 

,.  to  ,l.e  condition  oi  the  pelvic  and  rectal  content.,  V^^^^f^^^^^'^^ 

;.     1     the  ins,.eetion  ut  the  abdon>en  there  are  uuportant  ";'!-"";' ^' 
;  :;.,e    1  pronnnenee  in  certain  regions,  tl>e  occurrence  ol  '■•; ;  '      -^^  ^ 

;,;;  ,;,!:■  i.  iio  I.:.,.  ....^,1  ,v.i..i..  ,,,,,1  ,iuri„g  .,,.,„ , .. .., . . 

"'"\'r,'|":'ikn„„  »,„1  «>.,■..„,  .IK.  ,r....„.i""  i.  ..."v.  i"  the  contra!  portion 

;^;r;:u  r^iX":  e,.;;:;:":L.r';;i:^.,i.rv..,.  .„  r.i,i,,w. ^  ti. 

'"' '"■'""."•'■^' '""'"""■ ;  ';,.:;■;.  ¥1,  •  t„i tm* »«,,■  then >« 

lK.rho.)d  ol  a  stricture       I  ho  quantity  oi  ^^^^^^.^^  .^ 

;:;;;:;;;;;rh;l™".:'!J'".> ':::.■':«!..".  ..^  t,.  ot,.™.... ho  ,ar,o 

y;;';^::;  ■  r ;:;'  Lro  havo  1.™  ,-7:,-^:,:'.:' S'™is : 

„,.„  aro  ot,,.  o„oa  ,^*;  ,»'"';!,;=   ,;",,™;;,,t  „„,  ,ho  ohlraotor  of  the 


*  Edinburgh  nospital  Reports,  vol.  ii. 


1 


INTESTINAL  OBSTUUCTION. 


537 


ily  in  Cilices  of 
s  be  ielt.     In 
lolvis  and  can 
is  of  doubt lul 
indications,  as 
idolinito,  wcll- 
ivo  iteris^\lsis. 
n  diagnosis  of 
tJK'  lower  end 
)l()n  stand  out 
hes  of  the  <rut 
1  is  obstrneted 
iin  the  eoils  of 
e  other,  either 
tern."     In  ol)- 
i<iht  distention 
rapid  eoUapse 

central  portion 
[•urs  early.  In 
ve  and  general, 
id  l)l.)od.  The 
apidly,  and  the 

n  in  some  cases 
)igital  exaniina- 
)e  may  then  be 
ire.     in  the  nse 
el  in  the  neigh- 
i  be  jtassed  into 
le  large  bowel  is 
trom  a  height  of 
)\vel  the  jiatient 
he  side — best  on 
[lie  Ciccal  region 
r  diagnostic  pnr- 
or  by  the  nse  of 
'SO  measures  give 
ion  in  the  large 

not  infrequently 
,n  very  early  life, 
ulominal  pain,  or 
old  ])eritonitis  or 
e  character  of  the 
sea  and  vomiting 


may  be  absent.  The  vomiting  usually  Ixromes  fa'cal  from  the  third  to  the 
iifth  day.  A  tumor  is  not  common  iu  strangulation,  and  was  present  in 
onlv  one  Iifth  of  the  eases.     Fever  is  not  of  diagnostic  value. 

'l,ihtsi<us(ri>lion  is  an  atVection  of  childhood,  and  is  of  all  forms  of  in- 
ternal obstruction  the  one  most  readily  diagnosed.  The  prc.-ence  ol  tumor, 
bloody  sto(ds,  and  tenesmus  are  tlu'  important  factors.  Tiie  tumor  is 
nsualiy  sausage-shaped  and  felt  in  the  region  of  the  transverse  colon.  It 
existed  in  (;r,  of  [VA  cases.  It  was  present  on  the  lirst  tlay  in  more  than  one 
third  of  the  cases,  on  the  second  day  in  more  tiian  one  foiirtii,  and  on  the 
third  day  in  more  than  one  Iifth.  I'.lood  in  the  stools  occurs  in  at  lea>t 
three  lifths  ni  the  cases,  either  spontaneously  or  following  the  use  of  an 
enema.  Tlie  l)lood  nuiv  lie  mixed  with  mucus.  Tenesmus  is  pn'sent  in 
one  third  of  the  cases.  'Fa-cal  vomiting  is  not  very  common  and  was  j.res- 
cnt  in  only  U  of  tlie  !i;!  instances.  AI)dominal  tympany  is  a  symptom  of 
sli'dit  imiiortance,  occurring  in  only  one  third  of  the  cases. 

^Vnlniliis  can  rarely  lie  diagm.sed.  The  fre(iuency  with  which  it  in- 
volves the  siirmoid  ilexure  i-^  to  i)e  lioriie  in  mind.  The  passage  of  a  tlex- 
ii,le  tube  or  injecting  ilui.is  might  in  these  cases  give  valualile  iii.hea- 
tioiis.    An  absoiute  diagnosis  can  proliably  be  made  only  by  an  abdominal 

section. 

In  faral  oJistrwI'mu  the  condition  is  usually  clear,  as  the  ia'ces  can  he 
felt  per  rectum  and  also  in  the  distended  colon.  Fa^'al  vomiting,  tym- 
])any,  alidt.minal  i>ain,  nausea,  and  vomiting  are  late  and  are  not  so  con- 
staiit.  In  obstruction  by  gall-stone  a  few  of  the  cases  gave  a  itrevious  his- 
tory (d'  gall-stone  colic."  daundice  was  i.resent  in  only  'i  of  the  'i'i  cases. 
Tain  and  vomiting,  as  a  rule,  occur  early  and  are  severe,  and  fa'cal  vomit- 
ing is  ])resent  in  two  thirds  ot  the  cases.     A  tumor  is  rarely  evident. 

'"(r)  Diagnosis  from  other  Conditions.— Acute  enteritis  with  great  re- 
laxation of  the  intestinal  coils,  vomiting,  and  pain  may  i)e  mistaken  for 
olistruction.  In  an  autopsy  (Ui  a  case  of  this  kind  the  small  and  large 
bowels  were  inten.^ely  inllamed,  relaxed,  sodden,  and  enormously  distended. 
The  svm]itoms  were" those  of  acute  obstruction,  but  the  intestine  was  free 
from  "duodenum  to  rectum.  Of  late  years  many  instances  have  been  re- 
ported in  which  iieritonitis  following  disease  of  the  ajipendix  has  been 
mistaken  for  acute  obstruction.  The  intense  vomiting,  the  general  tym- 
pany and  abdominal  teiidernes-;.  and  in  some  instances  the  suddenness  of 
the  onset  are  very  deceptive,  and  in  two  cases  which  have  come  under  my 
notice  the  symittoms  iiointed  very  strongly  to  internal  strangulation.  In 
appendix  disease  the  temiieraturc  is  more  frequently  elevated,  the  vomit- 
ing is  never  fanal.  and  ii:  many  cases  there  is  a  history  of  ])revious  attacks 
in'~the  ca'cal  region.  Acute  luemorrhagic  ])ancreatitis  may  produce  symp- 
toms which  simulate  closely  intestinal  obstruction.  A  hoy  was  admitted 
to  tlie  Jolms  Hopkins  Hospital  with  a  history  of  obstinate  vomiting,  in- 
tense abdominal  jiain.  gradually  increasing  tympany,  and  no  passage  for 
several  days.  ITis  condition  seemed  serious  and  he  was  transferred  at  once 
to  the  surgical  wards.  At  the  operation  the  coils  were  found  uniformly 
distended  and  covered  in  jilaces  with  the  thinnest  film  of  lynijih.  No  ob- 
struction existed,  but  there  was  a  tumor-like  mass  surrounding  the  pan- 


DISEASES  OF  TDE  DUiESTIVE  SYSTEM. 


! 


538  , 

.....inn.....  ana  a..pl>-.ntlU™t.l  with  M l-     Tl.  ,.Uu..un,n.ov.l 

Treatment.-1'urgal.vc.s  .honia  no     '^  -      '  ,  ^,,^,  ,,i^„,,ii„,  v.nnii- 

<>-••-  "^•i-""r  ;"■  "riT"::  h^S^      Not  i^U  ?tht  .lin^tly  hen.ii.n>l. 
i„u.t!u'stonmch  slnuild  W'  nm^Ik  I   uit.     -n  ,        ,j        ,    ^,,,,  ,,,,,. 

,„a   Kus.n,anl  .lai.n.  that  ^'>-'''' '7';;,;  ^ ^    •^'     .  ,,^K  and  the  viil.nt 
,.nv  in  tlu.  houd  ahovc  tho  seat  "t  "'-  ^       ,,;;,,  ^,„,  u.ne.  a  clay, 

peristalsis  is  diminished      h  n>a>   he  ,   .      -d     n  _     ,^,^^^^^._ 

i,,l  in  son,e   instances  has  l''-f  J^  j,        .,.,., a  ,.  pnutised,  the 

,,,hini,a.innolthelar,oh...   U     .^n^^^^  .,,,1  „,, 

,ann  tUnd   iK.m,  a  h-wed   to    ^  ^     ^,  ,^,,i„^„„  ,,,.„„unen.ls  that  tl>e 

,,„„unt  earelnlly  estnnated.     J^^»  '  ^  '    '  ,       ,,^  thon-uddv  kneaded. 

j^Uient  he  plaeed  nnder  an  ana^sthe     .  '  ^,^j,;„,^      -n,en.  wth  the 

Ld  a  eovions  enema  ,.ven  -1"'-       ^  ^^  ^^       ,          ,Uorou,hly  shaken. 

i:vti;irt;:airrsi-;vn^^^ 

'"1n;i:uio.n.,yalsohetned.hyhn.u,.theai.in. 

'-•••'- '"••-^;•;;.;r:;^;7w:MIv;.:e;;^;^     nt^;^  ii.»..es 

as  instances  d  luptnu   m  j         ^^.^.y,,  .5..  f,.,,,.,  „t 

,how  that  in  the  iirst  o.ght  y;;^^''^^l^^Zunn  or  ,nohahle  intussns- 
...overy  anet-  nuectjon  -^^J^^'  ^  ,  ..jlt^^.^.tod  hy  inihu.on  or  ene- 
ception,  and  H  deat  ^.  ^^^-^^^^J-^  ^  ,^,.  ^^,,^,  ohstrnetion,  if  the^e  means 
-ata  10  veeovere  ^^^l^j^^^  J'  ^  ^^  ,,  v.  sur.ieal  measures  should  i.e  re- 
do not  prove  suc^  •e>.h  l.>  "  ;  ,,ersistent  and  the  condition 
Borted  to,  ^"•^/^'-"/•';;;t^            ,  .      t  Lu-e.     Of  Oi  cases  m  which 

serious,  laparotomy  ^1^'>"  '\   \,  "       "^     ^he  v.n.n.est  case  operated  upon 
laparotomy  was  i.erlormed.  n  ucoNcua. 

was  only  three  days  old.  miidieatioiis  may  l>e  ap- 

For  the  tympanites  turpentine  ^^"1^'?  ' "     ;    /^    ,,,„  aspirator  needle. 

be  had  to  surgical  measures. 


IV.    CONSTIPATION  {Co^t 


ivenes><). 


general  and  local.  (-,„„„itiuional    peculiarities:    Torpidity    of    the 

Oenrral    (  ausr^.—(n)    I  onstitiui  ■        1  ^^       ■     .-[.^.u  than 

bowels  is  often  a  familv  --M''^"  .J"'^  ;J;^  ^  1  '     V-'--  -'"^  -^  ^'^^ 
in  fair  persons.     (M  Sedentary  ha  u  .   P^>^  ^         ^^^  ^,^^^,,,  ,^^,u  ,,  .na- 

,„,h  and  t,eglect  ^^^  ^^V    ."Slni^  all^    i- "  of  the  liver,  stomach. 
r^nS^and^t^e^Sr^^^^^^^^  this  beading  n.av  appropri- 


COXSTIPATION, 


539 


il  imiii'oVL'il 

pain  hypo- 
•siuti"  voiuii- 
y  l)eiu'lu-iiil. 
ll.'tlK'  I'Vi'^- 
tliu  viuk'iU 
ti UR'S  a  (lay, 

tp  ...       Tlinf- 

nKliscil,  the 
,jie,  a  lit  I  tlio 
lids  that  the 
lily  kiK'ailtMl. 
icii.  witli  tiie 
o-hly  <hakoii. 
the  iiivfi'ted 

luin  with  the 

without  rit^k, 

Fitz'ri  iliTUivs 

re  \^■.^  oar^eri  of 

)ahlo  iiitii^suis- 

llatioii  or  ciic- 

il'  these  means 

shouhl  lie  re- 

llie  condition 

•ases  in  whieli 

operated  npnii 

us  may  he  ap- 
^pirator  needle, 
regulated,  and 
ins.  Enemata 
■te,  resort  luu^t 


av  l)e  classed  as 

)rpidity  of  ihe 
en  in  dark  than 
ons  who  eat  too 
es.  such  as  ana'- 
1  livor.  ptomacli. 
."•  niav  aiipropri- 


atelv  he  placed  that  umM  injnrinus  nt  all  hahits.  ,ln,ii-(iihUvj.  01)  Kither 
a  eoar>e  diet,  whieh  leaves  tun  much  n-idiu'.  or  a  .liet  whieh  leaves  too 
little,  mav  he  a  cause  of  costiveness. 

/,„,„/V„H,s7'.s-.— Weakness  ,.f  the  ahdnminal  nui>el.s  m  ohesily  <u-  in.m 
„vcrdi<tention   in   repeate.l   pregnancies.     Af.ny  of  the   lariie  iM.uel   Irom 
Hirunie  disease  of  the  mucosa;  the   presence  ..f  tumors,   physmluuical   or 
natholo-ieal.    pressin-    npun    the    huwl:    enteritis;    furei-n    hodie.     lai-e 
,„.,—  of  M'vhala.  and  strictures  of  all  kinds.     An  important  h.cal  cause 
,.'at.mv  of  t'he  c.d.m.  partieidarlv  .d'  the  muscles  of  the  sigmoid  Uexure  by 
whieh  the  livces  are  propelled  into  the  rectum.     Uv  far  the  most  ohstinato 
form   is  that  assoeiatrd   with   a   eontractrd   state  of   the   howrl,   which    is 
.nnntimes  spoken   of  as  spasmodic  constipation.     This   may  he   met  with 
ip  tiHHr  conditions:   First,  as  a  scpieiice  of  chronic  dysentery  or  ulcerative 
enliti-.  secondlv.  in  protracted  cases  nf  hysteria  an.l  nenra>th..n:a  m  wnn^ii 
partirularlv  iii"associati(m  with   uterine  disease;  and.  thirdly,  m  very  ol, 
pei-ons  .d'ten   without   anv   detinite   cause.      It   may   he   that   the  siginnid 
!•  xure  and  lower  c.dim  are  in  a  .nudition  u(  contract  ion  and  spa>m.  uinlo 
the  transverse  and  ascending  parts  are  in  a  state  of  atony  ami  dilatation. 
The  most  characteri>lic  >ign  nf  thi>  variety  is  the  presence  of  lianl.  globular 
,„;,.;<es.  or  more  raivh  small  and  sausage-like  fa'ces. 

Symptoms.— 'Hie  nin<t  pci-istent  constipation  for  weeks  or  even 
mnnths  mav  exist  with  fair  health.  All  kinds  of  evils  have  heen  atti'thnted 
to  pois.ming  l)v  the  resorptinii  nf  noxious  matters  from  the  retained  heees 
—oopra'mia— hut  it  is  not  likclv  that  this  takes  place  to  any  extent,  (hlo- 
ro«i.  which  Sir  Andrew  Clark  attrihutes  to  fa'cal  i.oisoning.  is  not  always 
asst.Jiated  with  cnn>tipation.  and  if  due  to  this  cause  shouhl  he  m  men, 
women  and  children  the  uin>t  cmninnn  of  all  disorders.  Dehilily,  lassi- 
tude, and  a  mental  depression  are  fre(|uent  symptoms  m  con.stipation, 
i.articularlv  in  iiersons  of  a  uervmis  temperament.  Headache,  loss  oi  :\\^w- 
tite  ami  a  furred  tomrue  mav  aUn  nccur.  Individuals  dilTer  extranrdina- 
iilv"  in  thi^  matter:  one  feels  wretched  all  day  without  the  accustomed 
evacuation;  another  is  comfortahle  all  the  week  except  on  the  day  on 
which  hv  iiuriie  or  enema  the  howels  are  relievt'd. 

When  persistent,  the  aceiimulation  of  lieces  leads  to  unpleasant,  some- 
tinu-  -erious  svmj.toms.  Mich  a~  piles,  ulceration  of  the  eolmi.  distention 
nf  the  sacculi.'i.erforati.ui.  enteriti^.  and  occlusion.  In  wmiu'ii.  pres.siire 
VAX  can-e  iiain  at  the  time  of  men-truati(.n  and  a  scnsatnm  of  lulness  and 
.tention  in  the  i-elvic  organs.  Neuralgia  -d'  the  sacral  nerves  may  he 
canned  hv  an  overloaded  si-moid  llexure.  The  fau-es  r.dlect  chiel ly  m  the 
cnlnn  F.ven  in  extreme  -rades  nf  cnn<tipati(m  it  is  rare  to  hnd  <lry  tares 
in  the  ca'cum.  The  iivces  mav  fnrm  large  tunmrs  at  the  heimtie  or  splenic 
tlcxures  or  a  sansaue-like.  donghv  mass  ahove  the  navel,  or  an  irivgular 
Innipv  tumor  in  the  left  inguinal  ivginn.  In  old  persons  the  sacculi  ot  the 
cnlnn' hec.mie  distended  and  the  scyhala  may  remain  in  them  and  undergo 
calciecation.  fn-niing  ontercdiths.  ,  ,,    i 

In  ca<e<  with  i.rolonued  retciitinn  the  liccal  masses  l.ecome  channelled 
and  diarrh.ea  mav  ne.nr  for  days  hefme  the  true  c.uidition  is  d.^^eovered 
hv  rectal  or  external  examination.     In  women  who  have  heen  habitually 


II 
di 


1: 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


.•     .    1    nH.u.k.  of  .liiurliuM  Willi  naus.Ni  and  vomitiiii,'  ^.lu.uld  oxcito 

i         .'Uont  c.,i,.li|..Uion.    The  c..„„liu....  ,.,.,...ir»  «.iii.ti„u-.<    • 
1,""  ..,"i"l,il.il  .U.IWt.     In  H,„...  nt  llic*  ,,.,ti..,.ls  tlioro  may  bo  .nnsu-.amg 

' ^:.;:;-.;;:i::rL^r:::;.:i™'rt:lcr:.«,.aH..n™;; 

okkT  >'1"1''  >■";',    '         ^;',',  ,,„rt'„t  ih.  ni..,lK.r  in  lliis  niatlor  ..(..■.. 

;::cr  ,i,w;;:^;(^™^"-- > t-"^ " """ "'.  inl;:;::;;;;: 

:;;::;::-:^;i;?:;i^™:';.;^t;rT;i;n^-;.;^.^x^i- 

is  Willi  many  men  an  iiilall.l.lo  remody. 

'^^HZy  nso-  ,,iiir..liv..  Vill.     'Avoorin  .illi..,-  in    1,0    n^^^^^^^^         -  • 


> 


FNTRRO  PTOSIS. 


r>4i 


lould  excito 

JO  in  whieli 

order.  The 
osj  in  wliiili 
il  niovo'iK'iil 
il  wiis  in  my 
11  aDVcnu'nl 
11  vwry  day, 
itliftor.  N" 
oi  tlio  largo 
H)iiu'tiinos  to 
I  const  rioting 

I  arisos  from 
10  colon,  and 
iiothorV  milk 
ittor.  as  some 
foods.     Uoli- 
110  causo.     In 
lial)its  should 
matter  often 
Imjiairment 
inllammation, 
nical  ol)struo- 
1  causes. 
4,  ])articularly 
anted.     Kxer- 
on  with  peiiil- 
mdage.     Fric- 
chronio  cases. 
pounds,  whioh 
r  ten  minutes. 
}s,  particularly 
t  to  all:  hrown 
liquids,  water 
)lerfid  of  cold 
A  glass  of  hot 
after  breakfast 

rv  to  relieve  it 
liicy  should  ho 
dor.  Enemata 
hem  early  than 
}  form  of  su])- 
h'achm  of  borio 
lie  injections  of 


tepid  water,  with  or  without  soap,  may  be  use.l  for  a  ))rolonged  period  witli 
good  ciVect  and  witiioiit  damage.  'I'lie  patient  should  bo  in  tlio  dorsal 
position  with  tlie  hips  elevatcl,  and  it  is  be.-l  to  let  the  tluid  How  in  slowly 
from  a  fountain  syringe. 

The  usual  ivmetlics  employed  are  often  useless  in  tlie  constijiation  asso- 
ciated with  contracted  bowel."  A  very  .-^atisraet-uy  measure  is  the  olive-oil 
injection  as  recommended  by  Kussmaul.  'i'he  patient  hes  on  ihe  liaek  with 
tlie  hips  elevated,  and  with  a  caniuda  and  tui>e  from  L".  to  Vt»  ounces 
of  pure  oil  are  allowed  to  How  slowly  (or  are  injected)  into  the  liowel.  The 
operation  fliouid  take  at  least  (ifteoii  minutes.  This  may  lie  repeated  every 
day  until  the  intestine  is  cleared,  and  sul)se(iuently  a  smaller  injection  every 
few  days  will  sutlice. 

There  are  various  drugs  which  are  (d'  special  service,  jiartieulaiiy  the 
combination  of  ipecacnaidia,  mix  vomica,  or  bi'llailouna,  with  aloes,  rhu- 
barb, colocynth,  or  podophyllin.  .Meigs  recomiiiends  particularly  the  com- 
bination oi'  extract  of  l)ellatloiina  (gr.  ^»j),  extract  of  nux  vomica  (gr.  ', ). 
and  extract  of  colocynth  (gr.  ij),  one  pill  to  be  taken  throe  times  a  day. 
In  amemia  ami  chlorosis,  a  sulphur  confection  taken  in  the  morning, 
and  a  pill  of  iron,  rhubarb,  and  aloes  throughout  the  day,  are  very  service- 
aide.  ,      ,      •     • 

In  children  the  indications  should  I)e  met,  as  far  as  possible,  by  hygienic 
and  dietetic  measures.  In  the  constipation  of  sucklings  a  change  in  the 
diet  of  the  mother  may  I)c  tried,  or  from  one  to  throe  teaspoonfuls  of  cream 
may  be  given  before  each  nursing.  In  artificially  fed  children  tlu'  top 
milk  with  the  cream  should  bo  used.  Drinking  of  water,  barley  water,  or 
oatmeal  water  will  sometimes  obviate  the  dilllculty.  If  laxatives  are  re- 
([uirod,  simple  syrup,  manna,  or  olive  oil  may  bo  sullleiont.  The  conical 
jiieco  of  soap,  so  often  seen  in  nurseries,  is  sometimes  ethcacious.  Massage 
along  the  colon  may  l)o  tried.  Small  injections  of  cold  water  may  lie  used. 
Largo  injections  slionld  bo  avoided,  if  possii>lo.  If  it  is  necessary  to  give 
a  laxative  Iiy  the  month,  castor  oil  or  the  iluid  magnesia  is  the  l)est.  If 
there  are  signs  of  gastro-intostinal  irritation,  rhubarb  and  soda  or  gray 
powder   may   bo  given.     In  older  chililreii   the   diet   should   Ijo   carefully 


regulated. 


V.     ENTEROPTOSIS  (GlfnanVn  Diseasi'). 


Definition.—"  Dropping  of  the  viscera,"  visceroiitosis,  is  not  a  disease, 
but  a  svmptom  group  characterized  liy  looseness  of  the  mesenteric  and  ])eri- 
tonealattachmonts,  so  that  the  stomach,  the  intestines,  particularly  the 
transverse  colon,  the  liver,  the  kidneys,  and  th-  spleen  occupy  an  abnor- 
niallv  low  iiosition  in  the  abdominal  cavity. 

Symptoms  and  Physical  Signs.— It  is  important  to  recognize  two 
groups  of  cases.  In  one  the  splanchnoptosis  follows  tlu'  loss  of  normal  suj)- 
jtort  of  the  abdominal  wall  in  conse.|uenee  of  roiieiued  pregnancies  or  re- 
curring ascites.  The  condition  may  lie  extreme  without  the  slightest  dis- 
tress on  the  ]>art  of  the  itatient. 

The  second  and  most  important  group  occurs  usually  in  y(uuig  persons. 


,- 


! 


DISEASES  OK  THE   DIGKSTIVH  SYSTEM. 


* 


It„  pro..,,..  ,vitl,  ,„l.„.l,„.f"-.  "-  '"""-  "'  """^'  "  "*'  ■""*"'  ""'" 
i'ii--tlu'iii'»-  .■  .,     f  ,1...  •ihilomen  shows  a  vcrv  n-liixwl  ali- 

.Iniuinal  wall,  aiul  as  a  mk  tlu    "'^-    '         ;,.  ..^tiviue  cases  the  oulli.as  "f 
IV.ri.tal.is  ot  the  intestu.es  may  he  .-  ei..  '''  '    '  \*--'\\7i,,,,,^,i,,..  Uie  stu.uaeh 

,tony  IS  iK'.-t  >tu.lud    1       I    .  ^^^^^^^  sy.ni>tnn,s. 

l,er  is  that  it  .nay  ex.>l  m  *>",''"',""  "'......i^.^t  i,iot  ley  scries  of  cases,  ui 

I„  the  other  Kr-u])  .^  on.hraee.l  a    on  e.    a^^    -u  K    neurasthenic  hasis, 
^vhich.  with  a  pronunneea  nerv,>us,  or,  «^  ^^^'  '  ",^,,,^.       ,ionts  are 

there  are  cUsplaeenients  ot  the  --^  •;^  .  \,  ^  ''  ' ;,,  ,,,„„  ,>hit.  The 
nsually  younjr.  more  ire<,uen.  y  -'-*^"^.  ^  ;;'^;;,  ^  Tlu'-  conM-lain,  as  a 
e.uulition  may  loHow  an  acute  ■In...  m  1  _^^'      "-  ;,    ,,,,^',  ^.^  ,veak- 

,,.,e.  of  .Ivspepsia,  throhh.n-'  in  the  a  ulonu  n.  >  '  -"  I  - j  ,;,.,_  _^  ,,,, 
,,..  i„  the  hack,  ana  inahility  to  l"''''''''"'    '';^;      j    ^^^  the  hu.il 

.onsi.,eraiae  ,,ro,orti.,n  "';•;  ^f^^^^,  \:;  li^  ^"l-nit.on  one  notices 
lealures  ot  enteroptoM..     \\  ^/'.'V^^''^  f "  Tiir  the  ^cratch  of  the  nail  is  fol- 

,„,„„.  ,1,0  ,„„.,„„i  i,.v,.i.  «„.n„  -'••:";;;;  ;;x',.  A  r  i,,,.,,.!..;, 

'„,,„  „„-.,o„io-.oi., .,,.  •;;;:;•; !::;!' ,:,';;;;;;, ;;;. ...,,.  ,r,h,.„.i.n.  ..t 

tlisplaee.l  ri-ht  khlncv.  ,  ^^^  ,,^^,  ,,^,,,t  constant 

Xe,anoptosis,ora.s,.la  ennntol^H  ku  u.    ^^    to  .listin^uish  hetween 

,„,,„„n,na   m  onteroi.toM..     H   '^    ,    1. In  in' nintion-i-alpahle  ki.lney, 

,,,  ,,i,,ney  wliich  one  can  ju^t  t.n,ch  '-^^^^^^^^  .".n  leiends  so  that 

,„,  vhich  is  freely  movahle,  and  whieh  on  do  P     ■    >™  .^  ^^^^^^^^^ 

one  can  i^t  the  tinkers  of  the  V^f}''f^'^^^;''^,l  the  costal  arch, 
and.  thirdly,  a  iloatiri,  kidney.  ^  ^J^^^.^rll^^^  line  and  low 
is  easily  .gasped  in  the  l^-^^'^.'^.f  ^^  ^^1  Id  b  onie  that  the  desicrna- 
down  t.nvard  the  riirht  iliae  fo^.a  .^  '^f  "^  ,,  ^^  ,,|,ioh  there  is  a 
tion  fl..atin,  kidney  should  he  ^-'-t^J't^^^^  •\;^^V  extreme  .rades  oi  renal 
,,eso.nephron.  but  this  is  cxces^vdy    ^^^^^,^%,,,„  of  movable 

^;Ss.::^rS?s  c^ ami  l^nXnt  hydronephrosis,  .ill  be  con- 
i;-!;?^;ri:Je^':iS  in^:r 'S\i::  abdommal  wal.  it  i.  .  ve. 


■^'iu. 


w 


.0. 


o^.  \t>T.^. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


!.0 

in  III  28 

■  50      "'^= 

.^  IIIIIM 

If  IM 
I:  1^ 

>-   . 

I.I 

1.25 

1.4 

M 

12.0 

1.6 


Photographic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


L<y 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


vV 


-I 

4 


m 


m 


ENTEKOl'TUSIS. 


543 


.nmiii'in  iiiistiike  \um\vy  those  ciiviinistiinn-s  t(.  think  tlint  tlio  nv^im  is  v\\- 
huLivd.      l)i.-h>eati()U  of  the  liver  itself  will  he  considered  later. 

.Mnhiliiy  id'  the  spleen  is  sometimes  very  marked  in  entero|.t(i>i>.     Jii 
"  ;ra(K'  it  niav  lie  I'nund  in  almost  any  regiini  nf  ilu'  ahdomeii.     It 


:ui  rxtreme 


ral 


)ie 


i>  verv  fre(|nentiy  mistaken  for  a  til)roid  or  ovarian  tmnor.     A  consider; 
|,roi»irtion  of  the  eases  eume  tirst  under  the  care  of  the  }:yneeolo-rist. 

Tlivre  is  usually  mueli  relaxation  cd'  the  mesentery  and  <d'  the  jieritoneal 
f,dds  whieh  suiiport  the  intestines.  The  eolon  is  displaced  downward  (eo- 
|,,i,tosis),  with  consetiuent  ki-dvin.u'  at  the  lle.xnres.  The  descent  may  he  so 
low  that  the  transverse  colon  is  at  the  hrim  (d'  the  pelvis.  It  may  indeed 
he  fixed  or  hent  in  the  form  of  a  V.  It  is  frequently  to  he  felt,  as  Ulenard 
states,  as  a  firm  cord  crossin,!;'  the  ahdomen  at  or  helow  the  level  of  the 
iia\el.  This  kinking  may  take  jilaee  iu)t  only  in  the  colon,  hut  at  the 
pylorus,  wiiere  the  .'uodenum  i>asses  into  the  jejunum,  and  where  the  ileum 
riili'rs  the  c;ecuni. 

The  explanation  of  the  piuMiomena  accompanying  enteroptosis  is  hy  no 
means  easv.  It  has  been  suggested  l)y  (^lenard  and  others  that  the  vascular 
di-tuihaiu'cs  in  the  alidominal  viscera  in  consequence  of  displacements 
und  kinking  account  for  the  feelings  of  exhaustion  and  general  nervous- 
iu>s.  in  a  large  ])roportion  of  the  cases,  however,  no  symptoms  develop 
until  alter  an  illness  or  some  jirotracted  nervous  strain. 

Treatment.— In  a  majority  of  all  cases  four  indications  are  itresent: 
To  treat  the  existing  neurasthenia,  to  relieve  the  nervous  dyspepsia,  to 
overcome  the  constiinition,  and  to  atford  mechanical  suiijtort  to  the  organs. 
Three  (d'  these  are  considered  uniU'V  their  apiirojiriate  sections.  In  cases  in 
which  the  entero])tosis  has  followed  loss  in  weight  after  an  actite  illness  or 
worries  and  cares,  an  inipiutant  indication  is  to  fatten  the  ])atient. 

A  well  adapted  abdominal  bandage  is  cme  of  the  most  important  mea.s- 
ures  in  enteroptosis.  In  many  of  tlu'  milder  grades  it  ahnie  sulHces.  I 
know  of  no  single  simple  measure  which  alfords  relief  to  distressing  sym])- 
toms  in  so  many  cases  as  the  abdominal  iiandage.  It  is  best  made  of  linen, 
should  fit  snugly,  and  should  be  arranged  with  strajis  so  that  it  cannot  ride 
uji  over  the  lii])s.  A  s]iecial  form  must  be  used,  as  will  be  mentioned  later, 
for  movable  kidney.  Some  of  the  more  aggravated  tyjies  of  enteroptosis  are 
eomhined  with  such  features  of  neurasthenia  that  a  rigid  Weii'  ^litchell 
treatnii'iit  is  indicated.  In  a  few  very  refractory  cases  surgical  interference 
may  he  called  for.  Treves,  in  AlUmtfs  System,  records  two  cases,  one  in 
which  the  laparotomy  was  resorted  to  as  a  medical  measure  with  ]ierl'ect 
results.  In  the  other  the  liver  was  stitched  in  place,  and  comidete  recovery 
foUoweil. 

And  lastly,  the  physician  must  be  earef\il  in  dealing  with  the  subjects 
of  enteroptosis  not  to  lay  too  much  stress  on  the  disorder.  It  is  well  never 
to  tell  the  patient  that  a  kidney  is  movable:  the  symptoms  may  date  from 
a  knowledge  of  the  exiiteuce  of  the  condition. 


ill 
111 


544 


DISKASES  OP  THE   DlftESTlVE  SYSTEM. 


VI.    MISCELLANEOUS  AFFECTIONS. 

1.    MUCOUS  COLITIS. 

This  nflVeti.ni  is  known  l.v  various  nanies,  such  iis  ma„hrauous  entenlh, 
lubular  diarrhuv.  an.l  m«ro.,s  colir.     It  is  a  ivnuirkabh"  disease,  to  wh.di 
„Hu.h  attention  has  been   paid  for  several   eenturies.     An  oxhaust.vo  do- 
Kvintion  of  it  is  j,nven  l,y  Woodward,  in  vol.  ii  of  th.  Me.hcal  and  ^urgu.al 
Heilorts  of  tlie  Civil  War.      It  is  an  aiVeetion  of  the  large  bowel,  charaeter- 
izod  bv  the  production  of  a  very  tenacious  adherent  mucus,  which  may  bo 
pass,..f  in  long  strings  or  as  a  continuous,  tubular  membrane.   /  >'";^'/";;;^; 
|,„1  opportunities  oi  .eeing  this  membrane  in  ,.</»,  closely  adherent  to    ht 
nnico'a  of  the  colon,  but  capable  of  separation  without  any  lesion  ul  the 
Mirface      .lud-ing  from  the  statement  of  English  authors  as  to  its  rarity, 
it  would  appear  to  be  a  more  fre^iueut  disease  in  this  country,  m  which  it 
\r,<  been  .'arefullv  studie.l  by  Da  Costa,  Kdwards.  and  others.     A.'cor.l.ng 
toHdwanls,  80  ^\vv  cent  of  the  recorded  adult  c-ases  have  been  in  women 
It  occurs  occasionally  in  children.     Of  111  cases  (1  were  under  the  ago  ot 
ten      The  cases  are  almost  invariably  seen  in  nervous  or  hysterical  women 
or  in  men  with  neurasthenia.     All  grades  of  the  atfoction  oc.ur,  irom  tho 
l,a.sa.ve  of  a  slimy  mucus,  like  frog-spawn,  to  large  tubular  casts  a  loot  or 
Lore^in  length.  '  Mic.rosc.oi-ically  the  cists  are,  as  shown  by  Mr  Andrew 
Clark    not  iibriiious,  but   ,mu...id,  an<l  even  the  lirmest  consis    of  dense, 
opaque,  transformed   mucus.     The  nature  of  the  disease  has  been   much 
di<cu-ed      It  is  i)robal.lv  not  an  enteritis,  but  a  secret mn   neurosi..     Jn 
favor  oi  this  view  is  tho  large  proi.nrti<.n  ..f  crises  in  neurotic  women. 

Symptoms. -The  disease  persists  for  years,  varying  e.xtremely  f.om 
time  to  time,  and  is  characterized  by  paroxysms  ot  pain  in  the  abdomen, 
ml  noss,  o  casionally  tenesmus,  and  tlio  passage  of  Hakes  or  long  strings 
^"m:c:s,  sometimes  of  deiinite  casts  of  the  boweh      Phere  -     -p.enUy 
a  spot  of  great  tenderness  Just  between  the  navel  and  the  leit  co.  al  b  .       . 
The  attacks  last  for  a  dav  or,  in  some  instances,  lor  ten  days  or  two  week>. 
'    ma        0  mns  and  worry  of  any  sort  seem  particularly  apt  to  bring  on 
m  attack.     Occasionallv  errors  in  diet  or  dyspepsia  precede  an  outbreaL 
i  embranes  are  not  passed  with  every  paroxysm,  even  when  the  ,.,ns  a  d 
cramps  are  severe.     There  are  instances  m  which  the  mor     la  habit  lia> 
l;!r  contra,  ted  on  account  of  the  severity  of  the  paui      'bore  may  ho 
,„arked  nervous  svinpfnis.  and  authors  mention  hysterical  outbreaks,  hypo- 
,.i,ondriasis,  and  melancholia.     lUood  may  be  passed  m  rare  mstaiuo      1  he 
;.;;,:ii,,.n  may  persist  for  years  and  load  to  great  emaciation  an     chrome 
invalidism.     Constipation  is  a  special  feature  in  many  case>.     1/  ''   '"^'^^' 
Hies  that  he  know  of  three  cases  of  mucous  colitis  ,n  w!r,<  i  doa  h  had  sud- 
;     ;,v  occurred,  in  all  with  great  pain  in  the  left  side  of  the  abdomen.     In 
another  case  there  was  an  abscess  in  tho  region  of  the  descending  <.o lo   . 

The  ,li<vwnsis  is  rarelv  d.nihtful.  hut  it  is  imi.ortant  not  to  lm^take  the 

,„,,nbranes  for  otluT  substances;  thus,  the  external  cuticle  of  asparagus 

d  undioested  portions  of  meat  or  sausage-skins  sometimes  assunic  forms 

not  unliiro  mucous  easts,  but  the  microscopical  examination  will  quickly 


~'J, 


MIS( 'KLLANE< )rs   AFFK( 'TI< )XS. 


545 


ililTorcntiate  IIhmii.     Twice  I  liavc  kiioun   mucous  colitis  with  sovcro  pain 
to  lu'  mistaken  for  iipiieiidieitis. 

'I'he  Iri'iihin'nl  is  very  unsatisractory.  I)i'U,us  are  of  doulitl'ul  tieiielll. 
treasures  directeil  to  the  nervous  eoii<lilion  are  |iei-haj)s  most  im|iortaiit. 
Sometimes  hual  treatment  with  Kelly's  lon,u-  fcctal  tul)es  is  henclicial. 
Hall'  White  fecommcnds  in  very  ohstiiiate  cases  in  which  lii'e  is  a  liurdeii 
rij:iit  iiiiiuinal  colotomy.  This  has  been  ]ierl'orme(l  with  success  now  in 
several  ca<es.     The  artiheial  anus  should  remain  open  for  some  time. 


II.     DILATATION  OF   TIIF  COLON. 

Hale  White,  in  Allluitt's  System.  i-ecoj,niizes  four  e-poups  of  cases, 
in  the  lirst  the  distention  is  entirely  jraseous.  and  occurs  not  infre(piently 
as  a  transient  condition.  Jn  many  cases  it  has  an  important  inlluence,  inas- 
much as  it  may  he  extreme,  pushiiijr  up  the  dia[)lii'agm  and  seriously  im- 
pairinj:  tlu'  action  ol"  the  lu'urt  and  lungs.  Jl.  Fenwiek  has  called  attention 
to  this  as  occasionally  a  cause  ol'  sudden  heart-failure. 

In  the  second  group  are  the  cases  in  which  the  distention  of  the  colon 
is  caused  hy  solid  suhstaiices,  as  fa'cal  matter,  occasionally  by  foreign  bodies 
introduced  from  without,  and  more  rarely  by  gall-stones, 

Jn  a  third  group  are  emi)raced  the  cases  in  which  the  dilatation  is  due 
to  an  <'rganic  oi)structioii  in  front  of  the  dilated  gut.  I'lider  these  circum- 
stances the  colon  may  reach  a  very  large  size.  These  eases  are  conimon 
enough  in  malignant  tumors  and  sometimes  in  voh-uhis.  Dilatation  of  the 
sigmoid  ilexure  occurs  particulai'ly  when  this  portion  of  the  i)owel  is  coii- 
genitally  very  long.  In  such  case>  the  bowel  may  be  so  distended  that  it 
jcupies  the  greater  part  of  the  abdomen,  ]iushing  up  the  liver  and  the 
diai)hragm.  An  acute  condition  is  sometimes  caused  liy  a  twist  in  the 
nieso-colon. 

Fourthly,  there  arc  the  cases  of  so-called  iJinpalhir  iJlhilnHon  of  flu; 
ciijon.  The  condition  has  been  very  carefully  studied  by  h'olleston,  ('.  F. 
^lartin,  and  others.  I  have  had  four  well-marked  instance-  under  my  care. 
Treves  suggests  that  the  condition  is  always  due  to  a  narrowing  low  down  in 
the  colon.  This  |)roved  to  be  true  in  Case  11  of  my  scries,  a  boy  who  died 
at  the  age  of  about  two  and  a  half  years.  There  was  a  distinct  stricture  in 
the  sigmoid  ilexure.  In  the  idio])athic  chronic  form  the  gut  reaches  an 
enormous  size.  The  coats  may  be  hypertrophied  without  evidence  of  any 
s|)ecial  (U'ganic  change  in  the  mucosa.  The  most  remarkalde  instance  has 
been  rcp(H'ted  by  Formad.  The  ])atient,  known  as  the  "  balloon-man,"'  aged 
twenty-three  years  at  the  time  of  his  death,  had  had  a  dist  ided  aixloinen 
from  inhmcy.  Post  mortem  the  colon  was  found  as  large  as  that  of  an  ox, 
the  circtunference  ranging  from  1.')  to  ;i()  inches.  The  weight  with  the  con- 
tents was  4T  ])ounds.  The  condition  is  incurable,  and  surgical  interference 
should  be  proliably  the  only  measure.  In  one  of  my  cases  good  results  I'ol- 
l(»wed  the  establishment  of  an  artificial  anus,  but  the  most  brilliant  case 
is  that  re])orted  recently  by  Treves,  who  excised  the  greater  part  of  the 
colon,  with  recovery. 


540 


DISEASES  OF  Till'.   DKiESTIVE  SYSTEM. 


HI.     INTESTINAL  SAND. 
"  ^„/>/.  Inh  '/,K,r-l'.ninrv  ^niv.!  nn,y  he  pns..-l  in  hn',o  npvmnt.  and 

r:-S;;;:''^:;:;r:;;:;-,;:r;^::t- 

iiKittcr. 

IV.    AFFECTIONS  OF   THE   MESENTERY. 

TluTO  arc  varion.  di.oa.es  ..f  the  structure  cn.hraecd  in  the  n.escnterv, 
^vhi.■h  are  of  ninre  or  less  in.iH.rtance.  i,u,,„liu-  is  «^on- 

1 1 ,  H«rhage  <".""-'";;'-):-;';::;;-,:,:       ^ ;  uV  Lliutiou  u 

J:^:;   ^iin^-hSn^mral-  n  ^f  the  .aucreas  an^  .ith  ... 
;:,.it::eal  ha.,norrha,e.     It  occurs  in  rupturj.  ;;----,   1^     /t.: 

ivtro-peruoncal   tissue.  "   '^'f  Vu     o    the  celiac  axis  or  of  the  meson- 
i„esenteric  vessels  are  l.loclscd  1a   cm  ho,  occlusion  of  small 

-■'■'-',/;:!::;;;!;i;r':;"™!;i;::i-"i  "''■-"' >■"•■": 


,u.;..utcric  artery  is  bloekcl.  a  serious  an.Uatal 


^.itaS.li.he.l.     Tf  tlH.  superior  ";"^'""";;;:;:  ;;,;,;;  ^^aor'jnv  oUservation.     lu 

autopsy  showcl  ,-reat  cou.uotiou.  ^^'^'\'     ''      ."  '     ^^..,,  ,,,„,,,,,-,  ,t  its  orifice 

.,1  n.nmi      The  superior  im'seuteric  aitei>  \\a.   oioi  is 
i:r;  fi  u/      "mluls      in' the  second  ..e,  a  ..nuau  a.ed  -venty-hve  wa 

sei.;.l  with  s,.vere  ahd inal  l^ji-^l^;:   j;^ r^l.tnl^^^^   w;^^ 

^vas  diarrluea:  suhse.,uent  y  the  ^>"  V  '";^^  "  ,,„,,^,,,,  ,,,,„,,a  the  .mall 
,n.at  distention  of  I  e  ^^^''^-.^/Vfl'-unu  and  the  last  six 
howel,  with  the  exception  ot  the  iu^t  loot  oi         ,|  j 


nit,  lUiil 
ry  luun- 
iburrous 
.yinatous 
was  in- 
liiive  ro- 
:'()nsi(l»'i'- 

Ul'     SlUilll 

^•ogctable 


icsL'ntorv, 

l<r    is    COIl- 

iditiou  is 
itli  rctrn- 
icr  (if  the 
lilt  forms 
in  wliom 
Hospital, 
1(1  (il)st'iire 
ration.     I 
y  and  tlie 
ro  was  no 
he  meson- 
Icatli  in  a 
)-eolon. 
(soi."    under 

■When    tlu' 
tion  of  in- 
in  of  small 
may  ')•'  rt'- 
is  and  fatal 
vation.     In 
tin<r.  wlii(.'Ii 
iinon.  tvni- 
a^fal.     Tho 
of  tlio  jej"- 
it  its  orifice 
nty-five  was 
t  first  there 
iction,  with 
:1  tlic  small 
the  Inst  six 


MISCELLANEOUS  AFFECTIONS. 


541 


inehes  of  llie  ileum,  greatly  disteudod  and  deeply  iiilillratcd  with  blood. 
'I'he  nies(.'iitery  was  also  coiifrested  and  infiltrated.  The  supt  rior  mesei  • 
teric  artery  contained  a  firm  lirownish-yellow  clot.  There  were  many  re- 
cent wartv  veiictations  dii  the  mitral  valve,  in  liie  third  case,  a  man  aged 
tiiity  was  suddenly  >eize(l  with  intense  pain  in  the  aiidomen,  became  faint, 
fell  "to  the  jiniuiui.  and  vomited  Kor  a  week  he  iiad  persistent  vomiting.', 
severe  (liarrJKea.  tympanites,  and  <.Mcat  ])ain  in  the  at)domen.  The  stools 
were  ihiii  and  at  times  idood-tinp'd.  Tiie  autojisy  showed  an  aneurism 
involving  the  aorta  at  the  diai>hragm.  The  superior  mesenteric  artery,  half 
an  inch  from  its  origin  (Hi  the  sac,  was  bhicked  by  a  portion  of  the  fibriiuuis 
clot  (d'  the  aneurism.  Watson  has  analyzcil  the  symptoms  in  -j;  eases;  in 
IS  there  was  jiain,  usually  ((dicky  and  violent;  diarrhiea  occurred  in  II; 
vomiting  in  If;  and  abdonunal  distention  in  1-'.  Jn  a  majoiity  of  the 
cases  the  heart  or  the  abdominal  aorta  was  diseased.  In  one  sixth  of  the 
cases  the  lesi(Hi  was  limited  enough  to  have  permitted  the  successful  re- 
section (d'  the  bowel.  .1.  W.  i'^lliot  has  operated  upon  two  cases  of  in- 
farction of  the  bowel,  in  one  of  which  (thrombosis  uf  the  mesenteric 
veins)  he  successfully  resected  forty-eight  inches.  In  the  horse,  infarcti(jn 
of  the  intestine  is  extremely  common  in  connection  with  the  vernnmnis 
iincurisni>  (d'  the  inesenterie  arteries,  and  is  the  usual  cause  of  colic  in  this 
animal. 

(:>)  Diseases  of  the  Mesenteric  Veins.— Dilatation  and  sclerosis  occur  in 
cirrhosis  of  the  liver.  In  instances  nl'  prolonged  obstruction  there  may 
be  large  saccular  dilatations  with  calciliealion  of  the  intinia.  a.-  in  a  (a>e  of 
obliteration  of  the  vena  porta'  described  by  me.  Suppuratioti  <d'  the  mes- 
enteric veins  is  not  rare,  and  occurs  u>ually  in  connection  with  ]iylephlebitis. 
'I'he  mesentei'v  may  be  much  swollen  and  i.-  like  a  bag  (d'  pus.  and  it  is  only 
on  careful  dissection  that  one  sees  that  the  ]nis  is  really  within  channels 
representing  extremely  dihited  mesciiterie  veins.  Two  uf  the  three  cases 
1  have  seen  were  in  connection  with  local  aiipeudix  abscess. 

(I)  Disorders  of  the  Chyle  Vessels. — ^'ari(■ose,  cavemons,  and  cystic 
(hvlangiomata  are  met  with  in  the  mucosa  and  suhmucosa  of  the'  >mall  in- 
testine, occasionally  of  the  .'^tomacli.  Extravasation  of  cliyle  into  the  n\v>- 
enterie  tissue  is  somelimes  seen.  Chylous  cysts  are  found.  1  s.-iw  one  tlu' 
size  of  an  egg  at  the  root  of  the  mesentery.  IJramann  record-  n  ca^e  in 
a  man  aged  sixty-three,  in  which  a  cyst  of  this  kind  the  size  id'  a  child's 
head  was  healed  by  operation.  Tliere  is  an  instance  on  re(>ord  of  a  con- 
genital malformation  of  the  thoracic  duct,  in  whi(di  tne  rece|)taeuliini 
formed  a  flattened  cyst  whi(di  discharged  into  the  jieritona'Um.  and  a  chylous 
ascitic  tlnid  was  withdrawn  on  several  occasicms.  lioT'ians,  of  liostoii.  re- 
ports an  extraordinary  case  <d'  a  girl,  who  from  the  third  to  the  thirl(.'enth 
year  had  an  enlarged  aljdoincn.  Laparotomy  showed  a  series  of  cysts  con- 
t.dning  clear  fluid.  They  were  sujiposed  to  be  dilated  lymph  vessels  ( on- 
iiected  with  the  intestines. 

(."))  Cysts  of  the  Mesentery.' — ^luch  attention  has  lieen  directed  of  late 
years  to  the  occurrence  of  mesenteric  cysts,  and  the  literature  which  is 
fully  given  by  Delmez  (I'aris  Tliesi'^,  ISUI)  is  already  extensive.  'I'hey 
may  he  either  dermoid,  hydatid,  serous,  sanguineous,  or  chylous.     Tlu'y 


9 

i 


i 


■i 


548  DISKASKS   OF   TllR   DIUKSTIVK   SYSTEM. 

r  ti  ,>  lULvctiti'i'v    mill  ranirc  fi'om  a   I'rw   incluT:  in 
(RC-ur  iit  iuiY  iw.rlion  <>1  the  nu'Mimi>,  .111  i  i.n 

.li.mu.trr  tc  lam>  luMsses  ..c.ui.vin-  tho  eutn-f  al..l.>i.u.n       IIh'N    au    lu 

;;;;;:;;;;;  ^nlhon'nt  t..  ,1...  ,...1,1,1.;.:...,  „,,„„,  t..  u..  uv..-,  s,k..,  utcr...,  a.,a 

^'^'tI;;!  XL.  usually  an.  tl.o.o  of  a  ,rogn.s.iu.ly  -^-'K-^,^--^;;; 

,1,0  alKlon.c.  Son.otin.os  a  „.ass  develops  rain.lly,  i.a.-tu.ula,ly  n.  tho 
'  ,no.Ti.a.Mc.   l'orn.s.     Colic   an<l   constii-atiou   a.v   vr.s.„t   ,n   so.no   .  .e.. 

T,  \rn.l  l.ealth.  as  a  ruU-.  is  well  maintaincl  ...  sp.to  ol  the  progn.- 
i"  e        ,:'......t  of  tho  alKlo.,.o,..  which    is  u.ost   ,n.o,n.uout   ,„   the  u,m- 

limc-al  l;;;on.     Mcse..te,.io  cysts  a..ay  persist  for  .,.a,.y  years,  eve..  to.>  o. 

'"'The  .lia.n,osis  is  oxtromelv  utu-ertain.  and  uo  si,t,lo  feature  i.  in  a.,y 
,,,v  ^^t     K  ve      At„a.tu.ur  Vivos  three  in.purtat.t  s.gns:  tho  great  n.o- 
,;      ::  ^luation  ,;  the  tnid-llo  lino,  and  the  zone  "^y-l-y  -/- 
of  til  >  tumor.     Of  these,  the  seeond  is  tho  only  one  ^vl„ch  i.  at  a  1  c  . 
tnn     as    vhon  tho  t..n,..rs  are  largo  the  mol.ility  disappears,  a.id  at  tl... 
'tlio       estiuos,  too,  are  vushed  to  one  side.     Jt  is  most  freeinently  nus- 
;;n  f  r  m)rian    nmor.     llovahlo  kidnoy,  hydronephrosis,  atid  cysts  ot 
t;;,,!:::,.;  have  al.,  heen  c<.nf...d  .itli  it.     ^^  -;^X::^:^:v:^ 
t,n-e  mav  ho  made  for  diagnostic  ,mrp..ses.  hut  .t  ..  hotte.  to  a.l   ..  a 

r!!tomy  for  tho  purpose  of  drainage,  or,  if  poss.hlo,  eiiucloat.on  may  ho  piac- 
lised. 


Yin.    DISEASES  OF  THE  LIVEIl. 

I.    JAUNDICE  (A7"«.s). 

Deflnition.-Taundico  or  ictcMn.s  is  a  condition  ehai-actorizoa  l.y  col- 
.,,,^:^:f'Se^i.,.  u,..cous  me.nh..ane<.  and  iluids  of  tho  hody  by  tho  Inle- 

^"^'1-;^';  full  eon^doration  of  the  theories  of  jaundice  tho  reader  is  referred 
t„  Wnulm  liu.ue.--s  article  in  Allhntfs  Systen,  of  Modtcme.  Iho  case, 
xvith  icterus  may  he  divided  into  two  groat  groups. 

1.  OiisTurcTivi:  JAtNincK. 

The  followin-^  classificath.n  of  the  causes  of  ol.structivo  jaundice  is  given 

,      A.       ,      n      in  Oh-truc.tion  hv  foreign  bodies  Mithm  the  ducts,  as  gall- 

•    ^  ;,  it         ••      V    .  llaniniato;-  tumefaction  of  tho  duodonum  or 

„.,nes  and  pa.a>.t.>,  (O  '>        '  •,     ^^  j^.^^,,,,  ,„  ohliteration  of  the 

r.f  tlH>  lin  u"- niemhrano  ot  tho  duct.  (.5;  o_\  i^uiLiui^ 

,  V  tumors  closing  tho  cuMilco  of  tho  duct  or  growing  m     .    n    - 

Am.;  „re.<nro  on  tho  duct  from  with(mt,  as  1)y  tumors  of  tho    i\oi 

;^:;:,;:^:io];      Fur  this  view,  however,  there  is  no  postttvo  evtdonce.     In 


JAUNDICK. 


r.49 


lliis  cliiss  iniiv  pcrliiiiis  lie  placed  \\\v  cum's  of  jaundice  fnnn  mental  shock 
„r  (jei.ressed  Vniuti.ins.  wliieh  "•may  c(.nceival.l;-  cau-e  .-|.asin  ami  reversed 
iHTistalsis  ol'  liie  iiile-duct  "  (W.  Ilnnter). 

(irnrriil  Siiniptnms  of  ()h.<lrurlirr  .1  utniillrv.—(\)  Icterns.  or  tintinc:  <d 
the  ^kin  and  conjunctiva'.  The  color  ran-es  I'rom  a  lenion-vellow  m  eatar- 
,.|,al  jaundic.'  to' a  dee].  olive--reen  or  hrouzed  !uie  in  |iernianent.  oh>trut- 
tion.'  in  some  instances  the  color  of  the  skin  is  niveiiish  hlack,  the  so- 
called  '•  hlack  jaundice."  . 

(■>)  Of  the  other  cutaneous  svuiptoms.  pruritus  in  the  more  ciironic  lorms 
,uav  he  intense  and  cause  the  "f^MTatest  distress.  It  nu.y  precede  the  onset 
„f  the  jaundice,  hut  as  a  rule  it  is  not  very  nuirked  e.vcept  \\\  eases  .d  pro- 
Inn-cd'oii-^truction.  Sweating  is  common,  and  may  he  curiously  localized 
to  tlie  ahdomen  or  to  the  palms  ,d'  the  hands.  Lichen,  urti.aria,  and  hoils 
may  develop,  and  the  skin  di.easi  known  as  xanthelasma  or  vitili-oidea. 
The  iaundice  mav  he  due  to  the  extension  of  the  xantleiuata  to  the  oile- 
pa-<a'.'-es.  The  v'isceral  localizati(.n  of  this  disc.rder  has  heen  chielly  ob- 
served when  there  are  numerous  punctate  tubercles  ..n  the  limbs  (llallo- 
l,eau)  In  very  chronic  cases  telan<,nectases  .levelop  in  the  skiii,  sometimes 
in  lar-M.  numbers  over  the  Imdy  and  face,  oecasionallr  ..n  the  mucous  mem- 
brane (d'  the  ton.irue  and  lips,  fornunjr  patches  of  a  bright  red  eohu'  Irom 
1  to  'I  cm.  in  breadth. 

(:i)  The  secretions  are  ccdorod  with  bile-pigment.  I  he  sweat  tinges 
•the  linen;  the  tears  and  saliva  and  milk  are  rarely  stained.  The  expectora- 
tion is  not  often  tinted  unless  there  is  intlammatioii,  as  wheu  pneumonia 
coexists  with  jaundice.  The  urine  may  contain  the  pigment  hefore  it  is 
ai.pareiit  in  the  .-kin  or  eonjnnctiva.  The  color  yaries  fnmi  light  greeni.-h 
yellow  to  a  deep  black-green,  (imelin's  test  is  made  by  allowing  iiye  or 
six  drops  of  urine  and  a  similar  amount  of  c(unmon  nitric  acid  to  How 
together  slowly  on  the  flat  surface  of  a  white  idate.  A  play  of  colors  is 
,,n„l,„.e,l— various  shades  of  green,  yellow,  violet,  and  red.  In  eases  (d 
jaundice  (d'  hmg  standing  or  great  intensity  the  urine  usually  cuitams 
albumin  and  always  bile-stained  tube-casts. 

(4)  No  bile  ])asses  into  the  intestine.  The  stools  therefore  are  ot  a 
jialo  drab  or  slate-gray  color,  and  usually  very  fetid  and  ].asty.  There 
may  be  constipation;  in  many  instances,  owing  to  decomposition,  therc^  is 

diarrlnea. 

(.-.)  Slow  juilse.  The  heart's  action  may  fall  to  10,  ;{0,  or  even  to  .0 
p,.r  minute.  It  is  imrticularly  noticeable  in  the  cases  of  catarrhal  jaundice, 
and  is  not  as  a  rule  an  nnfavorable  sympt.mi.  The  respirations  may  fall 
to  10  or  even  to  T  ]x>r  minutt'. 

(C))  nivinorrha-e.  The  tendency  to  bleeding  in  chronic  icterus  k  a  se- 
rious feature  in  s.ime  cases.  It  has  been  shown  that  the  blood  coagidation 
time  mav  be  much  retarded,  and  instead  of  from  three  minutes  and  a  half 
to  f(Hir  mtnutes  and  a  half  we  have  found  it  in  some  cases  as  late  as  eleven 
or  twelv"  minutes.  This  is  a  i-oint  which  should  be  taken  account  of  by 
surgeons,  inasmuch  as  incontrollable  Incmorrhage  is  a  well-recogmml  acei- 
deiU  in  operatintr  np<ui  imtients  with  chronic  obstructive  jaundice.  I'ur- 
]uira,  large  subcutaneous  extravasations,  more  rarely  haemorrhages  from  the 


If! 

i 


i 


550  Dli^EASES  OF  TnE  DIOKSTIVR  SYSTEM. 

nuu-m.  ,m.n1,ran..s,  oc<ur  iu  prutnu-t.-l  j.un.Ucc,  and  m  ih.  .u.-re  ...v.re 

0      a    a.  .,.  .l..liriuu,,  ur  convulsion,     rsually  the   vatu..    L-  .y        1 

,    ;   sl..l,t  t.v..r.  an.l  a  dry  ton^n..  and  l..  ,.,».s  nUo  .1,,.  so-..lK.d      t  - 

;  i  .„u..."     Tlu..  Icatun.  a.v  no,  n.arly  h,  .onnnon  u.  '''"tnuU  .    . 

',„,,,  j,„„„,i,.,  ,„„  tl.oy  not  inimi>H'ntly  tcrnnna,.  a  c-Ln-nu-  ..ton.. 

..l.a,.v;.r  .av    prodn.-.d.     'VU.  ,ronp   ol'   syn.^nn,.   ha.   I...n    ,.    m,  1 

llL  or.  on- til  snpposition   that   ehol.st.nn   >s  .h.  l-;'-;  ;^';  ^  - 

,,,./.;  hut  its  true  natuiv  has  not  y^^  larn  ck.tc.vniincd.     In  .uu.t  ul  tlu 

cases  the  symptoms  may  ho  due  to  nra'nua. 

2.  Tox-T-Mtr  JArN-nirK. 
I„  thi<  fonn  then.  i.  no  ol.tru.-tiou  in  the  hde-passa^es.  hut  the  jaun.liee 

is  a  U'd  .ith  toxK.  states  ef  the  hi 1    dependent  upon  v-'--  r- 

vhieh  either  aet  direetlv  on  the  bluod  it.ell'  or  ,n  ^o,ue  ea.e.  em  the  1. u 
:         "w      .     The  tern,  !uen,ato,e„ou.  .jaundiee  was  lorn-erly  apphed     o 
u       roup   in   eon.radi.t.nelion   to  ,he  hepatogenous  .aundu-e    a..oe      ed 
lluh^lhstnu-tive  changes  in  the  bile-passages.     Jlnnter  group-  the  can.. 

"'  ^l'^ lundiee  produced  hv  the  action  .d  poisons,  su.-h  as  toh.ylen.luunin, 

'''''?';i;;:;;;H;:rt':ui>;n'v;: 

vellow  lever,  malaria  <renu,tent  and  intermUlen,).  pya^nia.  lelap.mg  icxc 

,„;:;,;':::;;/inrective  nature,  and  variously  ''<-^';;-^  .^  ^^i^^r^-^l^td: 
tiuus.  Ichrile.  n.alignant  janndico,  icterus  gravis,  \\ed.  disca.c,  acutt  yi 

'^^i'l;:!;vmpton>s  of  toxic  Janndico  are  not  nearly  ..  striking  as  in  tho  oh- 
struc    V   ^     ivtv      The  hile  is  usually  present  in  the  stools,  sonietmu.  in 
^   :<       a      n^Verv  dark  movements.     The  skin  has  in  many  -- -^^  ^ 
■!mic  non  tint,  'm  the  severer  forms,  as  in  aente_  yellow  ''^[-nj    • 
nor    n'  •  ho  more  intense,  hut  in  malaria  and  pernicious  ana.,nia  the  tint 
u  n-     V  Ih  lit      In  these  mild  cases  the  urine  may  contam  l.tt  e  or  no  luU^ 
i  !ne  t    bu      he  nrinarv  pigments  are  considerably  increased.     In  nia 
ei<  Stle  toxic  varietv  ihe  constitutional  disturbances  very  proto 
and'tlte  L  high  fevei-  delirium,  convulsions,  suppression  oi  urine,  black 
vniiiit    and  cutaneous  ha'niorrhages.  . 

C        n  o^on  with  the  various  fevers,  malaria,  yellow  fever,  and  ^^e  Is 
in  (onnu  ion  ^       ,-,,^,-|      rp„.^  .^.p^ial  alVoctions  may  here  re- 


ACUTK  YELLOW   ATliOlMlY. 


551 


■cvcre 


fVfll 


11.    ICTERUS   NEONATORUM. 

\i.\v-l)orn  i.il'ants  aiv  lialilc  to  jaundico.  wliicli  in  soiiio  instaiurs  rapidly 
nvovcH  fatal.     A  mild  and  a  m'Vciv  Iniiii  may  he  rocojiiiizcd. 

The  wild  or  iihiisiulo,iinil  irli'Viis  ol'  tlu'  iicw-liorii  is  a  coimndii  disi'a-c 
111  luimdiinir  hospitals,  and  is  not  very  intrcinml  in  private  practic'.  In 
•  Kill  constrntivc  l.irths  at  tlic  Sloane  Matrrnily.  ictmis  was  notrd  in  :itM) 
niMS  (il(dt).  Thf  discoloration  ajipcars  raiiy.  u>ually  .ni  the  lir^t  or  scc- 
,,'nd  (lav,  and  is  of  moderate  intensity.  The  urine  may  lie  Inle-stained  mid 
the  lares  cidorless.  'I'he  nntrition  of  tlu'  ehihl  is  not  nsiially  dist  nrl.e.i, 
,„„1  in  the  majoritv  of  eases  the  jaundiee  disappears  within  two  u.rks. 
Thi<  form  is  never  fatal.  The  cause  of  thi>  jaiindue  is  not  at  all  clear. 
Some  hav  attrihuted  it  to  stasis  in  the  Miialler  liih-<liicts.  which  are  eoui- 
pre^^ed  hv  the  distended  radicals  of  the  j.ortal  vein.  Others  hoM  that  the 
j;niiidice  is  due  to  the  destruction  of  a  lar-e  niinihir  of  red  l)lo,,d-cnr|aiscles 
diiritii:  the  first  few  davs  after  hirth. 

TJie  snrrc  form  oi  ictervs  in  ihe  new-horn  may  dep*'"''  >il""i  <"'  '""- 
.'cnital  aoseiice  (d'  the  conmion  <«r  hcimtic  duet,  of  which  tluMv  are  several 
mstances  on  record;  (/-)  e(mnenital  syphilitic  hepatitis;  and  (r)  ,<eptic  poi- 
sonin'T.  a.ssoeiate'  with  jihlchitis  of  the  umhilical  vein.  This  is  a  severe 
and  fatal  form,  in  which  also  hwniorrhajie  from  the  cord  may  (.eeiir. 


III.    ACUTE  YELLOW   ATROPHY  pf"Jii/'iri>it  Jaiuiflirr  .- 


ffii'rii.'i  Ornvix). 


Definition.  — -Ian nd ice  associated  with  marked  cerel.ral  symptoms  and 
characterixed  anatomically  hy  extensive  necrosis  of  the  liver-cells  with  re- 
duet  inn  in  volume  of  the  or^raii. 

Etiology.— This  is  a  rare  disease.  No  case  has  heen  admitted  to  the 
,Iohn>  Hopkins  Jiosintal  in  the  nine  years  of  its  work.  Hunter  has  col- 
lected only  50  cases  hetween  hSMO  and  1M!I4  (inclusive),  which  l.rin.ufs  u]. 
the  total  numher  of  recorded  oases  to  ahoiit  •-.'."iO.  Hi  a  somewhat  varieil 
post-mortem  and  clinical  experience  no  instance  has  fallen  under  my  oh- 
servation.  On  the  other  hand,  a  physician  may  see  several  cases  within  a 
few  years,  or  oven  within  a  few  months,  as  ha])pened  to  JJeiss,  who  saw  live 
case.s  within  three  months  at  the  Chavite,  in  Berlin.  The  disease  seems 
to  he  rare  in  this  conntry.  It  is  inor':;  common  in  women  than  in  men.  Of 
the  KHI  cases  collected  "hy  Legfr,  UD  were  in  females;  and  of  Thierfelder"s 
14;')  cases,  88  were  in  women.  There  is  a  romarkal)le  association  hetween 
the  disease  and  i)re<xnaney.  which  was  ])resent  in  -.'5  of  the  (ID  women  in 
Le,<rf:'s  statistics,  and  in  [VA  of  the  8S  women  in  Thierfelder's  collection. 
It  is^nost  common  hetween  the  apes  (d'  twenty  and  thirty,  hnt  has  \,vvn  met 
with  as  early  as  the  fonrth  day  and  the  tenth  month.  It  has  followe.l 
fri-rht  or  i>rofonnd  mental  emotion.  Tn  hypertrophic  cirrhosis  the  symp- 
toms of  a  profound  icterus  (rravis  may  develoii.  wdh  all  the  clinical  features 
of  acute  vellow  atrophy,  including  the  ]m'sence  (d'  leucin  and  tyrosin  in  the 
urine,  and  convulsions.     T  have  seen  two  such  cases;  in  hoth  there  were 


% 


.J 


!<■* 


,,„  l.ISEASRS  OF  TllK   DUJKSTIVK  SYSTKM. 

,1.       lU..r,...IU        'l"llnll"ll    till'    .-VlliptnlllS    linuUlCcd    ll.V 

„    ,„inl  of  its  ...........  xvn^d.t.     It  is  llal.l.v  an.l  t...  c.a,wul.  ,s    ^  m  k.c.l^ 

ZL  tlu.  ...lur  is  or  a  v....owish  ...•own,  vcllowW.  rcl.  or  n,o„l.  ,  and 

.,  lines  of  tlu.  loi,ul..s  ■.nv  in-iistin.,.     'Vh.  yC.ow  '.'..    ..a.l.-.v.i       .- 

„s  n.,..vs.nt  .liir.v..nt  sta,..  of  tl,.  sun.  ,nK.c.ss-tl.e  y.ilow  an  .•  , 

\l  ro.l  I,  ...o,v  a.lvan.c..l  s,.,..     'Vh.  or.an  n.ay  .ut  w,t.>  -"-';-  ^^^'j 
,H.ss      Mi<Tos....,.i.a.ly  tl.e  .iv.r-.rlls  an-  s....  ...  all  sta^^.s  ot  "^- y"^;  *  ''^ 

i  ,  spots  a,.,...ar  to  l,av.  ......ergon.  ..onM.let.  ,..stn.c-t,on,  ..avn,  at, 

„,„,„•    iLs  wit.,   ,.ij:n.c..>t   t:...ins  an..   nTsta.s  ...   .cu'.n   and  t>  o  .n 

q'        .   .-d.i.ts  an.l  ,all-i..a...l..-  a.v  ..n,.ty.     ll......'.'  .o,H.ln.U;s    hat  jt    s  a 

t'!;.,;;!;.  .a.avh  of  U..  ii.u.r  biU-dncts,  sinu.ar  t.,  that  whu.h  .s  lound  alter 
iDiM.niii"-  l.v  t.)liivlcndianiin  or  i.husi.h..ii.-^. 

'      'n   !  r.tlu.r  ...-a.,s  show  cxtcnsiv...  hi.o-stainin,'.  an.l  the.-e  are  nnnuTou 
,,,,,,  ',,,u.oes.     The  l<i.l..evs  may  show  nuuke.l   ,M-anular  .l..,en..ra.,..n  ..1 
Ih  "".MuTiun,.  a.ul  u>nally  there  is  fatty  d..,enerati..n  ..1  the  heart.     1..  a 
in-iioritv  .>f  the  eas.'s  the  spleen  is  enlarjied.  ,      •,        ,       .      i 

Symptoms.-I..  the  initial  stage  there  is  a  ,astn.-dn..denal  catarrh, 
,„a  I,  liS  the  jann.liee  is  th.n.gl.t  to  he  of  a  sin.p.."  ^^^^'^  J^^^'^'^^^^^ 
.fun.-  this  lasts  ..nlv  a   f.'W  .lays,  m  ..thers  tw..  ..r  tiure  u.^eks      i  h.  > 

:     !    .■svn,p....ns  set  in-hea.laeh...  .le.iriun..  tren,l..in,  ...  the  —■l-- -'  ' 

i  ,    onu.'i..  tane...  n.nvnlsious.     V.....iti..g  is  a  e..nstant  syn,pt..m.  an.l  ...ood 

,         1     .  ,  d,t  .,p.     Ihnnorrhages  o....ur  into  the  skin  or  fr.un  the  nuu-n, 

;  •■  ,  J    i.^p.•e..nant  w.unen  ah..rti....  .nay  ...r„r.     With  the  .1..v..1,m.....'.. 

lie        •    npt..n,s  the  Jann.liee  usually  nu^vases.     (;,.n.a  s..  s  ,n  and 
„,      ,11,  ,,„•„„  s  nntil   .lealh.     The  h..dy   t..n,p....,ture   is   variaM...  ..,  a 

n  :.....  .-..s  the  ..is..ase  runs  an  alV^,rile  ..onrse,  th.u.gh  s,„ne  nn  . 

,1  .re  .l..ath  there  is  an  elevalio...     In  s..n.e  instanees.  ImvNexer,  theie 
{;;;::  ;:!;;  n;!;i;l'.l  pvexia.     The  pnlse  .s  nsnaUy  rap,,.,  the  tongue  .-..ated 
and  ,lrv.  an.l  the  j-atient  is  in  a  "  typh..i.l  stat... 

-n,;,   uriu..   is  l.il..-staine.l   a..d   ..ften  cntams  tuhe-ea.t>      ^^  '    '     '     ^ 
tvro^in  are  not  eonstantlv  pr..sent;  ..f  •-':'>  vv.vni  eases  e.dleeted  hv     I..ntc. 
,'     K      e"  was  loun.h'i,;   .0  Loth  were  p.vsent:  In'.^  tyn.sm  ..nly:  >n  1 
•  V      The  l.'uein  ....•urs  as  r..nnd...l  disks,  the  ty.-..s,n  in  neodlo- 

^::,;:;;;"  ^tals       n^  ^;    eitl,...  ..  ..undU.  .,r  m  ..■oups.  _  The  tyr..sin  may 

It  ,.       1  e  s  en  int.,e  urine  sediment,  hut  it  is  hest  lirst  t..  -ap.n-a  o  a 
s  ..!■  n,...e  .u,  a  e.ner-glass.     In  th..  nu.Jority  o    cases  no     .h.^.nt..s 
\Z  int  stines.  and  the  sto...s  are  c..ay-e.d.,red.     T.u>  disease  ,s  ahno^^in- 
;;,,.,,,!,  ,.,,,,.      ,„  a  few  instances  recovery  ..as  hee,.  noted.      I  saw   ,n 
T      1    •'■,iinu.   .>t  \Viir7lnir'.-  a  ease  which  was  convalescent. 
'^"ii;gnOSis  -d     ndH.e  with  .....iti.i..  din.innti.>n  of  the  liver  v-dume, 

dcl^^^tl...  p,-es..nce  of  lencin  a,..l  t,.y..s,n  in  the  --u-     -an  -..a^- 
a.,„vi>ti..  and  ....nlistakal-.e  gr.mp  .>f  syn.pf.n.s^     Loncm  '"^'^  '"  ^^ 

not.  ....wever.  distinctive.     T..ey  n.ay  ..e  present  in  cases  of  alob.ile  jaun 

dice  wit.i  slight  enlargement  of  the  liver. 


iced  liy 
hy,  tliV 

iks  thin 
(ir  ovi'ii 
riiikk'd. 
lid,  ami 
ix'd  \)ov- 

ciirlicT, 

lie  Urin- 
)si(i,  and 

a  fatty, 

ty  rosin, 
it  it  is  a 
111(1  aftor 

UUIKTOUS 

ration  of 
rt.     In  a 

1  catarrli, 
soiuc  iii- 
s.     Tiii'U 
;clcs,  and, 
nid  Itlood 
ic  iiuii'ons 
/(■loiiuicnt 
'Is  ill  and 
ililc;  in  a 
soiiu'tinios 
•wr.  thoro 
;iiL'  coatt'd 

(Micin  and 
ly  Hunter, 
only:  in  1 
in  lu'odlc- 
^•rosin  may 
vaiiorate  a 
hill'  enters 
ahnost  in- 
1  saw  in 

,-(>r  vohmie, 
inn  a  ehar- 
tvrosin  are 
,'hrile  jann- 


AFFEITIONS  OF  TllK    HLdoD-VHSSKLS   oF   TlIF,    l.WVAt.  :,r,;{ 

It  is  not  to  he  I'orL'otteii  that  any  severe  jaiiiidiee  may  lie  associated  Willi 
int.. use  eerehral  sviii|.|.ims.  'I'lie  efiiiieal  I'eatiires  in  eertain  eases  of  hyi.er- 
lr,,i,liie  cirrhosis  "aiv  alino>l  identical,  hut  the  cnlar-cnieiit  (.f  the  liver,  the 
in„re  constant  occurrence  of  fever,  and  tiie  ahscncu  ul  leiiciii  and  tyrosiii 
lire  distinjruisliinji  si^Mis.  l'lio.-|.liorus  iioisoiiiii.u'  may  clo>ely  simulate  acute 
vellow  ati'.pliv,  partieularlv  in  the  Iniiiiorrhn-.-.  .jaundice,  and  the  .limiiiu- 
ti,,„  in  the  liver  volume,  hut  the  -astric  .^ympt^uus  are  UMially  umre  marked. 
mid  leiieiu  and  tyrosiii  are  stated  not  to  occur  in  the  urine. 

iNo  known  remedies  liavc  any  inllueme  (ui  the  course  of  the  disease. 


IV      AFFECTIONS  OF  THE   BLOOD-VESSELS  OF  THE 

LIVER. 

(1)  Anfflmia.— On  the  po>t-iii<utem  tahle,  when  the  liver  locks  aiaeiiiie, 
iw  iM  the  fattv  or  aiuvhud  oro„M.  the  hh.od-vessels.  wliich  duriii-  life  were 
prohahly  well  tilled,  can  he  rca.lilv  injected.  There  are  m.  symptoiiis  in- 
dicative of  this  condition. 

(•.')  Hyperffimia.— This  occurs  in  two  forms,  {a)  Arlnr  hiji,crivui\n. 
After  each  meal  the  rapid  al.M.rption  hy  the  |.<M'tal  vessels  induces  transi.'Ut 
c,ui<'estioii  of  the  (U'^ran.  which,  however,  is  entirely  i.liysi.do-iical:   hnl    it 


i-  (|iiitc  possililc  that   in   1 


icrsoiis  who  pcrsistentlv  eat  and  drink  too  much 


..lis  active  hvpera'iiiia  may  lca<l  to  functional  disturhauee  <u-,  in  the  ease 
of  drinkinj,'  too  freely  of  alcolud,  to  (U'-aiiie  chan-e.  In  the  acute  fevers 
an  acute  Jivpera'inia  may  he  present. 

The  siimiihiiiis  of  active  hypera^mia  are  iiidelinite.  Tossihly  the  sense 
of  distress  or  fulness  in  the  ri^ht  hypochoiidrium,  so  (d'teii  nieulioiied  hy 
dyspcptio  ami  hv  those  who  eat  and  drink  freely,  may  he  i\uv  to  this  cau-e. 
'I'll,. re  arc  prohaiilv  diurnal  variations  in  the  volume  of  the  liver.  In  .ir- 
rhor-is  with  enlar-vnieiit  the  rapid  reduction  in  volume  after  a  copious 
luemorrha-e  indicates  the  imp(U'tant  part  which  hyperiemia  plays  even  in 
or<ranic  tnuihles.  it  is  stated  tluit  suppression  of  the  menses  ov  Mippio-ioii 
of''a  lueiuorrhoidal  How  is  followed  hy  liyi.eraMuia  (d'  the  liver.  Andrew  II. 
Smith  has  descrihed  a  .•ase  of  periodical  enlar,!:ement  of  the  liver. 

(//)  I'ltsxirr  ('<>iHi('sli<iii.~Th\^  is  much  nuuv  connnon  and  results  fnun 
an  increase  of  i)ressure  in  the  ell'erent  vosels  or  suli-lohular  hranches  of  the 
hepatic  veins.  Kvery  e(nidition  leading'  to  venous  stasis  in  the  rinht  heart 
at  (uue  all'ccts  tliese  veins. 

Tn  chronic  valvular  disease,  in  emphvsemn,  cirrhosis  of  the  lun,-:.  and 
in  intrathoracic  tumors  mechanical  c(Ui,uestion  occurs  and  iinally  leads  to 
very  definite  changes.  The  liver  is  enlarged,  lirm.  and  id'  a  deep-red  color; 
the  hei)atie  vessels  are  frreatly  en-orired.  particularly  the  central  vein  in 
each  lohule  and  its  adjacent  cai.illaries.  On  section  the  ortran  lU'csents  a 
peculiar  mottled  aitpearauee.  owin.ir  to  the  deejily  con.ircsted  hepatic  and 
the  ana-mic  portal  territories:  hence  the  term  iiiilinr<i  wliicli  has  hceii  ,i:iven 
to  this  condition.  Ciradnallv  the  distention  of  the  central  cai.illaries  reaches 
snch  a  }:rade  that  atrophv  of  the  intervening  liver-cells  is  induced.  I'.rown 
pigment  is  deposited  ahout  the  centre  of  the  lohules  and  the  connective 


t! 


il 


5-^  DISEASES  OF   THE   DIGESTIVE   SYSTEM. 

ti«.ue  i^  -n-ntlv  in.Tea...!.  In  this  cyanuti..  iiuluration  or  canliacliver  tlu" 
tZltv,.  in  tlu.  early  .ta,o.  l.ut  la,..-  >.  n.ay  ^'^^^^^ rVTl\2'Z 
2Zy  in  this  ronu  tl.;  .-onncHiv..  t-.u..  ..  incrcasc-l  ahout  tho  .0  uU.  a. 
^  mt  tin.  imH.c.s  usuallv  ext.M.U  In-n,  ,!..  sul.lohnlar  a.ul  central  v.n.s 
"  T  ".  .n,!ton.s  of  this  •tuvn>  aiv  nut  always  tu  1.  s.,,arat...l  n>n,  th.. 
,f  L  as;oc.iatca  c-onditiuns.  (;as,rn-int..>tinal  catarrh  ,s  usnally  pu..  t 
1  u  ha.n>atonR.sis  luav  .H-.-nr.  Th..  ,.nrtal  oh>tru<t.un  .n  a-lvan.-c  .as."^ 
t  Is"  -it..s.  which  may  im...,!..  the  .h.v.h.,.n,..nt  ..,  ,,.,.•,.  .In,,.  . 
Thctv  is  often  sl.,ht  Jaundiec.  the  s,u..i.  n.ay  he  elay-eulore,'.  and  the  ar.ne 

eoiitains  liile-piunient.  ,  .       •  i.  i 

";;;>.. xanuLiun, he  orpu.i.tound  to  he  inerea..d.n..e.     1,  urn  he 

,  lull  hand-s  hrea.lth  lud-nv  the  e-stal  inaroin  and  tender  on  P''''-  '"  •  " 
t  t  >  .•'.n.liti.m  particularly  that  we  n.eet  whh  puls.t.on  <  the  hve 
W  n  M  dis,in.in>h  the  conuannieated  thn.hhin..  o|  the  heart,  wh.eh  . 
^.  V  con  mon.  l-ron.  the  h..avin,.  dilVnse  in>,udse  due  to  ro,uv,>tat,on  ,uto 
h  :  lu,  ic  veins,  in  which,  .hen  one  hand  is  npon  the  ens,  orn.  car,,  a,c 
and  the  other  npon  the  ri,!,,  side  at  the  n.ar.in  ol  the  rd.s,  the  whole 
liver  can  he  IVlt  to  dilate  with  each  luipuNe.  ,  .   .,     ,i,., 

The  indications  lor  tn.ln.nt  in  passive  hypera.n>a  are  to  resto.e  the 

Lnlanco  of  tiie  circulation  and  «.  n.doa.l  the  enp.r-ed  portal  vesse  s.     li 
balance  Ol  u _^  ^^^  ^^,^^^^^^  ,^^,  directly 


Uaiillive    v'l    ii'^    v.iv>... 

cases  of  intense  hypera'inia   is  or  --in  oui 


pjises  of  intense    ivpera'nua    !■    <m    ^-^   -.... .  ,•     ,   i 

^  a  al  ^'.n  the-  liver,  as  advised  hy  Cieov^e  HarU,  '>-\  P™  -"\  ;> 
n  m  \noh.-lndian  phvsicians.  (iood  results  son.et.tnes  loUow  th.>  h. - 
Z  ph  :  ..n,v.  The  pron.pt  relief  and  n.arked  reduc-tjon  .n  t  e  volume 
o?  u  r.an  wliich  follow  an  attack  of  ha.natcniesis  or  hleedm,r  from  piles 
:1  ; ;  'ths  practice.  Salts  adnnni>tered  hy  Mattlu.w  1  ay  s  nu-tluul  d.- 
2i'L  P"^tal  svstem  freely  and  thoroughly.  As  a  rule,  the  treatn.ent 
must  he  that  of  the  condition  with  which  it  ,s  assocmted. 

(5    Diseases  Of  the  Portal  Vein.-(.)    nrn„>l.s,s:    A.^hrs,rr    7 //-- 
«/,H^^>^  •oa.nlation  of  hlood  in  the  p.alal  vein  i^  nu.  wUh  m  crrhoM. 
^   v  hilis  of  the  liver,  invasion  of  the  vein  1.-  cancer,  prohteratne  pen     - 
n  ti     nvolvincr  the  .astro-hepatic  on.entum.  perforatu>n  ol  the  ven   U  ,.,11- 
X  ;nnd  oecasionally  folll.ws  sclerosis  of  the  wall,  of  the  ,.;,  M  vein  or 
of  its  branches  (Borrn.ann).     In  rare  instances  a  canplete  eollateial  .  m     , 
tk>  '  is  ostahlished.  the  thromhus  nndergoes  the  usual  changes    and    dt  - 
niX Iv  the  vein  is  represented  hv  a  fihrons  cord,  a  conditu^n  which  h  s  heen 
Z^ZpZuis  llhrsira.     In  a  case  of  thi-  kind  which      d.sseeted  the 
"ln'\  ven   was  represented  hy  a  narrow  fihnaw  c-ord:  the  eoUatera    circnla- 
whhh  must' have  heen  completely  e>tahlishe     for  --s^  n    unaM> 
failed,  ascites  and  ha.maten.esis  supervened  and  rapully  h;--1  ^^^^1-      ^  ^ 
i.i.nio.is  of  ohstrnetinn  of  the  portal  vein  .-an  rarely  he  made.     A  sug- 
':C    vmpton.  however,  is  a  sn.l.lrn  onset  of  the  nu.st  nitense  en,or,e- 
nient  of  the  hranches  of  the  portal  systcu,.  leadm,.  to  luvmaten.es.s.  mela.ia. 
nseifee  and  pwcllini:'  of  the  P])leen. 

Fmlol    in  the  hranches  of  the  portal  vein  do  not    as  a  nde    prodnr.o 
infarction,  for  blood  reaches  the   lohular  eapillary^^-xns.   as  shown   1, 


.Tournal  of  ATiiitoiiiy  and  Pliysiolefrv,  vol.  xvii. 


DISEASKS   OF  TllK    lULK-PASSAOES   AND  OALL-ULADDEH.        555 

C'uhnhL.ini  ai.a  Litt.n.  tlmm.uh  tl.r  five  ai.n^tnnwisi^  with  a  hqutio  artiTy. 
In  niv  i.iMaiuo.  Iinsvrvrr.  a  r..n.litin.i  iv^rml.lm-  inlarctioii  doe.<  occur, 
suinctiiMcs  iM  mumU  luva..  at  n,l,.r>  u.  .,mtc  extensive  trrnloncH.  hcptio 
luilioli.  (.11  tlic  oilier  hand,  may  iii.liuc  Mi|.i'iiratinii. 

(//)  >',//v-Hn////r  inilrplilrhilis  will  l.c  cuu^i.kTc.l  ill  the  section  on  al-scc^s. 

(1)  Attections  of  the  hepatic  vein  arc  extremely  nuv.  Ihlatatiun  oc- 
,,„-  ill  c  a^e,-  of  chroiiu'  cnlai-cneiit  of  the  ri-hl  heart,  from  whatever  cause 
,„1„,,„,.  Knihoii  ...easionally  pa>^  from  the  ri.irht  auricle  mtn  the  hepa  ic 
v,.in-  \  rare  aiul  umiMial  event  is  >teno>is  of  the  orilices  ol  the  iici-atie 
vein^'  which  1  u.et  in  a  ca.e  of  lihroi.l  ohliteralion  of  the  mfcru.r  vena  cava 
,n.l  whieh  vsa^  a-o.iatcl  with  a  -reatly  eular-ed  and  in.liirale.l  liver. 

(.-,)  Hepatic  Artery.-Knlar-emciU  r.f  this  vessel  is  neu  m  .aM-  .d  cir- 
ri,.,.,/of  the  liver,  it  may  he  the  sea^  of  extensive  sclero-.s  Aneurism 
„f  the  hepatic  artery  is  rare,  hut  instaiKcs  arc  ou  record,  and  will  he  re- 
ferred to  ill  tile  .section  on  arteries. 


V      DISEASES    OF    THE    BILE-PASSAGES    AND 
GALL-BLADDER. 

(a)  AcTTK  C.vTAiMtii  OF  TllK  Hii.K-i.rcTS  {Catarrhal  .Jaaiulin). 
Definition.— lanndi.e  (hie  to  swellin-  and  oh>tniction  cd'  tlie  terminal 

portion  (d'  tlie  comiiKUi  dud.  ,■,!.• 

Etiology.— <icneral  catarrhal  intlammation  (d  Die  hde-ducts  is  usu- 
ally a-o<iated  with  -all-stones.  The  catarrhal  process  now  under  ..nisid- 
cration  is  i-rohahlv  alwavs  an  exten>ion  (d'  a  .irastr.wluodenal  catarrh,  and 
the  process  is  most  intense  in  the  pars  ialrsllnali.^  .d'  the  duct,  which  pro- 
iects  into  the  duodemun.  The  muc.ms  memhram'  is  >w..llen,  and  a  pln^ 
of  in-l.i-ated  mucus  lilU  the  diverticulum  of  Vater,  and  the  narrower  por- 
tion iu-t  at  Ihe  orifice,  completely  ohstnutintr  the  outflow  of  hile.  It  is  not 
known  how  widespread  this  ..atarrh   is  in   the  hih-passn-es.  and   whether 


it  reallv  passes  up  the  ducts.  It  would,  (d"  course,  he  pos>ilde  to  have  a 
catarrh". d'  tlie  liner  duct^  within  the  liver,  which  s.mie  French  writers  think 
m; 

UK 


u.v  initiate  the  attack,  hut  the  evidence  for  this  is  not  stnu,-.  and  il  seems 

inre  likely  that  the  terminal  p-u^tion  (d'  the  duct  is  always  hrst  inv.dved. 

In  the  only  iiKlance  which   1   have  had  an  opportunity  to  examine  ynn 

n„u-tem  the  .u'ifice  w;h  plu-ed  with  inspissated  mucus,  the  common  and 

d.itic  ducts  were  sli-htlv  distended  and   contained   a   hde-tm-ed.  not  a 

,,1,,',,.  n.ucus.  and  tlictv  were  no  ohservalde  chan-es  in  the  mucosa  oi  the 

ducts.  ,  ,,.!,• 

Thi<  catarrhal  or  simple  jaundice  results  from  the  t.dlowin.ir  caus(>.. 
(1)  Duodenal  catarvh.  in  whatever  way  i.roduced.  most  c(mimonl_y  iollow- 
in-  an  attack  (d'  nidio-.sti.m.  It  i>  mo-t  fre.piently  met  with  in  youn- 
pcrs.ms.  hut  may  occur  at  any  n-e.  and  may  folL^v  not  onlv  errors  m  diet 
Intt  also  ,^old.  exposure,  and  malaria,  a^  well  as  the  c.mdition^  associated 
Avith   jmrtal  ol)structi(m.  chronic  iieart-disease,  and    Ih-ight  s  disease.     (V) 

^^  Journal  of  Anaioiny  iiml  I'liysiulnj;)-,  v(j1.  xvi. 


i: 


.J 


il 


«^db 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


656 

Kmoti<.nal  disturbances  may  he  fulluwed  l.y  jaundice,  .hich  i';'''^li-vc.l  to 
b^  dul  to  eatarrhal  .welling,  fa.es  of  tin.  ku.d  are  .are  and  the  anaton - 
L  condition  is  unknown.  (:;)  Sin>ple  or  eatarrhal  .laund.ee  n.aj  ueKU 
"l^iclenuc  form.  0)  ^'^t-rhal  jaun.liee  ^  '7---;  ^ ^r;:.".  ':,  ^^ 
IVctimw  fevers,  such  as  pneumonia,  and  typho.d  lever,  ihe  nut  lie  ol  aeu  t 
c,  1  a  iaun  lice  is  sti  1  unknown.  It  n.ay  possihiy  he  an  acute  iniect.on. 
n '  r  his  view  are  the  occurrence  in  epidenuc  form  and  the  presouco 
o"  siiUt  fever.  The  spleen,  however,  is  not  often  enlarged.  In  onlj  4 
out  of'' -.'3  cases  was  it  palpable.  .,„,1   the  in- 

Symptoms.-rhero  may  l,e  neither  pain  nor  d.>t,e»    an.l   t  le      i 
tiei^V  fru^nds  mav  lirst  notice  the  yellow  tint,  or  the  patient  liuupdl  may 
Ilserve  it   in  tl,;  looking-gla.s.     In   othev   instances   there   are  .  yspe.  c 
.V„,ptoms  and  uneasy  sensations  in  the  hepatic,  region  or  pains  in  the  ba  k 
and    limbs.      In   the  epidemic   form,  the  onset   may  be  more  seven,    ni  h 
headache,  chill,  and  vomiting.     Fever  is  rarely  present,  though  the  t    n- 
ure  mav  reac.h    l.T,  sometimes   in-      Ml   the  signs  ot   .   -s  nict    e 
aundice  alirady  mentioned  are  ].resent,  the  stools  are  clav-eolmed.  a.  d 
"no  contains  bile-pigment.     The  Jaundice  has  a  '-^''^->';  l^:'     ^  J 
the  -M-eenish,  Imm/.cd  color  is  never  seen  in  the  simple  iorm.        he  pul  e 
Z/,0  normal,  but  occasionally  it  is  remarkably  ^•'>-  ->'    -'>;^'    J;,  ^ 
or  3U  beats  in  the  minute,  and  the  respirations  to  as  lou  a.  b  pa  m      it 
S  eepiness,  too,  mav  be  i-resent.     The  liver  may  be  normal  m  size,  bu    .. 
u  u     V  slightlv  enlarged!  and  the  edge  can  be  felt  beh.w  the  costa    margm 
Oce'  sionaMv  tiie  eiih:;gement  is  more  marked.     As  a  nde  the  f^;\ll-''l^'^l; 
e^  n     t  be  felt.     The  spleen  may  be  increased  in  size.     'I  he  duration  of    ho 
^^  <  un  four  to  eight  weeks.     There  are  mild  cases  m  which  the 

■  ui  e  ■<!  >  P  ars  within  two  weeks;  on  the  other  hand  it  may  persist 
K;  th^c'e  moiJhs.  The  stools  should  be  carefully  watched,  lor  they  give 
the  fiiNt  intiniaticm  of  removal  of  the  obstruction. 

The  dlinosis  is  rarely  diilicult.  The  onset  in  young,  comparatively 
lu-al  V  Xs,  the  moderate  grade  of  icterus,  the  absence  o,  emaciation 
o^  evidences  of  cirrhosis  or  cancer,  usually  make  the  'l';'^--;'  ;  " 
Oi«c-  which  persist  for  two  or  three  months  cause  uneasinoN  >  the  .n>- 
pSms  mused  that  it  may  be  more  than  simple  catarrh.  ^1  he  absem.e 
o  n  n  tl  e  negative  character  of  the  physical  exan.inatic.n,  am  the  main- 
?.nwe  the  general  nutrition  are  the  points  ,n  favor  o  simple  ,aundicc. 
11  e  ,re  i  ta^c'cs  in  which  time  alone  can  dc^termine  the  true  nature  of 
tile  !U      Tlu:  possibility  of  Weil's  disease  must  he  borne  in  mind  in  anom- 

"^"Treaiment.-As  a  rule  the  patient  can  keep  on  his  feet  from  the  out- 
let     AreasTrersionld  he  used  to' allay  the  gastric  catarrh,  it  it  ,s  present^ 

of  the  mucus. 


DISKASKS  OF  TIIK    BILE-PASSACJES   AND  GALL-IJLADDEU.        557 

{/>)  CimoNic  Catakkhal  An'oiocholitis. 

This  may  potrsibly  uccur  also  as  a  simhicI  of  the  acute  catarrh.  1  havo 
never  met  witli  an  in;-tanee,  however,  in  wliieh  a  chronic,  persistent  jaiuulico 
could  be  attriliiiled  to  tliis  cause.  A  ciironic  catarrh  always  accomimnies 
ol)stru(tinn  in  the  common  duct,  whether  hy  gall-stones,  nuilignant  disease, 
stricture,  or  external  pressure.     There  are  two  groups  of  cases: 

(1)  Willi  ('(iiniilclc  Uhslnniiiiii  i,f  llic  Cinninon  Durl. — In  this  i'orui  the 
hile-passages  are  greatly  dilated,  the  common  duct  may  reach  the  si/e  of 
the  thunil)  or  larger,  there  is  usually  dilatation  of  the  gall-liladder  and  of 
the  duets  within  the  liver.  The  contents  of  the  ducts  and  of  the  gall- 
bladder are  a  clear,  colorless  nuicus.  'l"he  mucosa  may  lie  everywhere 
smooth  and  not  swollen.  The  clear  mucus  is  usually  sterile.  The  patients 
are  the  subjects  of  chronic  jaundice,  usually  without  fever. 

(•>)  ir/Z/i  Im-oiiiplcte  Ubstrmlinii  of  the  /;«(•/.— There  is  pressure  on  the 
duct  or  there  are  gall-stones,  single  or  multiple,  in  the  cnuunon  duet  or  in 
the  diverticulum  of  Vater.  The  bile-passages  are  not  so  much  dilated,  and 
the  cimtents  are  a  bile-stained,  turbid  mucus.  The  gall-bhubU'r  is  rarely 
much  dilated.     In  a  majority  of  all  eases  stones  are  found  in  it. 

The  symptoms  of  this  type  of  catarrhal  angioeholitis  are  sonu'times  very 
distinctive.  With  it  is  associated  most  frnpiently  the  so-ca''  -d  hepatic  in- 
ternuttent  fever,  recurring  attacks  of  chills,  fever,  and  s\s..lS.  We  need 
still  further  informati(m  about  the  bacteriology  of  these  cases.  In  all  jirob- 
ability  the  febrile  attacks  are  due  distinctly  to  infection.  I  cannot  too 
.strongly  emphasize  the  jioint  that  the  recurring  attacks  of  intermittent 
fever  do  not  necessarily  mean  suppurative  angioeholitis.  The  (pu'stion  will 
be  referred  to  again  under  gall-stones. 


(t)   SUPPUR.VTIVE    AND   ULCERATIVE   AnGIOCIIOLITIS. 

The  oonditicm  is  a  ditl'use,  purulent  angioeholitis  involving  the  larger 
and  smaller  ducts.  In  a  large  proiiortion  of  all  cases  there  is  associated 
suiipurativo  disease  of  the  gall-bladder. 

Etiology. — It  is  the  most  serious  of  the  sequels  of  gall-stones.  Occa- 
sionally a  diiVuse  sui)purative  angioeholitis  follows  the  acute  infectious 
cholecvstitis;  this,  however,  is  rare,  since  fortunately  in  the  latter  condi- 
tion tlie  cystic  duct  is  usually  occluded.  Cancer  of  the  duct,  foreign  bodies, 
such  as  lumbricoids  or  fish  Ijones,  are  occasional  causes.  And  lastly  there 
may  be  extension  from  a  sup])iu'ative  ])yle|)hlebitis. 

The  coniinon  duct  is  greatly  dilated  and  may  reach  the  size  of  the  index 
finger  or  the  tluunl);  the  walls  are  thickened,  and  there  may  be  fistulous 
communications  with  the  stomach,  colon,  or  duodeinim.  The  he])atic  duets 
ami  their  extensions  in  the  liver  are  dilated  and  contain  jms  mixed  with  bile. 
On  section  of  the  liver  small  abscesses  are  seen,  whl  h  correspond  to  the  di- 
ated  supinirating  ducts.  The  gall-bladder  is  usually  distended,  full  of 
]ms,  and  with  adhesions  to  the  neighboring  jiarts,  or  it  may  have  perfo- 
rated. 

Symptoms. —The  symptoms  of  suppurative  cholangitis  are  usually 
very  severe.     A  previous  history  of  gall-stones,  the  development  of  a  septic 


J 


558 

fcvor,  t 

(.light. 

iUlll   It) 

which 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


iH.  .wcllin-  and  t..n.h.nu.s.s  of  the  liv.r,  the  enhu-euu  nt  ol  the  gall- 
'\uul  e\.ue.K.vtosi.  are  suggestive  features.  Jaund.ee  .s  aluaj. 
'  t  N  vanal.le:  In  s.Mue  eases  it  is  very  intense,  >n  othei.  t  ,> 
't  .,v  nav  U-  verv  little  ,.a,n.  There  is  I'-^-ss.ve  eujaeuU  n 
,s  !,i" Irength.  In  a  rece.U  ease  parotitis  developed  on  th-  lett  mU-  . 
vulwidi'd  witliout  suiiiniration.  ... 

;:aU;I:'\^neture.  i '..'.rati-n,  and  li.tnl.  ut  the  Inle-passuges  w.ll 


be  considered  with  gall-stones. 


{,1)    ACUTK   IXFECTIOUS   CHOLECYSTITIS. 


Etiology.-Aeute  inllannnation  of  the  gall-Madder  is  usually  d.K-  to 

et.es  or  grades  '  ;>  J'^  ^   ^    \  ,^,,.,  ,,,i(.us,  diilicult  to  diagnose,  olten 

1     ?"3:av      ;   ::l;;; Its^elief  pron,.   surgical  n.tervent.on.     The 

;        •  te  1  wi  h  oall-stones  have  of  course  long  been  recognized,  but 

,ases  ns>ocuitu    ^^^      -  p,ll-bladder  leading  to  snppura- 

out  known  pre-existing  f^^f^'  ^.^^^.^^  ^,f  i,,,terial  invasion.     The 

o«nriT.l  witinn  tlio  |..  -    >l  r  ^^^  ^^,^^^.,;^„  ^^„^ 

1„  till'  rasff  «-ill.  ic.ito  I'"'  :  ""  ™         ij,  ,,„,,,  i,  „„,„  f,„uul  d..s«l  0V.11 
the  al.<l..™on,  rigi.lity,  P'>,o„n  t™.lo™Ms  Woom,,,!:  l.-cabzcd     usuallj 


gall- 

IWilVS 


DISEASES  OF   TllK   BILK-I'ASSAGKS   AND   CiALL-lJLADDEU.        5jU 

](i\v  (Kicliiinlson).  In  this  fonii,  witlimit  gall-f^loiu's,  jaundice  is  not  oflon 
imscnt.  'I'iic  Idcal  tcnilcrncss  is  cxtrciiu',  hut  it  may  lit'  tk'fi'|itivt'  in  its 
situation.  Associated  iiroiiahly  witli  llic  adiu'siim  and  inllaniniatory  [H'o- 
fi'ss'.'s  lu'twcfn  the  gall-hladdcr  and  the  howel  arc  the  intestinal  symptoms, 
and  there  may  he  eomph'te  stoppage  of  gas  and  lieccs;  indeed,  the  opera- 
tion I'or  acute  ohstruttion  has  heeii  performed  in  .-everal  eases.  TIr'  dis- 
tended gail-liiadder  may  sometimes  he  felt. 

The  tliiiijiKi.sis  is  hy  no  means  easy.  Tlic  symptoms  may  not  indieate 
the  seetion  of  the  aliiiomen  inv<dve(I.  In  two  of  (Uir  cases  and  in  three  of 
llicliardson's  appendicitis  was  diagnosed;  in  two  of  his  cases  acute  intes- 
tinal ohstruction  was  suspected,  'i'his  was  tlie  diagnosis  in  a  ease  of  acute 
piilegmonous  cholecystitis  wiiich  I  re])orted  in  ISSl.  The  history  of  the 
cases  is  often  a  valuahle  guide.  Occurring  during  liie  convalescence  from 
typhoid  fever,  after  imeumonia,  or  in  a  patient  witli  previous  cholecystitis, 
such  a  group  of  symptoms  as  mentioned  would  i)e  iiighly  suggestive.  The 
diU'erentiation  of  the  variety  of  the  clioleey.<titis  cannot  he  made.  In  the 
acute  suppurative  and  phlegmonous  forms  the  s-ymptoms  are  usually  more 
severe,  ])erforation  is  very  apt  to  occur,  with  local  or  general  peritonitis, 
and  unless  operated  upon  death  ensues. 

Tiiere  is  an  acute  cholecystitis,  prohably  an  infective  form,  in  which 
the  ]iatient  has  recurring  attacks  of  pain  in  the  region  of  the  gall-bladder, 
'i'lie  diagnosis  of  gall-stones  is  made,  but  an  operation  shows  simply  an  en- 
larged gall-bladder  filled  witii  mucus  and  bile,  and  the  mucous  membrane 
perhaps  swollen  and  inflamed.  In  some  of  these  cases  gall-stones  may  have 
been  iiresent  and  have  ]mssed  before  the  operation. 

(e)  Canckr  of  the  Eile-passages. 

The  subject  has  been  very  thoroughly  studied  of  late  years  hy  Zeid^er, 
Musser,  Ames,  liolleston,  and  Kelynack.  Females  sull'cr  in  the  pro])or- 
tion  of  3  to  1  (Musser),  or  -1  to  1  (Ames).  In  teases  of  primary  cancer  of 
the  bile-duct,  on  the  other  hand,  men  and  women  ajjpear  to  be  about 
(•([ually  affected.  In  ]\Iusser"s  series  05  ])er  cent  of  the  eases  occurred  be- 
tween the  ages  of  forty  and  seventy.  The  association  of  malignant  disease 
of  the  gall-l)ladder  with  gall-stones  has  long  been  recogni/ced.  The  fact  is 
well  put  by  Kelynack  as  follows:  "  While  gall-stones  are  found  in  from  G 
to  12  per  cent  of  all  general  cases  (that  is,  coming  to  auto])sy),  they  occur  in 
association  with  cancer  of  the  gall-bladder  in  from  !»(»  to  100  per  cent." 

The  exact  nature  of  the  association  is  not  A'ery  clear,  hut  it  is  usually  re- 
garded as  an  effect  of  the  chronic  irritation.  On  the  other  hand,  it  is  urged 
that  the  presence  of  the  malignant  disease  may  itself  favor  the  production 
of  gall-stones.  Histologically,  "  carcinoma  of  the  gall-bladder  varies  much, 
both  in  the  form  of  the  cells  arul  in  their  structural  arrangement;  it  may 
be  either  columnar  or  spheroidal-celled  "  (l?olleston).  The  fundus  is  usu- 
ally first  involved  in  the  gall-hladder,  and  in  the  ducts  the  ductus  communig 
choledochus. 

Wlien  the  disease  involves  the  </(iU-hiad<kr,  a  tumor  can  be  detected  ex- 
tending diagonally  downward  and  inward  toward  the  navel,  variable  in 
35 


1? 

I 


I 


J 


DISEASES  OP  THE   DIOKSTIVE  SYSTEM. 

1„,  ..itluT  In   'Mviit  (listcnti.m   of  tlio   gall- 
S.wt"!™u:™- -.'-«""-' .^    H  ...»..".,.  « 

,,„  „.„t  ,.nluss,.r-.  ...-v.;    ■""•'",•;,„,,„,,  |„.;.sisl  i„  llH.  interval* 

,.,ns  tu,nnvs  tl,at.c:.n  1.  ^J  J  -  ^^^ "^  ^  ^^^^^^^  ,oints  in  the  dif- 
N.non,l.or,lS<)T)  gives  very  iullj  '   "    "  .  [^  \,,^,^  t^,„,or.  in  the  gall- 

f.vontial  diagnosis  l,ol.-o.n  inmo  s  ]-^^^  '^^.^i^^,,,  j,..,,!,..  The 
^,,,,,,,,  -nuTe  is  usual  y  an  ^'^^^^^^^.J,  j,  very  donhtful  un  ess 
,„ll-l.la(l(U'r  is  nuu'li  d.lalo.l.     At  1  c    tla       .     ;  ^^^,,,,ti„.  fovni  ..f  nial.g- 

tloaml  up  by  --rt'f^'ZM  inv.^vc;  Iho  divovticuUun  of  Vator. 
^ant,  di^oase  of  the  du.  s  ,s  *  '  *  -1"\^'  I  ^,^.,„,,,,  ,„,  ^n  elderly  wonuui 
lU.sson  has  collected  eleven    ■;•.;;  ^^  ,,„,,  ....nths  duration   wuU- 

^vas  admitted  nnder  n^yc.are  ^^^^  ^"^^^  ,,,,„,  ,„larged  gall-ldadder. 
,„t  vain,  Mith  vrogrc.s,ve  ^^^-'-  ^^^j^^  oll^truction  at  the  orilieo  of  the 
^ly  colleague,  llalsted.  -l"^''fV ",;",,     ,„noved   a   cylindrical-celled 

,;„,„oa  duc.t.     lie  opened     '-        ^   ^y'!  ;,,,„i  „,,  .onnnnn  duc-t  to  an- 
.^,,^,1- „„  „i'  the  anM;"l\'^  "'  ^ '*  tIu       t  ent  n.ade  an  uninterrupted  re- 

.i,,.  ,.„.tion  onhe  duo.^mu^^^       ,t  C^penU.on,  has  gained  t.enty- 

(  n   STEXOSIS   AXO   OHSTUUCTIOX   OF   THK   BlUC-m-CTS. 

f  11  .„.  i.l,-(Vfition.  most  commonly 
S,nosi.  or  contplete  occlusion  mjvy  ^  ^^^  ,,,  ,,„truction  is 

after  the  passage  of  a  ^\^^;!^ ^^J^^^l  Instances  are  extremely 
usually  situated  low  ^^^^^-'V"  '^  ^  /«  c  .  of  various  fruits,  may  en  er  the 
rare.     Foreign  bodies,  such  as  ^^''-  '''  'J^^^^  j^.     jn  the  Wistar-IIorner 

,,t.  and  occasionally  round  ;^<^'-"^",^^.,V  o,e  is  a  remarkal.le  specimen 
Museum  of  the  ^''--^^  ^  ^^i;;!^^  ^  "^.^m'lsly  distended  and  densely 
,l,„,vi„.r  the  common  and  hepatic    lucis  i  similar  specimens  exi^t 

S;d\ith  a  dozen  or  more  Unnl.r.co.d  ^^'^^^^a  Hospital,  Netley. 

n  one  of  the  Taris  museums,  and  at  the  K  ^  •„  ,„,„. 

Liver-flukes  and  echinoc.occi  are  ^^^^ ^^  ,,,,,,ont.     Cancer  of  the 
Ohstruction  by  pves^^rr  f  om  ^  '^1^^"^  ^  i,,terstitial  intlammation,  may 

head  of  the  1-— "  ^^^;,;:  r:f  the  d        "Irelv.  cancer  of  the  pylori,. 

compress  the  terminal  portion  ol  the    •'     '  ■  y        ■       common  cause 

Secondary  involvement  of  il>o   y-P  -^  ^^^^^    eases  of  cancer  of  the 

of  occlusion  of  the  duct,  and  is  met  ^^ 't^;;"      ^^^^^  obstruction  are  aneu- 

Sr:Vbl:r  "rSS^f  "^orta,  and  pressure  of  very  large 

abdominal  tumors. 


-"."S; 


CHOLELITHIASIS. 


0    gllll- 

I'ln  anil 

,t  in  <;',) 
sinul  in 
ntcrvals 
h  \\\\'  ri 
iiundioo 
svory  of 

id  rarely 
hroniclc, 
the  ilif- 
Iho  gall- 
ce.     The 
111,  unlosri 
of  iiiiilig- 
of  Vator. 
y  woman 
1011,  witU- 
l-l.laailor. 

ice  of  lli»- 
ioal-celled 
net  to  an- 
rupte'd  re- 
■d  tweuty- 


coinnionly 
truction  is 
>  extreinoly 
y'  enter  the 
itar-llorner 
le  ppeciinen 
and  densely 
•imens  exist 
ital,  Xetley. 
man. 

anecr  of  the 
nation,  may 
the  pylorus, 
immon  eanse 
aiicer  of  the 
ion  are  aneu- 
of  very  large 


Tlie  symptoms  ju-ddiiced  aiv  those  of  chronic  ohstructive  jaundice.  At 
!ii>t,  the  liver  is  usually  enlarged,  luit  in  chnmic  cases  it  may  lie  reduced  in 
size,  and  be  found  of  a  deeply  hmnzed  culnr.  'I'lie  hepatic  inlerniitteiu  ic\er 
is  not  often  as.s()ciatcd  with  ciimpletc  ccclusion  <>(  the  duct  fi'om  any  cau>e, 
hut  it  is  most  freipicntly  met  with  in  chronic  ol)structiuii  liy  gall-stmu-. 
IVrmanent  occlusion  of  the  duct  terminates  in  death,  in  a  majority  of  the 
lascs  the  conditions  which  lead  to  the  ohstruct'on  are  in  thciii-clvcs  fatal. 
The  liver,  which  is  not  necessarily  enlarged,  presents  a  moderate  grade  of 
cirrhosis.  Cases  of  cicatricial  occlusion  may  last  for  years.  A  patient  under 
mv  care,  who  was  permanently  jaumliccd  for  lU'arly  tliice  years,  had  a 
liliroiil  occlusion  of  the  duct. 

'J'iie  (Jiiii/iiiisis  of  tlu'  nature  of  the  o(  elusion  is  (d'leii  veiT  dillicnlt.  A 
history  of  colic,  jaumlicc  of  varying  intensity,  ]iaroxy>ms  of  pain,  and  in- 
tcrniitlent  fever  })oint  to  gall-stones.  Jii  cancerous  obstruction  the  tumor 
mass  can  sonu'limcs  be  felt  in  the  epigastric  region.  In  cases  in  which 
the  lymph-glands  in  the  transverse  fissure  are  cancerous,  the  primary  dis- 
ease mav  be  in  the  pelvic  organs  or  the  rectum,  or  tlu're  may  lie  a  limited 
cancer  of  the  stomach,  which  has  not  given  any  symptoius.  Jn  these  cases 
the  e.xamination  of  the  other  lymphatic  glands  may  be  (d'  value.  In  a  case 
will)  came  under  observation  with  a  jaundice  of  seven  weeks*  duration, 
believed  to  be  catarrhal  (as  the  patient's  general  condition  was  good  and 
he  wa.s  not  said  to  have  lost  llcsh).  a  small  nodular  mas.'5  was  detected 
at  tlie  navel,  which  on  removal  proved  to  be  scirrhus.  Involvenu'nt  of  the 
clavicular  groups  of  lymph-glands  may  also  be  servict'able  in  diagnosis. 
The  gall-liladder  is  usually  enlarged  in  obstruction  of  the  common  duct, 
except  in  the  cases  of  gall-stones  (I'ourvoisier's  law).  Great  and  progressive 
enlargement  of  the  liver  with  jaundice  and  moderate  continued  fever  is  more 
commonly  met  with  in  cancer. 

Ciini/ciiihtJ  ohiilcrnlidii  uf  llic  (liirls  is  an  interesting  condition,  of  wliieli 
there  are  some  (iO  or  Td  cases  on  record.  It  may  occur  in  several  meiiiliers 
of  one  family.  S}»ontaneous  lueinorrhages  are  frc(pient,  particularly  from 
tlie  navel.  The  subjects  may  live  for  three  or  even  eight  weeks.  For  a 
recent  careful  consideration  of  the  subject,  see  John  Thomson's  article  in 
Allbutt's  Svstem  of  ]\Iedicine. 


VI.    CHOLELITHIASIS. 

Xo  chapter  in  medicine  is  more  interesting  than  that  which  deals  with  the 
(piestion  of  gall-stones.  Few  affections  ])rcsent  so  many  points  for  study — 
chemical,  baeteri(dogieal,  ])athological,  and  clinical.  The  past  few  years 
have  seen  a  great  advance  in  our  knowledge  in  two  directions:  First,  as  to  the 
mode  of  formation  of  the  stones,  and,  secondly,  as  to  the  surgical  treatment 
of  the  cases.  The  recent  study  of  the  origin  of  stones  dates  from  Xaunyn's 
work  in  ISOl.  ]^^arion  Sims's  suggestion  that  gall-stones  came  within  the 
sphere  of  the  surgeon  has  been  most  fruitful.  Lawson  Tait,  Langenbuch, 
^hiyo  IJobson.  17ied'i,  Kehr.  and  in  this  country  Keen,  Fengcr,  ^Iuri)hy, 
Lango,  and  Ilalstcd  have  not  only  revolutionized  the  treatment  of  chole- 


1 


iii 


I 


5(52  DISEASES  OF  THE  DKiESTlVE  SYSTEM. 

,itl,ia.is.  l,.t  fr.>n,  thnr  work  w.  ,.l,vsi..ians  hay.  .atlH.ml  nuul,  of  the 
...vafst  numu.nt  in  sy.nptu.natolo^ry  and  diaf^noMS 

;;:i;;;::i.  • ;:; : ;  m';:.!;;  i.n;..:'!;...,  as  ..n  as  of  ti.  iin.  saus  fro.  ti. 

:  2;;:..nhrano  of  tiK.  ..iiian-  passages,  i-'^i-'-''^;;- ;;;;,';;  ;;:rS' 

\lA  the  ri'iuarkablo  association  of  n.icr..-or-anisn,s  with  -all->  oui^.     it    • 
t    HI       B  ^<.wo  lirst  noticed  tiu-  origin  of  ..holcstorm  .n  tin-  ,.  -  dm  - 
;!      i  f   hut  Naunvn's  observations  showed  that  both  ^1-  f  "1- ;'  ' 
1,  v.  in  .rr;..t  mrt  a  i.n>diuli«>n  (d'  tlio  nuicosa  ol  the  oall-hla(hU'r 

;:,  t;;:  :i  s;  1  ™i'.'iy  .i„.„ :,. ,.  ......mi.,,. ..« «„,rri„a  ;,*„,. 

„       .        l.y  tl. .  .ro..™c.c  ot  n,icn>l,«.     A«-or,lins  to  the  v.ows  ol    I., 
J  ,        \       I    I    P'no«  <..l.,Tl,  («l.i.lK  I'.v  tl"'  wny.  «  ...Mlo  an  ol,    «k.«) 

the  present-  of  nn<'ro-or-anisnis  in  the  centre  ot  gall-.tone..      iiuet 

"™?;;;;"2l;r::::;u  ti;^rtaM,i».i„o.  i.  a  i.,.*h,  ,ovor»,,io 

h.,1,  tat  to  ni  r.,.o,-anis,„..  Tho  ,-..lo„  haoilli,  staphylo.,..-.-,,  slr^.toooec, 
"■''"'•"  '  '  ,  ,  ,1  l\Z-  tvolioi.l  l,a<'illi  have-  all  l.o«i  toiuKl  lioro  ihuUt  vavyiiig 
ZZ::  Ih'^  ^"•-•-rUy^.  fact  is  the  lo„,th  ottinK.  wl,id,  tl,oy 
tomll tio,i»    !  I  ,    ,,  „,„  f,r,t  <loiii.msli-al,'(l  l.y  lllad.rf,.ni  in 

^S.;,'ria';: rato,?:"  tI::  .;;.u,i.l  l.a..-nh.  l.as  ben  i.o.atcO  in  „n.-c  onllnro 

f„ll^Zn;|'.li'iu.l  l',v  (lillKTt  U  l-oa„,ic,-  by  injoc-fng  nncro-ovgantsms 

"■'"CSv't't::i!,;'i;;;;"*.all.*n..  .in,  .be  .pecin..  tovors.     netn. 

1  i,„  {^S  tlr  t  ralle.l  atl.'nUon  to  tbe  tre,|n™ey  of  gall-stone  altaota 
'  ■,  .1  il  si  oe  .bat  tin.e  Dnfnv.  bas  eolloote.!  a  series  «'  ™-;^  "";' 
Cbilr!:  itoon.  and  Osier  bave  ealled  at.ention  to  tbe  great  freqnene.,  ot  gall- 

''''l'i^™;r;^;*b,"u;:r;bu::™::^:^:;:rind,,eed  by  n,iot„-o,.an 

isn,s  is  .be  tnolt  important  single  factor,  tbere  are  other  accessory  causes  of 

*="°';;™x"arlv  r,0  ,,er  cent  of  all  the  case,  occnr  in  persons  above  forty 
.e,;!'of  a.e      Thev  are  rare  nn.lor  t,vcnty-flvc.     They  have  been  n,et  ,v,tb 

'"  X:-^-tZ  ;;;':;;;:<:«:■  orrlnen.     rrcgnane,  has  an 
L^ptSnt   inflnencc.     Xannyn   states  .hat   90  per  cent  ot   ,von,en   .,th 


111 

i 


li  of  the 

)  the  for- 
uiyir.  (") 

from  the 
mod;  and 
.I'S.  It  is 
•.ndl-hliul- 
4i'rin  iiiid 
,11-bliidder 
liil  inilam- 
nvs  of  tliis 

ohl  idra) 
irs  the  de- 
its  of  lime 
nonstrated 
"hree  addi- 

v  favorable 
reptoeocci, 
ier  varying 
whieh  tlioy 
iichstein  in 
lire  culture 

xm  succops- 
L)-organisnis 

■ers.  Bern- 
:oTio  attacks 
f  cases,  and 
cue;  of  gall- 

tnicro-organ- 
)ry  causes  of 

above  forty 
■en  met  with 

lancy  has  an 
women   with 

adder  predis- 
;lonod  corset- 
cr  a  "  leanini:: 
,  ])articularly 
pressing  mcn- 
=.     The  belief 


CnOL?:LITIlIASIS. 


503 


jirevailed  formerly  that  there  was  a  lithiac  diathesis  closely  allied  to  that 


of  gollt. 


Physical  Characters  of  Gall-stones.— 'riuy  may  be  sin^de,  in  wiiidi  case 
the  stone  is  usually  ovoid  and  may  attain  a  very  large  size,  instances  are 
on  record  of  gall-stones  measuring  more  than  5  inches  in  length.  They  may 
be  extremely  numerous,  ranging  from  a  score  to  several  hundreds  or  even 
several  thousands,  in  which  case  the  stones  are  very  snudl.  When  moderately 
numerous,  they  show  signs  of  mutual  pressure  and  iuive  a  jiolygonal  form, 
with  smo(jth  facets;  occasionally,  howi'ver,  live  or  six  gall-stones  (d'  medium 
size  are  met  with  in  the  hladder  which  are  round  or  ovoid  and  without 
facets.  They  are  sometimes  mulberry-shaped  and  very  dark,  consisting 
largely  of  iiile-pignu'uts.  Again  there  are  snuill,  black  calculi,  rough  and 
irregular  in  shape,  and  varying  in  size  from  grains  of  saiul  to  small  shot. 
These  are  sometimes  known  as  gall-sand.  On  section,  a  calculus  contains 
a  nucleus,  which  consists  of  bile-pigment,  rarely  a  foreign  body.  The 
greater  portion  of  the  stone  is  made  up  of  cholesterin,  which  may  form 
the  entire  calculus  and  is  arrangetl  in  concentric  lamina;  showing  also  radi- 
ating lines.  Salts  of  lime  and  magnesia,  bile  acids,  fatty  acids,  and  traces 
of  iron  ar.d  copper  are  also  found  in  them.  A  majority  of  gall-stones  con- 
sist of  from  TO  to  St)  per  cent  of  cholesterin,  in  cither  the  amor[)l>ous  or  the 
crystalline  form.  As  above  stated,  it  is  sometimes  pure,  but  more  commonly 
it  is  mixed  with  the  bile-pignicnt.  The  outer  layer  of  the  stone  is  usually 
harder  and  brownish  in  color,  aiul  contains  a  larger  pro|»ortion  of  lime  salts. 

llie  Scat  of  .Formation. — Within  the  liver  itself  calculi  are  occasionally 
found,  but  are  here  usually  .-mall  and  not  abundant,  and  in  the  form  of 
ovoid,  grecnish-l)lack  grains.  A  large  majority  of  all  calculi  are  formed 
within  the  gall-bladder.  The  stones  in  the  larger  ducts  ha\e  usually  had 
their  origin  in  the  gall-bladder. 

Symptoms. — in  a  majority  of  the  cases,  gall-stones  cause  no  symp- 
toms. The  gall-bladder  will  tolerate  the  i)rcsence  of  large  numbers  for  an 
indefinite  ]ieriod  of  time,  and  ]iost-mortem  examinaf  mis  show  that  tlu'V 
are  ju'csent  in  2o  ])er  cent  of  all  women  over  sixty  years  of  age  (N'aunvn). 

The  French  writers  have  suggested  recently  a  useful  division  of  tlu 
symptoms  of  cholelithiasis  into  (1)  the  aseptic,  mechanical  accidents  in  con- 
sequence of  migration  of  the  stone  or  of  obstruction,  either  in  the  ducts  or 
in  the  intestines;  {'l)  the  se])tic,  infectious  accidents,  either  local  (the  angio- 
cholitis  and  cholecystitis  with  ein]>ycma  of  the  gall-bladder,  and  the  fistulaj 
and  abscess  of  the  liver  and  infection  of  the  neighboring  parts)  or  general, 
the  biliary  fever  and  the  secondary  visceral  lesions. 

It  will  be  better,  perhaps,  to  consider  cholelithiasis  under  the  following 
lieadings:  The  symjitoms  ]»roduced  by  the  passage  of  a  stone  through  the 
ducts — biliary  colic;  the  eifects  of  ])crmanent  plugging  of  the  cystic  duct; 
of  the  stone  in  the  common  duct;  and  the  more  remote  elfects,  due  to  ulcera- 
tion, perforation,  and  the  establishment  of  fistuhe. 

1.  Biliary  Colic. — Gall-stones  may  become  engaged  in  the  cy-tic  or  the 
common  duct  without  ])roducing  pain  or  severe  symptoms.  .More  com- 
monly the  passage  of  a  stone  excites  the  violent  symptoms  known  as  biliary 
colic.     The  attack  sets  in  abruptly  with  agonizing  pain  in  the  right  hypo- 


I 


DISEASES  OF  THE  DlftESTIVB  SYSTEM. 


1 


'"'■',";;: '  .    ;;  ;    ■    :        .nu^^  K^         .-«  very  smmur,  a„.l  s„r,,..m.  have 
ai„|lli„M.„l  «h.it«.  i.u  r»"  .  ,.„,„litic.n.  Lohcving 

"■';"";■""■■. ":;::'::;  [ " ' :  s.  •■(  'lu. ,,«.  j,.,....ii.-c  -lovoi..,..,  fut 

,„U,,1,  won.  |.ic.-n.t.        ' J^    '  ''  i,  ,,„^„  „„,  „,,„,  ,l„,.i„B  the  [ms- 

,  r     >    ,  ■  „r  ,n..iv      It  III.-  SI..IH.  Ii...-..n".s  iiiil..i.U..l  m  111..  ..nl.« 

;;,;:il;:?^,:r;::::i;::i;::;.K't.":,:t:'-.i.Hi-.."i:. -..-y 

''''"I'l"'"'-       „  -1     .  ,„.    «iu.h  -H  nii.tiuT  of  tlio  duct  with  fatal 

;  ■      : ;  '::„;„li,ii„  .l..«.vil,...l  l.y  »»..  "ilor.  as  o„„„„g  .,„  a™l.l> 

ea-'ofullv  iiUer..<l  tl>r.u,oh  ,  narrow-inohcd  ^  -^^^l-    /  '    1  ^^^^^  j^  ^^  gall-stones 
•    I-      ,,  ,n+lv  iiipf  with    u  norvoas  women,  and  tlio  uui^nosi.  ui  {.. 
''''T''    T   i;         -on    10  atie  colic  n,ay  he  periodical;  the  pain  n.,v  he  >n  the 
made.     1  tu^  nei\oii^  m  p.u  '   ,,„M.,fn,l  with  other  nervous  phenom- 

,.i,,l,t  si.l..  „„.l  .a.li»li..|.';  -i-t...-  ^»'*J," ■';,:;   i,„  ,™y  b'  tender, 
r'^;'!;^;;:■  ;:;    r;;::       •>      nfl"n,n;:t.,ry  con.li.i,,,.s.    T1,c  coml,ma. 
1'        1     .      ^     clU  so  aistinctive  of  gall-stones,  is  n...  always  present. 


CIIOLKLITIIIASIS. 


5G5 


l'  in  till* 
1  witli  a 
■uiilly  .■") 

luay  lie 
^H•(1,  ami 
L'asos  I  ho 
rinu  c'ou- 

L'rial)  iu- 
•lofystitis 
•(Ills  have 
lielieviiig 
'lops,  but 
;  the  pas- 
Ixroiiies 
ro^Tcss  in 
to  the  ar- 
on  wliifh 
teiiliou  of 

rs,  several 
the  (irilUe 
commonly 
ited  at  in- 
ms  lapitlly 

with  fatal 
nee  of  re- 
These  are, 
rt  may  lie 

jiaroxysm; 

on  acutely 

'  jiain  is  in 
n  nephritic 
ire  frecpient 
inics,  to  1)0 
do,  and  the 
s.     To  look 
I  water  and 
•  colic  is  not 
f  gall-stones 
i!iy  l)e  in  the 
JUS  phenom- 
y  be  tender, 
lie  combina- 
vays  present. 


TIh.  pains  m:,v  be  not  colicky,  but  more  constant  and  dra^.n.^  n,  .... 
,,r  Uf  M)  caM.s  o|K..alcd  up.m  hy  Uicdel,  K.  had  not  bad  cohc,  -mlj  1 
nrJsentcd  a  gall-blad-lcr  tumor,  wlnle  a  n.ajority  had  not  bad  jaunduc.     A 

'm    lable  Lntho.na  of  the  bdc-pa.ap.s  has  luvn  found  .n  -'";"-''; 

H.u'iti.'  cnlic.     1  have  already  ^-P'-^''"  "I'  H'"  <l'^'^"'<'^'>*  "»  '"'"<''  '•l'"'''^'  •»'♦'«"' 
p  c   dicitis  and  obstructiin  of  the  bowels.     UecurrinK  attae   s  o    pani 

;,,  the  region  of  the  liver  may  follow  adlK.sions  lie.ween  the  gall-bladde, 


inav 


lie  thus  eiinmer- 


aiid  adjacent  parts. 

•.'.  Obstruction  of  the  Cystic  Duct.-'riu'  eiL.t^ 

"'i;,)  Dilatati.in  of  the  gall-bladdcr-hvdrops  vesic;e  felleie.     In  aeute  oli- 
.trucli.m  the  contents  are  bile  mi.xed  with  much  mucou>  or  uiuco-puruient 
;, 'atcrial.     In  chronic  obstruction  the  bile  .s  replaced  l,y  a  clear  lluid  mucus, 
-riii.  i.  an  imi-ortant   point  in  diagn-isis,  particularly  as  a  dnipsual  gall- 
l.la.ider  may  form  a  very  large  tumor.     The  reacLion   is  not  always  con- 
stant     It  i;  either  alkaline  or  neutral;  th..  consistence  is  thm  and  mucoid. 
Albumin  is  u.uallv  present.     A  ddated  gall-bladder  may  reach  an  enormous 
.i,e   and  in  one  instance  Tait   found  it  oc.upying  the  greater  part  ol  tiic 
Abdomen.      In  such  cases,  as  is  not  unnatural,  it  has  been  mistaken    or  an 
„,„,ian  tunu.r.     I  have  dccrilied  a  case  in  which  it  was  attached  to    be 
ri-dit  broad  ligament.     The  dilate.!  gall-Ma.lder  can  usually  he  lelt  lielow 
tire  edge  ..f  the  liver,  m.hI  in  many  in>tauces  it  has  a  charactenst.c  out  hue 
like  a  gourd.     An  enlarged  and  relaxe.l  organ  may  not  be  palpable   and  in 
acute  cases  the  distention  may  be  upward  toward  the  lulus  ol     he  livu. 
The  dilated  gall-hladdcr  usually  projcts  .lircctly  ilownward,  rarely  to  one 
side  or  the  other,  though  occasionally  toward   the   muldle  line.     It  may 
reach  beb.w  the  navel,  and  in  persons  with  thin  walls  the  outline  can  be 
accuratelv  delined.     Ificlcl  has  called  attention  t.i  a  tongue-bke  projection 
of  the  anterior  margin  of  the  right  lobe  in  connccti.m  with  enlarged  gall- 
bladder     It  is  to  be  remembered  that  distention  of  the  gall-bladder  may 
occur  without  jaundice;  indeed,  the  greatest  enlargement  has  been  met  with 

in  such  cases.  ,  ,   , ,  ■•  n     c    <    , ,. 

Call-stone  creiiitus  may  be  fi'lt  when  the  bladder  is  very  lull  of  ston.  s 
and  its  walls  not  verv  tense.  It  is  rarely  wll  felt  unless  the  abdominal  walls 
are  much  rela.xcd.  'it  may  be  found  in  patients  who  have  never  iiad  any 
gYnnitoms  of  cholelithiasis.  ■,  ,     .,  ^ 

(h)  Acute  cholecystitis.  The  simple  form  is  common,  and  to  it  nre  due 
probably  very  many  of  the  sympbuns  of  the  gall-st.me  attack.  Ihleg- 
nionous'cholecYstitis  is  rare;  only  seven  instances  are  found  in  the  c-rmr- 
mou'^  statistics' of  Courvoisier.  It  is,  however,  much  more  common  than 
these  (Igurcs  indicate.     IVrforation  may  oecur  with  fatal  peritonitis. 

(r)   Suppurative  cholecystitis,  empyema  ..f  the   gall-bladder,   is  nn.c  i 
more  common,  and  in  the  great  majority  of  eases  is  associated  with  gall- 
ctone<— 11  in  55  cases  (Courvoisier).     There  may  be  enormous  dilatation 
and  over  a  litre  of  pus  has  been  found.     Perforation  and  the  formation  of 
abscesses  in  the  neighborhood  arc  not  uncommon.  _ 

(d)  Calcification  of  the  gall-bladder  is  commonly  a  termination  of  the 
previous  condition.     There  are  two  separate  forms:  incrustation  of  the 


1; 

.1 


^^ 


J.QQ  DISRASFS  OP  TllR  DIGRSTIVK  SYSTEM. 

orj;an  sl.rmk.  mto  ii  ■  "'■  "  "  ,  ,.      „,,,,,„,.  ni.vous  string;  moro 

:;;^    0  i-c  olnn,,.,,,  ,iuct.  Ti,o  i,»n..ii<.o  is  .i.., ;"" ;;';  "-s- 

1  '       '  4-    (•  ,*i>,..,.     Tlio  iniii*   the  urovious  attiuUs  ol  tone, 

lltilf"    The  duds  a?e  usually  nu.ch  dilaUnl  and  overywn.vo  contain  a  clear 
n\uri)i(l  fluid.  .   ,    ,.       ,7       ■!•„ 

T  Jre  0  a  series  ot  sf.nes  in  the  eonunon  .Inet,  a  s,n,le  stone  .he 

had  svn.pton,s  j.ointing  to  gall-stones;  hut  m  a  n>a,,out>  ot  ca.c.  the.e 
very  Vharaeteristie  f^^tures  .^  ^^^,^^  ^,^^^ 


nmcus. 

Naunvn  has  <;iven  tlu 


„win'^  as  the  (listintruishing  sifrns  of  stone  in 

if  hik 


Naunvn  nas  ^'      '    ^  !    ;  ;    r,  „„,  ,,  ,,,,,ional  presence  of  hile  .n 
the  eonmiou  duet:      (1)    I  lu  (oni,i  u«ni       .  „<•  ti,,,   -iniin.lice-    (o^ 

1       f    .n..    ^)\   .li^linet  variatinns    n  the   intensity  oi   the  jaumiict,    (,.; 

•     ,    ,  i;     rli,.„lmn  of  Vntor,  tlmuj-'l.  it  may  lio  ii.  tlK'  fomn.,m  (lutt  lt*ll. 


tniiliRLlTmASIS. 


607 


ic,  the 
iiic  l»y 


,  good- 
;  inoi'o 
tion  is 

cut  oti: 

i   stone 
stones, 

I  lies  in 
In  rare 
it  ocelli- 
hiuken- 
hepatic 

idiirinix, 
of  colic, 
on  from 
lith  ccr- 

II  a  clear 


no  wliicli 
of  Vater. 
:s  bavins 
tlierc  are 

duct  ami 
it  ion  may 
it  of  the 
ly  smooth 
le-^tainc(l 

f  stone  in 
of  bile  in 
ulico;  (:'») 
of  clisten- 
iliscnce  of 
tlic  jaun- 

nily  finnifl 
;luct  itself, 
paroxysms, 
harcot;  {h) 
years,  and 
lains  in  tbo 


roL'ion  of  tbe  liver  wilb  <ra-trir  disturbance.  Tliese  symptoms  may  continue 
,m  and  olV  for  tliree  or  four  jcars.  willmiit  the  d.vlopni.nt  of  suppurative 
,,|„,|.„i.riii<  in  one  of  my  cases  the  jamidi.c  and  iv.iirrin;,'  liepalie  inter- 
mittent fever  cxi^t.■.l  from  .lulv.  1ST!!,  until  .\u-ust.  iSS-.';  tbe  patient  re- 
ndered ami  still  lives.  Tlie  condition  lias  lasted  from  ei^dit  months  to 
tliree  vears.  Tbe  ri>tors  arc  of  intense  severity,  and  thr  temperature  rises 
to  l(i;f  or  lU.r.  The  chills  mav  recur  daily  for  weeks,  and  present  a  tertian 
or  nuartan  tvi'e.  so  that  tliev  are  often  attributed  to  malaria,  with  uliieli. 
however  tliev  have  no  connection.  The  jaundice  is  variable,  and  deepens 
after  each  paroxvsm.  The  itching'  may  be  most  intense.  I'ain  wbieh  is 
sometimes  .-eveiv'and  colicky,  does  not  always  occur.  There  may  be  marked 
vomitin-  ami  nausea.  As  a  ru..  there  is  no  progressive  dcterioratmn  ol 
liealth   "in  tiie  intervals  betwee.     N'  attacks  tin-  temperature  is  normal. 

Tbe  clinical  bi>torv  and  tbe  post-mortem  examinations  in  my  cases  show 
conchwivelv  tiiat  this  condition  may  persist  for  years  without  a  trace  of 
suin.nration  within  the  ducts.  There  must,  however,  be  an  infection,  such 
as  niav  .'xist  for  vears  in  the  gall-bla-bler,  without  causing  suppuration. 
Jt  is  prol^able  that  the  toxic  symi.toms  only  develop  when  a  certain  gra.le 

of  tension  is  reached.  r  ii  .  .■ 

An  interestiuirand  valuable  diagnostic  point  is  tbe  absence  of  dilatation 
,,f  tbe  gall-ldadder  in  cases  of  olistnicli  ni  from  stone— Courvoisier's  rule. 
I'cklin  who  has  reeentlv  reviewed  this  point,  finds  that  of  \ri  cases  a  olj- 
.truction  of  tbe  common  duct  by  calculus  in  :!  1  tbe  gall-bladder  was  normal, 
in  IK.  it  was  contraeted,  and  in  'i^  it  was  dilated.  ( »f  Dii)  ca<cs  of  occlusion 
Hf  lb.,  common  duct  from  other  causes  the  gall-bladder  was  normal  m  !i, 
shrunken  in  !».  and  dilated  in  IvM. 

(r)  Inr(iwi>h'tr  ohslnirHim,  irllli  sitppiiralirr  rlifihiniiih'i. 

^VIu•n  suiti.urative  cholangitis  exists  the  mucosa  is  thickened,  often 
eroded  or  ulcerated;  there  may  be  extensive  suppuration  m  the  duets 
tbiMUcdiout  tbe  liver,  and  even  emi-yema  of  the  gall-bladder.  Occasionally 
the  suppuration  extends  l.evond  the  ducts,  and  there  is  localized  liver  ab- 
scess, or  there  is  ])crforation  of  the  gall-bladder  with  the  formation  (d  ..1.- 
scess  between  tbe  liver  and  stomach. 

Clinicallv  it  is  characterized  by  a  fever  which  may  be  intermittent,  but 
more  commonlv  is  remittent  and  without  i.rolonged  intervals  of  apyrexia. 
The  iaundice  is  rarelv  so  intense,  nor  do  we  see  tbe  deei-ening  of  the  color 
after  tbe  paroxysms."  There  is  usually  great.>r  enlargeiiH.nt  of  tbe  liver 
and  tenderness 'a, :d  more  definite  signs  of  septicamiia.  The  cases  run  a 
shorter  course,  and  recovery  never  takes  ].lace.  r--  ,   > 

(A)  The  More  Remote  Effects  of  Gall-stones.— (<')  Ihltnni  Ft>^hihr. 
The-e  are  not  uncommon.  There  may,  for  instance.,  be  abnormal  commu- 
nication between  the  trail-bladder  and  the  bepatic  dm-t  or  tbe  gall-bladder 
■md  a  cavity  in  tbe  liver  itself.  :\roro  rarely  ]ierforation  occurs  between 
tbe  common  duct  and  the  portal  vein.  Of  this  there  are  at  least  four  in- 
stances on  record,  among  them  tbo  celebrated  case  of  Ignatius  I.oyobi. 
Terforation  into  tbe  abdominal  cavity  is  not  uncommon;  IV.^  cases  exist 
in  the  literature  (ronrvoisier),  in  m  of  which  tbe  ruiitnro  occurred  directly 
into  the  peritoneal  cavity;  in  40  there  was  an  encapsulated  al>scess.     Per- 


DISEASES  OF  TOE  PTOESTIVE  SYSTEM. 


I 


I 


,s 


508 

,um,.     r,„„„,unk,,li,.n  will,  ll.o  ilci.m  and  J.J.mun.  w    x  .1 
1  uloii=  oLLliinK  iut.,  ll.c  coUra  3'->  c«s  are  on  record      Ihce 

culou  that  the  large  gall-stones  escape. 

()(.,..i.iniiallv  the  urinary  passages  may  he  oponed  into  ant      it  .tone-, 

,,.,    t  Ca  in  the  hladd^r.'  Many  instances  are  on  --;f  ^  ^^^^-J- 

tu  ,.n  the  hile-i.assages  and  the  lungs.     Courvoisier  has  collected  .4  ca.cs, 

rwii^^hs    J.  E.^;raham  has  added  K.,  including  ^  cases  ofh.s  own 

T,^!"  of  Assoc,  of  Am.  Physicians,  xiii.)     Bile  n>ay  he  coughed  up  .ith 

the  expectoration,  sometimes  in  considerahle  quantities 

Of'all  fistulous  communications  the  external  or  -^arieous  i.  tlu^  mo 
common.     Courvoisiers  statistics  nnmher   181  cases    ^^y.'*^ J^^     \  f  " 
M  the  perforation  took  place  in  the  right  hypochondr.un,  "Y;:*,J  d 
:  nt   n  the^egion  of  tlie  navel.     The  number  of  stoiies  ^-^^^^^^^ 
?rom  one  or  t^o  to  many  hundreds.    Recovery  took  place  ,n  ..  ca^c,  .ome 

made  to  this;  its  frequency  appears  from  the  fact  tl>at  ot  .Jo  a^cs  ol 

-fS:rcSr?'S.u^::n^^:S  7o^'i  ri:g^ 

:,';'«;,:,..,"         h^v,,  ,*,,,,..     TKo  po.t-mor,e,u  ro,K,rt.  *ow  fat 
I'""'"''  '";";',•'  :,,,„„  vnr.V,r.>o  atones  liBVe  passed  prr  rl»»i  naliirakm, 

!         n  o  nr  er-  rain  doses.     In  an  agonizing  paroxysm  it  is  well  to  give 
ii  ff  0    iwo  of  c  doroform  until  the  morphia  has  had  tin.e  to  act.     Great 

StoK        i    >  Lave  lx«  rUrded  as  ™le»li    and  conoreUons  due    o 
:*„";*;  s. ,     ;  ei    S2d  r:  Lne.  ;.rlo„.  remedies  „ave  been  ad- 


iM 


THE  CIllIUlOSES  OF  THE  LlVEll. 


5G9 


hepatic, 
lie  most 

iistro-in- 
Betwc'Oii 
.  Cour- 
'  ductus 
IdtT  and 
X'  reiuely 
.  Tlifso 
liout  any 
uuuni  or 

le  stonorf 
stiiltu  Ijo- 
24:  cases, 
his  own. 
[  up  with 

the  most 
r  cent  of 
in  2d  per 
red  varied 
ises;  some 

■eady  been 
5  cases  of 
3  were  by 
iases,  in  6 
\  or  in  the 
ntaneously 
show  that 
naturalem, 
litting  the 
have  been 

n  attack  of 
ypodermic- 
,ell  to  give 
act.  Great 
I  tlie  region 
cl  drink  eo- 
>less  in  my 
passed  with 
ions  due  to 
iciated  with 
[  ether  and 
ve  been  ad- 


vised  to  dissolve  the  stones  within  tl>e  gall-bladder,  n,.ne  of  which  are 

'"'"t'diet  should  be  regulated,  the  patient  shmdd  take  regular  exercise 
.n.l  nvoid    -IS  much  as  possihle,  the  starchy  and  saccharine   loo.U.      llu 
1  "     f'r'o        cmedVv  rrout  are  believed  to  prevent  the  co,K.cntra- 
m  ;      hc'ul    and  the  formation  of  gall-stones.     Kitlu.  the  sulpluUc  or 
r  .holpl.ate  may  be   taken   in   doses   of  from   1   to  'i   drachms   dail 
t  tintolerahle  Itching  Mc.all  Anderson's  dusting  l-^-^^  Ic^h    f 
«t.,r<h   an  ounce-  camidior,  a  drachm  and  a  halt;  and  sulphate  oi  /mc,  1  all 
ou  n'ci      Sue  u  1th  s  sluaild  be  fmely  dusted  over  the  skin  with  a  powder- 
:r  iN;w.U:;:;  with  starch,  strong  alkaline  '-'>tb.  (bot)   ,uhK.arp.n  hypo 
luMinicallv  (gr.  i-\),  ami  antipynn  (gr.  vi.j),  may  be  tued.     bh.h>nl  and 
lam.lin  ointment  sometimes  gives  rebel.  -...i^n-    ;„  n 

Exploratorv  puncture,  as  practised  by    lu.  'f'^}'''}'^\''^;^'lJl^ 
case  0    empyJma  of  the  gall-bladder,  and  by  Bartholou    i      ^^'^    f    ^^ 
now  often  done.     Aspiration  is  usually  a  sate  procedure,  though  a  fatal 

"tl'r^ul'trtreatinent   of   gall-stones  has  of  late  years   made   rapid 

pro'rt      11>e  operation  of  cludecystotomy,  or  opening  the  gall-bladde 

S  ivnu>vin.'  the  stones,  which  was  advised  by  Suns,  has  been  rciiia  k- 

V  ^^M     The  removal  of  the  gall-bladder,  cholecysteetomy,  has  a^ 

inij  .utei,.u.  indications  for  operation  are:  ('/)  Re- 

:  r'mlf  of       iX^  colic    Vie  operation  is  now  attended  with  such 

^r'lf  ^  t^nt  th  pa^^  t  is  much  safir  in  the  hands  of  a  surge..n  than 
slight  1  >kluttc  pa  ant  ^^^^^^  ^^  ^^^^^  ^^^.^^^^^^^^  ^^^^^^_ 

Ir  wi  ev  r  (.)  When  a  gall-stone  is  permanently  lodged  ur  the  comnum 
duct  and  he  gr mp  of  svmptoms  above  described  are  present,  he  que - 
tion  'then  of  aclvising  operation  depends  largely  upon  the  personal  methods 
and'«m.c"C  c^  the  surgeon  who  is  available.  The  operation  necessarily 
^tl  no"  orious  ancl  dilbcult  than  that  upon  the  gall-bla  der,  is  now 
ieinarkably  successful  even  in  desperate  cases  of  years'  duration. 

VII.     THE   CIRRHOSES   OF  THE   LIVER. 

General  Considerations.-Thc  many  forms  of  cirrhoses  of  the 

livoTC  one  feature  in  common-an  increase  in  the  connective  tissue  of 

1     o  nn      Tn  fact,  we  u>e  the  term  cirrhosis  (by  which  Lannec  cliaracter- 

!!cHl  tlu  tawnv.  vellow  color  of  the  connuon  atrophic  form)  to  indicate  snm- 

'-'  SSX.:is  m::r  dassified,  etlologicany,  according  tc,  the  supj^sc^ 
cau^at^on!  anatomically,  according  to  the  structure  primarily  mvohed,  or 

play  a  minor  role. 


570 


DISEASES  OF  THE  mOESTlVE  SYSTEM. 


2.  lufecliou.   r,V,7,o.c...-Willi   many   of   the   specinc     over     no    o   c 

ohan<n.s  L-uv  in  tl>o  livor  ul.ioh,  uhon  Midosproa.!,  may  l.o  io  IunnocI  !>> 

in t.is.     rossil.lv  tho  In-portroi-hio  cirrhosis  of  ]lanot  and  othor  terms 

,  .1  whl.  in  oarlv  i'ilV  aro  duo  to  infection.     The  malarial  cirrhosis  is  a  Nvell- 

r^oognizcd  varidy.     The  syphilitic  poison  produces  a  very  characteristic 

^""3:  Chrhoxh  from  chronic  cougcstion  of  the  hhml-vcssds  in  heart-disease 

"^4'  rLT/'L-r/n>;»  chronic  ohslruclion  of  the  hik-ducts,  a  form  of  very 
slighi  clinical  interest.  In  anthracosis  the  carhon  pigment  may  reach  he 
liver  in  large  (inantities  and  he  deposited  in  the  connective  tissue  ahout  the 
Dortal  canal,  leading  to  cirrhosis  (Welch).  ,  •  ,     „       „„,„ 

^  Anatomial  Classification.-l.  Vo.^ndar  cirrhoses,  in  which  he  now 
growUi  of  connective  tissue  has  its  starting  point  ahout  the  hner  hranches 
tho  portal  or  hepatic  voins.  ■,   ,     ,      •       1      *. 

InHiary  Lhoscs,  in  which  the  j-rocoss  is  supposed  to  hegin  ahou 
the  finer  l)ile-dncts,  as  in  the  hypertroi)hic  cirrhosis  <.i  Ilanot  and  in  the 
form  from  ohstrnction  of  the  larger  ducts. 

;5.  Cnimdar  cirrhoses,  a  perihepatitis  leadi.-.r  to  great  thickening  of  the 
capsule  and  rediu'ti.m  in  the  volume  of  the  liver.  _ 

CUnical  Clas8iflcation.-l'nr  i)ractical  purposes  we  may  recognize  the  fol- 
lowing varieties  of  cirrhosis  of  the  liver:  -n   +1,:.  n„.  f.,Hv  cir- 

1.  The  alcoholic  cirrhosis  of  Lacnnec,  inchiding  with  thi.  the  tatt}  cir 

rhotic  liver. 

2.  The  hyiH>rtroi)hic  cirrhosis  of  Ilanot. 

3.  Svi>liilitic  cirrhosis. 

4.  Capsular  cirrhosis— chronic  perihepatitis.  , 
Other  forms,  of  sli.'ht  clinical  interest,  are  consulered  e  sewhore  under 

diahe  'rmalaria,  tuherculosis,  and  heart-disease.  The  cirrhosis  f roin  ma- 
ria.  upon  which  the  French  writers  lay  so  much  stress  one  descnhes  h  - 
00  viietiesi),  is  oxcessivelv  rare.  In  ouv  largo  experience  with  malar  a 
^  n^  he  palt  nine  years  not  a  single  case  of  advanced  --'>;- ^^-J^ 
Ihis  (:ause  has  heen  seen  in  the  wards  or  autopsy-room  of  the  John.  Hop- 
kins  Hospital. 

I.    ALCOHOLIC  CIRRHOSIS. 

Etiology.-The  disease  occurs  most  frequently  in  middle-aged  males 

wh.   h  ve  Wn  addicted  to  drink.     Whiskey,  gin,  and  brandy  are  more  po- 

cnt      cause  cirrhoses  than  heer.     It  is  more  common  in  countries  m  ^hich 

rong  spirits  are  used  than  in  those  in  which  malt  liquors  are   =f  -  ;^-g 

.orH^iutopsies  in  my  colleague  WelchV  department  of  the  J'^^"^;  "'!;"». 

TTospilal  there  were  C.3  cases  of  small  atropine  liver,  and  8_ cases  of         Y^; 

cirri  one  .>ruan.    Laneoreaux  claims  that  the  vin  ordmcure  of  France  is  a 

common  cause  of  cirrhosis.    Of  210  eases,  excess  m  w,ne  alone  was  pie.  nt 

in  (iS  eaces     He  thinks  it  is  the  sulphate  of  potash  m  the  plaster  of  Ian., 

ii.cd  to  ffive  the  "  drv  "  flavor  which  damages  tho  liver. 

C  rrluU^  of  the  liver  in  voun<r  ehildren  is  not  very  rare.     Palmer  How- 
ard cSltt^dGa  cases,  to  which  Hatfield  added  93.     In  a  certain  num- 


THE  CIRimOSES  OF  THE  LIVER. 


571 


ber  of  the  cases  tlu-ro  is  an  alonholir  hist..ry,  in  ..Huts  >yplul,s  lu.s  Ihtu  fivs- 
t-nt  while  a  tlurd  jrvoup,  due  t..  tlio  poisons  of  the  inteetmus  .hseases,  em- 
braces a  certain  nnniber  of  the  cases  of  Hanoi's  hvprrtrnphu-  <  .n  u,s,s. 

Morbid  Anatomy.-rractically   on  the   i-ost-nwuleui   tal.le   we  see 
■lU'olu.Uc  cirrhosis  in  two  well-.liiiraeterized  forms;  .       .. 

TiTaU-oMc  Cirrhosis  of  Lonn.r.-'Vh.  ..r,.>n  is  .really  reduced  >n 
«ixe  and  nuiy  be  deform...!.  The  weight  is  so.netim.'S  n..t  more  than  a 
;  nm  lor  a  u.un.l  an.l  a  half.  It  presents  nnn.erous  ,ranulatH.ns  .u,  the 
Sec;  is  irn,  hard,  an.l  cuts  with  great  n'sistance  'he  substance  . 
"n  to  be  made  up  ..f  ,reenish.u.ll..w  islands,  surr..un.ie.l  by  gray.sh-wln  e 
;.onne..tive  tissue.  This  yelh.w  app..aranee  of  the  liver  nulueed  Laennec  to 
oive  to  the  c.nditi.m  the  name  of  cirrhosis.  ,.,  .  f.,t   i.  in 

Thr  Folhl  i'irrholic  Lirer.-V.u'n  in  the  atr-rhic  f.^rm  the  fat  is  m- 
c.re.<...l  but  in  tvpi.'al  examples  ..f  this  variety  the  .u-an  .s  n..t  re.lueed  in 
1  e' b'it  is  enlari.d,  sm,...th  or  very  slightly  granular  aiuemu..  yellowish 
white  in  olor,  an.l  resembles  an  or.iinary  fatty  liver.  It  is.  h.>w..v..r,  l.riu, 
,nts  with  r..sistan.e,  and  micr<.sc..pically  slu.ws  a  great  uuMvas..  in  the  c.n- 
ne.tive  tissue.    'i"his  f..rm  occurs  nmst  fre.iuently  m  l)..M--drink..rs. 

Tl,e  tw.,  essential  elements  in  .Mrrhosis  are  de.4ructi.ui  o[  hvei-eells  ami 
obstructi.>n  t.)  the  jtortal  ci       '   .io".  . 

In  an  aut..psv  .'n  a  ease         tn.phic  cirrlu.sis  the  pentonaMun  is  usually 

found  to  contain  a  large  quantity  ..f  ''''''V'^  .7'''''''' 'irint  'iine"' 1^ 
there  is  chronic  catarrh  ..f  the  st..ma..h  an.l  ot  the  small  intestine..      1 1  k 
spleen  is  enlarge.l.  in  part,  at  k^ast.  fr.uu  tlu;chr.uucc..ng..stmn    possibly 
due  in  part  to  a  "  viial  reaction,"  b.  a  to.xu'  mlluen.r  (I'ark.s  A\  .'Ikm)       1  he 
kidneys  are  sometimes  cirrh.)tic,  the  bases  of  the  lungs  may  b..  much  com- 
„r,K<cMl  bv  the  ascitic  ilui.l,  the  heart  often  simws  mark.^l  .h-.meration, 
ind'arterio-s.lerosis  is  usually  present.     A  remarkable  feature  ..  the  asso- 
eiati.m  of  acute  tnbercuh.sis  with  cirrhosis.     In  s.^ven  cases  of  my  ^^;"<^- 
tbe  patients  died  with  either  acute  tubercuh.us  pent.uutis  or  acute  tub,.r- 
c.nl.ms  idc.urisv.     Tilt  states  that  2^  per  cent  of  the  cases  ..f  cirrhosis  dying 
in   (iuv-s  ll..;i.itnl   during  twelve  years  had   acute  tuber.ulosis.^   Ot   1.1 
aubmsies  at  th.>  Man.hest..r  U.nal  Iniirmarv  in  cirrh..s.s,  ab.mt  -o  per  cent 
ga  e  evi.lcnce  .,f  tub..rcuh,us  infection.     Twelve  ..f  th..se  ha.l  tuberculosis 
o?  the  perit..ineum.  and   VI  died  directly   from  the  tubercuU-us  infection 

^^''S^c^mipensatorv  circulation  is  usually  readily  demonstrate.!.     It   is 

carried  out  bv  the  foih.wing  set  ..f  vessels:  (1)  The  access.,ry  portal  system 

of  Sapnev,  of  wlm^h  important  branches  pass  in  the  round  and  s.ispensory 

li>ran 'e nt.<  and  unite  with  the  d.igastric  and  mammary  systenis.    Th.-se  ve.- 

cds  arc  numerous  and  small.    Occasionally  a  larg..  single  v..,n    whu  ,  ni  y 

attain  the  si.o  of  the  little  fing..,-.  pass.-s  from  the  h, bis  .,f  <'"'—'•;;;; 

the  round  ligam.mt.  and  .{..ins  the  epigastric  veins  at    he  nav.d.     .\1  h.    gh 

this  has  the  p..siti..n  of  the  umbilical  vein,  it  -s  usua  ly.  as  Sapp..>  sh.me.l, 

a  para-unibil  cal  vein-that  is,  an  cnlnrg..d  v..in  by  the  s,.  .•  of  the  ob btc  - 

atld  umbili<.al  vess.d.     There  ntay  be  produced  about   the  navel  a  largo 

bunch   .>f  varices,  the  so-callcd   caput  Medns.      Other  '"■«•;<  >-;;.^     '- 

system  occur  in  the  gastro-epii.loic  omentum,  ab.mt  the  gall-bladdci,  and, 


i! 


I 


572 


DISKASlvS  OF  TlIK  DKiESTIVE  SYSTEM. 


must  iiuiioitiint  " 


I   i„  ,h,.  si..iu.nsn,v  li-n„M.nt.     Tlu...  lattrr  f.M'm  large 

iH,  tlH.  vein  a/v-w      C')  I'-v  tlu"  anast..in(..is  la'twcrii  the  ..-.oi.h- 
::  a  I      ri         -"'^TlK.  uL  ;>t  tlu.  1.W0V  end  of  the  a.su,d.n,us  n.^ 

W    „      ImMv  ..nlar,..d.  pn.hu.iu,^  varices  vvhidj  ,.ro,,e.    «.'"  /l"'  ';7-  « 

,, ,     :    ,     (•;()  'nuMunumnmatin,,.  hetwcrn  the  ha^nnrrhouhd  and  the  iu- 
";";.„  en.,  veins.     The  Ireedu.n  ..f  eun.nuni.ation  ,n  th..  d.reet.on 

'      V      nal,le,  an.l  in  s„n,e  in.tanees  the  Inen.nr.l.oidal  vems  a,,  n..  im.e 
.nlan'-ed      (  D  The  veins  oi  IM/ius.  whuh  utnte  tl>e  radiek.s  ui  the  poita 

a  H    s  i,    the  intestines  and  n.esente.y  with  the  inlVnor  vena  eava  and 
^  H.hes.     To  this  svsten>  heh.n^  the  whuk.  ^nn,,.  oi    retropentcme 

;,i,       "hieh  are  in  n,nst  instanees  .norn.unsly  enlarge.!,  pavtuularly  ahout 


ani 


whuh  serve  to  earry  oil"  a  eon^i.k'.alde  i.roportion  of  the 

exist 


1,,.  most  extrenu'  j;vade  of  atroj^hie  eivrliosis  may 
-v.MUtnn.s.     So  lowi  OS  the  cnmi'rnsotunj  nrculalmn  is  wan,ta,ucd 


liu'  kiilney 
portal  lilood. 
Symptoms 

;^;'';;;;!i:nrnu;;-sn,lV.  little  ov  no  inJonvenienee.     The  ven.uUaWh 
tn         f  this  Collateral  einulation  is  well  seen  in  those  rare  n.sta.ues  o 
;;:;,;,•  nent  ohHtenmon  oi'  the  portal  vein.     The  .yn,pto,ns  n.ay  ho  dnuled 
int..  two  •Toups — ohstiiutive  and  tnxie.  ,  i  i 

'";.;//.. -The  overllllin,  <.r  the  Idood-vessels  of  the  ston.aeh  and 
i,tMin     lead  to  .hruni,.  eatanl,.  and  the  patients  sniVer  -t"'--- ^'Ij^ 
nni  in.',  partienlarlv  in  the  nu.rnin,;  the  ton,ue  ,s    nned  and  the  how   1. 
,  v.;  lar.      Ihenmrvha^e  f.on.  tlu.  stonuuh  n.ay  he  an  early  syn.ptonu 

;.  V;   profnse  and  liahle  to  reenr.     It  seldon>  proves  fatal.     '1  he  anu.u, 
■;;;.^  „,,,  ,,..  ,,,„„r,,,bk.,  as  m  a  ease  already  relerred  to,  .n  wlueh 
Is  were  ejeeted  in  seven  days,      l^dlowin,  the  l-".'^^>>'es,s  mc  a^ 
I      nnnon;  Init  haMnorrha.es  fn.n  the  howels  n>ay  oeeur  for  ---^1        - 
vi  i:.nt  ha.natenu.is.     The  hleedin,  very  o  ten  '->;- J-";  ^j^ ^'ti  ^ 
.oal  variees  alreadv  des.rihe.l  (p.  -i:.!»).     Knlaroenu.-t  of  the  M J'^  > '/ 
i  Ivre.'arded  as  a  si.n  -d'  the  ,.assive  eonjrestion,  n.ay   as  Parkes  \\  eher  sng- 
0    1.1,.  due  to  a  toxMnia.     The  organ  can  usually  he  felt      Kvulenees  of 
The  ;;tahlislnnent  of  the  eoUateral  eireulation  arc  seen  ,n  i  ) -■"!;> ^|^-^  ^PJ" 
n.trie  and  n.annuarv  veins.  nu,re  rarely  in  ti>e  presence  -d    he  eapu    Me- 
dui    a       in  the  develop.nent  of  luvnu.rrlu.ids.     The  distended  venules  in 
ttw  '    hora<.ie  xonellong  the  line  of  attaelunent  o    t   e  'l.'^Pl-^-;- 
not  speeiallv  n.arked  in  eirrhosis.     The  nu.st  stnk.ng  feature  ot  fad  no  m 
Z  compensatory  eireulation  is  aseites.  the  elfusion  of  serous  iln.d  .nto    1  e 
rih       d  eavit;.     The  eouditions  under  whieh  tins  oeenrs  are  stdl  o  1- 
,  r   Th    aluhuuen  gradually  distends.  n,ay  reach  a  large  s>ze.  ami  eon- 
t,in  a.  n.ueh  as  ir.  or  .>..  litres.     (Kdema  of  the  feet  may  precede  or  develop 
,vi,h  the  ascites.     The  dropsy  rarely  heeotnes  ,^;^'nera 

danndiee  is  nsnallv  slight,  and  was  present  in  onl  •>..  of  130  casi^  ot 
cin  si^  reported  hv-Fagge.  The  skin  has  fre.,nenlly  a  sallow,  sl.ghtj 
d  tin  The  nrine  is  often  reduced  in  amonnt.  contains  nrates  in 
nln  an  oft.n  a  slight  anionnt  of  albumin,  and.  if  jaundice  is  intense, 
tZ^:::  The  disease  may  he  afehnle  tlu^.g^on.  huMn  many  cases, 
as  shown  hy  Carrington,  there  is  slight  fever,  from  100   to  UK.o  . 


TIIK  CIUIlllOSES  OF  THE   LIVKU, 


573 


rxannniiti..n  at  nn  cavlv  sta-o  ..f  tlu>  .lisoasr  may  ,-h..NV  an  .nlai-i.l  an^ 
vainl'ul  livtT.     l)rc>tlil\'l.l"  h.xwrll.  ami  ..tlicis  in   Knglan.l  hav.«  ..l  lato 
rears  called  particular  attculiun  to  the  fact  that  iu  very  many  ui  the  ca^cs 
of  alcoholic  cirrho.i.  the  organ  is  "  cnhu-c.l  at  all  stages  of  the  disease,  and 
that  whether  enlarged  ..r  eontrac'ted  tiu'  clinical  >ynipto,ns  an.    course  are 
„nich  the  same"  (FoxnvcH).     The  imti-nt   n,av  ilrM  .on.e  nnder  ohserva- 
tion  for  dYspepsin,  haMnaten.esis.  sligiit   jaundirr,  or   nrrvous  syniploms. 
J.ater  in  tlie  disease,  the  patient  has  an  nnnii^takahle  hepatic  tacies;  lie  is 
thin,  the  eves  are  snnken,  the  eonjuiu'tiva'  watery,  the  n..>ean.l   cheeks 
show  distended  venules,  and  the  complexion  is  muddy  or  uleroi;  .     On  the 
onlai-ed  ahdoni.'n  the  v.-.'ls  are  dislende.l,  and  a  l.nmh  ol  dilafd  veins 
may  "surroun.l   tiu.  navel.     When   mnd,   llui.l   is  in   th.   pentoiueum   it   is 
impossihle  to  make  a  satisfactory  examination,  l.ut   after   withdrawal   the 
area  of  livr  dnlness  is  found  to  i,e  diminished,  particularly  in  the  middle 
line,  and  on  deep  pressure  the  edge  of  the  liver  can  he  ,letreted.  and  oeea- 
sionallv  the  hard,  linn,  and  even  granular  surface.      1  he  sphrn  can  he  Icl 
in  the' left  hyi-ochondriac  region.     Kxaminatioii  of  the  amis  may  reveal 
the  presence  of  luemorrhoiils. 

Turh-  S,implnuix.—\\  anv  stage  of  atrophi.'  cirrhosis  the  j^atient  may 
develoi,  eeivl.ral  svm|.toms.  ..ilher  a  noisy,  joyous  delirium,  or  stupor, 
eoma  or  ev,.n  convu^ion>.  The  condition  is  not  iiifre.,uently  mistaken  lor 
nneniia.  The  natuiv  of  the  toxic  agent  is  not  yet  settled.  The  syn.i.t..,iis 
may  develop  without  .iaundhe.  and  cannot  he  attrihutcl  to  .hohenna  and 
tlu'y  may  come  on  in  hospital  when  the  patient  lia>  not   had  ahmiol  lor 

^^^^The  fattv  cirrhotic  liver  mav  ].roduce  symptoms  similar  to  those  of  the 
atrophic  form,  hut  it  more  fre.pu'Utly  is  latent  an.l  i.  fouii.l  accidentally  m 
toper,  who  hav..  died  from  various  diseases.  The  greater  nuiuher  ol  the  cases 
,li„i,.nllv  dia-nosed  as  cirrhosis  with  enlargement  come  in  this  ' hv'Mon. 

Diagnosis.— With  ascites,  a  wi'U-marked  lii>tory  of  alcoholism,  the 
hepatic  facies.  and  luvmorrliage  from  the  stomach  or  how.'ls,  the  diagnosis 
is  rarelv  donhtfiil.  If,  after  withdrawal  of  the  lluid,  the  spleen  is  lound 
to  be  enlarged  and  the  live.-  either  not  imlpahlc  or,  if  it  is  enlarged  hard 
and  ro'nilar.  the  i)r(.l.al)ilities  in  favor  of  cirrhosis  are  very  great.  In  the 
early  shi-^es  of  the  disease,  when  the  liver  is  increased  in  si/e,  it  may  ho 
impossihre  to  sav  wh.'ther  it  is  a  cirrhotic  or  a  fatty  liver.  The  dillereiitial 
diagnosis  hetween  common  and  syphilitic  cirrhosis  can  sometimes  ho  made. 
A  marked  hist.m-  of  svi.liilis  or  the  existonce  of  other  syphilitic  lesions,  with 
great  irre-ularitV  in  the  surface  or  at  the  edge  of  the  liver,  are  the  points 
in  favor  of  the  latter.  Thromhosis  ov  obliteration  of  the  portal  vein  can 
nrely  he  dilTerentiated.  In  a  case  of  fibroid  transformation  of  the  fmrtal 
vein  which  came  under  mv  observation,  the  c.llateral  circulation  had  been 
established  fen-  years,  and  the  svmi.tonis  were  simply  those  of  extreme  jior- 
tal  obstruction," such  f^s  occur  in  cirrhosis.  Thrombosis  of  the  j^ortal  vein 
is  frequent  in  cirrhosis  and  may  be  characterised  by  a  rapuUy  developing 

"'"^ Prognosis. -The  prognosis  is  bad.     When  th .Uatcral  .'ireubtion 

is  fully  established  the  i«tient  may  have  no  symptoms  whatever.     Ihrec 


J 


?T" 


r^4  mSEASKS  OF  THE  DKJKbTIVE  SYSTEM. 

(,,.i-  of  a.lvancr.l  atn.pluc  cirrhosis  have  dii'.l  un.lcT  my  ol^^ervation  of 
othiT  atVfctions  witiioiit  i-rcscntin-  durin-  life  any  syinptonis  pointing  to 
,li.i.asf  of  the.  liwr.  'riuio  arc  w.Umvv>,  too,  ol  cnlai-vinviit  oi  the  hvcr, 
sli.Oit  ianndico,  crivl.ral  sy  M'toms,  an.l  cv.n  ha.u.atonK..iH  in  whidi  tlio 
livtr  becomes  re.hieed  in  m  '-  ^vmi-tonis  disappear,  and  the  patient  may 
live  in  comparative  comfo.  uany  years.     There  are  eases,  too,  pussihly 

.yi.hiiitie,  in  which,  after  o„.  -r  two  tappings,  the  symptoms  have  disap- 
peared and  the  patients  have  ap|.arently  recovered.  Ascites  is  a  very  serions 
event  in  ordinarv  cirriiosis.  Of  ;54  cases  with  asc.tcs  Id  .hc.l  he  ore  tap- 
pin.r  was  necessan-;  1  1  were  tapped,  and  the  average  dnrat.on  ol  life  alter 
th. "swelling  was  iirst  noticed  was  only  eight  weeks;  of  10  cases  the  diag- 
nosis was  wronir  in  1.  and  in  the  remaining  (;,  who  uere  taj-pcd  ol  enc^ 
than  once,  chronic  iieritonitis  and  perihepalilis  were  present  (liale  \Miite). 

II.    IIYrEUTROPIIIC  CTUUIIOSIS  {TTanot). 

Tlii<  wcll-charactcri/.cd  f..rm  was  first  descrihcd  by  IJcjuin  in  ISK!, 
but  onr  accurate  kimwiclgc  of  the  c.ndition  dates  from  the  work  ot 
the  lamented  Hanoi  (\^^:>),  whose  name  in  France  it  hoars— »;«/«(/ if  de 

"  ('irrho«is  with  enlargement  occurs  in  the  early  stage  of  atrophic  cirrho- 
«i<-  tiiere  i<  an  cnlargc.i  fattv  and  cirrhotic  liver  of  alcoholics,  a  pigmentary 
f.'.rm  in  diahetcs  has  heen  descrihcd.  and  in  associali-.n  with  syphilis  tiie 
organ  is  often  very  large.     Tlie  hypertrophic  cirrhosis  of  Hanoi  is  easily 
dislin-ruishcd  from  these  forms.  n        ,        •       .•,.> 

Etiology.— .Males    are    more    often    afTecled    than    females-m     .. 
of  Schachmann's  •>(;  cases.      The  subjects  are  y.)ung;    sonic  ot  the  cases 
in  children  i.robaldv  belong  to  tiiis  form.     Of  four  recent  cases  umler  my 
care  the  ages  were  from  twenty  to  thirty-tive.     Two  were  Im.ther.-      Alco- 
hol i.lavs  a  minor  part.     Not  one  of  Hie  four  cases  relerred  to  had  been  a 
heavy  drinker.     The  absciu-e  of  all  known  etiological  lactors  is  a  remark- 
able "fixture  in  a  majority  of  the  cases.  ....         .,  nr.n  +n 

Morbid  Anatomy.-The  organ  is  enlarged,  weighing  from  2,000  to 
4  000  .rranimes.     The  form  is  maintained,  the  surface  is  smooth,  or  presents 
small  gvan.ilalions:  the  color  in  advanced  cases  is  of  a  dark  olive  green; 
the  consistence  is  greatlv  increased.     The  section  is  uniform    greenish  yel- 
low in  color,  and  the  liver  lobnU's  may  be  seen  separated  by  connective 
lic.ue      The  bilc-i.assnires  ].resent  nothing  abnormal.     In  a   case  witlumt 
i,uuh  jaundice  exploratory  operation  showed  a  very  hii-ge  red  organ,  with 
a  sli'ditlv  roughened  surfa<.>.     Microscopically  the  following  characteris- 
tiec  are  described  bv  French  writers:  The  cirHiosis  is  mono-  or  niulldobu  ar 
with  a  connc.tive  tissue  ri..li  in  round  cells.     The  bile-vessels  are  the  seat  of 
an  angineholitis.  catarrhal  and  productive,  and  there  is  an  ^■-^t''aordinary 
development  of  new  biliary  canaliculi.     The  livei-cel  s  are  ne.Uier  fatty 
nor  pigmented,  an.l  mav  be  increased  in  size  and  show  karyokmeic  figures. 
From  the  supposed  oridn  about  the  bile-vessels  it  has  heen  calleel  bihary  eir- 
rho«is  but  the  hislolo-ic'al  details  have  not  yet  been  worked  out  tully,  ana 
the  separation  of  this  as  a  distinct  form  should,  for  the  present  at  least,  rest 


TilK  ('IUIIIU)SKS  OF  THE  LIVER. 


676 


upon  clinical  rather  than  ani.t.u.u.al  i^umiuU.     The  ^pUrn  i^  j^rcatly  on- 
lar''fa  and  may  \voi<;h  t;oU  or  more  j^raniincji. 

Symptoms.— i lamp's  hyp.rtroi.hic  .nrrhosis   pro.^cnts  tlie  lollowmg 
very  chauulc.ri.tic  group  of  syn>ploms.     As   previously  stated,   the  case, 
occur  in  vounj^  persons;  Ihere  is  m.t,  as  a  rule,  an  alcoholic    ustory,  and 
males  arc^isually  aiVected:  {<,)  A  remarkahly  chronic  curse  <.l  Irom  lour 
t„  six   or  even  ten  years.     {!>}  -laundicc,  usually  slight,  ..ften  not  more  than 
a  lemon  tint,  or  a  tinging  of  the  eonjunelivie.     At  any  time  during  the 
oours^o  an  iderns  gravis,  with  high  fever  and  d.'lirium,  may  deveiup.      I  here 
is  bile  in  the  urine;  the  stools  are  not  clay-col.,red  as  in  obstructive  jaundice, 
but  niav  be  very  dark  and  "  bilious.-'    0)  Attacks  of  pain  m  the  region  of  the 
liver  \vhieli  may  be  severe  and  associated  with  nausea  and  vomiting,     llie 
pain  may  be  slight  and  dragging,  and  in  some  cases  is  not  at  all  a  prom- 
inent  symptom.     The  jaundice   may   deepen   alter   attacks   of   pain.     (</ 
Enlarged  liver.     A  fulness  in  the  upi.er  al)dominal  zone  may  be  the  lirst 
complaint.     On  inspection  the  enlargement  may  be  very  marked.     In  one 
of  my  cases  the  left  k)be  was  unusually  prominent  and  stcol  out  almost 
like  a  tumor.     An  exploratory  operation  showed  only  an  enlarged,  smoo H 
organ  without  adhesions.      On  palpation  the  hypertrophy  is  nnilorm,  the 
consistence  is  increased,  and  the  edge  distinct  and  lianl.     'J  he  gall-bladder 
is  not  enlarged      The  vertical  tlatness  is  much  increased  and  may  extend 
from  the  sixUi  rib  to  the  level  of  tlu'  navel,     (r)  The  spleen  is  enlarged,  eas- 
ily palpable,  and  very  hard.     (/)  Certain  negative  features  are  ,d  moment- 
alienee  of  ascites  and  of  dilatation  of  the  subcutaneous  veins  of  the  abdo- 
men     Among  other  symptoms  may  be  mentioned  luvmorrhages.     One  of 
mv  cases  had  bleeding  at  the  gums  for  a  year;  another  had  had  for  years 
most  remarkable  attacks  of  purpura  with  urticaria.     I'ruritus,  xanthoma, 
lichen,  and  telangiectasies  may  be  j-resent  in  the  skin.     In  one  of  niy^  cases 
the  skin  became  very  bronzed,  alm.^st   as  deej-ly  as  in   Addison  s  disease. 
Sli-ht  fever  may  be"  present,  which  increases  during  the  crises  of  pain. 
There  may  Ut  a  milrked  leuc.jcyt(jsis.     A  curious  attitude  of  the  body  has 
been  seen,  in  which  the  right  shoulder  and  right  side  look  dragged  down. 
The  patients  die  with  the  synii.toms  of  icterus  gravis,  from  ha'iuorrhage, 
from  an  intercurrent  infection,  or  in  a  profound  cachexia.     Certain  of  the 
cases  of  cirrhosis  of  the  liver  in  children  are  of  this  type;  the  enlargement 
of  the  spleen  may  be  very  pronounced. 

III.    SYPIIII-ITIC   L'lllUlIOSIS. 
This  has  already  been  considered  in  the  section  on  syithilis  (p.  249).     T 
refer  to  it  again  toVmi^hasize  (1)  its  frecpiency;  (2)  the  great  importance  of 
its  diiferentiation  from  the  alcoholic  form;  (:5)  its  curability  in  many  cases; 
and  (4)  the  tumor  formations  in  connection  with  it. 

IV.    CAPSri.AH   ("lUUIIOSIS-fERIIlEPATITIS. 

Local  capsulitis  is  comiiKUi  in  many  conditions  of  the  liv(M-.     The  form 
of  disease  here  described  is  characterized  by  an  enormous  thickening  of  the 
entire  capsule,  with  great  contraction  of  the  liver,  but  not  necessarily  with 
30 


DISEASRS  OP  THE  niGKSTIVE  SYSTEM. 
570 

ir^    ]  i     m  F    X  u,,l  to  Hal..  Wlut...  who  l.as  ..oUcU..!  rn.,n  tl>«  roc- 
^'   r  . .  'iV  liv.T  suhsla.u.o  itsoir  was  "  n.v.r  mark.dly  crrhota.; 

its  tii>!*ue  was  nearly  always  solt.       uiioiiu     ap.  in  1  . 

.  "     '  4       •„  ,.       Lumdici'  i-i  not  0  ten  prcsi'iit.     1  liavo  mot  wmi 

lu.h  fi^e  the  dia.niosis  of  capsular  hepatitis  was  very  clear,  a.  the  hxcr 

fm-ns         w  a    ak  of  appreciation  of  the  essential  cond.t.ons  upon  winch 
.     foiniN  sliow  a  iuk  11  l,nowled<re,  no  remedies  at 

the  ^-v^-^;^^'^;;;^?;,  J;^;*^^  wimh  con- 

:uu';:^'t^\  «"■"-- ^^     -•^•>"^'^- ''''  ^"^  "^'"';  •;''"'' :: 

n  w    In    ex  r  nie  grades  of  ....ntraction  of  tlie  liver  may  persist  for  year 

t^  mn   "vm^ni  ^^.en  the  compensatory  circulation  exists.     Ihc  so-caUed 

f  1  inie'.ns  the  re-e  tahlishn.ent  of  this  compensation;  and  it 

;;;"i;  ,"  ^  ^  a™i.lo   o  speak  of  healing  a  chronic  valvidar  U.ion  when 

.      1    1,  ,1      ve  Inve  restored  the  circulatory  halanee  as  it  is  to  speak  ot 

:;:^;J:^::J:^Z  i:.L  .^.n  U-  tapping  and  other  measures  the  com- 

.  ^•^■"^:  p^s.;"i::id  7!^::::^t.  aic<.hoi.  am. .  p^sihu..  ..ndd 

mmmmm 


AIJSfESS  OF  THK   LIVKU. 


i>t  I 


ir  clik't 
pai'ticu- 
tho  I'oc- 
inhutie; 
II  and  a 
II  11)  of 
a  sequjl 
ity-nino. 
ring  and 
:not  with 
rogardfd 
;.     Signs 
0  aro  rt'- 
L'  tioc'ond 
orltDnitis 
.    In  one 
tlio  liver 
m  roseni- 
ii'diatrictj, 

0  liver  is 
if  certain 
ion  which 
medics  at 
hieh  con- 
hand,  wc 
for  years 
0  so-called 
)n;  and  it 
■sion  when 
i>  npeak  of 
s  the  cniu- 

l)le.  should 
iniola.     In 
ires  should 
ent  should 
L'ls  regular, 
give  either 
of  syphilis 
5  any  more 
re  tissue  in 
ar  tissue  in 
should  be 
?  distention 
V  tulic  may 
after  a  few 
line  purges. 


Fntni  half  an  ounce  to  an  oiincc  and  a  half  of  sulpliatc  of  magnesia  may 
hu  "iven  in  as  littk'  water  as  possililc  iialf  an  hour  l.efiirc  lireakra.-t.  Klate- 
riiim,  the  compound  jalap  jiowder,  or  the  hitartrate  of  poUisli  may  also  be 
eiiiiiloycd.  Digitalis  ami  sipiills  are  often  useful.  Surgical  treatment  has 
l)een  advocated  of  late.  Tlic  lluid  is  thorou'iiily  drained  and  the  surface 
of  the  liver  and  spleen  and  t'u'  parietal  peritonaum  is  tlieii  lirndy  scrul)l)cd, 
so  as  to  promote  adhesions,  in  which  compensatory  vessels  could  develop. 
Of  three  <-ascs  recently  treated  in  my  wards  in  tiiis  way  one  lias  recovered. 
In  the  sypiiilitie  cases,  or  when  syphilis  is  suspected,  iodide  (d'  potassium  may 
he  giveii  in  doses  of  from  lo  to  MO  drops  of  tiie  saturated  solution  tiirec 
times  a  day,  ami  mercury,  which  is  conveniently  given  with  sipiills  and 
digitalis  in  the  form  of  Addison's  or  Niemeyer's  pill.  A  patient  of  well- 
marked  syphilitic  cirrhosis  with  recurring  ascites,  in  which  tajipiiig  was  re- 
sorted to  on  eight  or  ten  occasions,  took  this  pill  at  intervals  for  a  year  with 
the  greatest  benclit  and  subsequently  had  four  years  of  tolerably  good 
health. 

Vlll.     ABSCESS    OF    THE    LIVER. 

Etiology. — Sujipuralion  witliiu  the  liver,  either  in  the  itarcnchynui  or 
in  the  iilood  or  l)ilc  pa.<.siges,  occurs  under  the  followiuij:  conditions: 

(1)  The  tropical  abscess.  In  hot  elinuites  this  form  may  develop  idio- 
])athically,  but  more  commonly  follows  dysentery.  It  frcipU'Utly  occurs 
among  Euroj)eans  in  India,  jiarticularly  tho.-^e  who  drink  alcolud  freely  and 
are  exposed  to  great  heat.  The  relation  of  this  form  of  ab.«(;ess  to  dysen- 
tery is  still  under  discussion,  and  Anglo-Indian  practitioners  are  l)y  no 
means  unanimous  on  the  sui)ject.  Certainly  cases  may  develoj*  without 
a  liistory  of  previous  dy.«entery,  and  there  have  been  fatal  cases  without 
any  atfection  of  the  large  bowel,  in  this  country  the  large  solitary  tropical 
abscess  also  occurs,  oftenest  in  the  Southern  Slates.  Jn  IJaltimore  it  is  not 
ver    infre(iuent. 

The  relation  of  this  form  of  abscess  to  the  aniwhn  coVi  has  been  care- 
fully studied  by  Kartulis  and  exhaustively  considered  in  a  monograph  by 
CouiU'ilman  and  l.alleur.  The  (lescri|itions  and  illustrations  <d'  these  au- 
thors are  most  convincing  as  to  the  direct  etiological  association  of  this 
organism  with  liver  abscess.  Clinically  the  patii'Ut  may  have  (uiuvliiv  call 
in  the  stoids  and  wt'll-markcd  signs  of  liver  abscess  without  marked  symp- 
toms of  dysentery  and  even  with  the  fa-ccs  well  formed. 

(2)  Traumatism  is  an  occasional  cause.  Tin;  injury  is  generally  in  the 
hei)atic  region.  Two  instances  have  come  uiuler  my  notice  of  it  in  brake- 
men  who  were  injured  while  coupling  cars.  Injury  to  the  head  is  not  in- 
frequently followed  by  liver  abscess. 

(M)  Kndioiic  or  |)ya'mic  abscesses  are  the  most  numerous,  and  may  de- 
velop in  a  general  i)ya'nua  from  any  cause  or  follow  foci  of  suppuration  in 
the  territory  of  the  portal  vessels.  The  infective  agents  may  reach  the 
liver  through  the  hepatic  artery,  as  in  those  cases  in  which  the  original 
focus  of  infection  is  in  the  area  of  the  systemic  circulation;  though  it  may 
happen  occasionally  that  the  infective  agent,  instead  of  passing  through 


57 


I.ISKASKS  OP  THE  DIOKSTIVH  SYSTKM. 


9 

m 


M 


an.l  n,y..lf.     In^'Hio,,  'l'-';^  ;,  '  ^        j^  tions  of  the  bowels,  »,.,.„- 

,,,s„lts  I'ron.  dvs.  ..tcTy  and  u  !,.;r  "  '     ;^<  ^^     '    ,  ,,v.vtions.  and  in  al.scr.s.s 

lantiitis.  ,.,„i„U  (,f  the  liv.T  t1.i'  aflVction  is  chicnv  of 

,,/;;c=rS'^.;;:  s:;;!:;r:.n." .,..  ^......0.  a.... ... 

as  a  nocUo,  .nay  pass  i,o,u  ^  ^  ^    '         ,  ;^,;,,,i,,,  i,;vo  hoen  roportea,  a     ■ 
excilo  an  abs.css.  or,  as  u.  ^^^"  f  ^'j^     ^^^   j,,,  pcTforated  a  branch  or 
f„,,n,n  body,  su,.h  ns  a  ^^l';; ''  /^^    .^^..^  .,,  .k.l>itis.     Echiuoeoccu. 
„,,  ,...Hal  vein  its.dl  and  •'^"^       '^/^^    ^  l,,  ...t,  ,,  .,f  round  worms  into 
(.v<ts  fre-inently  nmso  suppuration,  the  I'Vl'      *        ,•        j,^,,.,. 
\l  live,.  Us  eonnnonly ;  and  n,os    rare^  •>    >  U  i.  ^  ;.;;;;'^j,^,,,,._This 
Morbid  Anatomy.--(")  ^f  ^^^^'^^  Zn:  Ur^e  abseoss  cavities, 
is  not  always  single;  there  nu.y  1'     ^'^  .,^  ',    ^      ^n^.  largost-si^ed  ab- 
ran,in,  in  size  fn^n  an  oran.e  ^    a     hdd»       a  _^^^^^^  J^  ^^^^^^  ^^^^^^ 

,,ess  n>ay  eontam  from  3  to  <  ^^^^.^^^.^^-^^^  ^jo  j,er  cent  of  the  cases 
f.,„,tl,s  of  the  entire  oroan.  In  ^^;  ;•^;;  '  ^^  .^..^^  '^f  ^hc  cases  was  in  tlio 
,,,,,,  ,in.U^     The  abseess  m  nearl>    .  ^     t  ^^^  ^^^^^^^_ 

,i,„t  h,be.  n,ore  towar     1  ;:;;■'--  ".ilrt,,.,,  but,  as  a  rule.  tl. 

standin-  cases  the  ab>ee^>-wa     n u>     '^  ^   ^^^^.^j^,,,  „f  the  wall 

-^•^^^  ^'-^T^^'^  .r;;l:;!';;;!;i  i;t' :  1.;  t;:^i  •  -nd  made  up  of  nec^tic 

shows  an  internal  hnuMaKi.  ,^^,^^^^.^^^^,^  ^^.^^    ,, 

liver  substance.   pus-eell>.   an.l   J""^    "^  .    .^^^  ^,_     rj,,,,      ^^  i^  often 

,,,„r;  and  an  external  zone  "  ''M;  -  J' ^  ^^  ^.^  ^^„,,.  I  „ther  in- 
,,,adish  brown  in  color  cl..sel>  '>^"  '";  '^^^  ;.^,  .^eamv.  The  odor 
stances  it  is  grayish  white,  mncoid,  "  '^    >  >  i,!  ^.,„,  ,„;,ii  ,.f  ehyme, 

is  at  times  very  P-l'- .^  '\;7^;  ^H-    ^  am.ebic  dyson- 

-^:;^bacteri.d..i..lc.amination..^^^^^ 

.„,  in  some  cases,  s^^aphylocci,  ^<  "-l  7/;^  „,  „oted  in  Warings 

,,,,„i,ation  of  this  f  .rin  ..  ^I^;- ^  ;  ^ ^^^'^.a  bv  ,;perati.m,  10  per  cent; 
o,„o  ,ases:  l?ema.ned  intact.  ^.».  f  ^,"'\  '  .'  '  ..t^rel  into  the  right  lung, 
p,rforat..d  th..  right  P^-'''"' "^"'•1>'  V':'^^^  r  ^       ruptured  into  the 


I- 


AIJSCKSS  OF  THK   LIVER. 


679 


hepatic 

i^iu  was 
l)y  Uos> 
lion.     It 

S,  lipiH'll- 
lll)!*t.'l'S>t'S 

k',  within 

tlH.'  l)ili- 
itivo  cho- 

chicfly  of 
L'BtiCS   cou- 

ulics,  sucli 

liver,  iiiul 
•oported,  a     ■ 

hraiu'h  or 
hinoL'OCCUS 
vonus  into 

cess. — This 
.'ss  cavities, 
rit-sizeil  ah- 

tlian  three 
of  tlio  oases 
was  in  tlu' 
.     In  lon>;- 

a  ruk',  tlie 
of  tlie  wall 
)  of  necrotic 
nish  red   in 
jms  is  often 
[n  other  in- 
■.     The  odor 
?11  of  chyme, 
iiehic  dypcn- 
r,  containing 

■  a  sterile  pns 
acilius.  The 
1  in  Waring's 
.  10  per  cent; 
he  right  Inng, 
ured  into  the 
,.s  which  ni])- 
Ider.  riexner 
■a.    Tor  a  full 


consideration  of  the  suhject  of  anio'l)ic  ai)scess  of  tlie  liver  the  readier  is 
referred  lo  Lalleur's  artitle  in  AllUutt's  System  of  Medicine. 

(b)  Of  ^'(7</lr  (ind  I'liiniiir  .l/wr,s*r,s-.— These  are  iiswally  mnltii.jc.  tlmngh 
occasionally,  following  "injnry.  there  may  l)e  a  large  solitary  eojlcdion  of  pus. 
In  suppurative  pylephlcliitis  the  liver  is  uniformly  enlarged.     'I'lie  cap- 
sule may  be  smooth"  and  the  external  surface  of  the  organ  of  normal  aji- 
pearance.     In  other  instances,  numerous  yellowish-while  points  appear  be- 
neath  the   lap-^ule.      On   section    there  are    isolat.d    poekels   (.f   pus.   either 
ln'vin>'  a  round  outline  or  in  some  places  distinctly  dendritic,  and  from 
Ihe^e'the  pus  nuiv  l)e  s.iuee/ed.     They  look   like  small.  s..litary  abscesses, 
but    on  probing,  are  found  to  eouninmi(ale  with   th<'  poilal   vein  and  to 
represent  its  branches,  distended  and  suppurating.     Tlu'  entire  portal  sys- 
tern  within  the  liver  mav  be  involved;  soinetimes  territories  are  cut  oil  by 
thrombi.     The  sui)puration  nmv  extend  into  the  mam  branch  or  even  into 
the  mesent.a'ic  aiul  gastric  veins.     The  pin  may  be  fetid  au.l  is  oiten  lah- 
stained;  it  mav.  however,  be  thick,  tenacious,  an.l  laudable.     In  suppura- 
tive cholaic'ilis  there  is  nsuallv  obstruction  by  gall-stones,  the  duets  are 
greatly  distended,  the  gall-bladder  enlarged  and  full  of  pus,  ami  the  branches 
within  the  liver  are  extremely  distended,  so  that  on  section  there  is  an  ap- 
pearance n..t  unlike  that  described  in  iiylejihleltitis. 

Suopuration  about  the  echinococcus  cy.«ls  may  be  very  extensive,  tormmg 
enormous  abscesses,  the  characters  of  which  are  at  (.nee  recognized  by  the 
remmints  of  the  cysts. 

Symptoms.— ('()  Of  //"'  l'<'ni''  >'"/'/r/n/  . I /wyw.— l n  the  tropics  there 
are  instances  in  which  the  -ibsce-s  ap|.ears  to  be  latent  and  to  run  a  course 
without  delinite  symjitoms;  death  may  occur  ^u(l.lenly  from  rupture. 

l-'ever,  pain,  ei'ilargcment  of  the  bvcr.  and  the  dcvcloi.mciit  i,i  a  seiitic 
conditicm'  are  the  important  symptoms  of  hepatic  abscess.  The  tempera- 
ture is  elevated  at  the  outset  and  is  of  an  intermittent  or  septic  type.  It 
is  irregular,  and  mav  remain  normal  or  even  sul'uormal  for  a  few  days; 
then  the  i.aticnt  has  a  rigor  and  the  temperature  rises  to  10:!"  or  higher. 
Owing  to  this  intermittent  character  of  the  fever  the  cases  are  usually,  m 
this  latitude,  mistaken  for  malaria.  The  fever  may  rise  every  afternoon 
without  a  rigor.  I'rofuse  sweating  is  common,  iiarticuhirly  when  the  i>a- 
tient  falls*  aslccf).  In  chronic  cases  there  may  be  little  or  no  fever.  One 
of  my  patients,  with  a  liver  abscess  which  had  perforated  the  lung,  couglied 
up  ]")us  after  his  temperature  had  been  normal  for  weeks.  The  pain  is 
variable,  and  is  usually  referred  to  the  back  or  shoulder;  or  there  is  a  dull 
aching  sensation  in  tiie  right  hyi)ochoudrium.  When  turned  on  the  left 
side,  t"lie  patient  often  complains  of  a  heavy,  dragging  sensation,  so  that 
he  usually  prefers  to  lie  on  the  right  side:  at  least,  this  has  been  the  case 
in  a  majcu'itv  of  the  instances  whieii  have  come  under  my  observation.  Pain 
on  pressnre"over  the  liver  is  usually  present,  particularly  on  deep  pressure 
at  tlie  costal  margin  in  the  nipidc  line. 

The  enlargement  of  the  liver  is  most  marked  in  tlie  right  lobe.  and.  as 
the  abscess  ca^N-ity  is  usually  situated  more  toward  the  upper  than  the  un- 
der surface,  the  "increase  in  volume  is  npward  and  to  the  right,  not  down- 
ward, as  in  cancer  and  the  other  affections  producing  enlargement.     Per- 


% 


m 


DISKASES  OF  TIIK  DKIKSTIVK  SYSTEM. 
OS" 

„1  (liiliu>s  iiia\   IK   i.  (.immctcristic  fcatiir.'  is  not  pivs.MU, 

1  t  .1,,  .IVKroa.lth  or  n.oro  b.low  the  costal  .na.-.n.  1..  s.uh  .n- 
,,roj*rt  '\'''""':""'.  "',„.,,  i.,,i„ation  is  iminfiil,  and  tlicre  may  be 
.tancoB  the  ^"'•'«-  ^  ;^  ^^ '"  ,,  '  instanl.s  lludnation  may  bo  de- 

•:;:r^  U,.  :  rt    ;  .!  ll..  ai„lo„.inal  .aU  ami  the  abs^-ss  may 

.   1         1,     mai-in  of  tlu'  ribs,  or  ..v.n  i.i  the  i^\nffxAvie  rc-ioii.     In 
point  iH-loxv  tbo  maiKin        u  ,„,r.r^,stivL..     The  bkin  has  a 

,„any  cas^s  the  "I'l"-;'";;;;'  ,    '^^^^  ^   ,a  o      ^^  eomplexio.i  mu.bly.  the 

1  ,;..n.  rnuml  in  the  stools.     Constipation  may  occur, 
anue  nv  a.e    '^  "      "  !  "^^^^J^^  symptoms  arise  when  the  abscess  invades 

„      ^"'^'''th  inn-    ll!n.u,h  the  diaphragm,  without  actua 

the  lunj:.  '  .^  Vrr  r  u'^^  of  a  purulent  pleurisy  and  invasion  ot 
Ilirium^^Tiy  a  ntr; t^miUy  develop  a  severe  cou,h  usually  .^  an 
the  lung,     iiic  paiu        h  -        ,  j  ^,^  „f  involvement  at  the 

„,,ravatnl  -  Vi'T:;;  ri^  ^  4.  ^n  o^^^Ue  tubular  breathin,,  and 
base  ot  ^^^^;^^^J^;)^:Z  Z  most  characteristic  feature  is  the 
"""""  ':;  're  d  b  n  n  "peetorati.>n  of  a  brick-dust  color,  resembling 
p,,scnce  <,^*1';;  ;';.,,  I,,  ,.,,,d  originally  by  lUuld,  uas  present 
anchovy  sauce.  )  "•^'  \  "  '  ,„„|  ,,,,u.ur  found  the  anuvhe  coli  iden- 
in  our  cases  and  ")  «;W.t  m    ^^-  ^'^  "  ^^  ^^,,,i  ;„  <,,^,  ,t,„,,.     They 

tical  with  those  ^^1;;;;;,  ';,     ,.J';,rcispl  y  active  amceboid  movements. 

^;=:irt;r;;;'';b:^;;:.^o^ion,ia^-- 


The  "--"--;-  ;  ;.  1       ,:an.e-red  crvstals  or  iKcmatoidin 
corpuscles  and  thire  "^>       ;      ;     „     ^^  „,entioned  already,  or  into  the 


The 


"■m"'  .';:'':„;;  'in  1,  i^^°  .'  fon,„.v  ™l»rH  n„d  tender,  thonsh 
w.thm  0  P»™/' '"',',' .,„,,,.  Thoro  i  nn  irrcsnlar,  septic  fever,  and 
Z:^^^  r„l*;!  'riin.,,  distinct.,  ictcid.    T..C  features  are 


ABSCKSS  OF  TIIK  LIVKR. 


581 


il  limit. 
Ill'  mid- 
lIu)  ui'i'ii 
lia.     <U' 
pnsciu, 
lie  livir 
Jjj;e  may 
mull  ill- 
may  be 
y  bo  (le- 
I'l'Sr^  may 
[ion.     In 
in  bas  a 
uldy.  tbe 
is  in  tbc 
ji'stion  «it 
witli  sup- 
taiKt's  of 
le  pri'SL'nt 
eiilarly  if 

S8  invades 
out  ai'tual 
ivasion  of 
illy  of  an 
ont  at  tlie 
liiuj:,  and 
uro  is  tlu' 
resembling 
as  jireseiit 
"  coli  iden- 
ols.     Tboy 
iiovcmonts. 
and  blood- 

or  into  the 
tiim  of  cbis 
six  or  eight 

0  per  cent, 
ter  fearlcss- 

— Clinically 
pyemia,  no 
suppuration 
der,  though 
ic  fever,  and 
features  are 


indeed  tlioso  of  pvaMuia.  plus  a  sliglil  k  temhl  tinge,  an.l  an  .nhirged  and 
painful  hver.  The  latter  features  aloiu'  air  p<eiiluir.  '1  be  sweats,  liiill-, 
i.'n.stration,  and  fever  have  notbing  (lislinetive.  ,    ,      .,    ■ 

Diagnosis.— A b.-eess  of  the  liver  may  lie  eonf.iunde.l   Willi  int.TUiit- 
,,,„  i,vJr,  a  eummon  mistake  in  malarial  irginus.     Praetieally  an  intermit- 
tent  fever  wiiieh  resists  (|ninine  is  not  malarial.     LaveranV  orgaiii>ms  are 
„1m.  ab-eiit   from  tbe  blond.     When  tlie  abseess  bursts  into  the   pleura  a 
riirlit-Mded  empvema  is  prodmed  and  perforation  of  tlie  lung  usually  lol- 
l.,w<     Wben  tbe  liver  ab^r.-s  bas  been  lat.^nt  an.l  dysenteric  sympt.Mns  have 
not  'been  marke.l,  tbe  condition  may  b..  .■oi.Mdeiv.l  empyema  or  abscess  o[ 
the  lung      In  such  cases  tbe  aiubovy-sau.  e-like  eob.r  of  the  pus  and  tiie 
presence  of  the  am.eba'  will  enable  one  to  make  a  dellnite  diagnosis,  as  has 
l,c.en  d..ne  in  eases  bv  Lallcur.     IVrf..ratio„  e.xtrrnally  is  read,  y  v.rognized, 
and  vet  in  an  absces; cavity  in  tbe  epi^^'^tri.^  region  it  may  be  ditbeult    o  say 
whether  it  bas  proceeded  from  tbe  liver  or  is  in  the  abdominal  uall.     W  Hen 
the  abscess  is  large,  an.l  the  a.lbesions  are  so  llrm  that  the  liver  .Iocs  un[  de- 
seen.l  .luring  inspirati.-n,  tbe  expbuatory  nec.Ue  <l.>es  not  .nak.;  an  up-an.l- 
d.,wn  mov.incnt  -luring  aspiratu.n.     In  an  in>tan.e  ol  this  kind   wbuli 
SUV  with  llearn  at  tbe  I'hilad.'lphia  Hospital,  all  the  U.atnic.  bual  aiul 
creneral   -cemed  t..  j-oint  t..  abs.rss  in  tbe  ab.l..minal  wall,  but  the  operation 
revealed  a  large  perforating  abseess  cavity  in  the  left  lobe  of  the  liver,     iho 
diagnosis  of  siipi)nrating  eehinoeoccus   cyst   is   rairly   possible,  exci'i.t   iii 
\i^tralia  an.l  Kelaiid,  where  hvdatids  are  so  c.uumon. 

JVrhaps  the  most  important  aiVection  fr.iin  whi.-h  sup|iuratinii  within 
the  liver  is  to  be  sejiarated  is  tbe  intermittent  hepatic  fever  associated  with 
Lrall-<t..n.'s.  Of  tb.'  cases  reported  a  majority  have  been  considered  due  tu 
.ui.puration,  an.l  in  two  of  my  ca<cs  the  liver  ha.l  been  repeate.Uy  as|..ratc.l 
I'ost-mortem  examinati.ms  have  shown  conclusively  that  the  high  fever  an.l 
chills  may  recur  at  intervals  f.ir  y.'ars  without  suppuratmn  in  tbe  ducts. 
The  distinctive  features  ..f  this  c.mdition  are  paroxysms  .if  fever  with 
ri<'..rs  an.l  sweats— which  mav  ocrnr  with  great  regularity,  but  wbi.ii  more 
otUn  are  seimrated  bv  bmg  intervals— tbe  deepening  .if  the  jaun.li.r  alter 
the  imn.xvsms,  the  entire  apvrexia  in  tbe  intervals,  an.l  tlie  maintenance 
<,f  tbe  general  nutrition.  Tbe  time  element  also  is  imp.)rtant.  as  m  some 
of  these  cases  the  disease  bas  lasted  for  several  years.  Finally,  it  is  t..  be 
remembered  that  abscess  of  tbe  liver,  in  temperate  climates  at  least  is  in- 
variablY  secn.larv.  and  the  primary  source  must  be  careluUy  sought  tor, 
either  in  dyscnterv,  slight  ulceratb.n  of  tbe  rectum,  supinuatiug  haMn.|r- 
rlioids,  ulcJr  ..f  tbe  stomach,  .)r  in  suppurative  diseases  of  .)ther  parts  ot  the 
bo.lv,  iiarticularly  in  the  skull  or  in  the  b.ines. 

The  presence  of  a  leueocytosis  is  the  most  important  feature  m  all  forms 
.if  suppiirati.)n  of  the  liver. 

In  suspected  cases,  whether  the  liver  is  onlarge.l  or  not,  explorat.iry 
aspiration  may  be  performed  without  risk.  The  luedle  may  be  entered  in 
the  anterior  axillary  line  in  the  lowest  inters|)a.e,  or  in  the  seventh  inter- 
space in  the  mid-axillary  line,  or  over  the  centre  of  the  area  o  dulness 
behind.  The  patient  should  be  placed  under  ether,  for  it  may  be  neces- 
sary to  make  several  deep  punctures.     It  is  not  well  to  use  too  small  an 


^^^ 


\  1 


5S2  DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

, ,    +  Vol      TTvvi'..  hoNVcvcr.  reports  a  case  ot  pyannic  aus.:f>. ..I'-'o 

variably  fatal.  ^['^'^^'"''.^  ,  .eovore.l  after  an  exploratory  operation, 
appendicitis  in  which  the  pati  it  '']'''  ^  ^s  an  abscess  sh..\vs 

JJ,,i.jl  ineasui^s  -  -  ,^;;-  -,;;;;-  :;;u:a^:i.tery  are  o.on  single, 
signs  of  pointing.  ^^^/^^  '  ;  ^  k,,,,u  fn.in  operation.  If,  however,  the 
tlu>y  aiVora  a  r.^asonable  Ipc  o    h  lu    t  1  ,,^  j^       ,^  ,,a  the 

j,,ticnt  is  expectorating  ^  -  1'  .  ^^  '- ^^  ^  „,^^^,,„^  ^,  ,,,,y  ,f  these  in- 
hectic  fever  not  marked,  it  i.c-t.i  ^  ^^_^  ^j^^  ^^^^^^ 

of  ordinary  septicivmia. 


i!!l 


IX.     NEW   GROWTHS    IN    THE    LIVER. 

,r   nitl„-r  nriinirv  or  secondarv,  sareonui,  or  angioma. 
These  may  be  cancer,  c.t  (1     ^  ^^  ^'^  >  ;     ,„;,,,,  .^^  frcpieney  of  in- 

Etiology.-Caneer  of  the  In   r  .11  u^  1^^^^,  .^^  ^^^^^^.^ 

ternal  cancer.  It  is  rarely  ^^^^^^^^  --^.^^.^  ^^  ^^.i.Htonstern, 
organs.  It  is  a  d.sc.vse  ot  1;'^^  '  !'  ';^^.,^  ^i^,.  f,,,ti,tl,  and  the  sixtieth 
over  50  per  cent  of    he  ^^--;^''^^^^^      Won.en    are    attacked    less 

f^'"^-  .  •    on  nnt.Medent    and  cancer  of  the  bile-passages 

In  many  cases  tranma  is  an  «.'  '    ;  "^^.^     ,.,,„,r  is  stated  to  be  less 

the  l-iv,.,-  =,-,1  hav.  n  .liiA-a.  "";."';;I."";X,,  (,,„,  t„„„.  ,„av  1.0  .■...■ogni.o.I* 

^i^;;ir":r  s'"  f^^  :SE -"  :-"^ 

,i,H,i  rr.™,  .1.0  '•'•"«»"'"!;'';"!|"'^';",i'v„  i.  noc..,.i..i  i.y  ..™l"i«.  ">»»««. 


,  „a,.o.  i^:^«>.  fo«i-  "■'  1™  "«'"^«'  •■"  '■■'°''''  ''•*■  ""'■ 


NEW  GROWTHS  IN  THE  LIVER. 


688 


1  may 

11(1  yi't 

portal 

irc  in- 

^'■' n 

.Tati'-n. 
i  showri 
,  single, 
•or,  the 
uul  llie 
R'so  in- 
ic  most 
i  is  that 


mjiioma. 
■y  of  in- 
in  oilier 
tcnstern, 
(  sixtieth 
■koil  less 
lary  can- 
L>r  of  the 
0  20  per 

>passafres 
to  he  less 
's  may  he 
;ed  to  the 
oaiieer  of 

3  oceur  in 

cognized.* 
on  section 
jiortion  of 
•iiptly  out- 


lar  masses, 
ij;an.  Usu- 
inass.vhich 
idary  to  it 

B8. 


Tliis  form  is  mucli  like  the  seeoiulary  can.'crous  involvement,  except  that 
it  seldom  readies  a  large  size. 

(,.)  Tlie  third  is  the  reinarkahle  and  rare  variety,  ninrrr  wilh  cirrhosis, 
^vhieh  forms  an  anatomical  pieture  perfectly  nni(iue  an.l  at  hrst  very  puz- 
yliiicr  The  liver  is  not  mnch  enlarged,  rarely  w.Mghing  more  than  2h  ov 
'  kilo-'rannnes.  The  surface  is  grayish  yellow,  stiuld,.!  over  w.tli  nodular 
^ell  S masses,  le.emhling  the  projections  iu  an  ordinary  e,rrln>t.c  hver. 
m  sectini  the  cancerous  noduh-s  are  seen  scattered  throughout  the  entuo 
organ,  varying  in  diameter  from  :?  t.i  10  -r  move  millimetres  and  sui- 
rounded  with  iilirous  tissue.  . 

lli.tolooieallv.  the  primary  cancers  are  cpithelioniata-alveolar  and 
trihecnlar  "  The' character  of  the  cells  varies  greatly.  1  n  some  varieties  they 
a,;  polvmorphous:  in  others  small  polyhedral;  in  others,  a^;^'";  S-an  ceH^ 
are  found.  In  rare  instances,  as  in  one  descnhed  hy  (  reeniicld,  the  cells  are 
cylindrical.    The  trahecular  form  of  epithelioma  is  also  kn..wn  as  adenoma 

or  adeno-carcinoma.  ,         ^         ^        ^ 

(o)  S,'ro,ular„  C.^rn-.-The  organ  is  nsnally  enormously  enlarged,  and 
iinv  wei<d,  •->(»  pounds  or  more.     The  cancerous  nodules  pro.iect  henea  h 
lK:ca].suh..  and  can  he  felt  during  life  or  even  seen  through  the  th.n  ah- 
doniin  d  walls.    Thev  are  nsnally  disseminated  e.iually,  though  ni  rare  m- 
anees  thev  mav  he  con  lined  to  one  lohc.     The  cons.stence  ol  the  nodule 
varie-   in  iomeVases  thev  are  iirm  and  hard  and  those  on  the  surtace  sh,)W 
a  distinct  nmhilieation.  due  to  the  shrinking  of  the  tihrous  t.s.ue  m  the 
centre      These  sui.erflcial  cancerous  masses  are  still  sometimes  spoken  ot 
M.  '•  Farre*^-.  tuhcrcles."    More  frequently  the  masses  are  on  section  grayisli 
Vhite  in  color,  or  luvnun-rhagie.    I?uptnre  of  hlood-vessels  is  not  nnconin.on 
in  the^e  ea^e-      In  one  specimen  there  was  an  enornions  clot  honeath  the 
can-nle  of  the  liver,  together  with  luemorrhage  into  the  gall-hladder  and 
into  the  peritona'um.     The  secondary  cancer  slu.ws  the  same  structure  as 
the  initial  lesion,  and  is  nsnally  either  an  alveolar  or  cylindru'al  carcinoma. 
Defeneration   is  common   in   these  secondary  growths;    thus  the  hyaline 
tran^formathm  mav  convert  large  areas  int..  a  dense,  dry,  grayish-yellow 
ma-      Extensive  areas  of  fatty  degenerati.m  may  occur,  sclerosis  is  not 
uncommon,    and    hamiorrhages    are    frcpient.      Supimnition    sometimes 

follows.  ,  ,  •11 

("A  Cinnr  of  thf  hik-passaiics  which  has  i.een  already  considercl. 

Sarcoma. -Of  in'imarv  sarcoma  of  the  liver  very  few  cases  hav.-  heen 
reported.  Secondarv  saVcoma  is  more  fre.p.ent.  and  many  examples  ot 
lynipho-sarconia  and'myxo-sarcoma  are  on  record,  less  frequently  glio-sar- 
coma  or  the  smooth  or  striju'd  niy.mia.  ,  .  ,    -,      ,        •     n 

The  most  imi.ortant  form  is  the  melano-sarcoma.  which  develoi.s  in  the 
liver  secondarilv  to  sairoma  of  the  eye  or  of  the  skin.  Very  rarely  melano- 
sarcoma  develops  primarily  in  the  liver.  Of  the  reported  cases  1  anot  ex- 
clude* all  hut  one.  In  this  form  the  liver  is  greatly  enlarged,  is  either  uni- 
formlv  infiltrated  with  the  cancer,  which  gives  the  cut  surface  the  ai.peai- 
ance  of  dark  granite,  or  there  are  large  nodular  masses  of  a  deep  bhickor 
marhled  c.dor.  There  are  usually  extensiv  metastases,  and  in  some  in- 
stances everv  organ  of  the  hody  is  involved.     Nodules  of  melano-sarcoma 


r«i 


^^ 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


584 

•      o  .l.,u-  h,  Ihe  (lia^niosis.    ITamburgor  (J.  H.  II.  CuUe- 

oTKhuv  canccT  of  the  hvor  lU.U..^  the  1"  "^;^  >  ;"*'  ^  ^,^^,  ,^,,t„„,,  or  of  a 
as  in -the  ca^o  of  scirdnu.  of  the  brea.  ,  «^  ^^^^f  ^^,^,f  .h^  Uver  is 
,,„„,•  in  the  .toniach,  .h.ch  can  be  le        A    a  no  can 

,  .tea  with  ixii;:.:::s:^^rii';^^^-  ™^^  -'  ^^-- 

nodular  cancer,  and  in  tnt  cautci  >  „.,„^,.i   -ind  vomit  nff  are  fre- 

lar,e.l.  (Jastric  ^i^turbam.  lo.s  ^^^^J^^^'CL  first  s  mpton.. 
.I'.ent.  rro.ress.ve  loss  of  llesh  aiu^  !;;":;:  t  In  pochondriac  re^on  may 
rain  or  a  sensation  of  uneasiness  '^^J^''^]^^  ^ccur  without  tbe 

be  present,  but  enormous  enlargement  '  /  \  Yc^^"^^.  i,,„  „£  the  cases, 
.lightest  pain.  '^---^'^'' f^^f' ''^'''^  Z^on^CU  --luded.  As- 
is  usually  of  moderate  ex  ent,  ^''■^^'T'^.l  ;.  wliich  the  clinical 
cites  is  rare,  except  in  the  form  ot  cancel  \  '  ,  '  /-^  ^^^,^^,  „„  the  portal 
picture  is  that  of  ^le  atrophic  ^nu     ^^     ;;^^^>,^    ,,,,  ..^ucc  ascites. 

<^^^-}^^^--^^^''''^^J:Xr.Xor  more  below  tlie  costal  margin,  de- 
the  hver  is  felt,  a  ^'^''''^ '  !'\''''\y,  ,^„,f,,ee  is  usually  irregular,  and  may 
.oending  with  each  inspirat  on.  ;^     2^;  ^.^^,^,.  ;,,„,aed  or  with  cen- 

,  .,t  large  mas..  - -;^-  [^  Intation  the  liver  may  be  greatly 
tral  depressions.    In  instantts  oi  "'  ,j,j  ^i,  jg  progres- 

enhirged  and  present  a  F'-f^'^'^'j  ^^mitd y  ext'end  below  the  level  of  the 
sive,  and  the  edge  of  the  bver  may  ^^1^"  a^^^-^  ^  ^^^  enlargement  of  tlie 

navel.  Although  P--™"^  -'^j™  ^l^^  dS  P^fr.mi  the  left  lobe,  it 
whole  organ,  occasionally.;  ben  the  ^""^^  ^  ^  ^  ^  ;„„.  Bv  percussion 
„,av  form  a  solid  mass,  which  ^-,^-1.7^/';;jlE'  ^  J^e^sive  growth  of  the 
thJ  ..utliiie  can  be  accurately  limited  and  t  I'l  -  ^  j^  ^^^,^,,,t  in  many 
tumor  estimated.    The  sple.i  -;-  ^ -J^^^  i^^^  1^2^;  it  may  be  in- 

-t-^wi^b^r^^^^^^^^^^^ 

„„,1  II,,.  ''"••'»"\''"'lf  ■■■,,,"';;'  ,1    ivcr,  l..,t  tl,o  r''™"  "f  i»™- 


FATTY   LIVER. 


585 


I.  Bulle- 

rs  in  the 
size  of  a 
onally  in 

I  avo  not 
ongcuital 

and  soc- 
s  evident, 
1,  or  of  a 
lie  liver  is 
f  primary 
lot  be  en- 
\g  are  fre- 
symptoius. 
[?(j;ion  may 
ithout  the 
;  the  cases, 
ided.     As- 
[he  clinical 

the  portal 
ace  ascites. 

I  the  njiper 
:1,  the  ean- 
•e  instances 

II  ])alpation 
uargin,  de- 
ir,  and  may 
)!•  with  cen- 
y  be  greatly 

is  progres- 
level  of  the 
iient  of  the 
left  lobe,  it 
y  percussion 
owth  of  the 
icnt  in  many 
t  may  be  in- 
>er  alone,  or, 
rom  anaemia, 
teen  months. 

atly  enlarged 
rcinoma  may 
:'nce  of  jann- 
i  will  nsually 


snfTice  to  diirerentiate  it.  Perhaps  the  most  ])iizzling  conditions  occur  in 
the  rare  cases  of  enlarged  aniylnid  liver  witli  irregular  guniniata.  The 
large  ecliinococciis  liver  may  present  a  striiviiig  similarity  to  careiuuiua,  but 
the  i)rojecting  nodules  are  usually  softer,  the  disease  lasts  much  longer,  and 
the  cachexia  is  not  marked. 

Hypertrophic  cirrhosis  nuiy  at  fh'st  be  mistaken  for  carcinoma,  as  the 
jaundice  is  usually  deep  and  tlie  liver  very  large;  but  the  absence  of  a 
marked  caehexui  and  wasting,  and  the  i)ainless,  smootli  character  of  the 
enlargement  are  jjoints  against  cancer.  When  in  doid)t  in  these  cases, 
asjiiration  may  be  safely  performed,  and  positive  indication  may  be  gained 
from  the  nuiterials  so  obtained.  In  large,  rapidly  growing  secondary  can- 
cers the  superficial  romided  masses  may  almost  lluctiiate  and  these  soft 
tumor-like  projections  may  contain  blood.  'JMie  form  of  cancer  with  cir- 
rhosis can  scarcely  be  .separated  from  atrophic  cirrhosis  itself.  IVrhaps 
the  wasting  is  more  extreme  and  more  rapid,  but  the  jaundice  and  the 
ascites  are  identical.  Melano-sarcoma  causes  great  enlargement  'of  the 
organ.  There  are  frequently  symptoms  of  involvement  of  other  viscera, 
as  tlie  lungs,  kidtu'ys,  or  spleen.  Secondary  tumors  may  develo|i  on  the 
skin.  A  very  important  symptom,  not  present  in  all  cases,  is  melanuria, 
the  ]iassage  of  a  very  dark-colored  urine,  which  may,  however,  when  first 
voided,  be  quite  normal  in  color.  The  existence  of  a  melano-sarcoma  of 
the  eye,  or  the  history  of  blindness  in  one  eye,  with  su1)se(iuent  extir[)a- 
tion,  may  indicate  at  once  the  true  nature  of  the  liepatic  enlargement. 
The  secondary  tumors  may  develoj)  some  time  after  the  extirpation  of 
tlie  eye,  as  in  a  case  under  the  care  of  J.  ('.  Wilson,  at  the  Philadelphia 
Hos])ital,  or,  as  in  a  case  under  Tyson  at  the  same  institution,  tlie  pa- 
tient may  have  a  sarcoma  of  the  choroid  which  had  never  caused  any  symp- 
toms. 

The  firati))P)it  must  be  entirely  symptomatic — allaying  the  pain,  reliev- 
ing the  gastric  disturbance,  and  meeting  other  symptoms  as  they  arise. 


X.    FATTY    LIVER. 

Two  dilTerent  forms  of  this  condition  are  recognized — the  fatty  infil- 
tration and  fatty  degeneration. 

Fatty  infiltration  occurs,  to  a  certain  extent,  in  normal  livers,  since 
the  cells  always  contain  minute  globules  of  oil. 

In  fatty  degeneration,  which  is  a  much  less  common  condition,  the 
proto])lasm  of  the  liver-cells  is  destroyed  and  the  fat  takes  its  place,  as  seen 
in  cases  of  malignant  jaundice  and  in  phosphorus  ])oisoning. 

Fatty  liver  occurs  under  the  following  conditions:  (a)  In  association 
■with  general  obesity,  in  which  case  the  liver  ajipears  to  be  one  of  the  store- 
houses of  the  excessive  fat.  (h)  In  conditions  in  which  the  oxidation  jiro- 
cesses  are  interfered  with,  as  in  cachexia,  profound  ana'mia,  and  in  piitliisis. 
The  fatty  infiltration  of  the  liver  in  heavy  drinkers  is  to  be  attributed  to 
the  excessive  demand  made  by  the  alcohol  u])on  the  oxygen,  (r)  Certain 
poisons,  of  which  phosphorus  is  the  most  characteristic,  produce  an  intense 


i' 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

,,tv  dc..c.noration  .ith  .ecro.is  of  the  livev-o.Us.  Tl.  poi.on  of  acute 
'a  /atn^phy,  whatever  Us  nature,  a^--.^^-  ^^^  ;^;,,,  ,,.  reach 
^     The  fatty  liver  i.  ""''"""'JV'-'  1     looH  in  e  ami  l.h)o.lle.s;   on 

l>dow  tlie  level  of  the  uaveL      t  is  ^"/'-^^''/"'^^  J^*^  Za<x.     Tlio  liver 

,H,y  weijrh  unu.y  pounds,  aud  >et  the  .ludlic  ,ia      ^ 
entire  or^m  lloats  in  water  definite      Jaun.lice  is  never  prcs- 

-n,,  syuM'ton.s  ot  i-'tty    ner  au>  "^t/^^.     '   ^    ^  ^^^,^^^  ,,^,,,,,,a  .nules 
ont;  the  sto.ds  may  he  l.ght-eoh.reH,  hu.  [^  "  '  J  ^°  \^^,  ,,,.,.      n^mov- 
.Ue'hile  is  still  formed.      Signs  "^  1-     ^ ^^^^h^   :^^^^^^^    ..o  iU-deflued, 
,l,oids  are  not  very  .nfrequent.     ^^,'^J,['^\iJ.,„  .ration  is  associated. 
^„„,  ,Hi,,,v  those  of  the  disease  ^uth   ^^'^  ^^^  ^^  uncertain;    hut  in 

1„  eases  of  great  ";-'^^;.;  i;,;;^^;;::'  ,  r::;!',;:  felt  to  he  greatly  en- 
phthisis  and  .achectu^  c.nid.tionN  t  le  or  ^,^^  ^^^„^^^ 
larged.  thongh  smooth  and  painless,     i.ittj   inci- 
met  with  at  the  hedside. 


:i.     AMYLOID    LIVER. 


\\\ 


,i„„  ,„■  „„.  r,,.tmn.  u,ll,  »1'\,,'         ,";'„„  „,,|,„r„tivo  ohan-c.    It 

!i';;::';::,i;:;;s:';;s*:in  ;*.'.o^  ^ •-■-  *'- «-  '■"- 

„,  „„„,  „    .IH.  .....■.--  ".;  J     ,„,'„„  „,H„„  „„„.,„i.,  »..l  l.»s  a 

toen  pounds.      It   is  solid,  mm,  m.,:,,,.!  with  a  dilute  soUitum  of 

.omitJanslueent,  inllUrated  'MM-'J'^'^'-  j^  ^  ^^^  !'^,,,,,  ,  ,ich  nudmg- 
5„V,ue.  the  areas  inliltrated  with  '^^^^^'^^^^^^  ;,  .till  in  question, 
auy-hrown  colo,-      The  precise  na  o       -^    ^^one  of  the  lohnles, 

jLf :;.:::;;;^;:t^  tir;;;;:;«^"^^^^ '-  ^-  -—  ^'-- ''- 

cells  are  hnt  little  if  at  all  anected.  ,   ,f   n,;.   condition.      Jaundice 

|,„„o.,  an,l  ,.i„1,.,,  tl'V''t"o,ir    ho    .=     --,.,,  in  v.TV  ,roa.  onl„r,o. 
no  evidences  of  portal  ohstrnctmn.  _  Pvo-rcFsive  and  great 


ANOMALIES  IX   FORM  AND   POSITION   OF  TlIK   LIVKU. 


587 


acute 

n'iich 
ss;  on 
0  liver 
lat  the 


!!yi)hilis,  is  iilmost  always  of  this  nature.      Tii  rare  instanec?,  however,  the 
amyloid  liver  is  reduced  in  size. 

Tn  kiihr)tii(i  the  liver  may  attain  eonsiderahle  size  and  he  smooth  and 
nnil'orm,  resend)lin{r,  on  pliysieal  examination,  the  tatty  organ.  The  hlood 
condition  at  ouce  indicates  the  true  nature  oi'  the  case. 


r  pres- 
grades 
lemor- 
lefined, 
[)ciated. 
but  in 
itly  en- 
largest 


\eval  do- 
of  long- 

:>f  tul;er- 
■r  of  fre- 
L>  uleera- 
liseaso  of 
nges.  It 
;he  infcc- 

Ued  only 
ing  f'HiT- 
iid  has  a 
dution  of 
■h  mahog- 
qucstion. 
ic  lohnles, 
sue.     The 

Jaundice 
inn  of  hile 
fornily  en- 
d  the  eon- 
at  enlarge- 
t  there  arc 

e  and  great 
ig  or  with 


XII.     ANOMALIES    IN    FORM    AND    POSITION    OF   THE 

LIVER. 

In  trans]iositi()n  of  the  viscera  tlie  right  lolie  of  the  organ  may  occupy 
the  left  side.  A  common  and  important  anomaly  is  tlie  tilting  forwartl  of 
the  organ,  so  that  the  long  axis  is  vertical,  not  transverse.  Instead  of  tlie 
edge  of  the  right  lohe  presenting  just  l)elow  the  costal  margin,  a  consider- 
able portion  of  the  surface  of  the  lobe  is  in  contact  with  the  abdominal 
parietes,  and  the  edge  may  be  felt  as  low,  ju'rhaps,  as  the  navel.  This  an- 
teversion  is  i\\)i  to  be  mistaken  for  enlargement  of  the  organ. 

The  "  lacing  "  liver  is  met  with  in  two  chief  tyjies.  In  one,  the  anterior 
portion,  chiefly  of  the  right  lobe,  is  greatly  jirolonged,  and  may  reach  the 
transverse  navel  line,  or  even  lower.  A  shallow  transverse  groove  sepa- 
rates the  thin  extension  from  the  main  portion  of  the  organ.  The  peri- 
toneal coating  of  this  groove  may  be  flltroid,  and  in  rare  instances  the  de- 
formed jiortion  is  connected  with  the  organ  by  an  almost  tendinous  mem- 
brane. The  liver  may  be  compressed  laterally  and  have  a  pyramidal  shape, 
and  the  extreme  left  border  and  the  hinder  margin  of  the  left  lobe  may  be 
much  folded  and  incurved.  The  jirojccting  ])ortion  of  the  liver,  extending 
low  in  the  right  flank,  may  be  mistaken  for  a  tumor,  or  more  frecpiently 
for  a  movable  right  kidney.  Its  continuity  with  the  liver  itself  may  not 
be  evident  on  palpation  or  on  ])ercussion,  as  coils  of  intestine  may  lie  in 
front.  It  descends,  however,  with  inspiration,  and  usually  the  margin 
can  be  traced  continuously  with  that  of  the  left  lobe  of  the  liver.  The 
greatest  ditliculty  arises  wlien  this  anomalous  lap]H't  of  the  liver  is  cither 
naturally  very  tliick  and  united  to  the  liver  by  a  very  thin  membrane,  or 
when  it  is  swollen  in  conditions  of  great  congestion  of  the  organ. 

The  other  princijtal  type  of  lacing  liver  is  quite  dilTerent  in  shape.  It 
is  thick,  broader  above  than  below,  and  lies  almost  entirely  above  the  trans- 
verse line  of  the  cartilages.  There  is  a  narrow  groove  just  above  the  anterior 
border,  which  is  ])laced  more  transversely  than  normal.* 

Movable  Liver. — This  rare  condition  has  received  much  attention  of 
late,  and  J.  E.  Oraliam,  in  a  recent  ])aj)er,  has  ctdlected  70  re])orted  cases 
from  the  literature.  In  a  very  considerable  number  of  these  there  has  been 
a  mistaken  diagnosis.  A  slight  grade  of  mol)ility  of  the  organ  is  found 
in  the  pendulous  abdomen  of  enteroi)tosip,  and  after  rejieated  ascites. 

The  organ  is  so  connected  at  its  posterior  margin  Mith  the  inferior 
vena  cava  and  diaphragm  that  any  great  mobility  from  this  jioint  is  im- 

♦  See  P.  llcrtz,  AbnormitiUcn  in  dcr  Lago  und  Form  dcr  Bauchorgnne,  Berlin,  1894. 


rs8  DISEASES  OF  TOR  nmEBTIVE  SYSTEM. 

:::tK  ?Iw  .t  c»l»l  „,»/«:..    Vl,..  ,...n,li,i.,n  i.  rarely  n>.t  «,lh  ..,  .uon; 
50  ol  thu  cases  vac  in  "oiueii. 


IX.    DISEASES  OF  THE  PANCREAS. 

Tl,.,  imvorinnoo  ot  ,lis»s,.s  .,t  tin.  pnnoro.as  1,n,  '-";:;;i;|;3'^;,,i::: 

Kort(;'s-  rccL'iit  monograph. 

I.     HiCMORRHAGE. 

1-1    ♦   1  orl.liHmvil  «tmlio«      In  4,000  anto])sios  Draper  met  Mith  IJ  cabcs 

In  n      no     n^ich  there  .-as  a  .mall  growth  in  the  tail  of  the  panerea.  I 

Jl^lhannorrha    ■  into  the  .land  and  into  the  retro-pentona^uin,  forming 

o  1>lnn(1  s'lp  wlucli  surrounded  the  loft  kidney.  ,11. 

^v^iM^  that  the  sndden  death  in  these  ea.es  is  due  to  shoek 

'"''^^^Z^ZJ^L.  hrieflv  summarized  hy  Prinee:  "Tin.  patient, 
.dio  las  r.  i^  V  heen  perfeetlv  well,  is  suddenly  taken  with    he  illnes 

:-wh^:;:^;Xs\is  lif^. . .  when  the  i;-o"|;^--- ^/:s 

„iav  he  quietly  resting  or  pursuing  his  usual  oocupatiom     ^h    P^;n  ^  ^^^ 
u.liers  in  the  attaek  is  usually  very  severe  and  located  m  the  upper  pan  01 
?lfe  ahaomon.'  It  steadily  increases  in  seventy,  is  sharp  or  perhaps  col.ckj 


1 


ACUTE  PANCREATITIS. 


5S9 


ncntous 
how  an 
iUiguliir 
i  in  the 
rface  !;> 
in  men; 


2cd,  par- 
i  liivinor- 
:«  created 
he  organ 
he  wcji'ks 
-e.  The 
Vmerican 
loldsmith 
'reelv   on 


li  hfrnior- 
.t  vnedieo- 
r.  Draiier, 
have  oon- 
1  It)  cases 
death  was 
e  gland  is 
other  in- 
esscr  peri- 
connection 
rjhind.     In 
pancreas  I 
n,  forming 

c  to  shock 

he  patient, 
the  iUness 
the  patient 
pain  which 
»per  part  of 
laps  colicky 


in  character.  It  is  almo.*t  from  the  first  acrdnqianied  by  nausea  and  vom- 
iting; tlie  latter  l)econu'S  freijuent  and  ohstinate,  hut  gives  no  relief.  The 
patient  soon  })ecomcs  anxiou.s,  restless,  and  d('pre.«:scd;  he  tosses  about,  and 
oidy  with  diiliculty  can  he  be  restrained  in  bed.  Tiie  surface  is  cold  and 
the  forehead  is  covered  with  a  cold  .sweat.  The  pulse  is  weak,  rapid,  and 
sooner  or  later  im|)erceptil)le.  Tlie  abdomen  beconu's  tender,  the  tender- 
ness being  located  in  the  u])per  part  of  the  abdomen  or  epigastrium.  Tym- 
panites is  sometimes  marked.  The  temperature  in  most  cases  i,s  either 
normal  or  below  normal.  The  bowels  are  apt  to  be  constipated.  These 
symptoms  continue  without  relief,  those  which  are  most  striking  being 
tiie  pain,  vomiting,  anxiousness,  restlessness,  and  the  state  of  collapse  into 
wliich  the  patient  soon  falls.'' 

It  has  Iteen  suggested  in  such  cases  to  open  the  abdouien,  expose  the 
pancreas,  and  relieve  the  tension,  since  the  fatal  result  is  often  due  to  the 
l)res^ure  ami  not  to  the  loss  of  blood. 


II.    ACUTE    PANCREATITIS. 

(a)  Acute  HsBmorrhagic  Pancreatitis.— 1  n  this  form  the  inilammation 
is  combined  with  hiemorrhage,  and  it  is  dillicult  to  separate  clearly  tlio  two 
processes. 

Etiology. — Korte  has  collected  -11  instances,  of  which  only  -l  were  in 
women.  A  large  majority  of  the  cases  occur  in  adult  males.  Mcl'hedran 
has  reported  one  in  a  nine  month.s'  old  child.  Many  of  the  ])atients  iuid 
been  addicted  to  alcohol;  others  had  sull'ered  occasionally  with  severe  pains 
and  vomiting. 

Morbid  Anatomy. — The  ])ancreas  is  found  enlarged,  and  the  inter- 
lobular tissue  infiltrated  with  blood,  and  jierhaps  with  clots.  In  some  in- 
stances the  contiguous  tissues  may  also  be  luemorrhagic.  and  the  whole  may 
form  a  large,  firm  mass,  situated  at  the  upper  and  back  part  of  the  ab- 
dominal cavity.  The  root  of  the  mesentery,  the  mesocolon,  ami  the  omen- 
tum may  also  show  lucmorrhages;  the  other  organs  may  be  iiractically  nor- 
mal. As  a  rule  there  can  be  seen  about  the  lobules  areas  of  opaque  white 
tissue,  and  Ti])on  the  omentum  and  mesentery  similar  opaque,  white  specks, 
which  will  be  referred  to  subseciuently  as  the  fatty  necrosis  of  Balser.  In 
s]H)ts  tl;e  gland-cells  may  also  be  found  necrotic,  while  tliere  may  be  cases 
slu)wing  a  marked  increase  in  the  fibrous  tissue. 

Symptoms.— One  of  the  most  characteristic  features  is  the  sudden- 
ness of  the  onset,  usually  with  violent  colicky  pain  in  the  upi)er  part  of  the 
ahdonu'u.  Nausea  and  vomiting  follow,  with  collapse  sym])toms,  more  or 
less  severe  according  to  the  intensity  of  the  attack.  The  abdomen  becomes 
swollen  and  tense  and  there  is  constipation.  The  temperature  at  first  may 
he  low;  suhsequenly  fever  sets  in,  sometimes  initiated  by  a  chill.  There 
may  be  early  delirium.  Colla])se  symptoms  supervene,  and  death  occurs 
usually  from  the  second  to  the  fourth  day,  or  even  earlier.  The  swelling 
and  infiltration  in  the  region  of  the  pancreas  necessarily  involve  the  coeliac 
plexus,  and  the  stretching  of  the  nerves  may  account  for  the  agonizing  pain 


-    " 


,gO  DISEASKS  OF  THE  DIGESTIVE  SYSTEM. 

II,,  ,lia.-n.,«s   »rra  n-mm  lias  1,,,.,,  m«h  (I.J  ImU,  «".1    >.    I  I'.'M  i  ■       A'    > 

ol.-trnction  l.ut  in  the  n-i.m  of  llu"  luuurcMS  aiul  at  the  loot  ol  tne  me  tu 
rv    lu      V-      I'lense,  thiek,  in.lurated  mass,  and  there  uero  areas  of  fat- 

u^ro        n  i;>t     m    enterv  •,u.^  ou.ent.nn.     O.hlly  enough  th,s  pat.ent  re- 

"u-'i  fo"  r  vears  afterwar.!   with   another  attack,  hut   he  relused  to  he 

,„„.nite(l  niion  and  was  taken  away  hy  his  friends 
'       Acute  Suppurative  Pancreatitis-Pancreatic  Abscess.-I.  d.         h  . 

nioJoiiti-li  in  IS.!),  reported  .'.'  eases.     To  this  list  Korte  has  a.hled  .1. 

''  !|-S,:  -ZP^-^^  cases  is  donhtfnh    .ysp.jtie  dist,...ances 

;i;  ne    i.  re  was  a  ditrnso  puruU-nt  infiltration.     Some  o     the  sequel 
i^c^  ;:H.an<.reatie  ahs.^ss,  perforation  into  the  stomach,  the  duodenum,  or 
the  peritona-um,  and  thromhosis  of  the  portal  vein. 

ko  s,p>,r(o,ns  of  suppurative  pancreatitis  are  not  always  we     d         d 
In  one  case  in  mv  wards  Thayer  made  a  correct  drnprns  s.      Ihe  pat    nt 

"ed'nAv-four.  had  had  occasional  attacks  of  severe  pa, n  nn<l  vom     n^ 

m  h  more  eh  onic.  Tcterus,  fatt.  ,linrrh»«a,  and  su.ar  in  thenrino 
;;a"  h'm  n^t  .Ith  in  some  cases.  The  presence  of  a  tumor  mass  m  the 
ei.iirastrium  is  of  the  jzreatest  moment.  .i„„inrmrt 

(c)  GanffrenousPancreatitis.-Completc  necrosis  of  the  ^dand,  or  part 
of  t  ni.v  folW  cither  ha-morrhape,  acute  inflammation,  or  siippuratne 
MrS,^  in  exceptional  cases  may  occur  after  injury  or  the  perfora- 


A(  TTK    PANCUKATITIS. 


M>1 


iomiluiiiiT 
I  iiitt'i'sti- 
lU'igliljoi'- 

licriton'tis 
or  known 
,    *'  Atnte 
or  a  suf- 
1  a  violent 
the  couvHC 
vinpanitic 
I'd  tciulor- 
e  alxlonion 
Iti'il  to  tlu' 
(luiifj;  n\an 
(lays.    'T'li' 
aihnission, 
him  to  bo 
'videncc  of 
the  nicscn- 
roas  of  fat- 
pat  iont  re- 
nted to  he 

itz.    in    his 
i  added  24. 

listuvliancos 
cases  there 

■i.  In  other 
the  seqnels 

ludennni,  or 

veil  defined, 
rhe  ]tatient, 
id  vomitin};. 
?  was  felt  in 
1  and  found 
•otic  pancre- 
nrativo  form 
in  the  urine 
mass  in  the 

land,  or  ^lart 
-  snppnrativc 
■  the  perfora- 


tion of  an  nleer  of  tiie  stomiu  !i.  In  l-"it/'s  mon>>irraph  l.">  caso  are  rrpuried. 
i\(iit('  lia.-  increiisi'd  this  numlirr  to  Hi.  Syiiiptoins  ut  lui'mcirrlia^nc  |i,in- 
(ii'iititis  may  precede  or  1m'  asxpciatt'd  with  it.  heatli  n>iially  l'iillnu>  in 
liMin  ten  to  twenty  <lays.  with  .-ymptoms  of  coliapx'. 

.Viiatomicaily  the  pancreas  may  prociit  a  dry  necrotic  appearance,  imt  as 
a  rule  the  origan  is  converted  into  a  dark  >ialy-c(ilorcd  mass  lying  nearly 
lice  in  the  omental  cavity  or  attached  hy  a  few  shreds.  In  other  instances 
liie  totally  or  partially  se(|nestrated  organ  may  lie  in  a  large  ali^ci'.-s  cavity, 
forming  a  palpalile  tumor  in  the  epiga>tric  region.  In  \\\n  cases,  reported 
liy  rhiari.  the  necrotic  pancreas  wa>  diMharged  per  rectum,  with  recovery. 

Relation  of  Fat-necrosis  to  Pancreatic  Disease.— in  conmction  with  all 
lorms  of  pancreatic  (li~ea.-e  small  yellowish  area>,  to  which  lialser  lirst  di- 
rected attention,  may  he  I'liind  in  the  interloluilar  ]tancreatie  ti>sue,  in  the 
mex'titery.  in  the  omentum,  and  in  the  ahdominal  fatty  tissue  generally,  in 
>liglit  grades  they  may  he  present  withi>id  other  changes,  and  they  have  heeii 
,-een  in  the  living  witlnuit  any  disea.-e  ni  the  glaiul  lieing  diM-overed.  They 
are  mo.»t  fre(piently  in  the  luemoi'i'liagic  and  necrotic  forms  of  |)ancreatitis, 
less  comnKUi  in  the  Mippurative.  In  the  pancreas  the  lolmles  are  seen  to  he 
separated  hy  a  dead-white  necrotic  tissue,  which  gives  a  remarkable  ajipear- 
ance  to  the  section,  in  the  abdominal  fat  the  areas  are  usually  not  larger 
than  a  pin's  head;  they  at  once  attract  attention,  and  may  he  mistaken,  on 
superlicial  e.xamination,  for  miliaiy  tidiercles  or  neo]ilasms.  They  may  be 
larger;  instances  have  been  reported  in  which  they  were  the  size  of  a  hen's 
(.nc_r.  On  section  they  have  a  soft,  tallowy  consistence.  Langerhans  ha.s 
shown  that  this  substance  is  a  combination  of  lime  with  certain  fatty  acids. 
They  may  be  crusted  with  lime,  and  in  a  man,  aged  eighty,  who  died  of 
Itright's  disease,  I  foumi  the  lobules  (d'  tlu'  pancreas  entirely  i>olated  by 
areas  of  fatty  lu'crosis  with  extensive  deposition  of  lime  salts.  There  is  no 
necessarv  etiological  relation  between  disease  id'  the  pancreas  and  dissemi- 
nated fatty  necroses  of  the  abdomen  at  the  time  the  latter  are  discovered. 
Cases  have  been  found  accidentally  in  laparotomy  for  ovarian  tumor  and  in 
in>tanccs  in  which  the  pancreas  has  been  normal.  They  may  be  present  in 
thin  persons  or  in  association  with  gall-stones.  The  Iniitfriuiit  rail  (1,111- 
iiiinii'  was  present  in  two  instances,  with  di]ihtheritic  colitis,  I'xainined  by 
Welch,  though  in  most  cases  the  areas  of  necrosis  are  sterile.  Langerhans 
produced  fat-necrosis  by  inject'ug  extract  of  paiU'reas  into  the  peri-renal 
fattv  tissue  (d'  a  do<v;  and  Ilildcbraml  ami  Williams  have  shown  ex|ieri- 
mentally  that  the  fat-necroses  are  cau>ed  by  certain  coii>tituents  of  tlie  pan- 
creatic juice,  but  mit  hy  tryjjsin.  FU'xner  has  (h-monstrated  by  cheiincal 
tests  the  existence  of  the  fat-splittiiig  ferment  in  peritoneal  fat-necroses  in 
recent  human  and  experimental  cases.  The  ferment  (stcapsin)  disappears 
after  live  or  six  day>  in  cNperimeidal  necroses,  ami  cannot  be  demonstrated 
in  the  lime-incrusted  human  (tnes.  II.  V.  Williams  has  ]u-oduce(l  similar 
lesions  in  the  subcutaneous  fat  by  inserting'  bits  (d'  sterile  pancreas  beneath 
the  skin.  In  their  experimental  studio  ITildebrand,  Williams,  and  Flexner, 
\\  bile  thev  were  able  to  produce  fat-necroses  by  tying  the  veins  of  and  some- 
times lacerating  the  |)aiicreas,  never  actually  succeeded  in  re|)roducing  the 
picture  of  luemorrhagic  and  necrotic  pancreatitis.     This  has  recently  been 

a: 


.1: 

t  , 

I' 

i 


il»2 


mSEASHS  OK  TIIK  DldF.STlVF.  SYSTEM. 


c:-'n::'S;;:;:::i:,,;!:r,.r  ,,;;■;« ...-.'. * > 

tlu-  lat->i.littii.-  iVrmcnt  (M.'.mut).  ^,^^,  ^^^,,^, 

,t  is  u.ll  for  su.-oons  to  n.m.n.lu.    tl.at    "  ^         '           ,  j„  ,,,,„,,,„„„ 

.,n.,us  svnM..-ns  of  >u.ut.  1«:>'- l'^  ^^  '"         "    ','  ,v,„.,,.d  l.y 

.ilh  only  w>.l..s,.n.a.l   »'>^-"--'-'V  ,:^'",;  •.„     v  rru.u   '■:,;,■..,....  wns 

Stockt.m  a.ul  Willian.s  a  nun,,  o     1  >           "  ;';',(^  ^,  ^.,,.,  ,„..,',  ,,,,„.. 

sn„..l  wi.h  vnn.itin,-  an<l  ,.a.n    without    <■      .  "  ■'        •               ;^_.^^,,_, 

The  patent  du.  --;-;-  .jii^t:. .';;;;>!:  hut  ^,,0..:.  o..  ...10.. 


III.     CHRONIC    PANCREATITIS. 

•     .  +«.n  fnrnw-  ( 1 1  Tlu'  most  i(.iniu..n,  a  chronic  inlhim- 
l)u.ckh..tVrcco>:.n/.eshvo   onn  .(   )  i       "  association  will. 

;x;;;;,:;;lr;:::;;f:r  SS 

of  the  tissue  of  the  f:hin(l.  ^      association 

:;.:;•  sir  :;tr.  J;r:;. :  -  ;.-i .—.  ■- 

ductus  cunununis  cboledochus  and  caused  the  jaundice. 
IV.     PANCREATIC   CYSTS. 


Of  m  cases  operated  upon  l.y  -';^;;;;; ^^'^  ^;;;;;; 'i;?' U.c  ca.. 


and  •><>  HI 
oc- 


f.,.ales:  in  .the  sex  was  -^j,^--  .^;:;;:';.,;'^  •  ,  ,;  .i,  in  Kiirtcs 
curred  in  the  fourth  decade.  T  C .  ^  'l"'^  .  ;;^;.;^,^^,,  ;,,  ,  ,iuld  of  thir- 
Beries).  an  infant  a<j:ed  six  months,  and  h>hattuckb  ca.c 


PAXCRKATIC  CYSTS. 


5y;j 


juice  mill 
'I'lif  vt'iy 
.•iity-l'iiiir 
Is  liul  liv 

tilt'    llici>t 
.•.7.(niil!iiili 

|icii'tc(l  l>y 
r(i|i('.  wiis 
i.'ll  jiuIm'. 
,1  uiiirti'iii 
nil  sfctidii 


nic  inlliim- 
atiiin  with 
a  ihe  bilf- 
iltiiiu'  Iriiiii 
Tlic  (iififlii 
;is  St't'll   iii't 

1,  ,111(1  may 
1).     In  cDii- 

;  ill  ilsHiciil- 

I'oUow  inm- 
v\\t  wasting 

association 
);((////  to  the 
the  licail  of 
let.  Hicilcl 
r  oall-stoncs 

dreaded  tlie 
1(1  were  Well 
mdition  was 
odllle  of  the 
ly   ujion   the 


I's  and  •)'>  111 
the  cases  oe- 
lot  in  Kiirte's 
child  of  thir- 


teen and  a  half  month?!,  are  the  yoimgot  in  the  literature.     .Vccordin-,'  to 
the  origin  Kiiite  recooni/.es  three  varieties. 

(I)  Traumatic  Cases.— in  this  li>t  of  ;;;!  ca.MS  :!<!  were  in  men  and  only 
:;  in  women.  lUows  on  the  ahdonieii  or  constantly  re|ieated  pressure  are  the 
most  coiiiiiion  forms  of  trauma.  One  case  followed  severe  massage.  I'sii- 
ally  with  the  onset  there  are  inllammatory  symptoms,  iiain,  and  vomithig. 
soiiietiines  suggestive  of  jieritonitis.  The  contents  of  the  cy>t  are  usually 
hloodv.  though  in  l:i  of  the  traumatic  cases  it  was  ileur  or  yellowish. 

(■/)  Cysts  following  Inflammatory  Conditions.— in  .M  cases  the  trouble 
began  gradually  after  attacks  of  dysiiepsiii  with  colic,  simulating  somewhat 
that  of  gall->tones.  Occasionally  the  attack  set  in  with  very  severe  symp- 
toms, suggestive  of  ob>triiction  of  the  bowel.  In  this  group  Mie  tumor  ap- 
i.eared  in  lit  cases  soon  after  the  onset  id'  the  pain:  in  others  it  was  delayed 
i'or  a  period  of  from  a  feu  weeks  to  two  or  three  years.  Mei'hedran  has  re- 
ported a  remarkable  instance  in  which  the  tumor  developed  in  the  epigas- 
trium with  signs  of  severe  iiiilammation.  It  was  opened  ami  draini'd  and 
believed  to  be  a  hydrops  cd'  the  lesser  peritooeal  cavity.  Tliri'e  months 
lati'r  a  second  cyst  ileveloped,  which  appeared  to  spring  directly  from  the 
[lancreas. 

(■.\)  Cysts  without  any  Inflammatory  or  Traumatic  Etiology.— of  ;5;5 

cases  ill  this  group  "^(i  were  in  women.  .V  remarkable  feature  is  the  jiro- 
loiige<l  period  of  their  existence — in  one  case  for  forty-seven  years,  in  one 
for  between  si.xteen  and  twenty  years,  in  others  for  sixteen,  nine,  and  eight 
vears,  in  the  majority  for  from  two  to  four  years. 

Anatomically  Kiirte  recognizes  (1)  irli'iilioit  ri/six  due  to  plugging  of 
the  main  duct;  ("J)  proUfcrnliou  riisls  of  the  |mncreatic  tissue — the  cysto- 
adeiioma;  (:'))  irtrntioii  r//s/.s  arising  from  the  alveoli  of  the  gland  and  of  the 
smaller  ducts,  which  become  cut  otT  and  dilate  in  conse(|uence  of  chronic 
interstitial  pancreatitis;  (1)  iisnidu-ri/sls  following  inllammatory  or  trau- 
matic alVeetions  (d'  the  pancreas,  usually  the  result  of  injury,  causing 
iKeniorrhage  and  hydrops  of  the  lesser  peritona'iim. 

SiliKttinn. — In  its  growth  the  cyst  may  (1)  develop  in  the  lesser  peri- 
toiueum,  imsli  the  stomach  upward,  and  reach  the  abdominal  wall  between 
the  stomach  and  the  transverse  colon;  Ci)  more  rarely  the  cyst  apjiears 
aliove  the  lesser  curvature  am!  pushes  the  stomach  downward;  in  both  of 
these  cases  the  situation  of  the  t'lmor  is  high  in  the  abdomen,  but  in  (;5) 
it  niav  develop  between  the  leaves  of  the  transverse  ineso-colon  and  lio 
iielow  both  the  colon  and  the  stomach.  The  relation  of  these  two  organs 
to  the  tumor  is  variable,  but  in  the  majority  of  cases  the  stomach  lies 
al>ove  and  the  transverse  coIoti  below  the  cyst.  Occasionally,  too,  as  in  T. 
('.  Railton"s  ease,  the  cyst  may  develoji  from  the  tail  of  the  jianereas  and 
iiroject  far  over  in  the  left  hypochondrium  in  the  ])osition  of  the  spleen 
or  of  a  renal  *  .;mor. 

General  Symptoms. — Ajiart  from  the  features  of  onset  already  re- 
ferred to,  the  jiatient  may  complain  of  no  trouble  whatever,  particularly  in 
the  very  chronic  cases,  unless  the  cyst  reaches  a  very  large  size.  Painful 
colicky  attacks,  with  nausea  and  vomiting  and  iirngressive  enlargement  of 
the  abdomen,  have  frequently  been  uoted.     Fatty  diarrlia-a  from  disturb- 


$ 


bdi 


DISEASKS  (.F  TllK   DIOKSTIVF  SYSTEM. 


ance  ..f  tl..  fu.utiun  oi  ihv  pannvas  is  ra.v.     Su>rar  in  tlu;  urmo  has  Ik., 

,„rH.Mt  in  a  nun.l.r  uf  n.^cs.    Inuvasc.l  s.-rctiun  ot  the  .aUva.  the  so-ca-lnl 

.aM...vatie  salivation.  1«  also  rarv.      l>.v.>urv  oMl.e  ^•^^7"^>,  -';-';;;;;,; 

•a,,.,  iaun.lin.,  and  in  rare-  instancrs  av^i-nu-a.     \  .ry  niarkc..!  W  ol    U>i 

,,;,.  1,.:!.,,  ,.re<...t  in  a  nun.hor  of  cases.    A  runarka Me  leatiuv  o  ten  notice.! 

l.as  i..en  tl.e  transitory  disappeannuo  of  the  eyst.     h.  -Hie  of  '"'^^'"l; '•;';;;; 

,|H.  .'irth  of  tl.e  al.lon.en  .ieereascl  fnnn  V^  to  :!    uulus  n,    en  .lav^  ^^..h 

,,,„lnM.  ,i;arrho.a.     Son.etin.es  the  .lisa,.pearan.r  has  tollowe.l    '  ''Y',,,,,,.^ 

Diagn08i8.-'n,e  eyst  oeeupies  the  upper  a  .lon.en,  nsnal  >    ln„n  ,; 

a  sen.u^-enh.r  M.lgin;:  in  the  n.e.lian  line,  rarely  to  e.ther  s.de.       n   f  ^ 

(.„..s  Ki.rte  states  that  tl.e  el.ief  projection  was  l.elow  the  navel.      '   ""^  '"^^ 

operated  upon  l.v  llalste.l  th.'  tun.or  occupie.l  the  >:reater  part  ot  the  alul..- 

2.        The  cvst"is  in.n.ohile,  ropi.-ation  having  little  or  no  m  h.ence  on 

it.    As  already  mentione.1.  the  ston.ach,  as  a  rule,  lies  ahove  it  nn.l  the  colnn 

^''''l^  a  u.aioritv  of  the  cases  the  llnhl  is  of  a  red.lish  or  dark-hrown  color, 
and  contains  Idood  or  blood  coloring  n.atter.  cell  detntus.  la     jrrannles. 

d  son.etin.es  cholestorin.    The  consistence  of  the  Ihnd  ,s  --^^'v  ;';;';;";  ; 
rarelv  thin      The  reaction  is  alkaline,  the  spec.t.c  grayity  iron.   l.UK.  to 
1  o-'u      In  '^^i  cases  Kiirte  states  that  the  lluid  was  not  hieniori-ha^nc. 
■    The  existence  of  fern.ents  is  important.     In  -U  cases  they  were  presen 
i„  (,,,  iLnd  or  in  the  material  from  the  fistula.     In  W  cases  only  one  ternient 

aJpresent.  in  ''U  cases  two.  aud  in  If  eases  all  three  of  the  pancreat.c  er- 
,„„>;.  were  fonn.l.  As  diastatic  an.l  fat  enu.lsifving  ferments  occur  widely 
in  various  exudates  the  most  important  and  only  i-ositive  sijrns  ,n  the  diag- 
nosis of  the  pancreatic  secretion  is  the  digestion  of  libnn  and  albumin. 

;.,,„//,._K;-,rte  states  of  1(»1  cases  in  which  the  cyst  was  op^'ne.l  an.l 
drained  4  deaths  followe.l  th.^  operath.n  directly.  1  resulted  r..ni  infec- 
tion of  the  fistula.  In  11  cases  the  cyst  was  extirpated;  ot  these  1.  re- 
covered. 


V.     TUMORS    OF   THE    PANCREAS. 


Sarcmia, 


Of  new  gr..wths  in  the  ..rgan  carcin..ma  is  the  most  frequent 

adenoma,  luul  iymi.h.mia  are  rar  .,.,..  •      .o  or..  .n,t,nwi.-s 

;,,,,,„,,„,,/._At  the   (iene-  ital   m   A  K'nua   in   l.s.Of.M    iji Oj-sus 

.1    ,  r.    •■'•    c.<e<  of  c.  .e  pancreas  (P.iach).      In   11.47->  j-.-st- 

,        t  Vlil  in    Se!^  io->  tumors  of  the  pancreas.  l-.'T  ..f  whi.^h 

:;;::;•  ImaiaN  :;;.  ...  .  cysts,  and  1  syphil.nna.     In  .000  autop- 

Bics  ,t  (;uv-s  ILispital  th.-re  were  only  20  cases  ot  primary  malignant  .!.>- 

•nse  of  tin".  ..r.an  (Hale  ^Vl,ite).     In  the  first  1.000  autopsies  at  the  .T..hus 

Hopkins   IL.spital  there  were  r.  cases  of  adeii..-carcinoma.  an.l   1   doubt- 

fnllase  in  which  the  exact  origin  cul.l  n.^t  l.e  stat..d.       here  wc.^.  .  casc> 

of  secondary  malignant  disease  .>f  the  pancr..as.     '1  -o  liea.l  o    th.    gl  n 

is  most  commonlv  inv.dved.  hut  the  dis..ase  may  be  Inn,  ed  to  the  bo.  >  ,.r 

to  the  tnil     The  maioritv  of  tlu-  patients  a,-e  ,n  the  m,ddle  i.eriod  ..f  life. 

sVmptoms.-Tlu.  diagnosii  is  n..t  ..ften  possible.     The  f.dlowmg  are 
the  niost  important  and  sugg<.stive  f..atures:    (.)  Kpigastric  pams.  oiten 


i(i-iallt'il 
ua'tiiiii.-* 
of  lU'sli 
,  iiDticrtl 
(I's  rasi'fi 
iiV!-  witli 

AS. 

,  In  Iti 
(lilt'  cftfie 
he  alido- 
itc'iU'i'  mi 
the  CMildii 

uii  t-olor. 
^'vamili's. 
'  imuiiiil, 

1.010  to 
<:ic. 

V  in'osi'iit 
['  fcriiK'nt 
roatio  fer- 
uv  widely 

tlu'  (liag- 
iiiiiiin. 
H'lK'd  anil 
oiu  iiitVc- 
.'se  I'i  I't'- 


Sarc'iima, 

a\it(>i>sies 
.47--'  i.ost- 
;  of  wliich 
:iOO  autop- 
trnant  dis- 

thc  JnhllS 
I  1  doiilit- 
cr"  .")  cases 

tlu'  gland 
1)0  liodv  or 
d  of  life, 
llowing  are 
lains.  often 


I'ANCUK.VTH'  CAi.Cl'Ll. 


.Oo 


(Mciirring  in  painxysins.  (//)  .laiindi. c  due  to  |ire>siire  of  tlie  tumor  in 
llir  heaiFof  the  paiureas  on  the  l.ile-du.I.  The  jaiiiuiiee  is  inlen>e  and 
|,rriiiaiieiit,  and  a.«>oeialed  with  dilatation  nf  the  gall-liladder,  which  may 
ivaih  a  \eiy  large  size.  (' )  'i'iie  preseiiee  of  a  tuinor  in  the  e|iigastriuin. 
'I'lii.-  is  Miy  variahle.  In  \-u  eases  Da  Costa  found  the  tumor  luvseiit 
in  onlv  l:l.  I'alpalion  under  aiia'sthesia  with  the  stoniaeli  em|ity  would 
priiliiil'dy  give  a  very  iniieh  larger  pereeiitage.  A>  the  tiiiuor  re>ts  directly 
ii|iun  till'  aorta  there  is  usually  a  marked  degree  of  puUation,  sonu'tiiiies 
with  a  iiriiit.  There  may  lie  |.re»ure  <.n  the  jiortal  vein,  cau>iiig  thn.in- 
h,i>i«  and  il-  usual  se(|uels.  («/)  Syiiii>tnuis  due  to  juss  of  fniiclioii  of  the 
pancreas  are  less  important.  Fatty  iliarrluea  is  not  very  ofleii  present,  in 
.•o!i.«ei|Ueiice  of  tlii'  aiiseiice  (d'  liile  tile  >lon|s  are  loually  viMT  clay-colored 
imd  greasy.  Dialietes  also  is  not  eoinuiDn.  (')  .\  very  rapid  wa>ting  and 
(achexia.  "  Of  other  symptoms  iiaii.-ea  and  voniiling  are  eoinmoii.  hi  i^oine 
iii-tanccs  the  jivloriis  is  compressed  and  there  is  great  dilatation  of  the 
-.tninach.     In  a  few  cases  there  has  liccn  pnd'iise  salivation. 

The  points  (d'  greatest  importance  in  the  diagnosis  are  tlii'  intense  and 
]icrnianent  jaiimliee,  with  dilatation  of  the  gall-ldadder.  rapid  emaciation, 
and  the  presence  of  a  tiinior  in  the  epigastric  region.  Of  less  imimrtancu 
are  features  pointing  to  disturlmiice  uf  the  I'uiiclioii  ol'  the  gland. 

Of  other  new  growths  sarcoma  and  lymiihoina  have  hocn  occasionally 
found.  .Miliary  tuhcivle  is  not  very  iincoiiimon  in  the  gland.  Sypliili:4 
may  occur  as  rather  a  chronic  interstitial  inllammation.  ov  in  the  form  of 
giimmoiis  tumors. 

The  outlook  in  tumors  of  the  iMiicrcas  is.  as  a  rule,  hopeless.  How- 
ever, of  10  cases  operated  upon  of  late  years,  (I  recoveretl  (Kiirte). 


VI.     PANCREATIC    CALCULI. 

Pancreatic  litliiasis  is  coinparatividy  rare.  In  lss;5  (ieorgo  W.  John- 
ston collected  ',\r,  cases  in  the  literature.  In  l.ooO  autopsies  at  the  Johns 
Hopkins  llosjiital  there  were  2  cases. 

The  stones  are  usually  numerous,  either  round  in  shape  or  nmgli, 
spinous  and  coral-like.  The  color  is  opaque  white.  They  are  coiii])0.s4'd 
chiefly  of  carhonate  of  lime.  The  eil'ects  of  the  stones  are:  (1)  .V  chronic 
interstitial  iullanimaticm  of  the  gland  substance  with  dilatation  of  the  duct; 
sometimes  there  is  cystic  dilatation  of  the  gland:  {-2)  acute  inflammation 
with  suppuration;  (ii)  the  irritation  of  the  .stones,  as  in  the  gall-hladder, 
mav  lead  to  carcinoma. 

Symptoms. — ]V]>l^er  in  1SS2  made  a  diagnosis  of  calculus  of  the  pan- 
creas, of  which,  however,  there  was  no  confirmation  either  by  the  ]iassage 
of  the  stone  or  hy  autojisy.  ;^[innich  has  rejiortcd  a  case  in  which,  after  an 
attack  of  colic,  calculi  composed  of  calcic  carhonate  and  phosphate  were 
passed  in  the  stools.  Lichtheini,  in  a  case  with  severe  colic,  diabetes,  and 
fatty  diarrhoea,  made  the  diagnosis  of  pancreatic  calculi,  which  was  after- 
ward confirmed  by  autopsy. 


DISEASES  uF  THE  DIGESTIVE  SYSTEM. 

X.    DISEASES  OF  THE  rERITON^UM. 
I.   ACUTE   GENERAL   PERITONITIS. 
Deflnitioil.-Acuto  inilamn.ation  of  tlio  peritona.um. 

U^^  oHhis  fonn.    In  these  there  wa.  su.ne  pre-ex.st.ng  chvcnnc  d.ea.e 

of  the  .pU.e.K  liver,  panerea.,  retroperitoneal  tissues,  and  the  pch.c  m. 

""iVrforative  peritonitis  is  the  most  conunon   foUo.^n.  exterinU  .Ws, 
I  r.  . m   of  1  .leer  of  the  stomaeh   or  bowels,  perioration  of  the  gall- 
perforation  oi   1";^'^  "   J^"^  j..;,i„,.,.,_    Two  important  eauses  are 

■-"°T^::;s;:s';;i  ::,r  ;:"t?  ,= . ». ^^  i..™--^'.  "■;  - 

.„lt   ,■  J        1  pro..-.     A„  ««.c..li„glj  acute  toon  ol  ,,..nto,„.,.  ,«aj  1.0 

""^  "i-r  A^aSy'  i„'"t:t^:"or„::;;i';;  .,,0  .„., „ ... 

„,„,  ,"«>■  l«'-  <","!"'?,•;,         ,,,)  Sorn-ni.rmou..     TI,o  foils  nro  cov- 

sero-fibrinoi is  thiid.     In  "!■    >"J*^  ^  ,^  Purulent,  in  which 

.^rforated  this  ->;  -,;--  ;^;  ^^^1^  ;;Cin  Joior,  or  opa.pie  M-liite 
tho  exudate  -      ^lu     tin    -  j--^  ^,    >      ,^^  ^^^^^  ^^„^     ,rf,,,tive  peri- 


ACUTE  GENERAL  PERITONITIS. 


M 


9T 


ntly  the 
illiic  iii- 
y  follow 
instance 
out,  and 
Of  10-i 
Hospital, 
le  disease 

from,  or 
'eritonitls 
tines,  ex- 
inmations 
elvic  vis- 

1  wounds, 
tlie  gall- 
eauses  are 
tuljes  and 
'uptiiro  of 

some  dis- 
ojierations 

)1y  the  re- 

tis  may  bo 

ilomen  the 
1  tlie  ]ieri- 
lie  exiula- 
cw  ]iockets 
Is  are  cov- 
:  yellowish, 
intestine  is 
t,  in  which 
acpie  Avhite 
rative  pcri- 
the  exudate 
[c)  ITfrmor- 
acute  peri- 
tuhcrculoiis 


forms  (/)  A  rare  form  occurs  in  wliich  tiie  inject  inn  is  present,  V)Ut  almost 
.,11  .i-ns  ..r  exudation  are  \vantinf.^  flo^e  in.pction  may  l.e  necessary  to 
,K.t..c't  a  sli-ht  .lullin-  of  the  serous  surfaces.  The  l.actcriolo-u'al  exanu- 
natjon  reveals  larj:e  nuniliers  of  l)acteria. 

'I-Ih.  amount  of  the  clVusion  varies  from  half  a  litre  to  '20  or  .)(»  litres. 
There  are  prohal.ly  essential  dill'erences  hetween  the  various  kinds  ol  peri- 

"" Bacteriology  of  Acute  Peritonitis.— Much  work  has  ])een  done  lately 
„p„n  the  sul.jcct.     I'lexner  lias  analyzed  lOV'  cases  of  i)eritoniiis,  in  wiiuli 
l,acteriol..j.ncal  studies  were  made,  wiiich   came  to  autopsy   m  the  dohns 
ll.^pkins  llosi)ital.     lie  makes  tiiree  classes.     The  lirst  class  cmhraces  tiic 
nriniarv  or  idiojiathic  lorni,  of  which   l'.'  cases  were   f.uind.     These  were 
with  o"ne  exception  mono-infections.     Tlie  i)revailinj,'  inicro-<n'<ianisni  was 
the  streptococcus  pvo>.a'ncs  (live  times).the  remaining  ones  l)eing  the  stapliy- 
hu-occus  aureus,  micrococcus  lanceolatus.  bacillus  proteiis.  pyocyaneus,  and 
,.,,li  c(.mmunis.    The  second  class  fcdlowed  operations  upcu  the  pcntona-uin, 
cxccptimr  operations  upon  the  intestine.    The  majority  of  tliesc  cases  were 
cxaniplcs  of  w..und  infection.     Tliev  were  :'.:!  in  number.     In  •,'.-)  of  these 
mono-iiifcctions,   in   S   mixed   infections   existed.      The   prevailing   micro- 
,,,-aiiism  was  tlie  staiilivlococcns  aureus,  which  was  present  alone  m  Iv 
and  conil)ined   in  'i  cases.      Tlie  streptococcus  occurred  5   times  uneom- 
hined  and  4  times  combined.     The  bacillus  coli  was  found  5  times  m  all, 
hcin.^  nnassociated  in  :5   cases.     Other  organisms  found  were  the  miero- 
.•occus  lanceolatus,  sta].hvlococcus  allms.  bacillus  pyocyaneus,  and  a-rogenes 
.apsulatus.    The  remaining  bi\  cases,  forming  the  third  class,  were  instances 
of  intestinal  infection.     These  comprised  •.>:!  mono-  and  3:5  polyinlections. 
The  i.redominating  micro-organism  was  the  bacillus  coli  communis  which 
<Hcurred  in  -!:]  ca«cs.  8  times  alone  and  ao  in  association.     The  strepto- 
COC.-US  was  present  in  37  cases,  being  alone  in  7.     The  staphylococci,  ]meu- 
nioroccus.  bacillus  iiroteus,  i)y.)cyaneus,  typhosus,  and  aerogenes  cai)sulatus 
occurred  in  a  smaller  nnml)er  of  instances. 

\nion-  tiie  micro-organisms  thus  far  found  rarely  in  peritonitis,  may 
1,,.  mentioned  the  gonococcus,  the  anthrax  1,acillus,  the  proteus  bacillus, 
and  the  tvphoid  bacillus.  .\s  illustrating  the  imi.ortance  of  the  gonococ- 
eu<  I  mav  state  tliat  as  1  write  there  are  two  young  girls  both  of  whom 
were  a.linitted  to  niv  wards  with  dilfusc  iieritonitis  arising  from  fresh 
..onorrlueal  salpingitis.  I'.oth  w,.re  operated  upon  by  Cushing  success- 
fully. Welch  has  found  the  bacillus  coli  communis  in  peritonitis  due  to 
nlcrraiion  of  the  intestines  without  perforation.  _ 

Symptoms.— In  the  perforative  and  septic  cases  the  onset  is  marked 
bv  chilly  feeliniis  or  an  actual  rigor  with  intense  iiain  in  the  abdomen.  In 
tvi.hoid'  fever, 'wlien  the  seiisorium  is  benumbed,  tiie  onset  may  not  be 
noticed.  Tlu>  pain  is  general,  and  is  usually  intense  and  aggravated  by 
movements  and  pressure.  A  position  is  taken  wliich  relieves  the  tension 
of  the  abdominal  mnscles.  so  that  the  patient  lies  on  the  back  with  the 
thi-hs  drawn  np  and  the  shonlders  elevated.  The  greatest  pain  is  usually 
below  the  nmbilicns.  bnt  in  peritonitis  from  perforation  of  the  stomach 
pain  mav  be  referred  to  the  back,  the  chest,  or  the  shoulder.    The  respira- 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


508 

'  , '  tho  in.,  reason  the  action  ol  cou.lun,  .s  n.>,raUH.,l.  an.l  .nth. 

,  vc.monts  nci-ossarv  for  talking-  are  linut...l.  In  tins  early  .ta.ue  the  m'u  ,- 
^^  n>av  he  ,reat  and  tlu^  ahdununal  nm.ele.  are  olten  n^nl  y  eon- 
;      :i      If-the  ilatient  ..  a,  perleet  r..st  the  ,.a,n  n.ay  he  very  sh,ht    a   . 

;;;::,l^are  >nstanee.  n.  whieh  U  ■>  not  at  all  nunke.l.  an.l  n.ay.  .n-iee.!.  W 

"''"rh;.  •.h.hmu.n  ..■a.lnallv  he.-..n...  .Iist..n.le.l  an.l  tens.,  an.l  is  tynMunitu. 

on  ilr  >      on     Tl^.  pnlse-is  ra,.,.l.  .n,all,  an.l  har.l.  an.l  .....n  has  a  i^enhar 

r    .      h  V      It  ranU  In.n,  IK.  t.,  i:.n.    Th..  t...n,u.ra.ur..  n,ay  n...  rapul- 

TheCt.e ;;  ;;;:;v:]ntn;:^  ni^ 

!    ;.:X,;:;  hs^ure...     Vonnt.n.  i.  an  early  an..  1'---- ^  ^  -j;;: 
,..„,<..<  ..reat  pain.     The  eontents  of  the  slonia.h  are  li^t  ...le.tul.  tn.  n 
;   .  wW    a  I     hUe-staine.1   llni.l.  an.l   linally  a   ^reen.sh  an,l.  in   nnv   u.- 
H.     a      ownish-hlaek  1>mu,.1  .uh  sU.ht   ta..al  ...h.r.     Th..  h..w..ls  n,a> 
^  h    ::    to  onset  an.l  tlJn  cons,M.a.,..n  nuy  iolL-w.     I  re,ju..nt  nuetnr - 
;ln  Uv  he  present,  le.s  ..ften  retentum.     The  nr.n..  .  nsnally  seant>  an.l 
hi..l>-eolore.l.  an.l  contains  a  lar-e  (piantity  ol  nuliean. 

^The  appearance  of  the  ].atient  uhen  these  syn.pf.n.s  hav..  iul  >  1..  1- 
.,,„.  ■:  verl  eharaeterist,e.  The  faee  is  pinelu.d.  the  eyes  -^  ■-';:;  -^ 
the  ox„res;i.>n  is  verv  anxions.  The  e..nstant  v..nut.n,u  of  ih ml^  cuu-c.  a 
w^ted  ppearanee,  an.l  th-^  han.ls  son.etin.es  present  the  -asher-vs-ma  . 
!l^n  kI  eiH  in  eh..lera.  we  see  the  Ilipi-.H.ratie  iae.es  nK.re  tre.j  entl> 
in     his  t^un    in  anv  other  diseas..-"  .  slun-p  ,r.r.  h.lhur  e,,..  rollop.nl 

ti      tChlai  lirid.  or  kad.oUnrdr     There  are  .,ne  ..  tw..  a.hl    ...na 
ZL  ahont  the  ahdon.en.    The  tyn.pnny  is  nsnally  excessive,  own,,  t.)  the 
a-      'relaxation  of  the  walls  .d'  the  intestin...  hy  inllanunat.M,  an.    exnda- 
^    The    picnic  .lulness  n.ay  h.>  <.hlit..rated.  the  diaphra.n,  pushed  np 
an    "the  apel  heat  of  t.he  heart  disl...ate.l  t..  the  l.u.rth   ,nt..rspa...>.      1  h 
U ver     nlnL  n.av  he  jrreatlv  trduech  or  n.ay.  in  the  n.anunary  line.  h.. 
ohi  en  'r    It  has  hJ^n  ehiin.e.l  that  this  is  a  distin.tive  leat.ne  ol   pe,- 
W"  peritonitis,  hut  on  sevc^al  .u-casions  1   have  he..n  ahle  to  den..n- 
tnt  .  th  t  the  liver  dnlncs,s  in  the  n.i.ldle  an.l  n.an.n.ary  hno  was  ohht  r- 
nW  hv  tv„  panit..s  alone.     In  the  axilla,-y  line,  on  th.>  other  hand,    he 
tr  *1^.1ness    th,u„h  din.inished.  n.ay   persist.     Pn..u,....-Per.t.u,aMnn     o  - 
ow  nc.  perforati..n  it.oro  certainly  ..hlit...'ates  the  hepatic  .Inlness.     1,.  sn.- 
^  "th^lluid  effused  produces  a  d.,ln..ss  in  the  lateral  t..jon     h,,    w 
..,«  in  the  perit..na.un,.  if  the  ,v,,tient  is  t.,rn..d  ..n  the  lett  Md...  a  .  h  ..r 
not..  Is  h^,^  honeath  the  sevc.th  and  ..i.h.h  ril  .     Acute  per.ton.fs  n..y 
i.re-^ent  a  flat,  ri'dd  ahd..ni..n  thi'ou,Ld.out  its  oui'se. 

'      m,  i  "t    oi   fluid-ascit..-is    usually    present    except    ,u    son.e    an,  e 

r..,,id  V  fatal  cases.     The  flanks  a,v  -lull  ....  percss.o,.      The  duhu.ss  may 

;' nLd^,  tl'nn.h  this  d..pen.ls  al,..,v.her  up.vn  the  decree  of  adhes.ons^ 

The  OB.  V  he  considerahle  etfusion   with.mt   either  n...vahle  dnlness  or 


ACLTE   (JKNEIIAL   PEUlToNlTIS. 


bW 


•('11  llic 
f  sciisi- 
ly  con- 
lit,  iiiiil 
k'fd. 


inaiHlif 


tluctuiitidii.     A  l'rii-ti(iii-nil)  umy  lie  |ir(-.-cnt.  ;i.-  lii^t  iioimcil  mil  liy  lliiyiit, 
1)111  it  is  iiui  Hourly  so  coiimioii  in  tirutf  a.-  in  i-hroiiic  |K'rilonilis. 

Course.— 'riiJ  iitulc  dill'iu-L'  peritonitis  usually  tuniiiiiates  in  death. 
The  iiio.i  inleiisu  I'urins  may  kill  williiu  thirly-aix  lo  iorly-eighl  hours; 
iiioii'  coinnioiily  dcalii  n■^ults  in  I'oiir  or  livu  days,  or  tlio  lUtatk  may  lie 
|ir()|on-vd  to  ciuiit  or  ten  days.  'VUr  pulse  lieeoiiies  irre;^nlar.  the  heart- 
;.,,un(l.-^\veak.  tlie  hreathin'r  ^llallo\\  :  there  are  lividity  with  jiallor.  a  eoid 
>kin  with  hij:h  rectal  temperatun — a  .uroiip  of  symptoms  indieatin.u-  pro- 
Iniiiid  hiilure  of  the  vital  I'mietions  for  which  (iee  ha-  revived  the  old  term 
Uliiilln/iiiiii.  Occasionally  death  occurs  with  -real  >iiddenne->.  owin-:  po- 
sihly.  to  ]iaralysis  id'  the  heart. 

Diagnosis. —  In  typical  ca^es  the  scvei\'  pain  at  onset,  the  di>tention 
(.1'  the  abdomen,  the  "tenderness,  tho  lever,  the  -gradual  development  of 
c'Ifusioii,  collapse  symptoms,  and  the  vomit in>:-  j;ive  a  characteristic  picture. 
I'arefiil  iiupiiries  should  at  once  he  made  concern Iii.l;-  the  previous  coudi- 
tioii.  from  which  a  clew  can  often  lie  had  as  to  the  >tartin,-r-point  of  tin' 
tnud.le.  in  younu-  adults  a  eonsideralde  proportion  .d'  all  cases  depi'iids 
upon  perlorating-  a|ipendicitis,  and  there  may  he  an  account  of  previous 
attacks  of  pain  in  the  iliac  re<iion,  or  of  constipation  alternatin.u;  with  diar- 
iluea.  Ill  women  the  most  l're(iuent  causes  are  suppurative  processes  in 
the  pelvic  viscera,  as.«ociated  with  salpin.uilis,  ahscessos  in  the  broad  liga- 
ments, or  acute  puerperal  infection.  IVrfoiatioii  of  <;astric'  ulcer  is  a  more 
common  I'actor  in  women  than  in  men.  It  is  not  always  easy  to  determine 
the  cause,  ^laiiy  eases  come  under  ohsi'rvatioii  for  the  lirst  time  with  the 
ahilomen  distcmieil  and  tender,  and  it  is  impos>ible  to  make  a  satisfactory 
cxainiiiation.  In  such  instances  the  iielvie  organs  should  l)0  examined 
with  the  greatest  care.  In  tyjihoid  fever,  if  the  |mtient  is  conscious,  the 
sudden  on>et  of  ])aiii,  the  develoinnent  (d'  great  meteori^m.  and  the  aggra- 
vati(m  of  the  general  symptoms  indicate  clearly  what  has  happened.  When 
the  patient  is  in  deep  coma,  on  the  other  hand,  the  perforation  may  be 
overlooked.  The  following  conditions  are  nio^t  apt  to  be  mistaken  for 
acute  peritonitis: 

(d)  Anilc  Eiitcro-colilis. — Hero  tho  ]mu  and  distention  and  tho  s.'U- 
sitiveness  on  ]iressure  may  ho  marked.  The  ].ain  is  more  colicky  in  char- 
acter, tho  diarrluoa  is  nioro  frocpiont,  and  the  collapse  is  more  extreme. 

ill)  The  So-r(ilk<l  Ihisleriatl  iVri7f>/n7(',s.— This  has  deceived  tho  very 
elect,  as  almost  everv  featnro  of  genuine  jioritonitis,  even  the  eollaitse.  may 
he  simulated.  The  onset  may  ho  sudden,  with  .severe  pain  in  the  alidomeii, 
tenderness,  vomiting,  diarrhiea,  diniculty  in  micturition,  and  the  eharac- 
toristie  docuhitus.  ilven  the  temperaLure  may  he  elevated.  Tlieiv  may  \w 
reeurrence  of  the  attack.  A  case  has  heeii  reported  hy  Uristowo  in  which 
f.uir  attacks  occurred  within  a  year,  and  it  was  not  until  special  hysterical 
symptoms  developed  that  the  true  nature  of  the  troiihle  was  suspected. 

{(■)  OhMrurtii'H  of  flic  bowel  as  already  mentioned,  may  simnlato  i>cri- 
tnnitis,  hoth  having  pain,  vomiting.  tymi)anites.  and  constipation  in  com- 
mon. It  may  for  a  couple  of  days  really  he  impossihle  to  make  a  diagnosis 
in  the  absence  of  a  satisfactory  history. 

(,7)    Biipfiire  of  an  ahdominal  aneurism   or  emholi^m   of  the  svprrmr 


GOO 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 

^iiiiulato  ]uTit(initis 


ll!   tlio 


latter, 


av  cause  sviniitoins  wim 

mill,  the  collapse  symptoms 
alxlomcii  mav  be  jirosciit. 

fact  that  acute  luemorrhagie  pan 

taken 


nirxcnlcric  arlvry  m 

-uddeii  onset  with   severe 
Yomit'inji,  and  great  distention  of  tlie 

.j;liAr^,:S.:;:-^.'"-"^^-'-''- -"""'- 

iiulic-y  iiiuy  iTsi'iulilf  iHUlo  l.i'rit..i"lis. 


II.   PERITONITIS   IN   INFANTS. 

lVrit„„i.i.  ...ny  ...-,•.„■  h,  the  ra.t>«  ».  .  .,.,«oquc,K.o  ot  .yl.hili.,  ».«1 

1,.;' ,,i.,„  ..r  .1.0  ....1...,.™.  -ii.i.'  ^«';;  '-^r  i  T  "™.* .  ' .  : ;;:;;! 
^v:,r::;.',r;,.i.!i..!  n,  ";.,;;;:i;.,;,^....."  A..^.io  .....^  .1.0  ro..,„„r.e,n 

wound  of  which  he  died. 


III.    LOCALIZED    PERITONITIS. 

1.  Subphrenic  Peritonitis.-The  general  peritona.nm  ^'"^""^  /^J^  j;^^ 
and  left  lobes  of  the  liver  may  be  involved  in  an  extension  troin  tli  pie  ra 
"  !urative,  tuberculous,  or  cancerous  processes  In  v---  al^ecf  - 
of  the  liver-cancer,  abscess,  hydatid  disease,  and  m  allections  ot  the 
'  11-  laddei-the  inilamniation  may  be  localized  to  the  peritonannn  co^er- 
; !!  he  H-r  surface  of  the  organ.  These  forms  of  I'-f'-'^^-  ll''";;!- 
^itoniti  n  the  greater  sac  are  not  so  important  m  reality  as  those  wl  h 
o  r  i  the  lesscrr  peritonanim.  The  anatomical  relations  of  his  struc- 
t  m    a  e  as  follows:    It  lies  behind  and  l>elow  the  stomach,  the  gastro- 

ate  omentum,  and  the  anterior  layer  of  the  great   --^"t;'- 

lower  limit  forms  the  upper  laver  of  the  transverse  meso-colon.     (  n  either 

^d     u"    ches  from  till  liepaiic  to  the  splenic  ilexui-e  of  t^he  co  oil,  and 

f  o  n    he  f.>ramen  of  Winslow  to  the  hilus  of  the  spleen.     Behind  it  cov- 

r      n     i^    i-^btlv  adherent  to  the  front  of  the  pa  -reas.     Its  upper  Inn, 

f:  ed  bv^the  transverse  fissure  of  the  liver,  and  y  t'-^t  por  ion  o  t^^ 
diaphragm  which  is  covered  by  the  bwer  layer  of  ^^^  ";!'*  ^J^  ^^ 
nient  of  the  liver;  the  lobus  Spigelii  lies  bare  in  the  caMtj.     The  foiamen 


LOCALIZED   I'EKITUNITIS. 


601 


ll!    tllC 

f'w  pan- 
al  lii'c^'- 


iliS 


and 


K'd  cord, 
•ord,  and 
flit,  and 
cord  and 

tliose  al'- 
nitis  I'lil- 
y  at  this 
)y  dilV\iso 
iaphra^iiu 
occnrrinji; 
to  SL'wor- 
nd  at  the 
it-niortera 


t  the  right 
the  pleura 
atl'ections 
)ns   (if   the 
Mim  eover- 
siihphrcnic 
hose  whieh 
this  stnic- 
the  gastro- 
itnni.       Its 
On  eitlier 
fcdon,  and 
lind  it  cov- 
njiper  limit 
rtion  of  the 
lateral  liga- 
'he  foramen 


of  Winslow,  through  whieh  the  lesser  eoiuniunicates  with  the  greater  pen- 
Idiueum.  is  readilv  closed  liv  inllammation. 

Inllaunnatorv' processes,  exudates,  an.l  lueniorrhages  may  he  conlmed 
(■mirely  to  the  I'esser  ].eritona'uni.  The  exudate  of  tul.ereulous  luTitonitis 
,nav  he  cr.nlined  to  it.  IVrforatious  of  certain  parts  of  the  stomach,  of 
tlu"<luo(leiium.  and  of  the  colon  may  excite  inllammation  m  it  ah.ue;  and 
in  various  atVections  ..f  the  pancreas,  i.articularly  trauma  and  iueuiorrliage, 
the  cirusion  into  the  sac  has  often  lieen  confounded  with  cyst  of  tins  organ. 
••  I'atliological  distention  of  the  lesser  iieritomcum  gives  rise  to  a  tumor 
in  tiic  IcfHivpochondriae.  epigastric,  and  umhiiical  regions  of  a  somewhat 
cliaracteristic  siiape.  hut  whicii  apj.ears  to  vary  from  time  to  time  m  torm 
iind  size,  according  to  the  c(.nditions  of  the  overlying  stomach:  lor  wiieu 
tlic  visciis  is  full  of  liijuid  contents  it  increases  the  area  of  the  tumors 
.hilncss.  while  it  makes  its  outlines  less  delinahle  1)y  ])alpation.  and  if  tho 
stomach  is  distended  with  gas  the  dull  area  hecomes  resonant  and  appareiit- 
Iv  the  tumor  may  disaj.i.ear  altogether.  The  c.lon  always  lies  lielow  the 
tumor  and  never* in  front  of  or  ahovc  it.  as  is  tiie  case  in  kidney  enlarge- 
ment "  (Jordan  Lloyd).  ,    , ,     ,  f      i    i 

Special  mention  must  he  made  of  the  remarkable  form  of  suhphremc 
abscess  containing  air,  which  may  simulate  closely  i.neuiuotliorax.  and 
hence  was  called  hv  l.evden  Pi/o-pncumothorax  siibiihrcnirns.  The  atlectien 
has  been  thorongl'ilv  studied  of  late  years  by  Scheurlen,  :Mason,  :\Ieltzer, 
and  Lee  Dickinson. "  In  \ Vi  out  of  170  recorded  cases  the  cause  was  known. 
In  a  few  instances,  as  in  one  reported  by  :Meltzer,  the  subphrenic  abscess 
seemed  to  have  followed  ].neum<mia.  I'yothorax  is  an  occasional  cause. 
J'.v  far  the  most  fr-'cpient  con<liti<ui  is  gastric  ulcer,  which  occurred  m  80 
of  the  cases.  Duodenal  ulcer  was  the  cause  in  C  per  cent.  Li  about  10 
per  cent  of  the  eases  the  ai-i-cudix  was  the  starting-point  of  the  abscess. 
C'ancer  of  the  stomach  is  an  occasional  cause.  Other  rare  causes  are  trauma 
which  was  present  in  one  of  my  cases,  i.erforation  of  an  hepatic  or  a  renal 
ab-^ce<s   lesions  of  the  s])leen,  aliscess,  and  cysts  of  the  i)ancreas. 

In  a  majority  of  all  the  cases  in  which  the  stomach  or  duodenum  is  per- 
f„,ated-sometiiues,  indeed,  in  the  cases  following  trauma,  as  m  (  asc  3 
of  mv  series— the  abscess  contains  air. 

The  «vmptoins  of  subphrenic  abscess  vary  very  considerably,  depending 
a  .u.od  deal  ui.on  the  primary  cause.  The  onset,  as  a  rule,  is  abrupt,  par- 
tirularlv  when  due  to  i.erforation  of  a  gastric  ul  r.  There  are  severe 
niin  vomitin>',  often  of  bilious  or  of  bloody  material;  respiration  is  ein- 
1,,rra-ed  owing  to  the  involvement  of  the  diaidiragm;  then  the  constitu- 
tional svmi.toms  develo].  associated  with  suppuration,  chills,  irregular 
fever,  and  emaciation.  Subse.iuently  perforation  may  take  place  into  tiio 
yileura  or  into  the  lung,  with   severe  cough   and  abundant  i-urnlent  ex- 

iiectoration.  .      „      ,    ,        •      i 

The  conditions  are  so  obscure  that  the  diagnosis  of  subphrenic  abscess 
i*  not  often  made.  The  perihepatic  abscess  beneath  the  arch  of  the  dia- 
phragm, whether  to  the  right  or  left  of  the  suspensory  ligament,  when  it 
does  not  contain  air.  is  almost  invariably  mistaken  for  empyema.  _  \\hen  a 
pus  collection  of  any  size  is  in  the  lesser  peritonaeum,  the  tumor  is  formed 


r.(i-2 


I.ISF.ASES  OF   THE   DIOKSTIVE  SYSTEM. 

characters  al.va.ly  n.rntiourd  in  a  'i'" 


uuiti'm  I'roin  Mr.  .T"V- 


wliiili  ha-  tilt 

tlu.  ah..s.  .avUy  .nntan.s  a.r.  J^^-^^\^X.W  nf  the  l.ver,  th-  .l,a- 

is  ,u  the  greater  V'-'-'^^'-        ',;';[;  !seeon,l  o.  thinl  rH.,  and  the 

,,l,n,-.n  mav  hv  pushe.l  up  to  the  1'^'       ';  j   ^^^,  „,•  j,„,u,nuthurax. 

,,vsieal  ..ns  nn  ,.ereu.»on  -''    ;'-;  ^^     !  ^  ,      ,  .luluL.     The  hvev 

is  uMiallv  -leatlv  .lepre»e.l  ''"'/"";  ,,i„,,.ses  .lue  to  perloratmn 
,„..,,  .,,,;,.uve  are  the  ...es  '^'''••;;        '  '    f.  *       s' eontaine.l  in  the  h.ser 

I""'"'"""'"''''    "",  ""'■  /       :.,.t,Me   Hirer  the  elVu>ion   lie.  hetween   iho 

''^'':n.p,.o.no.i.in.hphre.i....s<...^ 

on  reeonl  ahout  --'n  per  eent  only    nne  ''"'■.  ,,„,,tion. 

ve  eo,.e  .n.ler  n.y  ohsorvat.on.  three  m.n  m  d    Uc    •  ,  ^^^^^^^   ^^^   ^^^^  ^^^_^^  , 

,.  AppendiCuUr.-'lhe  ";-\,  -J  ,     ",  ..'^..nnis.     The   Mtnat.on 

peritoniti.  i.  inthnnmatun  f .  ^'^'  J  ;'\.^,,,,,,i..  ..r.an.  The  adhes.on, 
laries  with  the  pos>t,on  ot  tins  ;'  -'  ;  ;\,.,,  ,],  ,ithin  the  pelvis, 
l">'-f-'''^'i'">-  '^"'^   i"traper,to„ea    'i'";  ^     "     ;>,  ^.„.  .„,,  j,,  ,he  lower  vij^ht 

-■  t''  the  left  of  the  n,e,han    '-'-^^^.^.r^ituatiot.-.-r.  of  course. 

quadrant  of  the  utubdual  re.jo  -^  -^^  "^  ;\,^  „,„,,  ,,„,,,,,  .i,„ation 

--^  ^'-'r'^'r^';-  "\^';;:,::;     u  ^^  1--  -usele.  bounde,l  by  the  ea.<-un. 
,lu.  loeah/.e.l  al.see>.  lie>  upon  me  .^^  „,csentory  lu 

,i„ij..ril,v  ..t  tlio  onso».      Ihc  niiii"> ..(„„litiMi  of  tliiil<rni",i;-  "t 

„,„  ,,„,,s.  in  .Imh  tl.o  ,„.l.v«l>.»l  ".■?«"^  ••';"',.    ,„„i  „,„,  „,„v  he 
,„,„.l  »r.  ,lil».o.l  nnJ  WW  »'tl>  ',';;;■';:;;'"'!,,       :,1  .'no  ..t  .lu-*.  nn,y 

as  in  tuberculosis  of  those  parts. 


IV.    CHRONIC    PERITONITIS. 


■  .•     ,„nv  be  rocvniized:  {a)  Local  adhesive  perito- 

Tl,o  folloNvin?  varu'tu^s  may   be     oco_    /        \^J      ,^    ^^^^^^  ^|,,  ,,,ieeiv 


the  ciisc-* 
SOS  \v!i it'll 

locali/.fil 

siuiatitiii 

ailhi'sidn. 

the  jii'lvis, 

Liwcr  vi^lit 

,  of  c-mirsi', 

11  situation 

tlio  ca'ciun 

cscntL'VV  in 

is  perfect, 

plaee  with 

iition  al)i)ut 
vvlKea.  anil 
:-lioint   in  a 
sely  matted 
liekenin;:'  I'f 
izal)le.     The 
iiere  may  l>e 
if  these  may 
)V  extension, 


tiesive  perito- 

nt  the  P]ileen^. 
)Out  the  liver, 


I 


rniiONlC    PHUITONITIS. 


603 


los.  freMnenllv  al.unt  the  intestines  and  -.esentery.       'onUs  uf    1'     -"'^ 
:  p,Kk  nn,-  un  the  peritunaunn  neeur  scnetunes  w,th  unu.n  nl  llie  eu;U   . 
•  i;,,.   lilnUshan.li      In  a  n,a,junty  uf  .ueh  ea.es  the  enudn....   »  m. 

,„,,i.,.,„„|lv  ,„.,  UH.rtu,..     Two  sets  of  .yn.l-to.ns  n.ay    however,  he  ea u>ed 

;  ,1,,..,  adles.uns.     When  a   lihrous  hand  is  attached   m  sueh  a  w  >    a> 

n    H.  a  loo,,  or  .,KUv.  a  eu,l  of  ,nte.t>ne  may  ,.a>s  thron;.h  ,..      Ihu. 

!:  ;;,;■.,,:,  .Js  of  ,nt...t,nal  ol^tmction  analyzed  hy  ht/.  0:5  were  due  to 
,l,i.  cau^e.  The  second  irrou,,  ,s  h'.s  senou<  and  (on.prises  eases  with  pcr- 
Mstcn.  ahdonnnal  pain  of  a  colicky  character,  sonietunes  rendenn,  h le  nu^ 
„,,l,|c..     instances  of  this   kmd    have  hecn   >ucce.>lully   operated   upon   hv 

Ijoinans  and  H.  A.  Kelly.  . 

(/,)  Diffuse  Adhesive  Peritonitis.-Thi.  is  a  c.mse.inenee  .d  an  mute  u- 
„,„i„„tion.  either  sin.ple  or  tuhenuhms.  The  pcritona;u.,i  is  ohliteratcl. 
,,„  ,„ttin-:  throned,  the  ah-hmunal  wall,  the  coils  of  intestn.es  are  utu- 
,„,,„lv  ,„atted  to,s.ether  and  can  neither  he  separated  Irom  each  other  nor 
,an  the  visceral  an.l  parietal  layers  l>e  .listin-u.shed.  I  here  may  he  tluek- 
,,ning  of  the  layers,  ami  the  liver  and  spleen  are  usually  mvolve.l   m  the 

'*  "(r)"prolif9rative  PeritonitiS.-Apart    from   cancer  and    tuh..rcle.   which 
,„,,.lu.-e  tvpical  lesions  oi  chronic  peritonitis,  the  n.ost  eharactenstic  lorn. 
I  that   winch  mav  he  .hscrihed  nnder  this   hea.lin,:^.      1  he  essential   a.n,- 
to.mcal  r..ature  is  -reat  thickening  of  the  peritonea    layers,  nsudly  without 
lunch  adhesion.     The  cases  are  sometimes  seen  w>th  sclerosis  ot  the  stom- 
,,1,      In  one  instance  1  found  it  in  connection  with  a  sclerotic  condition 
i,r  the  eu'cnm  and  the  lir^t  ,,art  of  the  col.m.     In  the  inspection  ot  a  ease 
of  this  kind  there  i.  usually  moderate  elVusi.,n.  m.nv  rarely  extensive  ascies 
The  peritona.nm  is  opaqne-white  in  color,  and  evei^where  tucla.ned    o    en 
;„  „,tclKs      The  ..nientum  is  usually  rolled  and  tonus  a  thickened  ma.^ 
,  ,:;^.ersel"v  phurd  hetwcen  the  stomach  and  the  colon.     'Ihe  pentmiannn 
,v..r  the  stomach,  intestines,  ami  mesentery  is  sometimes  greatly  thickened 
^n,,  liver  and  spleen  mav  simply  he  a.lherent.  or  there  ,s  a  condition  ot 
',;„       perihepatitis  or  ,,erisplenitis,  so  that  a  layer  of  i^n.  almos    gr.   y 
,,„.,„,ti;,,  tissue  of  from  one  fourth  to  half  an  inch  in  thickness  enc.ic  e. 
tlH..e  .r<nu<       Tsuallv  the  volume  of  the  liver  is  in  c.msequence  greatlv 
,,„,uced.'"    The  gastrolhepatic   omentum    may   he  '■""^^'•",^'"\''>; ,!,  j'^   'i;."' 
,.,,,„ th  and  the  calihre  of  the  portal  vein  much  narrowe.l      A  >eu)u.  .11   - 
Mon  mav  he  present.     On  accmnt  of  the  adhesions  winch  torm.  the  pe    - 
,,„„„„;  ,„av'he  divided  into  three  or  four  different  sacs.  -';;"--> 
descrihed  under  the  tuhercuhms  peritonitis.      In  these  cases    lie  n.totUH, 
e"  nallv  free,  though  the  nu.entery  is  greatly  shortem^d.    Ihere  are  m- 
ances  of  chronic  peritonitis  in  which  the  mesentery  ,s  so  shortened  hv 
,1 -s  ;voliferative  chan.e  that  the  intestines  fonn  a  hall  no    liyger    han  a 
,„,„  -„ut  situated  in  the  middle  line,  and  alter  the  removal  <;    ^h      ^        " 
ti.„  ,,„  ,„  felt  as.a  solid  tumor.     The  i"'''^'-!. -'  .'J  .^'jf  ^.^  ^     ;  ^ 
,„1  the  mucous  memhrane  of  the  ileum  .^thrown  m  o  hdds  like     -    '^^  ^ 
,.,„„iventes.     This  pndiferative  peritonitis  ,s  lound  IreMUentlv   in  th.     uh 
jects  of  chronic  alcoludism.     In  cases  of  lon.-continued  ascites    '"■  -  '  '^ 
surfaces  generallv  heeome  thickened  and   present  an  opa.p.e.  dead-N\lute 


DISEASES  OK  THE   DKlESTIVR  SYSTEM. 


004 

""Tr;,;'i=  ri't:ri^?"-i:': «... >  ...■  <•»  - >  -  '"•' 

terin  |.lat«,  «l,i,.l,  »■■".  .u,,  aino^^  ».tl. n.  ""-;,,   ,,,t,„i,„„   i„    ,|,„ 

,„,Bt  conmumly  m  tlu'  pfh.-.     '';>;';,     „„,,,,  ,,,,„„  .l.kl,  l.»'U...i- 

munly  circumseribed. 

V.    NEW   GROWTHS    IN    THE    PERITONAEUM. 

'  ,„)  Tuberculous  Peritoums.-'n,.  ik,s  ai,.™iy  j-^™;;*;';:';:,  ,i„.„e 

.„„a.„m   .o„K..i„.c.  s,„al  Ian.   n.  ™.  j- 

withpufkeml  centres,     iho  diM.i.c  i  ic  i  .  _   ;,,   ^i,berculou.< 

aeh  cir  the  ovaries.     Tl,e  <.mentjuu  is  -.lur  U  1  <  j   /^^  ^^      ,,,., 

:xrtr;:  ~s;:*;;: -r. - - - 


t  attondrf 


V  m 


I  ho 


s  mimcr- 
L'lu'V  may 
iiuly  'litli- 
iiiiio  tlu'ir 

willi  tli'^- 
is.    It  has 

luihmI  l)y 

wdulil,  as 
apaii,  lias 
site.      Olio 

as  rluik's- 

uk'S. 

IIS  in  tlie 
se.  Tliure 
paihyiuon- 
s  l()cali'/A'(l 
e  form  on 
L'h  liii'inor- 
rnuUion  of 
moix'  coiu- 


VI. 

re.l. 

•y  to  disease 
r  have  heeu 
I'  tlie  serous 
ihiry  mali^'- 
It  is  usually 

entire  peri- 
11(1  noilular, 
111  the  slom- 

tuhereulous 
pjjer  portion 

is  extrenuiy 
(OS,  whieh  in 
aiie  siiveads, 
n  the  lympli 

of  ojiposing 
id  more  eoiu- 

history  of  a 


ASCITES. 


♦lOf) 


local  niali^Miant  disease;  as  when  it  oeeiirs  with  ovarian  tumor  or  with 
earner  uf  the  pylorus,  in  eases  in  whieh  there  is  no  evidenee  of  a  primary 
legion  the  dia^^nosis  may  he  doui)tful.  The  elinieal  picture  is  usually  that 
of  chronic  ascites  with  progressive  emaciation.  There  may  he  no  fever. 
If  there  is  much  elVusiou  nothinjj:  deliiiite  can  he  felt  on  examination.  After 
tapping,  irregular  nodules  or  the  curled  omentum  may  he  felt  lying  trans- 
versely across  the  upper  |)()rtioii  of  the  alidomcii.  rnfortunately,  this  tumor 
upon  which  so  much  stress  is  laid  occurs  as  fre(|ueiitly  in  tul)erculous  peri- 
tonitis and  may  he  |ii'cscnt  in  a  typical  manner  in  the  eiironie  |)rolil'erative 
form,  so  that  in  itself  it  has  no  s])ecial  diagnostic  value.  Multiple  iioduh  ■ 
if  large,  indicate  cancel',  particularly  in  [lersoiis  aiiove  middle  life.  Nodu 
lar  tuherculous  peritonitis  is  most  frecpient  in  children.  The  jircsence 
about  the  navel  of  secondary  nodules  and  indurated  masses  is  more  com- 
mon iu  cancer.  Inflammation,  suppuration,  and  the  discharge  of  juis  from 
the  navel  rarely  occurs  exce[it  in  tuherculous  disease.  Considerable  en- 
largement of  the  inguinal  glands  may  be  present  in  cancer.  The  nature 
of  the  fluid  in  cancer  and  in  tubercle  may  lie  much  alike.  It  may  be  luenior- 
rliagie  in  both;  more  often  in  the  latter.  The  histological  examination  in 
cancer  may  show  large  multinuclear  cells  or  grouiis  of  cells — the  sprouting 
cell-groups  of  Foulis — which  are  extremely  suggestive.  The  colloid  cancer 
may  jiroduce  a  totally  diil'erent  ])icture:  instead  of  ascitic  fluid,  the  abdo- 
men is  occupied  by  the  semi-solid  gelatinous  substance,  and  is  lirm,  not 
Huctuating. 

And,  lastly,  there  are  instances  of  echinococci  in  the  peritoiiieum  whieh 
may  simulate  cancer  very  closely.  1  have  re|)orted  a  case  of  this  kind,  in 
which  the  enlarged  liver  and  the  iniuiinerable  nodular  masses  in  the  peri- 
tonieum  naturallv  led  to  this  diagnosis. 


VI.    ASCITES  (Ilydro-peritonaum). 

Definition. — The  accumulation  of  serous  iluid  in  the  jieritoneal  cavity. 

Etiology. — ( 1 )  Local  Causes. — {a)  Chronic  intlammation  of  the  peri- 
toiKvum,  either  simi)le.  cancerous,  or  tuberculous.  (I))  I'ortal  obstruction  in 
the  terminal  branches  within  the  liver,  as  in  cirrhosis  and  chronic  passive 
congestion,  or  by  compression  of  the  vein  in  the  gastro-hepatie  omentum, 
either  by  jirolil'erative  ])eritonitis,  by  new  growths,  or  by  aneurism,  (c) 
Tumors  of  the  abdomen.  The  solid  growths  of  the  ovaries  may  cause  con- 
siderable ascites,  which  may  completely  mask  the  true  condition.  The  en- 
larged s]ileen  in  leuk:eniia,  less  commonly  in  malaria,  may  be  associated 
with  recurring  ascites. 

(•I)  General  Causes.— The  ascites  is  \m-i  of  a  general  dropsy,  the  result 
of  mechanical  etl'ects,  as  in  heart-disease,  chronic  emphysema,  and  sclerosis 
of  the  lung.  In  cardiac  lesions  the  eifiision  is  sonu'tinies  contined  to  the 
]ieritonanim,  in  which  case  it  is  due  to  seeomhiry  changes  in  the  liver,  or  it 
has  been  suggested  to  be  connected  with  a  failure  of  the  suction  action  of 
this  organ,  by  which  the  ])eritona'uni  is  ke])t  dry.  Ascites  occurs  also  in 
the  dropsy  of  Bright's  disease,  and  iu  hydra'mic  states  of  the  blood. 


OuO 


ItlSKASKS  (.l-  TIIK   DIOKSTIVK  SYSTKM. 


Svinptoms.-A  ^m.lu.l  unilnnu  .Mhn-H.u.ut  of  th.  aMouu.n  ,.  the 

W./..^-A.-.un!>^      tn   ,1...  a.nuUM.    of   llni-l   ti.e  "  'l---'  .'V  ;:, 

II,  J,  „„.,  „,H..,u..l  at  .!...  >i.l....     W.th  lar...  HVus...ns.  tlj.  >km  ■>    ... 

,v  ,..VM.Mt  .1...  liu.a.  allman...s.      lMv.,.u.Mtl.v  t h.  nav.l  n.  I  an.l  t   c 

iJu  „  a,v  v.Tv  ,.n,nniH.nt.     In  ,nany  n,>o>  ,1,.  MMHTtuial  v..^  a.. 

:;;;,',  Hi....!  l.v  ,.,;s>uu.  ....  .1....  v..,ns  ,l.a.   .!u.  .ur.vn,   >.     nm, 

1,;::;:;:,.;;;  u..n..Un......nu.. --•;;-;;';-;:'^;t:: 

pnrial  v m.  tlus.  M.iKTli.ial  alulnumial  v.ss.ls  may  1..  .^Wn.^^.U  van  mm 
lul'ul  .IH.  nav.l  in  'a.,  of  cirrhosis  then-  is  .K.a>,..nally  a  iar,.  l.u.uh  .1 
iti>;t(.iulid  \v\n<   till'  su-calK'il  (iii>ut  Mfdusa'. 

,,„,l',poM  on.,  .id.  of  tlu.  alulo.n.n  and  l.y  ,..v.ng  a  slmr,.  tap  on  th        - 
I    nW  xvtl,  tlu.  otluT  hand,  when  a  wav.  is  felt  to  strda.  a.  a  ddnut. 
k  a.un>t  tlu.  ai.pli.d  tlnpTs.     Kv.n  con.pan.tiv.ly  sntall  <,nant,  u.s  ol 
,      I    ,;;;•   .nv.   tins   Ihutua.ion    shock.     When   the   al.donuna     walls   ar. 
.        u.;-  fat.  an  a.si.tant   n.ay  ,.hue  the  e.lge  of  the  hand  or  a  ineee 
;.f';';;;hoa..d    in   the    font    of    the   ahdon.en.      A   ^'''V^-";,^  •;— I'-;: 
,,1     t,.l  i„  ,„l,,atinj:  for  the  solid  organs  u,  ease  of  aseite..    ^^^^f^^  \^ 
,„Jthe  hand  llat  n,,on  the  ahdon.en.  as  in  the  ordu.ary  ;>';;   ><;;^    ^^^ 
of' the  lin.'ers  onlv  are  ].laeed  lightly  upon  the  skin,  an.lthen  h>  a  .  Rl.ki 
,    I.;^s;:n  of  the-tinge,;  the  Ihud  .  d.splaeed  and  the  -";  ^'^j;  ^    X 
„K  V  he  felt.     I'.v  thi.  method  oi  -  .lii-ping     or  .hsplaeement,  ab  it  is  c.  Ikd. 
thcMver  n.ay  he  felt  helow  the  costal  nu.rgin.  or  the  spleen,  or  sometnne. 
solid  tumors  of  the  ouR'ntnui  or  intestine. 

;,   l'nru..ion.-\n  the  dor.d   position   with   a  moderate  .|uanti>    cd 
ll„i,l  i„  ,1k.  peritoiueum  the  flanks  are  dull,  while  the  umhilieal  a.ul  epi- 


1,1  which  the  intestines  float,  are  lympanitic. 


and 
Thi^ 


art.a 


1  outline.     Having  ohtained  the  lateral 


gastric  regions,  in 

of  clear  resonance  mav  have  an  oval  outline, 
limit  oi  the  .lulness  on  one  side,  if  the  patient  turns  on  the  ..ppos,  e  sule. 
the  lluid  gravitates  to  the  dependent  part  and  the  uppermost  Hank  is 
,..v  tvn,i.UHtie.  In  moderate  ciVusions  this  nio.dile  <1';'--,^  ;^;^-,^  f,; 
Iv  in' the  ditVerei.t  po.tures.  Small  amounts  of  lluid.  l-n-ha  In  und  .  a 
Htre.  wouhl  scarcely  give  movahle  dulness.  as  the  pelvis  and  the  mial  - 
.i„n  hold  a  considerable  quantity.  In  such  cases  it  is  .est  to  place  1 
r.  tieiit  in  the  knee-elhow  l.osition.  when  a  dull  note  will  he  determined  at 
!,;!', „I,st  dependent  porthm.     l^y  careful  attention  to  these  details  nn>- 

fake-  art.  usuallv  avoided.  .  „ 

The  following  are  among  the  couditious  whu-1,  may  he  mistaken  for 
.Iroiwv  Oran.nhnn.r.  in  which  the  sac  develops,  as  a  rule,  unilatera  ly. 
tl^  when  large  it  is  centrally  placed.  The  duhiess  is  -^^enor  and  he 
Induce  is  in  the  Hanks,  itito  which  the  -^.'stines  are  pushed  h,  he  c,M 
Fxamiiiation  /.r  r.nmnnn  mav  give  imi.ortant  iiidicatu.i.s.  In  th..>e  an 
1,.  which  .''is  develoi.s  in  the  cvst  the  diagnosi-^  nia\  he  very  dilh- 
;!;nr  S,;.; „:'::!  li  L.  L.n.^  m  sucH  cases.  .V  ,i.,e„,.l  m^l^r 
,,v  reach  ahove  the  umhilicK.  In  such  instance,  s.une  ririne  drihhle. 
nwav.  and  suspicion  of  ascites  or  a  cyst  is  oceasioually  entertained.     I  once 


II  IS  tlio 
liuclive. 

is   iiru- 

is  \vn>c 

and  till' 
vi'iiis  ai'L' 
iiiu-tinus 

iy  fnnii 

III  (if  till' 
vark'oso. 

lllllull    111' 

rs  (if  diu' 
:i  the  (ip- 

II    (U'lillitC 

ntitii's  (if 
walls  arc 
ir  a  iiii'ii' 
(.'Otliire    is 

(I  of  Jtlill'- 

tlio  pads 

a  siuldi'ii 

ur  tiiiiKir 

;  is  calk'd, 

soim.'tiiiii'b 

lantity  nf 
1  and  ('iii- 
This  area 
tlic  lateral 
i(isil(.'  side. 
t  Hank  is 
i<res  ^M'cat- 
y  under  a 
L'  renal  re- 
I  jilaee  the 
eniiinod  at 
etails  iiiis- 

istakeii  fnr 
nilaterally, 
lor  and  the 
ly  the  cyst, 
tlidM'  rare 
c  vory  difl'i- 
(Icd  hhtihh'r 
ne  drilihles 
ed.     I  once 


ASCiTFS. 


tiUT 


saw  a  tnuliar  llini-^t   into  a  di.teiided  hladder.  uhieli  was  supiiosed  to  In- 
an  -ivarian  ex^t.  and  it   is  >lated  that  dohn   llunler  taliped  a  Madder,  .^up- 
|,„,iiijr   it    tn'   he   ascites.     Such    a    iiii«tal<e   slmnld    he   avoided    hy    eaivtiil 
lalheterizatidh    prinr  tn  any   (i|icrative    proeediii'es.      .\nd    la>lly.   l here  arc 
hiPM'  panerealie  «ir  iivdalid  cysts  in  the  ahddineii  which  may  >ininlate  a^'ites. 
^'Siihnr  of  llir  Asrilir  /••////</.— I'sua I Iv  this  i>  a  clear  serum,  li-hl   yel- 
l,iw  in  the  axites  .if  aiKcnua  and  Uri-ht's  disease,  dftcii  darker  in  cohir  m 
ciirlid>is  (if  the  liver.     The  >iiccitic  -ravity  is  luw.  seldom  more  than  l.oH) 
,„•  l.dl.-),  whereas  in  the  lluid  ..f  (ivarian  cysts  the  specilic  ,i:ravity  is  hi;,di. 
l.o-.'o  or  n\cr.      It   is  alliiunindus  and  ximelimes  cda,i:ulales  spdiitaneou-ly. 
I  luck   ha>  called  attciilidii  td  the  impdriaiice  df  the  study  of  the  cells  in 
ihe  exudate.     In  cancer  very  chaiaetcristic  fdrms.  with  nuclear  lii;ures.  may 
l,e   fduiid.      lla'iiidrrha-ic  elVii-idii    ii>iially   dcciirs   in   cancer  and    liilicivu- 
Inri^.   and    dcca>idnally    in   cirrhdH^.      1    have   already    referred    td   the   in- 
Manees  df  lui'iiidrrha-ie  clfusidii   in  cdnnecti.in   with   ruptured   luhal   prci:- 
iiaiicy.     A  clivldii>.  milky  exudate  is  dccasidiially   fniiiid.      I'.iisey   has  cul- 
Ircieil  :'i;l  cases  fi'diii  the  literature,     'riiere  are.  as  (.tuiiickc  has  pointed  diil. 
two  distinct  varieties,  a   hitty  and  a  chyldus.  which  may  he  di^lillglli^hed 
hy  the  micrdscoiie.  as  in  the  fdruier  there  are  ilL-liiict   rat--ldhiile-.     'I'li-'sc 
cast's  have  hecii  ximetiincs  Cdiinected  with  peritdiical  (ir  moeiiteric  cancer. 
Ill  the  true  clivldii>  ascites  the  tluid  is  turhid  and  milky.      In  sdinc  of  the 
cases,  as  in    Whitl.-rs.  a   perfdration  of  the  thoracic  duel    has  hecn    loiind. 
The  (■diidilion  ddcs  iidt  necc^sirily  fdlhiw  ohjitcratidii  of  the  thoracic  duct. 
Mild  v:v:uh-~  of  chylous  ascite-.  which  are  dcca>idiially  found  clinically,  may 
he  due  td   the   la'ct   that    the   patient    upon   a   milk   did    has  a    pcriiiaiiciit 
lipa-mia.  >iich  as  is  pre-eiit  in  youuL;-  aiiimaU  and  in  diahctics.  in  wimm  the 
ri,|Uor  sni-iiini>  is  alwav>   fatty,      ruder  such   ciicum>tan(,-cs  an   exudate 
uiay  contain  eiioii-h  of  the  molecular  lia>e  of  the  chyle  to  pniduce  turhi(]- 
iiv'df  the   lluid.     Some  of  the  ca.-es  have  heeii   associated    with    lilaria>is. 
I„  ,,   recent  ca.e  in   my  clinie  X.  .McL.   Ilarii>  iMilated   the  llaclllu^  diph- 
theria' from  the  chvldus  lluid.  . 
Treatment   of    the    Previous    Conditions.— (")    Acute    Fen- 
tonitis.— Kest  is  cnjdined  uiidU  the  patient   hy  the  severe  pain  which  fol- 
low-^ the  s1i<--htest  iiiovemciit.  and   he  -hould   lie  iiropiicd   in  the   iidsilidii 
which  oiveshiin  on,itcst  relief.      For  the  pain  morphia  should  he  injected 
hvpodmiiicallv  in   full  doses,      in  an  adult  it  is  hettcr  to  give  a  third  or 
hiilf  a   "-rain   at    oiicc.  and   suhM'.pieiitly  at   intervals  repeat   it  m   smaller 
doM.<     when    nccc>sarv.      The    action    of    the    drui:-    should    he    carefully 
watched  and  the  iiati('nt  should  not  he  alhiwed  td  Jiass  into  such  a  de.unx'c 
of  nncdnseidusness  that  he  caniidt   he  amused.     The  respiration  and   tli.^ 
condition   of  the  iiupils  also   -ive  valuahle  infcrmatiim.     The  aiudunt   (if 
opium  wliich  has  liceii  -iven  in  certain  instances  is  remarkahle.  and  indi- 
cates a  tdleraiice  of  the  dru,>r.     The  (hiscs  jriven  hy  the  late  Al.inzo  Clark, 
of  New  York,  iiiav  lie  trulv  termed  heroic,     .\ustin  Flint  notes  that  a  ])a- 
tient  under  the  care  of  this  phvsician  took  "  in  the  first  twenty-f(nir  liours. 
df  dpium  and  tlie  sulphate  df  morphia,  a  .piantity  e(|nivalent  to  10(1  jrrain« 
of  oimim:  in  the  second  twentv-four  Imurs  she  took  4^2  <rrains-,  on  the 
third  day,  '>3G  grains;  on  the  fdurtli  day,  ]-.'<•  grains;  rm  the  fifth  day, 
;j8 


608 


PISKASKS  OK  TlIK   DKJKSTIVH  SYSTKM. 


51  "rains;  on  llu'  mmIi  .lay,  -J--'  >.naiii>; 


,11  thesevoiilli  thiy.  IS  ^n'ains;  nfur 


wlii.h  llu'  tivatiiH'iit  was  susiu  iiilc'l.       H  i>  uiuuie. .  a.x  ^ 

under  th.'    lit Uhmic'C  1)1  tlu'  <liii^-      '"  •'  '"""■^'        .,,  ,   ,.  i;..r 

,,.,., I  ■- ' - ';,■'"  •;;;,,  i;     - 

.,i:ts£:rr:s:xr:::.f'^~-;::t - 

I'L  m.'l  i..i«-ti»"»  «.i.i^""i"i-'  t"n...mm.  i,«..v  1..  in.'.l.    im.;:,  l.>  tl.' 

t:ziJz^X'«<>^ ' "  <i-'""'  ■>'  »:'",»■■""  T^  '^  :'- 

•     ,;r  V   ,!^       n  the  acut.  i'o-ns  of  tuUTculous  perilonifs  opera  iv.  nu.- 
cate.1.     The  treatment  of  tul.ereulous  peritonitis  ha»  ialkn  Lu^eU 


ASCITKS. 


001) 


lu«c    I'Uiil-- 

!  to  a  liall 
llioi'tiiij:lily 
;('cll  at   till 

ivli.'f. 
wnuiji  nllt 

sdincliiiH':- 

f  latf  li»'»'ii 

C'     llSfll     till' 

itis.     Tht'ii- 
iriii.   wiiiili 
iiial  vf«si'! 
.  iiii|i()rtaiit 

irasi'tl  I'l'i'i- 

)rtfi  of  tlu'M' 

]u'riti)niti> 

'Xlclisidll    "T 

laiiy  ca  IV  I'll  I 
k  inmi  pi'''- 
l'  iHM'itoiiili'* 

0  al)t-lnllUllill 

Iciini,  or  till' 
H'liilix  cases, 
s  tiTatiueiit. 
ilsis  and  the 
alone  is  ol' 
(.(1  to  relieve 
serious  tliaii 
.  ul'  the  lon^f 
)nigs  liy  tlu; 

may  lie  em- 
nit  iiig  is  tlis- 
1.  hut  to  use 
o  ha VI'  a  sur- 
i]K'i'ation  may 
(litions  under 
The  aeute 
occur,  usually 
111  are  steadily 
lerative  mea-- 
I'essl'ul. 

il'evative  peri- 
iiat  of  ascites, 
pjiing  is  indi- 
11  largely  into 


tii(>  iiand<  ol'  the  surg. .-.  and  the  lonll-  in   many  cas.s  are  very  j^ood. 

Aeeonlin-  to  the  >tali.«ti.'s  of  Mauriin-c.*  of  ',  1  ea>es.  -.'8  survivd  the  opera- 
Ijoii  lor  more  than  a  year.  Of  -.'il  additional  ea.-es  which  I  have  colleetcil.f 
1  I  were  dead  at  the  lime  oT  the  re|.ort.  Within  two  years  ami  three  months 
there  were  (I  oi.erati<in>  iierlormed  at  tiie  Johns  ll(.[.kins  Hospital  in  tuher- 
(uloiis  pi'riluuitiji,  with    1  rceuVLTies. 

('■)  Ascites.— The  treatment  depend-  .-oinewhat  on  the  nature  of  the 
caM'.  In  cirrhosis  early  and  repeated  tapping  may  give  time  for  tin'  e.-lali- 
li.,l,i„enl  ol'  the  collateral  circulation,  and  temporary  cures  have  followed 
this  prccediire.  rermam'i\t  drainage  with  Southcy's  tidie,  imision,  and 
wa-^hing  out  the  peritonauim  have  also  l.cen  practised.  In  the  ascites 
,,f  ear.liac  and  renal  di>ea.-e  the  cathartics  are  most  satisfactory,  parlicidarly- 
the  l.ilartrale  (d'  potash,  given  alone  or  with  jalap,  and  the  large  doses  of 
salts  given  an  Inmr  hefore  hrcaUl'ast  with  as  little  water  as  possil.le.  TIicm' 
soiuetinu'-  cause  rapid  disappearance  of  the  elfu>ion.  hut  they  are  not  so 
siiccessfid  in  ascites  as  in  pleurisy  with  elVusioii.  The  strongi'r  cathartics 
inav  sometimes  he  necessary.  The  ascites  fornnng  |iart  of  the  general 
anasarca  of  Jiright's  disease"  will  receixe  cun-uderation  under  anoihcr  .-ee- 
tion. 


*  Paris  Tlu'sis,  188!). 

t  On  Tuberculous  Peritonitis,  .lolins  Hopkins  IIos[iital  Reports,  1890. 


SFXTIOX   VI. 
DISEASES   OF   THE    EESPIRATOP.Y   SYSTEM, 


I.    DISEASES  OF   THE  NOSE. 
I.    ACUTE   CORY2     . 

„„:';,:,' a  ".a.anV  or  a  "  coUl."  is  usually  an  in,lc,.u,k.ut  aHccfon. 
l„,t  nnv  i.rcccdf  tlu'  (IcvcloMiuciit  of  aiiotluT  diseasi'. 

Etiology.-lt  ,n.vaUs\uost  .xtvusivlv  in  the  chan.oal.l..  u^atluT  of 

tlH     p  u  °  m  1  .a.l  •  wiul.r.  an.l  n>ay  oc.ur  in  viMvnu.  lorn,,  niany  ea.. 

.;,        r/        a   ..onununi.y   uhhin   a    Lw   w..ks.       These   outhreaks  are 

V        1  l^thon.h  less  intense  than  the  ephlemie  inlUu.nxa.  ea.es  ot.lueh 

:.h,  with  svuM-ton.  of  or-linnry  eoryza.     The  disease  prohahly  -le- 

;;;;■  Is  .M,on  a  u.ienMUni.u.     Irvitatin,  fun,es.  sueh  as  tlu.e  ot  .od.ne  o. 

inunonia.  also  may  eanse  an  aeute  ealarrh  ..t  the  no>e. 

Svmptoms.-The  patient  feels  indisposed,  perhaps  ehdly.  ha>  >l..ht 
l..adS  and  M.ee.es  fre.p.entlv.  In  severe  eases  there  are  pains  m  tie 
l;  ;U  and  InuU.  There  i.  usually  slight  fever  the  t-M'-  -  nsin,  o 
l„r  The  pulse  i>  quiek.  the  skin  is  -Iry.  and  there  are  all  the  ieatnu  I 
\t  iir-t  the  nmecnis  menihrane  -d  the  nose  is  swollen, 
,.nt  has  to  hreathe  thn.u.uh  the  nnuilh.     A  thin. 

fs  of  the  nostrils  sore. 


a  feverish  attae 
••  stulfed  up."  and  the  pati 

clear    irrilatin--  seereti(Ui  Hows,  and  makes  the  edj 
The  muc-ons  memhrane  of  the  tear-dnets  is  swollen,  so  that  the  -^-^^ 
ami   the  eonjunetiva.  are  injeeted.     The  sense  ot   smell   and    in   pa.t.  th 
n<e  of  taste  is  hw,.     With   the  nasal  eatarrh  there  >s  slight   soreness  ol 
1  "    h     ai  ami  stUrness  of  the  neek:    the  pharynx  looks  ivd  and  swolU.i 
,d  lunetimes  the  a.,  of  swallowing  is  paininl.     The  l^O-  also  lua        > 
i„,„U..d.  and  the  voice  heeomes  husky  or  ,s  even  lost.      li  the       11  mn 
tion   extends  to  the    Knstaehian    tuhes   there   may  he   impairment   ot    tla 
i^.      m  more  severe  eases  there  are  hronehid  ivntatmn  and  .m, 

!»--i-'>ll^-  ^'-'-  '^  '^'^  ""^•'■•"'''^  '"■  '''''-•''  '"'  r^^'^'T-       '^r  fu      ' 
thirtv-six  hours  the  nasal  secretion  hec.nnes  tnrlud  and  nmie  pi.dus     t  u 

dln.^of  the  mucosa  suhsides.  the  patient  .raduallv  heeomes  ahle  o 
1  .cltl,;  through  the  nostrils,  and  within  four  or  five  ^^^^^  ^^y^;^^^ 
disapppear.  with  the  exception  of  the  increased  discharge  liom  tlie  noso 


610 


t^STEM, 


's.    ]i(i|nilarly 
jut  ulVi-'ction. 

Ic  wcatluT  nf 
1,  iiiany  ^■il^^■^ 
nUl)i'c'iiks  arc 
iscs  (if  which 
I  in  ilia  lily  ilc- 
[■  of  iddiuc  111' 

lly.  lia>  sli.oht 
]iaiii«  ill  the 
tuve  rising-  to 
lio  iVaturc?  of 
ISC  is  swiillcri, 
mill.     A  tliin. 
nostrils  sore, 
llic  eyes  weep 
.  in   part,  the 
lit  soreness  of 
1  anil  swollen. 
X  also  may  he 
the  inllaiiinia- 
irniciit   of   the 
;in  anil  eiiii<2'h. 
Usually  within 
re  prol'iise.  the 
H'dnu's   alile   to 
the  syniptonis 
from  the  no?o 


CIIIIOXIC   NASAL  CATARUII. 


Cll 


ami  n]>|>cr  |iharynx.  There  are  rarely  any  hail  elVeuts  from  a  simpK'  eoryza. 
When  the  altaek>  are  fieiiiieiitly  re[ieateil  tiie  disease  may  liecome  chronic. 

The  iliiiijmi.-^is  'i>  always  easy,  luil  caution  mu>l  lie  cxerci>eil  lest  the 
ini'ial  catarrh  of  measles  or  severe  inlliiciiza  shmihl  lie  mistaken  for  the 
simple  eory/.a. 

Treatment. — Many  cases  are  so  niiM  that  the  patients  ai'c  ahle  to  he 
ahoiit  ami  to  attemi  to  their  work.  If  there  are  fever  and  constitutional 
di>tiirhancc.  the  patient  shoidd  he  kcjit  in  hed  and  should  lake  a  simple 
fever  miMni'e,  and  at  ni^'ht  a  drink  of  hot  lemiinade  and  a  full  dose  of 
l)o\er"s  powder.  .Many  persons  liml  <.n'eat  lieiieiit  from  the  Turkish  hath. 
I'or  the  distrcssiiiii-  >cnse  of  ti;:htness  and  pain  over  the  frontal  >iiiuses, 
lucaiiie  i>  very  useful  and  Mimetimes  ^ives  immediate  relief.  'I'he  l-]ier- 
ceiit  solntion  may  he  injected  into  the  nostrils,  or  cotton-wool  soaked  in 
it  may  he  inserted  into  them.  Later,  the  sniilf  recommended  liy  Ferrier 
is  advantai^eous,  comjiosed.  as  it  is,  of  morphia  (jir.  ij),  hisninlh  (.liv), 
acacia  powder  (.~>ij).  'I'liis  may  occasionally  he  lilown  or  suull'ed  into  the 
nostrils.  The  lluid  extract  of  iiainaniclis,  "  j-nuU'ed  "  from  the  hand  every 
two  or  three  liours.  is  much  heller. 


II.    CHRONIC    NASAL    CATARRH. 

{Rhinitis;  lihinitis  liypi-rtrophicu  ;  Jiliinili.^  atniiiliicd). 

In  simple  chrunir  atlnrrli  there  is  increased  irritahility  of  the  mucous 
memhrane,  particularly  of  the  erectile  tissue  on  the  septum  and  turhinated 
hones.  There  is  a  tendency  to  frequent  stoppage  of  one  or  hotli  nostrils 
and  tiie  patient  very  easily  catches  cold.  The  secretion  is  at  first  clear 
and  afterward  thick  and  tenacious.  The  sense  of  smell  is  not  specially 
disturhed  at  this  stage.  With  the  mirror  the  niucons  memhrane  hioks 
congested  ami  swollen  and  the  veiiKs  may  he  distended. 

In  hii/iiTlmpliic  rhiiiilis,  which  is  usually  a  .sequel  of  the  former  con- 
dition, the  nasal  ]iassages  are  ohstructeil.  cdiielly  liy  enlargement  of  the 
lower  turhinated  hodies  and  swelling  id'  the  mucous  nu'inlirane  of  the  sep- 
tum. \'ery  often  there  is  hypeilroiihy  of  the  adenoid  tissue  in  the  vault 
of  the  pharvnx  and  of  the  mucous  memhrane  ahout  the  orilices  of  the 
Kustachian  tuhes.  The  two  conditions  frequently  go  together  as  expressed 
in  the  designation,  chronic  naso-pharyngeal  catarrh.  The  symptoms  of 
this  hvpertrophic  rhinitis  may  he  Imal  or  general. 

The  most  important  local  symptom  is  the  ohstruction  of  the  passage  of 
air  through  the  nostrils,  so  that  the  patients  hecome  mouth-hri'athers. 
During  the  day  this  may  not  he  very  distressing,  hut  at  night  the  mouth 
and  throat  get  extremely  dry  and  tlie  sleep  is  di.sturhcd.  The  voice  he- 
comes  nasal  in  quality  and  in  advanced  eases,  when  the  Eustachian  tuhes 
are  ohstrneted,  there  may  he  deafness.  It  shonid  ever  he  home  in  mind  hv 
the  praetilioiH'r  that  a  very  large  proportion  of  all  cases  of  deafness  origi- 
nate in  chronic  naso-pharyngeal  catarrh.  'I'he  general  symi)toms  have 
heen  considered  more  fully  under  chronic  iiliaryngeal  catarrh  and  mouth- 
hrcathing. 


lb 


f 


1 ; 


Q12  DISEASES  OF   THE   IlESPIRATORV   SYSTEM. 

Alrnphir  rhiiiilis,  wliicli  is  also  known  undcT  the  niuncs  coryza  IVtiiLi 
iind  o/n'iKi.  niiiy  l)c  a  si'(iucn(c  of  tla'  liyportropliic  lonn.  Uzii'iiu  is  only  a 
t-vmiilom,  and  "is  met  with  in  many  xikrrativi'  conditions  of  the  nostrils, 
partirnlaiiv  as  a  result  of  syphilis,  foreign  bodies,  caries  and  necrosis  o( 
the  liones,"  and  -landers.  Fortunately,  the  atrophic  form  hy  no  means 
lK■ccs^arilv  follows  the  hypertrophic  sta^e.  The  cases  are  much  more  fre- 
quent in  women  than  in  men,  ami  usually  occur  ca  ly  in  life.  The  mucous 
membrane  is  thin  and  covered  with  -rayish  cru>ts  which,  when  .vmoved, 
sh.tw  a  sliiihtlv  excoriated  surface,  but  true  ulcers  are  nwvh  seen.  The 
erectile  tissue  is  completely  atrophied  by  a  process  of  slow  connective-tissue 
ji-rowth,  or,  iis  ,1.  N.  Mac"kenzie  calls  it,  a  cirrhosis.  The  nnicuis  mem- 
lu'ane  of  the  jiharynx  is  usually  dry  and  glazed. 

The  symi)toms  are  most  di.-tinctive,  owin--  to  the  horrible  odor  winch 
comes  from  the  nose,  ami  of  which,  fortunately,  the  jiaticnt  is  himself 
unc(mscious,  because  the  sense  of  smell  is  lost.  The  secretion,  winch  is 
piirilorm.  dries  and  forms  lar-e  crusts,  which  are  dislod-ed  by  iiickin-'  or 
which  -radiiallv  fall  olV.  The  cause  of  the  olVeiisive  odor  has  been  much 
,li^,,„s^,',,|_\vhc'ther  it  is  due  to  a  special  organism  or  to  specially  favorable 
conditions  for  the  .urowtli  and  develoiuiieiit  of  the  .u'crms  of  putrefacti(m. 
I'robablv  the  latter  view  is  correct. 

Thv  lira  hue  lit  cd'  liy|iertrophic  rhinitis  consists  in  the  thorough  cleans- 
ing of  the  nasal  i»assages,  the  removal  of  the  pharyngeal  growths,  and  the 
reduction  of  the  hypertrophied  nasal  mucosa.  It  is  best  to  use  a  simple 
douche,  in  order  to  keep  the  membrane  absoluti'ly  cli'an.  The  JWrming- 
liam  nasal  dcmche  is  the  most  simple  and  satisiactory,  and  may  be  tilled 
with  alkaline  and  antiseptic  or  deodorizing  soluticms.  One  of  the  most 
satisfactory  is  the  bicarbonate  of  soda  ( 1 .1  drachm),  listerine  («  drachms), 
and  wati'r(l  •>unee).  Operative  jirocednres  are  necessary  in  a  majority 
(d'  the  cases,  and  the  practitioner  .should  early  call  to  his  assistance  the 
specialist.  It  is  sid  to  think  of  the  misery  which  has  been  entailed  upon 
thousands  of  people  owing  to  neglect  of  naso-pharyngeal  catarrh  by  iiarciits 
and  iihysieiaiis. 

'I'he  treatment   of   atrojiliic   rhinitis   comes   more   properly   under   the 
special  nionoirraphs. 


III.    AUTUMNAL    CATARRH  (//'«.'/  /•>"')■ 

An  affection  of  the  nppcr  air-passages,  often  associated  witi.  asthmatic 
attacks,  due  to  the  acti(m  of  certain  stimuli  uimhi  a  hypersensitive    nncous 

membrane. 

This  affection  was  first  descrilied  in  1S19  by  r>osiock,  who  called  it 
riihtrrliiis  rr.s-/)/';/.«.  'Mnrrill  Wyniiin,  of  Cambridge,  :\rass.,  wnUe  a  niono- 
n-rai.li  on  the  sub.i(>ct.  and  described  two  forms,  the  "June  cold."'  or  "rose 
cold,"  which  comes  on  in  the  spring,  and  the  autumnal  form  which,  in 
this'oountrv.  does  not  develop  \intil  Angnst  and  Septendicr.  and  never 
persists  after  a  severe  frost.  Pdakely  stndied  its  connection  with  the  iiol- 
len  of  various  >rrasses  and  flowers.      The  late  Oeorge  ^l.  IJeard  made  many 


n 


;7.i\  IVtida 

i<  only  a 

■  iiiistrils, 

nil   iiR'iins 

lllOVf    il'L'- 

i't'iiiii\('il, 

CMl.         Tlu- 

tivo-t  issue 

oils    llU'lll- 

l(ir  whicli 
is  liiinsL'll' 
,  wiiicli  is 
[)ickin,U'  or 
ii'i'ii  imifli 
ravoi'iiblc 
trel'actiiiii. 

gh  floaiis- 
s,  and  the 
I'  a  siiuple 
'  liirminj;- 
y  be  iilled 
tlie  most 
draelnns), 
11  majority 
stance  the 
ailed  upon 
hy  parents 

under   tlie 


,  asthmatie 
ive    nueous 

0  called  it 
le  a  moiio- 
,"'  or  "  rose 

1  whicli.  in 
and  never 

111  the  ]iol- 
made  many 


AUTUMNAL   CATARRH. 


013 


,,reful  (,l.servations  on  the  .Urease.      Until  recently  this   l'..rm  ol  catarrh 
vv,<  helieved   to  result  exclusiv.'! V  froui   the  action  ol'  certain   irritants  on 
,h,    mueous    ineii.hraue    of    the    no>e.    parlicularly    the    pnll-.n    oL    plants, 
which,  as  the  experiments  of  IJlakeley  showed,  play  an  iniportanl  /c/k:  in 
,|„.  disease.     Other  emanations  also  may  induce  an  attack,  as  in  liie  ease 
of  the  late  Austin   Flint,  who  was  liahle  to  tory/.a.  or  even  a>tlima.  it   he 
.!,pt  on  a  certain  sort  of  leather  pillow.     This,  however,  is  only  one  tactor 
in  the  (li>ease.     A  second,  most  important  one.  was  di.cov.'ivd  in  the  coii- 
,li,i,,n  <.f  the  nasal  mucous  meniliraue  in  tlies..  cases.     Vollolini.  of  l',re>lau 
i„   is:i    ohserved  the  cure  .d'  a  case  .d'  asthma  hy  the  ivnioval  <d  a  iiasil 
pnlvpiw      Since  that  date  the  ohservatioiis  of  Jlaek.  in  (lermany.  and  par- 
,i,.,'ihrlv  .d'  l>alv.  of  I'ittshuru.  h'oe.  of  IJoeliestcr,  .l..lin   N.  Mackenzie,  of 
P,,l, •„„;„,..  and' Harrison    All.m.  of    I'hihidelphia.   have   dem..iistrate<l    the 
a-ociati<ui  .d'  a.sthmatic  attacks  with  nasal  disease.     Daly  discovered  that 
in  a  lar-e  propor'ion  of  the  cases  of  hay  asthma  there  was  hu-d  disease  ol 
,1,,.  muc.uis  memhrane  of  the  m.se.  the  cure  .d'  which   rendered^  the   pa- 
tient in<iisceptihle  to  cimditions  previously  exeitinu-  the  attacks.     This  has 
hcen  ahundantlv  conlirmed.     Still  identical  lesions  exist  iii  many  i-eop-le 
win.  never  suifeV  with  the  disease,  so  that  there  must  he  a  third   lactor    a 
iH.urotic  constitution.     In  the  etiolo-y  cf  hay  fever,  then,  these  three  e  e- 
ii,,,,„,  prevail— a  nervous  const ituticni.  an  irritable  nasal  mucosa,  and  the 

'""'rhe'disease  aifeets  certain  families.  i)articnlarly,  it  is  said,  those  wHh  a 
neurotic  taint.     The   peculiaritv  may  occur  through   several  generations. 
It  is  eertainlv  nmre  e..nini.m   in  the   United  States  than  in  Europe,  am 
much  more  common  in  the  United  States  than  in  Canada.     The  United 
States  llav  Fever  Association  now  uunihers  ihonsands  ot  members. 

Dwellers  in  cities  are  more  subject  than  residents  in  the  country  Ihc 
structural  peculiarities  of  the  nasal  mucous  membrane  are  those  ot  liyi.er- 
trophi<-  rhinitis.  Harrison  Allen  states  that  the  inferior  turbinated  l)ones 
lie  well  above  the  lloor  of  the  nostrils,  which  renders  the  mucous  niem- 
brane  more  liable  to  irritation  from  inhaled  substances.  Deilectiou  of  the 
septum,  hvpertroi.hv  of  the  soft  inirts,  and  excessive  hypenesthesia.  so  that 
th.e  mere  "touch  with  a  probe  may  be  sullicient  to  induce  an  attack,  are 

common  conditions.  . 

Symptoms.-These  are.  in  a  maj.)rity  of  the  eases,  very  like  those  of 
ordinarv  corvza.  ^Phere  mav,  however,  l)o  much  more  headache  and  dis- 
tre.-^  and  s-une  patients  become  very  low-spirited,  ("ough  is  a  cnnmon 
svmptom  and  mav  be  verv  dislivssing.  Paroxysms  of  astlnna  niay  dev.^op, 
.0  like  a<  to  he  indistinunishable  from  the  ordinary  bronchial  form,  the 
two  conditions  mav  indeed  alternate,  the  patient  having  at  one  time  an 
attack  of  common  hav  fever  and  at  anotlier.  under  similar  circumstances, 
an  attack  of  bronchial  asthma.  Of  the  immediate  exciting  causes  of  the 
attack,  nn(inesti(mahlv  in  a  majority  of  the  cases  .-oming  on  in  the  autumn 
there  is  an  association  with  the  presence  of  p.dlen  in  the  atmosphere,  but 
this  is  milv  one  of  a  host  of  exciting  causes.  In  certain  persons  the  parox- 
vsms  mav'develoii  at  anv  season  frori  sudden  changes  in  the  teinperatnre. 
An  attack  mav  even  come  on  through  association  of  id('as.       The  well- 


'i' 


^■A 


rr 


i;i4 


DISKASKS   OF   THE   KKSriltATOUY   SYSTEM. 


known  I'XiiL'i-inifiit  <il'  J.  N.  ^hukcnxii'.  of  induiin.u'  an  iiUiick  in  a  pus- 
(rptililc  pcmm  by  oIlY-iin-:-  her  an  artiliiial  rot-e  to  Mnoll,  >trikinj:ly  illus- 
traU's  the  iicurotie  clement  in  tlie  disease. 

Treatment.— This  may  be  comprised  under  three  liead>:  Fir>t.  since 
the  disease  af. pears  in  many  instances  to  l)e  a  form  of  clironic  neurosis, 
remedies  which  improve  the  stability  of  the  nervous  system  may  be  em- 
],l,,_vi.,l_sueii  as  arsenic,  riiosphorus.  and  strychnia.  Second.  cUmatic. 
Dweller.-  in  the  cities  of  the  Atlantic  seaboard  and  of  the  Central  States 
t'lijoy  complete  immnnity  in  the  Adirondacks  and  White  .Mountains.  As 
a  rule  the  disease  is  ag-nivated  by  residence  in  a-ricuitural  districts.  The 
dry  mountain  air  is  nmiuestionably  the  best ;  there  are  cases,  however,  which 
du  well  at  the  seaside.  Third,  the  lhor,ui-h  local  treatment  of  the  nose. 
])arlieularly  the  destruction  of  the  vessels  and  sinuses  over  the  sensitive 
areas. 


IV.    EPISTAXIS. 

Etiology. — r.leedino-  I'mm  tju'  nose  may  result  from  local  or  consti- 
tutional conditions.  Amonji-  local  causes  may  be  menti(med  traumatism, 
small  ulcers.  i)ickiu,i:-  or  scratchin-;-  the  n(«se.  new  or,,\vths.  and  the  luvsence 
of  forei-;n  bodies.  in  chronic  nasal  catarrh  bleeding;-  is  not  infreipient. 
The  blood  may  come  from  one  or  both  nostrils.     The  How  may  be  profuse 

after  an  injury. 

AnuuifX  iicneral  conditions  with  which  nose-ble<'din,u-  is  assoi-iatcd.  the 
i'ollowin,!:  are  t!ie  mo.-^t  important:  It  occurs  with  jircat  Imiueiicy  in  jirow- 
iuir  children,  particularly  about  the  ajre  of  puberty:  more  l're(iuently  in^ 
the  delicate  than  in  the  stron,i;-  and  vigorous.  I  have  seen  two  cases  of 
elironie  recurriui:-  epistaxis  in  adults  associated  with  remarkable  telangiet- 
tases  of  the  skin  and  visilile  mucous  meml)ranes. 

Kiiistaxis  is  a  very  comn\on  event  in  persons  of  so-calleil  plethoric 
habit.  It  is  stated  sonu'times  to  precede,  or  to  imlicate  a  lialulity  to,  apo- 
plexy, but  this  is  very  doiditful. 

In  venous  enjioro-euu'nt.  due  to  heart  or  pulmonary  disease,  epistaxis  is 
not  common  ami  tliere  may  be  a  most  extreme  ,i:rade  of  cyanosis  witlumt 
its  oicurrence.  fn  balloon  and  nu)untain  ascensions,  in  the  very  rarotied 
atmosi)here.  luvnu)rrhage  from  the  nose  is  a  common  I'vent.  In  banno- 
jihilia  the  nose  ranks  first  of  the  mucmis  membranes  from  which  bleedin,!: 
arises.  It  occurs  in  all  forms  of  chronic  ana-mias.  It  ]n'ecedes  the  onset 
of  certain  fevers,  more  particidarly  tyi)hoid,  with  which  it  seems  assoeiateil 
in  a  sjiccial  manner.  Vicarious  ejiistaxis  has  lieen  described  in  cases  ot 
su].pression  of  the  numses.  Lastly,  it  is  said  1o  be  brou.irht  on  by  c(M'1ain 
tisvchical  imiu-es!<ions.  liut  the  oliservations  on  this  point  are  not  trust- 
■vrthy.  The  lilood  in  epistaxis  results  fnmi  cajiillary  oozino-  or  diajiedesis. 
Tl\e  mucous  nu'mbraue  is  (h'(>ply  eonirested  and  there  may  be  small  eechy- 
moses.  The  l>leedinp-  area  ii  usually  in  the  res|)irat(n'y  p(U-lion  of  one  nos- 
tril and  niion  the  cartila,i:inous  senium. 

Symptoms.— Sliirht  ha>morrhai.M'  is  not  associated   with   any  special 
features.     When   the  blecdinjx  is   protracted   the   jiatients   have   the  more 


mm 


mm 


mm 


ACl'TK  CATAHKllAL   l..\KYN(ilTlS.  tU.") 

^..riuus  mniiilV.-tations  of  lo>s  of  \>\n,n\.  Ju  the  >lnw  drippin-  whirl,  takes 
phu-c  ill  >'>\nv  instiiiu'cs  oi  luiMiK.pliiliii.  tln'iv  iniiy  Im.  Inniin!  a  ivmarkahU: 
l,l(H.(l   tmnnr   pn.j.vtiii--  Imiu  uiio    m>tril   ainl   fMm.liii-   rvm    l.rl-w    tlio 

miiuth.  1    ■     I 

Death  i'rom  onliiinry  i'i.ista.\i>  is  v.tv  raiv.  'V\u^  ui.uv  l,iun,|  is  lo-i, 
the  fiirater  is  tiio  teiuk'iK'V  t<.  eh-ltin-  «ilh  >pnuliinruu>  (■.•.->alinii  of  tlie 

hh'cdin;;'.  .        , 

'l"h,'  dliiiiiinx!.^  is  usually  easy.  (Uw  pniut  (Uily  need  In'  mciition.Ml; 
uaiiu'lv.  that  l.hrdiu.i;-  Ir.'iu'  tho  iM.>i.Tinr  uaivs  .).va>i(.iially  nccurs  diinii.ii; 
.Ircp  and  the  hhuxl  trii-kk's  iutn  ihc  phaiyiix  and  may  1m.  ^wallnwvd.  li 
viuuiti'ii.  il  may  he  .•(.nlnuiuK'd  with  lurmal.  inr.-i>;    or.  if  cnii-hrd  up.  with 

lia'iin>]itv>is.  ■  ■      II' 

Treatment.  — lu  a  majority  of  the  CUM-  ihf  lilcrdiuc;-  orax's  ol  itsdl. 
Various  simpk'  mca>uivs  may  hr  employed.  Muh  as  holdiii-  the  arms 
ahove  the  head,  the  appUealion  (d'  iee  to  the  imse.  or  the  iiijeetiou  of  .■idd 
or  hot  water  into  the  nostrils.  Astrinp'iits.  siudi  a-  xiue.  alum,  or  tauuiu, 
may  he  used;  and  the  (dd-lasiiioiied  and  >ometime>  Mic(M-stiil  remedy,  a 
eohweh.  mav  he  intrudueed  into  the  nostrils.  If  the  hlee.lin--  e.unes  from 
an  ulcerated  surface,  an  attemj-t  should  he  made  to  apply  cliroinic  acid  or 
to  cauterize.  ]f  the  Ideedin--  is  at  all  seveiv  and  ohstinate.  the  posterior 
nares  should  he  plu-iied.  Krp.t  may  he  given  internally  or  hypodermically. 
The  inhalation  of  carhoiiic-acia  gas  may  he  tried  or  a  .ululiuu  of  gelaliue 
injected  into  the  nos^tril. 


ir.   DISEASES   OF   THE   LARYNX. 
I.    ACUTE    CATARRHAL    LARYNGITIS. 

This  may  eonie  on  as  an  independent  ailectioii  or  in  association  with 
.Tcneral  catarrh  of  the  ujipcr  respiratory  passages. 

^  Etiology.— -Man V  cases  are  dm'  to  catching  cold  or  to  overuse  ol  tho 
voice'  others  develop"  in  cousetpiciice  of  tlie  inhdation  of  irritating  gases. 
]t  mav  occur  in  the  ueiK-ral  catarrh  associated  with  influenza  and  measles. 
Verv  'severe  larvn-ntis  is  excited  hv  traumatism,  either  injuries  from  with- 
out'or  tlie  hxlgment  of  foreign  ho,lies.  It  may  he  caused  hy  the  action  of 
verv  hot  liquids  or  corrosive  i)oisons.  ,  ,      ,  ,, 

'Symptoms.— There  is  a  sense  of  tickling  relerred  to  the  larynx;  tlic 
cold  air  irritates  and,  owing  to  the  increased  se.isihility  of  the  nuu.ms  nieni- 
hrane  the  act  of  inspiration  may  he  painful.  Theiv  is  a  drv  congli.  and 
the  voice  is  .nltered.  At  first  it  is  simi-ly  husky,  hut  soon  phonation  he- 
comes  painful,  and  finallv  the  voice  may  he  completely  lo.t.  lu  adults  the 
respirations  are  not  increased  in  fre(|uency.  hut  in  children  dy<pn.ea  is  not 
uncmnion  and  mav  occur  in  spasmodic  attacks.  If  niu.di  .edema  accom- 
panies the  inflammatorv  swelling,  there  may  he  urgent  dvspn.ea. 

The  larvn"o<eoi)e  shows  a  swollen  and  tumefied  mucous  niemt)ran<'  o. 

.  larvnx/particularlv  the  arv-epiglotticleau  fold^.     The  vocal  cords  have 


the 


ft 


^,j^  DISEASES  OF  THE  KESPIHATORY   SYSTEM. 

lu>t  tl.uir  Muooth  and  shiuin-  nir^'annur  Mtul  aiv  iv.l.lcnrd  and  swollen. 
-n^.i,.  „iul,ilitv  al>n  is  -m.tly  in, paired,  .uvm-  to  the  mliltratiun  et  the 
,,li,,i„i„„.  nnieons  n,end,rane  and  nf  th..  innsehs.  A  >li-lit  nnieoid  exiida- 
tinn  eevers  the  i^irls.  Th..  .■on^titnthmal  on'l't'""^  "••^'  ""^  -y,';-  "■''^' 
i.  nnvlv  nineh  fever,  and  in  many  eases  the  iMlieiil  w  n..t  sernai-ly  lU.  Oe.a- 
siunally  eases  e.une  on  with  -reater  intensity,  tlie  e.,n-;-li  i^  very  distressing, 
d.-iulilion  i>  paiiirul.  and  tiiere  may  he  iir-cnt  dysj.mea. 

■' Diagnosis. -Tliere  is  rarely  any  dillieiilty  in  determining  the  natnre 
,,f  •(  c'l"  if  a  siti-faelorv  larvn'i-o.-eo|m-  I'Xiiinination  ean  lie  made.  liie 
severer  I'nrnis  mav  simulate  cedenia  of  tlie  el„ttis.  When  tlie  los.  of  v.neo 
i.  marked,  the  ease  mav  he  mistaken  I'nr  one  of  nervous  aphonia  hut  tlie 
l,,rvii..'o~eolK.  would  deei<le  the  .|Ue>tion  at  onee.  .Mueli  more  dilheult  is 
tlu'.  dueniosis  of  aeiite  iarvn-itis  in  ehildreii.  partieularly  m  the  very  ymm-. 
in  whom  it  is  so  hard  lo  make  a  proper  eNaminaliou.  From  onlinary  iaryn- 
,n<,mi-  it  is  to  he  di<tim:ui>hed  hy  th..  pr.>..iiee  of  fever,  the  in.ule  ..f  ..ns..t. 
and  i.artieularlv  the  e.^ryxa  an.l  the  previ.ms  sympt..ms  ot  hoarseness  .n;  oss 
of  voiee  M..mhranoii<  larvn-ilis  may  at  lirst  he  .piite  impossii»le  to  .liller- 
nitiate  hut  in  a  maioritv  .d'  .aM  s  ui  this  aiV...-ti..n  there  aiv  l-atehes  .m  the 
pharynx  and  early  swelling  .,f  the  eervieal  glands.     The  sympt.mis,  t...,.  are 

mueli  more  severe.  .  .   ■      ^         e  i 

Treatment.— l.'.'^t  .if  the  larvnx  sli.mld  be  eiij.inud.  s.i  lar  as  phona- 
tiou  is  c-.meeriu..l.  In  cases  of  any  severity  tiie  patient  sluud.l  he  kept 
in  hed  The  ro.mi  sli.mld  lie  at  an  even  temperature  an.l  the  air  saturate.l 
with  moisture.  Karlv  in  the  disease,  if  there  is  much  fever,  aeonite  and 
eitrate  .if  ii.itash  mav  he  given,  and  f.ir  the  irritating  pamlul  ...mgli  a  full 
dose  of  Dover's  [Hiwiler  at  night.  An  ice-bag  externally  often  gives  great 
relief. 


, 


t 
i 

u 

1 1 


II.    CHRONIC    LARYNGITIS. 

Etiology.— The  eases  nsnally  foll.iw  repeated  acuve  attacks.  The  most 
common  cause's  are  overuse  of  the  voiee.  particularly  in  iiersons  whose  occit- 
jiathin  necessitates  sluntting  in  the  open  air.  The  ccmstant  inhalation  of 
irritating  substances,  as  tobacco-smoke,  may  al<.i  cause  it. 

Symptoms.— The  voice  is  usually  hoarse  and  rough  and  in  severe 
cases  may  be  alnmst  lost.  There  is  usually  very  little  jiain;  only  the  un- 
pleasant 'sense  of  tickling  in  the  larynx,  which,  causes  a  fre.iuent  desire  to 
cou"h.  With  the  laryngoscope  the  mucnis  nienibranc  ]o.iks  swollen,  but 
nnu'^h  less  red  than  in'  the  acute  condition.  In  association  with  the  granu- 
lar pharyngitis,  the  nuicms  glands  of  the  epiglottis  an.l  .if  the  ventricles 

n.av  l)e  inv.ilved. 

Treatment.— The  n.istrils  sh.nild  be  carefullv  examined,  since  m  some 
iiKtanees  (lir.mie  larvngitis  is  ass.iciated  with  and  even  dependent  np.m 
obstnu'tion  t.i  the  free  jiassage  .if  air  through  the  nose.  Local  application 
must  be  made  directlv  t.)  the  larynx,  either  with  ..  brush  or  by  means  of  a 
spray.  Amonfi  the  remedies  most  reeominendod  are  the  solutions  of  nitrate 
.if  silver,  chlorate  of  ]iotash.  perchlori.le  of  zinc,  and  tannic  acid.  Insuffla- 
tions of  bismuth  are  sometimes  useful. 


<\\r^. 


srASMODlC    LAKYNC.ITIS. 


t'.lT 


~\V(ill('n. 
I  (if  the 
1  ixiida- 
'riuTO 
i.  Occii- 
irc'ssin,::, 

('  nature 
U:  Tho 
III'  vdico 
liul  tin,! 
Ilifult  is 
y  yiuin;:, 
rv  laryn- 

(if   (lllSI't. 

ss  or  Idss 
to  diiVcr- 

L'S  Oil    till' 

;,  too,  are 

IS  pliona- 
lie  kept 
.■^at  united 
mite  and 
ijili  a  full 
ives  <:reat 


The  most 
lose  oeeu- 
alatioii  of 


Among  directions  to  be  given  are  tlie  avoidance  ot  lieated  rooms  and 
l(,iid  speakiug.  and  ali>tiiK'nee  from  tol.aceo  and  alcohol.  'I'he  throat  should 
iKit  he  loo  much  innllled,  and  morning  and  evening  the  neck  .-imnld  he 
sponged  with  eold  water. 

III.    CEDEMATOUS    LARYNGITIS. 

Etiology.— CEdeina  of  the  glottis,  or.  more  correctly,  '.f  the  structures 
which  hirni  the  glottis,  is  a  \ery  ^erions  alVei-tion  which  is  met  with  (n)  As 
a  rare  seiiueiiee  ol'  ordinary  aeule  laryngitis,  (h)  lu  ehronie  diseases  ol  the 
larynx,  as  sviihilis  or  tuhercle.  (' )  in  severe  intlaninialdry  diseases  like 
(iil'ihtheria,  in  erysiju'las  of  the  neck,  and  in  variou-  forms  of  cellulitis,  (i/) 
Oeeasidiiallv  in 'the  acute  infectious  (li>eases— -scarlet  fever,  tyidius.  or 
ivphoiil.  Ill  Ihight's  disease,  eitlu'r  acute  or  cln'onic.  there  may  he  a  rap- 
iilly  developing  (edema.      ('')  in  angio-neni'(jtic  ledenia. 

'  Symptoms.— There  is  dyspmea.  increasing  in  intensity,  so  that  with- 
in an  hour  or  two  the  condition  hecoiues  very  serious.  There  is  .sometimes 
lunrked  .-trid(U'  in  resi.irati(m.  The  voice  hecomes  husky  and  disappears. 
The  laryngoscope  shows  enormous  swelling  of  the  epiglottis,  which  can 
<ometiiu'es1)e  felt  with  the  linger  or  even  .seen  when  the  tongue  is  strongly 
depressed  with  a  spatula.  'I'he  ary-epiglottidean  folds  are  the  seat  of  the 
ehief  swelling  and  may  almost  meet  in  the  middle  line.  Occasionally  the 
(edema  is  helow  the  true  cords. 

The  dia'Hiosis  is  rarely  dillicult.  inasmuch  as  even  without  the  laryn- 
goscope the" swollen  epiglottis  can  he  seen  or  felt   with   the  linger.     The 

disease  is  verv  fatal. 

Treatment.— An  iee-hag  should  he  placed  on  the  larynx,  and  tlie  \k\- 
tieiit  -iven  ice  to  suek.  If  the  symptoms  are  urgent,  the  tl.roat  should  be 
<praved  with  a  strong  solution  of  cocaine,  and  the  swolhm  epiglottis  scari- 
iied"  If  relief  does  not  foUow,  traeheot(miy  sh.mld  immediately  he  per- 
formed. The  high  rate  of  mortality  is  due  to  the  fact  that  tins  operation 
is  as  a  rule  too  long  delayed. 


in  severe 
y  the  un- 
:  desire  to 
olleii,  hut 
he  graiui- 
ventricles 

ee  in  some 
Llent  upon 
ipplication 
neans  of  a 
;  of  nitrate 
Insuflla- 


IV.    SPASMODIC    LARYNGITIS  (Larunghmu.^  slri^hihis). 

Simsm  (if  the  glottis  is  nic^t  with  in  many  atl'ectioiis  of  the  larynx,  hut 
tluM'e  is  a  si-ecial  disea,«(^  in  children  which  has  received  the  ahove-meiitioncd 

and  other  names.  ■    n  > 

Eti0l0gy.-.\  luirelv  nervous  allVctiim.  without  any  inflammatory  con- 
diti.ni  of  the  larynx,  ii  (■.ecurs  in  children  hetweeii  the  ages  of  six  months 
and  tliree  vears.' and  s  most  conimoiily  seen  in  connection  ^vlth  rick(Ms. 
\s  F.eheriVh  has  slioAvn,  the  disease  has  close  relations  ^vlth  tetany  and 
mav  disi.lav  manv  of  the  accessory  phenomena  of  this  disease  Olten  the 
attack  c.m;es  on' when  the  child  has  been  crossed  or  scolded,  ^[others 
sometimes  call  the  attacks  « pas.sion  fits"  or  attacks  of  "holding  the 
breath  "    It  was  supposed  at  one  time  that  they  were  associated  M'lth  en- 


rr 


I 

•I 


11 


01  s 


DISEASKS  OK   TIIK    HHSPIUAToIJV   SYSTKM. 


ivcciv(Ml  ilic  nniiu' 


liir-ciiu'iil   n|-  the  Ihyimis,  ami  the  cniiditicm   ihcrclorc 
of  Ihiiiiiic  iisllniKi. 

'Vhv  iicliiiil  Miilc  nl'  llic  larviix  dmiii,-  a  pan.xvsm  i>  a  ^|laMu  nl  lli.« 
,„l,l,„.iuis.  lail  111.'  |uv,is..  naluiv  „r  thr  ii.lln.'.ucs  (•aii>iii,i:-  H  i>  uul  U't 
kn..\Mi.  \\\n\hvv  .rnlnc  or  irll.'X  finiii  iMTiplural  irnlalHU..  I  1h'  'li>fa><' 
is;  lint  -I,  (oiiiiiinii  ill  America  a-  in   iMi^laml. 

Symptoms.— 'r ho  attaoks  mav  chu.'  nii  .at her  in  iIh'  lu-lit  <m'  hi  tiic 
,i.iv  (.ll.a.   \u<\  as  til.'  cliil.l  awak.s.     Tliciv  is   ii<.  .■.ui-h,  n.i  luiarsniess. 
In.'l'tiu'  iv^piratiun  is  arrol.'.l  an.l  tl.c  cl.il.l  stni-ol.s  f..r  l.ivath,  the  la.r 
.rds  .•..n.M.^f.l.  and  IIumi,  will,  a  su.l.l..;!i  ivlaxati..ii  ..I'  the  simsui    t  u'  air 
?.  dfuwn   int.>  llR'  lun-s  with  a   hi-h-|.il.dH..l  cT.iwin-  s.huhI,  wliiH.   lias 
.riven   t.i   the  atVeeti.-n   tlie   name  -f   -  eliild-en.uin.u/-     (;..nvnl-i..n>    may 
ue.ur  .lurinti-  an  attaek  ..f  there  may  Ik'  ear|M'-lH'<lal  spasms.      Deatli  may. 
1„„  ,,nvlv  (In....  ...rur  duriim-  tlie  atta.-k.     Willi  the  cyanosis  the  simsm  iv- 

hixes  ami  ivspirati.-n  l.e-ins.     The  attacks  may  recur  with  -reat  ire.,uency 

thnm-h.ait  the  day.  .  ,     •,•,,.  i 

Treatment.— The  -un.s  sh.ud.l  he  .areinlly  examined  and.  il  sunl- 
1,,„  ,,n.l  Imt.  riv.'lv  lanced.  Th.'  Ih.wcIs  >h.,uld  be  carefully  re-ulate.  .  an.l 
MS  tlu-e  chil.lren'are  usually  .leli.ate  ..r  rickety,  nourislun-  diet  and  cn.i- 
liv.r  oil  sh.ud.l  he  uiv.'n.  J'.v  far  the  m..st  sati>fact..ry  metli.Ml  ..I  treat- 
ment is  th.'  c.Kl  siK.n-in-.  In  severe  cases,  Iw.,  or  three  times  a  day  the 
child  shoul.l  he  |.lace.l  in  a  warm  bath  an.l  the  back  ami  chest  llmrougiiiy 
<n,>n..e.l  lor  a  minute  .u'  two  with  cl.l  wafr.  Sin.r  learnm-  thi>  iu'acti.x> 
fnnii  Iv'iiP'er.  at  the  rniversitv  ILisj-ital.  i  have  seen  many  cases  m  which 
it  nrov.d "successful.  It  mav  lie  emi)loyed  when  the  child  is  m  a  par..xysiii. 
th.urdi  if  the  attack  is  severe  an.l  the  lividity  is  jrreat  it  is  much  better  to 
dasirc.ihl  water  into  the  face.  Sometimes  the  intro.luction  of  the  linger 
far  back  into  the  tlir.)at  will  relieve  the  sjiasni. 

Spasmodic  croup,  bdicv.'d  t.)  be  a   functi.mal  spasm  (.f  the  muscles  .d 
th.'  larynx,  is  an  all'ecthui  seen  nmst  c..mni.inly  between  the  ajies  of  two  ami 
live  years.  '  According  to  '{'r.-ussi^au's  descripti.)!!.  the  child  goes  to  l)ed  well, 
and  "about  midnight  or  in  the  early  nmrning  hours  awakes  with  oppressed 
breathin-;-.  harsh,  cr.uipy  cough,  an.l  perhaps  s.uiie  huskiness  of  voice.     'J'he 
„pprossi.'"ii  and  distri'ss  f.)r  a  time  are  very  s."ri.>us.  the  face  is  congested,  an.l 
there  are  siuns  of  api»roaehing  cyanosis.     The  attack  i)asses  otV  abruptly, 
the  ohil.l  falls  aslee])  and  awakes  the  next  morning  feeling  perfectly  well. 
These  attacks  mav  be  repeated  for  sev.'ial  nights  in  successi.m.  an.l  usually 
cause  great  alarm  to  the  parents.     Whether  this  is  entirely  a   functional 
spasmus.   !   think,  doubtful.     There  are  instances  in   which  the  child  is 
s,mu-,vhat   h.Mi'*.'  Ihrouglumt  the  dav,  ami  has  slight  catarrhal  symi'toms 
ami  a  brazen,  croupv  cough.     There  is  i.r.ibably  slight  catarrhal  laryngitis 
with  it.     These  cases  are  not  infre.iuently  mistaken   for  true  cr.mp,  an.l 
l)areiits  are  s.)metiines  unnecessarily  disturbeil   by  the  seri.)us  view   which 
the  physician  takes  of  the  case.     To.,  often  the  ji.u.r  child,  deluged  with 
drugs,  "is  h.ntier  in  recovering  from  the  treatment  than  he  \vould  be  from 
the  disease.     T.)  allav  the  spasm  a  wliilV  of  chloroform  may  be  administered, 
which  will  in  a  few' moments  give  r.dief.  or  the  child  may  be  ])hiced  in  a 
hot  bath.     A  prompt  emetic,  such  as  zinc  or  wine  of  ipecac,  will  usually 


TrnKRcri-ors  i,.\i!YN(iiTis. 


('.lit 


rrlicvc  till'  spiisni.  ninl  i>  siuviiilly  iiidicntr,!  if  tlio  cl.ild  li;i>  ovrrlniuh.l  tlio 
i-tiiiiiiicli  tlir<iii;:li  the  diiy. 


V.    TUBERCULOUS    LARYNGITIS. 

Etiology.— 'riilu'ivlcs  tiiiiy  (li'Vtluii  iHiuKirily  in  llu'  luryiipiil  iiuKwa, 
imt  111  liic  <;mil  majority  ol'  casi's  the  all'ccti(m  i-  sivoiidaiy  tn  pulmniiary 
tiduTiiilosiJ^  in  which  it  is  iiu't  witli  in  a  variahlr  iir(,iM,rti(ni  nf  I'mni  IS 
t,,  ;;()  per  (cnt.  Larviiuitis  may  dt'cur  viTV  early  in  pulnKmary  lidR'irii- 
l,,Ms.  Tiiciv  niav  lie' wi'll-niarkrd  involvviurnt  of  the  huTiix  with  si-ns  of 
very  limited  trouhU'  at  one  apex.  Tiicsr  aiv  caMs  which,  in  inv  cxpniciKv, 
run  a  vci'v  unfavorahlc  course. 

Morbid  Anatomy.— 'I'ho  nuicnsa  is  at  tirst  swolkai  and  piVM nts  scat- 
Irivd  luhiTclcs.  whicli  sfcni  tu  l)",i:in  in  the  ncighhurhoud  df  the  hludd-ve." 
scls.  I'lV  ihcii'  fnsiiai  small  inhiTcnlnus  masses  arise,  uhicli  easeate  and 
liiially  iilcerate,  leaving'  >hall(iw  irre-ular  losses  of  snl)stance.  Tlie  nleers 
are  iisnailv  ei.vered  with  a  i;rayi>li  exudation,  and  tliere  is  a  ,-vneral  thick- 
ening- of  the  miu-osi  alxuit  them,  which  is  parlicularly  mai'kcd  np.m  the 
iiryli'noids.  'I'lie  ulcers  may  erode  the  true  cords  and  linally  destroy  them, 
mid  pa.->ing  deejilv  niav  cause  perichondritis  with  necrosis  and  occasionally 
,  xfoiiation'^of  the  "cart  i'lages.  The  disea>e  may  extend  laterally  and  involve 
the  pharynx,  and  downward  over  tlie  mucous  mendirane.  covering  the  cri- 
coid cartiia-e  toward  the  (esophagus.  .\l)ove.  it  may  reach  the  po>terior 
wall  of  the  i.harvnx.  and  in  rare  cases  extend  to  the  fauces  and  toiisds. 
The  epi-iottis  niav  he  entirely  destroyed.  Tlieiv  are  rare  in.-lances  m 
which  cicatricial  changes  go  „n  to  such  a  degree  that  stenosis  of  the  larynx 

is  induced. 

Symptoms.— The  lirst  indication  is  slight  linskmess  ol  the  voice, 
which  iinallv  deepens  to  hoarseness,  and  in  advanced  stages  there  may  he 
,,„uplete  loss  of  voice.  There  is  something  very  Miggoiive  in  the  early 
h,,aiseiiess  of  tuhercuh.iis  larvngitis.  My  attention  has  freipiciilly  hecii 
directed  to  the  Inngs  simply  hy  the  (piality  of  the  voice. 

The  coULih  is  in  part  due  to  involvement  of  the  larynx.  I'.arly  m  the 
di-case  it  is'imt  verv  tnudihsome.  hut  when  the  ulceralion  is  extensive  it 
]„.,..'mies  huskv  an,rineiVcctual.  Of  the  sympt(niis  of  laryngeal  tuherculo- 
sis.  none  is  niore  augravating  than  the  dysphagia,  which  is  met  with  iiar- 
ticulaiiy  when  the  epidottis  is  involved,  and  wlien  the  ulceration  has  ex- 
tended'to  the  pharvnx.  There  is  no  nnn-o  distressing  or  jminful  compli- 
cation in  phthisis.'  In  instances  in  whicli  the  epiglottis  is  in  great  part 
destroyed,  with  each  attempt  to  take  food  there  are  distressing  paroxysms 
of  eongli.  and  even  of  snifoeation. 

Witli  the  larvniroscoiie  there  is  seen  early  in  the  disease  a  pallor  of  the 
mucons  membrane,' which  also  looks  thickened  and  iniiltratt'd.  parlicularly 
that  coverinLT  the  arytenoid  cartilages.  The  tuherculons  ulcers  are  very 
characteristic.  Thev'are  hroad  and  shallow,  with  gray  hases  and  lU-dehnod 
outlines.  The  vueal  cords  are  iniiltrated  and  thickened,  and  ulceration  is 
verv  c(mnnon. 


t  f 


'ii 


<is 


t;2(» 


DISKASKS   OF   TITi:    UKSnUATORV   SVSTE:\I. 


'I'lic  iliiiji'iiosis  (if  liilicrciildiH  liirvimitis  i-  I'anly  (lilliciilt.  ii^;  it  is  usiiiilly 
nsjocialcil  witli  wcll-niinkrd  |iul:iiniiiirv  (lisca-c.  In  i-asc  ol'  ddulil  sumh'  <iI' 
the  sriiTtiuii  Iniiii  tlu'  InisL'  uf  an  iikrr  filmuld  bu  iviiiovt'd  and  examini'd  I'm' 
liacilli. 

Treatment. — riiysioians  pay  scarcely  siiHicit'nt  attention  to  the  laryn- 
;:(id  iiini|iliiati(>ns  ol'  c()nsnni|ptioii.  'I'lic  niters  slionid  lir  spi'aycd  and  ki'|it 
tliiu'dugldy  clcansfd.  Sulutions  oi'  tannic  atid,  nitralo  ui'  silver,  ur  sulpliido 
of  zinc  may  l)o  cuiployod.  '['\\v  insidllation.  two  or  {\\i\v  times  a  day.  of  a 
powder  of  iodoform,  with  morphia,  after  tlioroii.uhly  eleansinji  tiie  nk'ers 
willi  a  spray,  relieves  the  ]iain  in  a  majority  of  tiie  eases.  C'oeaine  ( 1-per- 
eent  solntion)  a|)plied  witli  llie  atomizer  will  often  enalile  the  patient  to 
swallow  liis  food  eomfortalily.  'I'liere  are.  however,  distressinj:  cases  of  ex- 
tensive laryn^^eal  and  pliarynj;eal  uleeralion  in  which  even  cocaine  loses  its 
jroiid  clVccts.  When  the  epij^lutlis  is  lost  the  dillicnlty  in  swallowini;  lie- 
comcs  veiT  ureal.  Wolfenden  states  that  this  may  he  obviated  if  the  pa- 
tient lianas  his  head  over  the  side  of  the  lied  and  sucks  milk  through  a  ruh- 
lier  tubing  fi'<ini  a  mug  placed  on  the  lluor. 


VI.    SYPHILITIC    LARYNGITIS. 

Syphilis  attacks  the  larynx  with  great  fretpu'iicy.  It  may  result  from 
the  inlierite(|  disease  or  be  a  secondary  or  tertiary  manifestation  of  the  ac- 
(piir<'d  I'oi'm. 

Symptoms.  —  In  secondary  syphilis  there  is  occasionally  erythema  of 
the  larynx,  which  may  go  on  to  definite  ealariii.  hut  has  nothing  charac- 
teristic. 'I"he  process  may  procci'd  to  the  formation  of  superlicial  whitish 
idcers.  usually  symmetrically  plat'cd  on  the  cords  or  ventricular  bands. 
Mucous  patches  and  condylomata  are  rarely  seen.  The  syni]itonis  are  jirac- 
tically  those  of  slight  loss  of  voice  with  laryngeal  irritation,  as  in  the  simple 
catarrhal  form. 

The  tertiary  laiTugeal  lesions  are  lunuerous  and  very  serious.  True 
gumniaia.  \ai'ying  in  size  from  tlu'  lu'ad  of  a  pin  to  a  small  nut.  dt'velop 
in  the  suhiuucous  tissue,  mosi  comntoidy  at  the  base  of  the  epiglottis.  They 
go  thi'ough  the  changes  chai'acteristic  of  these  structures  ami  may  I'ither 
break  down,  producing  extensive  anil  deep  ulc<'ration.  or — aiul  this  is  more 
chai'acteristic  of  syphilitic  laryngitis — in  their  healing  form  a  hbrous  tissue 
which  >hriid\s  and  produces  steno>is.  'i'he  ulceration  is  ajit  to  extend 
deeply  and  involve  the  cartilage,  inducing  necrosis  and  exfoliation,  and 
even  haunorrhage  from  erosion  of  the  arteries.  (Kdenia  may  suddeidy  pidve 
fatal.  The  cicatrices  which  follow  the  sch'rosis  of  the  gnmmata  or  the 
healing  of  the  idcers  produce  great  deformity.  The  e])iglottis.  for  instance, 
may  he  tied  down  to  the  ]iharyngeal  wall  or  to  the  epiglottic  folds,  or  even 
to  the  tongue:  and  eventually  a  steiio.-is  results,  which  may  necessitate 
tracheotomy. 

The  laryiigt'al  symptoms  of  iidu'rited  syphilis  have  the  usual  course  of 
these  h'sions  and  appear  either  early,  within  the  first  live  or  six  months,  or 
after  jmberty:  nuist  commonly  in  the  former  period.     Of  Tti  cases.,  J.  X. 


«■■■ 


ilMi 


ACUTE  nudxniiTis. 


t\-2\ 


Miickciizic  fntinil  tliiit  fi;'.  (Mciirnd  within  the  tiist  year.  Tin'  <:iiiiiiiiiili)iis 
iiililtriiliiiii  Iciiils  tci  ulcfi'iUioii.  must  ciimiiiiinly  nl'  the  cpiizlnttis  luiil  in  tlic 
V('ntri(lr>.  juhI  tin'  |inMc>s  iiuiv  cxlrinl  (lri|i|y  ami  iiiMiIsc  tiir  lartiliiuc 
Ciciiti'icial  ciiMti'actinii  may  •,\\>n  tucur. 

'i'lic  (lia.uuiisis  (if  >y|iliilis  (if  the  laryn\  is  rardy  (lillicult.  since  it  (uciirs 
iiiii.-t  (■(iiuiiKinly  in  (•(inin'clnin  with  dthci'  syni|iliim>  nf  the  ilix'asc. 

Treatment. — 'I'lic  iuhninistratidn  (if  cunstitutidnal  rcnuMlic.-,  is  the 
iiKisl  ini|iiirlant.  and  nndcr  mcrcnry  and  iodide  of  |i(ilas,~i\im  the  hieal  symj)- 
tdins  niav  I'apidly  he  I'eheved.  The  teHiaiT  laryngeal  nianifolatimis  are 
always  sei'ions  and  dillieult  lo  treat.  The  deep  uhcfation  is  specially  hard 
til  ((imhat.  and  the  cicati'i/.atioii  may  uece>.-itate  Iraeheutdiny,  ur  the  uradnal 
dilatatidn,  as  practised  hy  tSehrueller. 


III.    DISEASES   OF   THE    BIIOXCTII. 
I.    ACUTE    BRONCHITIS. 

Aciito  catarrhal  inilannnatidn  (if  the  hi'diieliial  nineoiis  memhraiie  is  a 
very  cdmiiidn  disea.-e.  rarely  serious  in  healthy  adults,  hut  very  fatal  in  the 
old  and  in  the  yuniiL;'.  dwiii;^'  to  a^suciated  pulniduary  cdniplicalidns.  It  is 
hilateral  and  alVects  either  the  larji'er  and  medinni  sized  tnhes  or  the  smaller 
hronchi,  in  which  ease  it  is  known  as  capillary  hi'onchitis. 

We  shall  speak  only  of  the  former,  as  the  latter  is  [lart  and  parcel  of 
hronchd-pneunidiua. 

Etiology. — Acute  hronehitis  is  a  comnidn  se(piel  df  catchin;,^  cold, 
and  is  often  ndthiiijj;  more  than  the  extension  downward  of  an  ordinary 
coryza.  Jt  occurs  must  l're(|iu;ntly  in  the  chanp'ahle  weather  of  early  siirin^- 
and  late  autumn.  Its  association  with  cold  is  well  indicated  hy  the  jiopu- 
lar  expression  "cold  on  the  chest."  It  may  prevail  as  an  epidemic  aiiart 
Irom  iidhieiiza.  of  which  it  is  an  important  feature. 

.\cute  hronehitis  is  associated  with  many  other  all'eetions.  notahly 
measles.  It  is  hy  no  means  rare  at  the  onset  of  typhoid  fever  and  malaria. 
It  is  present  alsi)  in  asthma  and  whoopin,u-cou>:h.  The  suhjccts  of  spinal 
curvature  are  specially  lialih-  to  the  disease.  The  hronehitis  of  i'.rig'ht's 
disease,  -(mt.  and  heart-disease  is  usually  a  chronic  form.  It  attacks  per- 
sons of  all  a,L;-es.  hut  iuo>t  fre(pieully  the  youn,u-  and  the  old.  There  ai'c  in- 
dividuals wiio  have  a  special  disposition  to  hronchial  catarrh,  and  the 
sli;;htest  exposure  is  ajit  to  l)riii.<;  on  an  attack.  Persons  who  live  an  out- 
of^loor  life  are  usually  less  sulijecl  to  the  disease  than  those  who  follow 
sedentary  occupations. 

'Pile  allVct ion  is  jirohahly  luicrohic,  thou.!:li  we  have  as  yet  no  dellnito 
evidence  npon  this  iioint. 

Morbid  Anatomy.— The  mucous  memhrane  of  the  trachea  and 
bronchi  is  reddened,  con.u'ested,  and  covered  with  mucus  and  niuco-]nis, 
\vhich  may  lie  seen  oozin.ir  I'rom  the  smaller  bronchi,  some  of  which  are 
dilated.     The  finer  chanues  in  the  mucosa  consist  in  desriuamation  of  th(^ 


^^k 


&2'2 


DISKASKS  OF  TIIK   UKSIMH.VT015V  SYSTKM. 


IS 


1.1 

M 


^.  ! 


,.ilii,t,,l  ..piilHlinin.  >\v.lliii^'  Mii.l  n.U.inii  nf  ili..  Milmiii.osi.  milI  inliltr.itH.ii 
,,f  111,.  ti>M:r  with  Inicocvtc.-.     Tlu'  iiiucoiis  uliuids  mit  much  >\V(.ll.-ii. 

Symptoms.— 'I'hc  "sviiiptoms  ..r  an  nnliiiiiry  "  cdhl  "  iHcomiMiiiy  ihr 
,,,i-,i   nl   ;iii  iirntr  hnpn.liili-.     'I'hc  .nryzii  .■xtcinls  t-.  thr  luhr>,  iin.l  may 
aNuair.vl  th.'  hirvnx,  laodiuiiiL'  li..aisciu'>s,  whidi  in  many  casis  is  mark.'.l. 
A  ciiill  is  rare.  I'mt   th.iv  is  iiivarial.ly  a  sens.-  ol'  oppiv^HniK  with  licavi- 
ill■^s  and  laii-nor  and  l^aiiis  in  the  l.oiu's  and  Im.k.     In  mild  la-'s  thciv  is 
MMivcIv  anv'l-cvcr.  Imt   in  macht  lnrm>  ih.'  raiip'  is   from   luT  In   H'lr. 
-n,..  iM-nn.hial  svni|.t..nis  set    in   willi   a    Icrlin-  -d'  ti-htncss  and    'awnrss 
hcni'alli   the  >t(Tnnni  and   a   sensation   of  npiirc-sioii   in   the  idirst.       Ihr 
nnndi  is  ron-h  at   iirst,  and  oft -n  of  a  rinjiiiifi  cliaractvr.     It  •'""H'^  ">'  "» 
,,aroNVMn>   which    ra.k   ami   diMivss   the   patient   ...xtivmrly.      hnnn-   the 
.rvciV  spells  the  pain  mav  \>v  verv  intense  I.en.'alh  the  Meiniim  and  alon.i,' 
,1„.  altaehm.'nt>  of  the  diaphragm.     At   liivt   the  eoii-li   i>  dry  and  the  e\- 
n,.etorati.m   s^antv  and   vIm  id.  Imt    in  a    few  .lays  the  seeivlion   h.romes 
uimu-pmnlent   and  ahundant.  and   iinally   imimleiit.     With   the  loo-eimit; 
,,r  the  ecm-h  -reat  relief  is  .■\peri..need.     The  >pmiini  IS  made  lip  largely 
of  pii-<vlls.  with  a  variahle  miniher  of  the  !ar-e  roiiml  alveolar  eells.  many 
„f  whieh  e.mtain  earhoii  -rain>,  while  others  have  undergone  the  myelin 
de;j;eneral  ion.  . 

riii/slnil  ,</,///,<.— The  respiratorv.  iiiovemonts  aro  not  greatly  iiierease.l 
i„  freqiienev  inih-s  the  fevr  i>  hi.-h.  There  are  instanees,  In.wever.  in 
which  the  'hreathin>r  is  rapid  and  when  the  smaller  tuhes  are  invoUvd 
tlierc  i>  dv>pmea.  On  palj-atioii  the  hmiichial  rremitus  may  often  he  Iclt. 
On  aiixnitation  in  the  early  >la--e.  pipinu'  sihilant  rales  are  everywhere  to 
1m.  heard.  Thev  are  very  ehan-vahlo.  and  appear  and  disappear  with  coii-li- 
iii^r.  With  tii'e  rclaNal'iou  of  the  hroiidiial  memhraiies  and  the  ,L;realer 
almndance  of  the  >ecretion.  the  rales  dian-e  and  hecoiiu'  miic.n-  and  huh- 
hliii-'  in  .piality.  The  l.ases  of  the  luiies  should  he  carefully  examined 
each  day.  particularly  in  children  and  the  a-vil. 


"he    fi'lirsc   oi    the   disease   depelKls    ( 


in  the  conditions  under  which   it 


develops.  Ill  healthv  adults,  hy  the  end  of  a  wirk  the  fever  snhsides  and 
thi'  cou-ii  loosens.  '  111  another  week  or  ten  days  coiivalescence  is  fully 
estahlishcd.  In  voun-  cliildren  the  chief  risk  is  in  the  extension  of  the 
process  downward.  In  measles  and  whoopin,<r-o<m.i:h.  the  ordinary  hrou- 
chial  catarrh  is  verv  apt  to  descend  to  the  (Iner  tuhes.  which,  hecoiiie  dilated 
nii.l  pluen-ed  with  muco-i.us.  induein.i;-  areas  of  collapse,  and  (inally  hmncho- 
pneiimonia.  This  extension  is  indicated  l.y  cliau'res  in  the  phyc:eal  signs. 
r<iiallv  at  the  l.asp  the  rales  are  suberopitant  and  numerous  and  there 
mav  he  areas  of  d(d'ective  resonance  and  of  feeble  nv  distant  tuhnlar  lu-eath- 
in.r  In  the  n-ed  and  debilitated  tliere  ore  similar  dangers  if  the  procesi= 
expends  from  the  lai-er  to  the  smaller  tubes.  In  old  age  the  bronelnal 
mucosa  is  less  capable  of  e.xpellinL'  the  mucus,  wliic-li  is  more  apt  to  sag  to 
the  dependent  parts  and  induce  dilatation  of  the  tubes  witb  extension  of 
the  inflammation  to  the  contiguous  air-cells. 

The  (1iaqi}n><if>  of  acuto  bn.ncbitis  is  rarelv  dillicult.  Although  the 
mode  of  onset  mav  be  brus.pie  and  i-erliaps  simulate  i.neumonia.  yet  the 
absence  of  dulness  and  blowing  breathing,  and  the  general  character  of 


CIIUONIC    HUONCIHTIS. 


t;ii;i 


tln'  liromliiiil  iiitliiiiiiiiiitiiui,  rt'iidcr  (lie  (liii^^Miosis  siiii|ilt'.  Alioiit  oiux'  a 
yciir  I  sec  a  case  of  ly|ilini(l  Icvcr.  in  vvliicli  the  (lia),'ii(isis  at  lir.-l  lias  Imcii 
a(  iilc  lii'niicliitis.  'I'lii'  cdiniilii  alinii  nl'  lirniiclKi-iiiicntiKUiia  is  iiidicali'd  liy 
til"  ^Tfitcr  si'vcrity  ol'  the  sviiijituiii!?,  jiiirliiiilaily  liic  ilyspiiu'a,  lln'  ihaii^'i  d 
C'liinr.  and  the  physical  si^^ns. 

Treatment.— -Ill  mild  ca:i'-.  iHHisclmld  measures  siijlice.  The  hot 
f(M)t-lialli,  or  the  warm  hath,  a  drink  of  hot  lemonade,  and  a  mustard  [ilaster 
on  the  chest  will  often  'nve  relied'.  For  the  dry,  racking  cough,  the  synip- 
toiii  iiio.-.t  coiiijilaiiu'd  of  by  tiu-  patient,  Dover's  powder  is  the  hesl  remedy. 
It  is  a  popular  helitd'  that  ([iiiiiine,  in  full  doses,  will  cheek  an  oncoming 
coM  oil  the  chest,  hut  this  is  doiihtfiil.  It  i.s  a  common  custom  when  per- 
sons feel  the  approach  of  a  cold  to  take  a  'I'urkish  hath,  and  though  tht" 
tiglitiu'ss  and  oppression  may  he  relieved  hy  it,  there  is  in  a  majoiily  (jf  the 
cases  great  risk.  Some  of  the  severest  ca-^es  of  hronchitis  which  1  have 
seen  have  followed  this  initial  Tnikish  hath.  No  doiiht,  if  the  person 
could  go  to  hed  directly  from  the  hath,  its  actioti  would  he  lieiielicial,  hut 
there  is  great  risk  of  catching  aildilimial  "  cidd  '"  in  going  home  from  the 
hath,  liclitd'  is  ohtaiiied  from  the  iiiiplea.saiil  sen.se  of  rawness  hy  keeji- 
iiig  the  air  of  the  mom  satiirati'd  with  moisture,  and  in  this  dry  stage 
the  old-1'asliioiieil  mixture  of  the  wines  of  antimony  and  ipi'caciiaiilia  with 
liipior  ammoiiii  acetatis  and  intious  ether  is  useful.  if  the  pulse  is  very 
rapid,  tincture  of  aconite  may  ho  given,  particulaiiy  in  the  ca.se  of  chil- 
dren. l'"(ir  the  eongh,  when  dry  and  iriitating,  opium  should  ho  freely 
u.-cd  ill  the  form  of  i)over'.s  powder.  Of  counse,  in  the  very  young  and 
llie  agod  care  must  he  exercised  in  the  nso  of  opium,  particularly  if  the 
secrotions  are  free;  hut  for  the  distressing,  irritative  cough,  which  keeps 
the  patient  awake,  no  remeily  can  take  its  place.  As  llio  cough  loosens 
and  the  expectoration  is  more  ahuiidant,  the  patient  hoeomos  more  com- 
fiirtahle.  In  this  stage  it  is  customary  to  ply  him  with  expootorants  id' 
various  sorts,  'riioiigh  nscd'ul  occasionally,  they  should  not  he  given  as  a 
matter  of  rontiiio.  A  mixture  of  s([uills,  ammonia,  and  senega  is  a  favorite 
one  with  many  pr.-ictitionors  at  tlii.s  stage. 

In  the  acute  hronchitis  of  children,  if  the  amount  of  secretion  is  largo 
ami  dillieiilt  to  expectorate,  or  if  there  is  dyspmea  and  the  color  hegins 
to  get  dusky,  an  emetic  (a  tahlespoonfiil  of  ipecac  wine)  should  he  given 
at  once  and  repeated  if  necessarv. 


II.    CHRONIC    BRONCHITIS. 


Etiology. — This  aifeclion  may  follow  re])eated  attacks  id'  acute  hron- 
cliitis,  l)ut  it  is  most  commonly  mot  with  in  ohronie  lung  alTections,  hoart- 
disease,  aneurism  of  the  aorta,  gout,  and  renal  disease.  It  is  frequent  in 
the  aged;  the  young  rarely  are  alTected.  f'limato  and  season  have  an  ini- 
jinrtant  influence.  It  is  the  winter  eongh  of  the  old  man,  wliicli  recurs 
with  regularity  as  the  weather  gets  cold  and  ehangealile. 

Morbid  Anatomy. — The  bronchial  mueosa  ])resents  a  great  variety 
of  changes,  depending  somewhat  upon  the  disease  with  which  chronic 
39 


fV 


021 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


l.ronchilis  is  assoeiaiccL      lu  so.no  cases  llu>  mucons  mon.l,raiio  is  ^    j 
i   ,    o  Ihat  tlu>  lou,ntu.1inal  hands  of  olastu.  lissn.  stand  nut  pronunonll  . 
Tlu.  lulu's  aro  dilatc-.l,  tl..  muscular  and  gla.idular  tissues  are  utmpln.d. 
and  the  onitlu'liuni  is  in  great  part  shed. 

In  other  instances  the  nn,c.,sa  is  thickened,  grannh.r,  and  infdtra  .;d 
There  n.av  he  nh'eration,  partienhirly  of  the  nu.cous  hdhch's.  I.runchial 
dilatation^  are  not  uncon.n.on  and  emphysema  is  a  constant  acconipani- 

'  ""  Symptoms.-] Ti  the  form  n.et  with  in  old  men,  associate  d  with  em- 

^  pln°m,a,  g-ont.  or  hcu't-lisea^c.,  the  chief  sympton>s  are  as  ioUows:  Short- 

I  Us  of  hreath,  .inch  may  not  he  noticeahle  ^^^;;^^\  ;^%^^'%'l 

^  patients  "  pniV  and  hlow  "  on  going  ni*  lull  or  up  a  tl.ght  of  stan..      ilus  i. 

due  not  so  much  to  the  chronic  hronchitis  itself  as  to  associated  emphysen.a 
or  ev..n  to  cardiac  weakness.  They  complain  oi  no  pain,  ihe  cough  .. 
variahle.  .'hangiug  with  the  weather  and  with  the  season.  During  the 
iner  they  .nav  remain  tree,,  hut  each  succeeding  winter  the  cough  con.es 
on  with  severity' and  persists.  There  may  he  only  a  spel  in  the  morning. 
<,!■  the  chief  distress  is  at  night.  The  sputum  in  chronic  hronchitis  is  very 
varial.le.  In  cases  of  the  so-called  dry  catarrh  there  is  no  expectoration. 
r<uallv,  however,  it  is  abundant,  muco-purulent,  or  distinctly  purulent  m 
character.  There  are  instances  in  which  the  patient  coughs  up  lor  years 
a  thin  tluid  sputum.  There  is  rarely  fever.  The  general  health  may  he 
good  and  the  disease  may  present  no  serious  leatures  apart  Irom  the  l.a- 
hilitv  to  induce  emid.vsema  and  bronchiectasy.  In  many  cases  it  is  an 
i,H.u"ral)le  alfection.  I'atients  improve  and  the  ctmgh  disappears  m  the 
summer  time  only  to  return  during  the  winter  months. 

Physical  Signs.— The  chest  is  usually  distended,  the  movements  are 
limited,  and  the  condition  is  often  that  which  we  see  in  emphysema.  J  he 
percussion  note  is  clear  or  hy].erresonaiit.  On  auscultation  expiration  is 
prelonged  and  whee.v  and  rhonchi  of  various  sorts  are  heard-some  Ingh- 
pitclied  and  piiiing,  others  deep-u>ned  and  snoring.  Crepit>ition  is  com- 
mon at  the  bases.  _  . 

Clinical  Varieties.— Tlie  descrij-tion  just  given  is  of  the  or.hnar.v 
chronic  bronchitis  which  occurs  in  connection  with  emiihysema  and  heart- 
disease  and  in  many  elderly  men.  There  are  certain  forms  whu^li  merit 
special  description:  (a)  On  several  occasions  I  have  met  with  a  lorm  ot 
rhroiiir  bronrhilis,  particularlv  in  women,  which  conies  on  between  the  ages 
of  twentv  and  thirtv  and  m.iy  continue  indefinitely  without  serious  impair- 

il  ment  of  the  health. 

(h)    7?n)»r7(orr/((W.— Excessive  bronchial   secretion   is  met   witii   uiuler 
several  conditions.     It  must  not  be  mistaken  for  the  i.rofuse  exi)ectoration 
of  bronchiectasy.    The  secretion  may  be  very  liquid  and  \y:x{vry—hn»irhn,- 
i\  rlnva  serosa,  anil  in  extraordinary  amount.    :\l<n'e  commonly,  it  is  purulent 

f  though  thin,  and  with  greenish  or  yellow-green  masses.     It  may  be  thick 

;  and  uniform.    This  profuse  bronchial  secretion  is  usually  a  manilestation 

il   '    >  of  chronic  bronchitis  and  may  lead  to  dilatation  o^  the  tubes  and  ultimately 

'  t  to  fetid  hronchitis.    In  the  vouiur  the  co'id'lion  may  persist  for  years  witli- 

V.  out  impairment  of  health  and  without  apparently  damaging  the  lungs. 


CIIROXIC  BRONCniTIS, 


0:25 


ano  IS  vorv 
iromiiu'iuly. 
i  atn>itliiiMl, 

1  inCiltvati'il. 

IW'oncliial 

accDiupani- 

■,  (1  witli  oni- 
lows:  Short- 
■rtidii.  The 
irs.  This  is 
I  cinpliysema 
lie  cough  is 
Duriiii;-  the 
cough  comes 
the  morning, 
cliitis  is  very 
xpectoration. 
■  purulent  in 
\\\)  for  years 
•alth  may  he 
from  tlic  lia- 
ases  it  is  an 
ipears  iu  the 

:)vements  are 
lysema.  The 
expiration  is 
— some  liigh- 
ition  is  com- 

the  ordinary 
na  iintl  lieart- 
which  merit 
ith  a  form  of 
ween  the  ages 
erious  impair- 

t  witli  nniler 
expectoration 
„>ry — h  mil  rill  I  r- 
it  is  ])urulent 
may  he  tliick 
manifestation 
md  ultimately 
'or  years  with- 
tlie  lungs. 


(r)  Pull-id  Broneliilis. — i'etid  expectoration  is  mot  witii  in  ccmnection 
Aviih  hroiicliieetasis,  gangrene,  al)scess,  or  with  decom|>osilion  of  secretions 
witiiin  phthisieal  cavities  and  in  an  empyema  wJiich  has  perforated  the 
lung.  'I'here  aie  instances  in  which,  ai)art  from  any  of  these  slates,  llio 
expectoration  lias  a  fetid  character.  Tiie  spula  arc  ai)un(hint,  usually 
thin,  grayish-white  in  color,  and  they  separate  into  an  upper  lluid  layer 
cai)]ied  with  frothy  mucus  and  a  thick  sediment  iu  whieh  may  sonu'tiuics 
])(■  huind  dirty  yellow  masses  the  size  of  i)cas  or  heaiis — the  so-called  iJit- 
triclTs  plugs.  The  all'ection  is  very  rare  a[)art  from  the  al)ove-mentioned 
conditions,  in  severe  cases  it  leads  to  changes  in  the  hroiuihial  walls, 
jineunionia,  and  often  to  ahscess  or  gangrene.  Metastatic  hrain  ahscess  has 
followed  putrid  hronchitis  in  a  certain  iiumher  of  cases. 

(il)  Drij  Valarrh. — Tiic  ailarrlic  nee  of  Lacnnec,  a  not  uncommon  form, 
is  characterized  hy  paroxysms  of  coughing  of  great  intensity,  with  little  in- 
no  expectoration.  Jt  is  usually  met  with  in  elderly  persons  with  emphy- 
sema, and  is  one  of  the  nu)st  ohstinato  of  all  varieties  of  hronchitis. 

Jn  England  the  dam])  cold  of  the  unwarmcd  houses  is  res])onsiI)lc  in 
great  part  for  ihc  prevalence  of  chronic  hromhitis  anu)ng  tin-  aged  ami 
weak.  An  cquai)Ie,  warm  tcniiierature  is  of  the  (irst  importance  to  all 
persons  ])rone  to  the  disease. 

Treatment. — JJy  far  the  most  satisfactory  method  of  treating  the 
recurring  winter  hroiu-hitis  is  change  of  climate.  l\cuu)val  to  a  southern 
latitude  may  i)revent  the  onset.  Southern  France,  s(Uithern  Calirornia, 
and  Florida  furnish  winter  climates  in  which  the  suhjccts  of  chronic  i)ron- 
chitis  live  with  the  greatest  comfort.  All  cases  of  i)rolonged  hronchial 
irritatio]!  are  hcnclitcd  hy  change  of  air. 

The  lirst  eiulcavor  in  treating  a  case  of  chronic  hronchitis  is  to  ascer- 
tain, if  possil)le,  whether  there  are  constitutional  or  local  affections  with 
which  it  is  associated.  In  many  instances  the  urine  is  found  to  he  highly 
acid,  ])erhaps  slightly  alhuminous,  and  the  arteries  are  stiff.  In  the  form 
associated  with  this  condition,  sometimes  called  gouty  hronchitis,  the  at- 
tacks seem  related  to  the  defective  renal  elimination,  and  to  this  condition 
the  treatment  should  l)e  firr.,  directed.  In  other  instances  there  arc  heart- 
disease  and  emphysema.  In  tlie  form  occurring  in  old  nu'n  much  may  he 
done  in  the  way  of  ])rophYlaxis.  Se])tuagcnarians  should  read  Oliver  Wen- 
dell Holmes's*  "De  Scnectute  "  with  reference  to  the  care  of  the  health. 
There  is  no  douht  that  with  i)rudence  even  in  our  changealjlc  winter 
weather  much  may  he  done  to  jirevcnt  the  onset  of  chronic  hronchitis. 
Woollen  undergarments  should  he  used  and  especial  care  should  he  taken 
in  the  s])ring  months  not  to  change  them  for  lighter  ones  hefore  the  warm 
weather  is  cstahlishcd. 

Cure  is  seldom  effected  hy  medieinnl  renu'dies.  There  arc  instances 
in  which  iodide  of  ))otassium  acts  with  remarkable  hcnefit,  and  it  should 
always  he  given  a  trial  in  cases  of  paroxysmal  bronchitis  of  ol)scure  origin. 
For  the  morning  cough,  bicarbonate  of  sodium  (gr.  xv),  chloride  of  sodium 
(gr.  v),  spirits  of  chloroform  (niv)  in  anise  water  and  taken  with  an  equal 

♦  Over  tlie  Toa-cups,  Boston,  1890. 


020  DISEASES  OF   THE   RESPIRATORY   SYSTEM. 

niiKnnit  of  warm  wntoT  will  bo  found  useful  (Fowler).    When  tlioro  is  much 
t^on^^o  of  li-htiU'.-H  aiid  fuluoss  of  the  clivst,  tho  portable  Turkish  l)ath  may 
I  ■  ije  tried.     When  the  secretion  is  exeosive  mnriale  of  ammonia  and  senei:a 

are  useful.  Stimulatiiifj;  expeetorants  are  eoniraindieated.  ^Vhcu  the  heari 
is  feeble,  tlie  eoml)imition  of  digitali-  and  strychnia  is  very  lieneficial.  Tur- 
pentine, the  old-fashioned  remedy  ,-o  warndy  recommended  by  the  Dublin 
])hysicians,  has  in  many  quarters  fallen  undeservedly  into  disuse.  Prepara- 
tions of  tar,  creasote,  and  terebene  are  sometimes  useful.  Of  other  balsamic 
remedies,  sandal-wood,  the  compound  tincture  of  benzoin,  copaioa,  Indsam 
of  I'ern  or  tola  may  be  used,  lidialations  of  eucalyptus  and  of  the  spray 
of  ipecacuanha  wine  are  often  very  useful.  If  fetor  be  present,  carbolic 
acid  in  the  form  of  spray  (10  to  -.'0  jier  cent  solution)  will  lessen  the  odor, 
or  tiiymnl  (1  to  l.ddO).  ^  For  nrgent  dyspnuL'a  with  cyanosis,  Ijleeding  from 
1  the  arm  givi's  most  relief. 


III.    BRONCHIECTASIS. 

Etiology.— l)ilatati(ni  of  the  bronchi  occurs  under  tho  following  con- 
ditions: (1)  As  a  congenital  defect  or  anomaly.  Such  cases  are  extremely 
rare,  eonnnonly  unilateral.  (Jrawitz  has  described  tho  coiulition  as  hroii- 
rhicrtasix  viiirnyali.t.  "Welch  has  met  an  instance  in  a  young  girl.  (2)  In 
connection  with  inllammation  of  the  bnuichi,  particularly  when  this  lea<ls 
to  weakness  of  the  walls  with  the  accuundation  of  secretion.  I  have  seen 
an  instance  after  iniluenza.  I'nder  this  category  comes  the  dilatation  met 
with  in  chronic  bronchitis  and  emphysema,  the  dilated  bronchi  in  chronic 
phthisis,  in  the  catarrhal  pneumonias  of  children,  and  particularly  the  dila- 
tation which  results  from  the  i)resence  of  foreign  bodies  in  the  air-tubes 
<ir  from  ])ressure,  as  of  an  aneiu'ism  on  one  bronchus.  (3)  In  extreme 
contraction  of  the  lung  tissue,  whether  due  to  interstitial  pneumonia  or  to 
comitression  by  pleural  adhesions,  bronchial  dilatation  is  a  common  though 
not  a  constant  acconi]ianiment. 

Unciuestionably  tlie  weakening  of  the  bronchial  wall  is  the  most  impor- 
tant, probablv  the  essential,  factor  in  inducing  bronchiectasy,  since  the  wall 
is  then  not  able  to  resist  tho  jiressure  of  air  in  severe  spells  of  coughing 
and  in  straining.  In  some  instances  the  mere  weight  of  the  accumulated 
secretion  may  bo  suiTicient  to  dLstend  the  terminal  tubules,  as  is  seen  in 
compression  of  a  bronchus  by  aneurism. 

Morbid  Anatomy. — Two  chief  forms  are  recognized— the  culin- 
dricol  and  the  saccular — which  may  exist  together  in  the  same  lung.  The 
condition  may  be  general  or  ])artia].  T^niversal  bronchiectasis  is  always 
unilateral.  Tt  occurs  in  rare  congenital  cases  and  's  occasionally  seen  as  a 
soquence  of  interstitial  pneumonia.  The  entire  bronchial  tree  is  repre- 
sented by  a  series  of  sncculi  opening  one  into  the  other.  The  walls  are 
smooth  and  possibly  without  ulceration  or  erosion  except  in  tho  dependent 
parts.  The  lining  nuMubrano  of  the  saccidi  is  usually  smooth  and  gliston- 
insr.  The  dilatations  mnv  form  large  cysts  immediately  ben(>ath  the  pleura. 
Tntcrvenini;-  between  the  sacculi  is  a  dense  cirrhotic  lung  tissue.      The 


ore  is  much 
li  l)iith  limy 

ami  ycnegii 
Ml  the  hcaii 
ticiah    Tur- 

iIk'  Dublin 
.'.  rivi)ara- 
lev  balsamic 
lioa,  balsam 
)f  the  spray 
'lit,  carljolic 
jn  the  odor, 
ut'diiig  from 


BRONCHIECTASIS. 


Ilowiiig  pon- 
IX'  extremely 
ion  as  hruii- 
•;\r\.  (-i)  In 
!n  this  Icadri 
I  have  seen 
latation  inel 
i  in  chronic 
.rly  the  dila- 
:hc  air-tubes 
In  extreme 
imonia  or  to 
nion  though 

most  impor- 
ince  the  wall 
of  coughing 
accumulated 
IS  is  seen  in 

— the  cijlin- 
-i  lung.  Tlio 
sis  is  always 
Uy  seen  as  a 
rcp  is  rejire- 
'ho  walls  are 
le  dependeut 
and  glisten- 
h  the  pleura, 
tissue.      The 


G27 


jiartial  dilatations — tlie  saccular  and  cylindrical — are  common  in  chronic 
liiitliisis,  particularly  at  the  apex,  in  ciironic  pleurisy  at  the  base,  and  in 
emplivsema.  Jlerc  the  dilatation  is  more  commonly  cylindrical,  some- 
times fusiform,  'i'lic  hroncliial  mucous  mcnduane  is  much  involved  and 
sometiii!"'  there  is  a  narrowing  of  tiie  lunu'U.  Occasiomdly  one  meets 
with  a  single  saccular  hroncliit'ctasy  in  connection  with  chronic  Ijronchitis 
or  emphysema.  t?ome  of  these  look  like  simple  cysts,  with  smooth  walls, 
without  lliiid  contents.  A  form  of  acute  bronchiectasis  in  (iiildreii  has 
been  described  by  Sharkey,  Carr,  and  others.  A  good  account  of  it  is  given 
in  Fowler  and  (iodlee's  work  on  the  lungs. 

Histologically  the  bronchi  which  are  the  scat  of  dilatation  sliow  im- 
portant changes.  In  the  large,  smooth  dilatations  the  cylindrit'al  is  re- 
placed by  a  pavement  epithelium.  The  muscular  layer  is  stretciied,  atro- 
phied, and  the  lil)rcs  separated;  the  clastic  tissue  is  also  much  stretched 
and  separated.  Jii  the  large  saccular  bronchii'ctascs  and  in  some  of  the 
cylindrical  forms,  due  to  retained  secretions,  the  lining  membrane  is  ulcer- 
ated. The  contents  of  some  of  the  larger  bronchicctatic  cavities  are  hor- 
ribly fetid. 

Symptoms.— Tn  the  limited  dilatations  of  phthisis,  emphysema,  and 
chronic  bronchitis,  the  symptoms  are  in  great  part  those  of  the  original 
disease,  and  the  condition  often  is  not  suspected  during  life. 

In  extensive  saccular  bronchiectasy  the  characters  of  the  cough  and 
expectoration  are  distinctive.  The  patient  will  pass  the  greater  part  of 
the  day  without  any  cough  and  then  in  a  severe  paroxysm  will  bring  up 
a  large  (pmntity  of  simtuin.  Sometimes  change  of  the  position  will  bring 
on  a  violent  attack,  jtmbably  due  to  the  fact  that  some  of  the  secretion 
Hows  from  the  dilatatii  to  a  normal  tube.  The  daily  spell  of  coughing 
is  usually  in  the  morning.  The  expectoration  is  in  many  instances  very 
characteristic.  It  is  grayish  or  grayish  brown  in  (olor,  lluid,  purulent, 
with  a  peculiar  acid,  sennet imes  fetid,  odor.  Placed  in  a  conical  glass,  it 
separates  into  a  thick  granular  layer  lielow  and  a  tliin  mucoid  intervening 
layer  above,  which  is  caiiped  by  a  bnjwnish  froth.  ]tlicrosco])ically  it 
consists  of  pus-corpuscles,  often  large  crystals  of  fatty  acids,  which  are 
sometimes  in  enormous  numbers  over  the  held  and  arranged  in  bunches. 
Ihematoidin  crystals  are  sometimes  present.  Elastic  filu'cs  are  seldom 
found  except  when  there  is  ulceration  of  the  bronchial  walls.  Tubercle 
bacilli  are  not  ]>resent.  In  simie  cases  the  expectoration  is  very  fetid 
and  has  all  the  characters  of  that  described  under  fetid  lironchitis.  Xum- 
mular  exyiectoration,  such  as  conies  from  ])htliisical  cavities,  is  not  com- 
mon. Ila'morrhage  occurred  in  l-±  out  of  35  cases  analyzed  by  Fowler. 
Aliscess  of  the  brain  has  in  a  few  instances  followed  the  bronchiectasis. 
Rheumatoid  affections  may  develop,  and  it  is  one  of  the  conditions  with 
which  the  i)ulmonary  ostco-artbropathy  is  commonly  as.sociated. 

The  diivinnsis  is'  not  ])ossibIe  in  a  large  number  of  the  cases.  Tn  the 
extensive  sacculated  forms,  unilatoral  and  associated  with  interstitial  iineu- 
monia  or  chronic  iileiirisy.  the  diagnosis  is  easy.  There  is  contraction  of 
the  side,  which  in  some  "instances  is  not  at  all  extreme.  Tlie  cavernous 
signs  may  be  chiefly  at  the  base  and  may  vary  according  to  the  condi- 


T" 


628 


DISEASES  OF  THE  RESPIRATORY   SYSTEM. 


ti.,n  of  the  cavitv.  wliolhcr  full  or  oini.ty.  There  may  bo  Iho  mn<i  ox- 
uiii«ito  aini)horic"  phenomena  and  loud  resonant  rales.  The  condition 
persists  lor  years  and  is  not  inconsistent  with  a  tolerably  active  life.  The 
iiatients  frtniuentlv  show  sijrns  of  marked  embarrassment  of  the  pul- 
monary circulation.  There  is  cyanosis  on  exertion,  the  finj,MM--tips  are 
cliil)bed,  and  the  nails  incurved.  A  condition  very  ditlicult  to  distin- 
guish from  bronchiectasv  is  a  limited  pleural  cavity  communicating  '.vith  a 

l)ronchus.  .         ... 

Treatment.— :\rod leal  treatment  is  not  satisfactory,  since  n  is  impos- 
Mble  to  heal  the  cavity.     I  bave  practised  the  injection  of  antiseptic  Ihuds 
in  some  instances  with  benefit.     Intratracheal  injections  liave  been  very 
warmlv  recommended  of  late.     With  a  suitable  syringe  a  drachm  may  be 
injected  twice  a  day  of  tlie  following  solution:    IMenthol  10  parts,  guaia- 
co'l  2  parts,  olive  oil  88  parts.    The  creasote  vapor  bath  may  be  given  m  a 
small  room.    The  ])atient*s  eyes  must  be  protected  with  well-lUtmg  goggles 
and  the  nostrils  stulfed  with  cotton-wool.     Commercial  creasote  is  poured 
into  a  metal  saucer  on  a  tripod  and  the  saucer  heated  by  a  spirit  lamp.    At 
first  the  vapor  is  very  irritating  and  disagreeable,  but  the  patient  gets  used 
to  it.     The  bath  should  be  taken  at  first  every  other  day  for  iifteen  min- 
utes, then  gradually  increased  to  an  hour  daily.      The  treatment  should 
be  continued  for  three  montlis.      Fowler  states  that  be  has  known  the 
fetor  to  disappear.     In  suitable  cases  drainage  of  the  cavities  may  be  at- 
tem].ted,  ]mrticularly  if  the  ])aticnt  is  in  fairly  good  condition.     For  tlie 
fetid  secretion  turpentine  may  be  given,  or  terebene,  and  inhalations  used 
of  carbolic  acid  or  thymol. 


l-i:'  I 

K  1 


IV.    BRONCHIAL   ASTHMA. 

Asthma  is  a  term  which  has  been  apjdied  to  various  conditions  associ- 
ated with  dvs])na'a— hence  the  names  cardiac  and  renal  asthma— but  its 
use  should  be  limited  to  the  all'ection  known  as  bronchial  or  spasmodic 

asthma.  ....  f 

Etiology.— All  writers  agree  that  there  is  in  a  majority  of  eases  ot 
broncliial  asthma  a  strong  neurotic  element.  Many  regard  it  as  a  neu- 
rosis in  which,  according  to  one  view,  spasm  of  the  bronchial  muscles,  ac- 
cording to  the  other  turgcscence  of  the  mucosa,  results  from  disturbed  m- 
nervathm,  inieumogastric  or  vaso-motor.  Of  the  numerous  theories  the 
following  are  the  most  important: 

(l)That  it  is  due  to  spasm  of  tlie  bronchial  muscles,  a  theory  which 
has  perhajis  the  largest  number  of  adherents.  The  original  experiments 
of  C.  J.  B.  Williams,  upon  which  it  is  largely  based,  have  not,  however. 
been  confirmed  of  late  years. 

(2)  That  the  attack  is  due  to  swelling  of  the  bronchial  mucous  niem- 
l^rane— fluctionary  liyiteru'niia  (Traube),  vaso-motor  turgcscence  (Weber), 
diffuse  liypeiwmic  swelling  (Clark).      , 

{:])  Tliat  in  niiiny  cases  it  is  a  special  form  of  inilammation  of  the 
smaller  hwmcKwli^s—bronchwUtis  exudatica   (Curschmann).     Other  thco- 


10  most  ox- 
.'  condition 
3  life.  Tlie 
)!'  tlio  piil- 
pM'-tij)S  are 
t  to  (listiii- 
itiiig  with  a 

ii  i;j  iinpos- 
septic  fluids 
i-  lioeu  vory 
:Iiin  may  be 
parts,  guaia- 
e  given  in  a 
ting  goggles, 
te  is  poureil 
it  lamp.  At 
>nt  gets  iised 
iii'teon  min- 
nient  should 
;  known  the 
5  may  be  at- 
M\.  For  the 
alations  used 


itions  associ- 
iina — but  its 
or  spasmodic 

y  of  cases  of 

it  as  a  neu- 

l  muscles,  ac- 

disturbed  in- 

theories  the 

theory  which 
I  exjH'riinents 
not,  however. 

mucous  mem- 
Hice  (Weber), 

nation  of  the 
Other  theo- 


nilOXCIIIAL  ASTHMA, 


C2'.) 


ries  which  may  be  mentioned  are  that  the  attack  depends  on  spasm  ol  tl.e 
diaphragm  or 'on  reilex  spasm  of  all  the  inspiratory  muscles. 

As  already  mentioned,  tiie  so-called  hay  fever  is  an  alVcction  which  has 
many  rc.cnd)lances  to  bronchial  asthma,  with  which  the  attacks  may  alter- 
nate,    in  the  suddenness  of  onset  and  in  many  of  their  features  these  dis- 
eases have  the  same  origin  and  ditfer  oidy  in  site,  as  suggested   by  Sir 
Andrew  Clark  and   now  generally  acknowledged   by  specialists.     .Making 
due  allowance  for  anatomical  dilferenccs,  if  the  structural  changes  occur- 
rin<>-  in  the  nasal  mucous  membrane  during  an  attack  of  hay  fever  were  to 
occ^ir  also  in  ■  arious  i.arts  of  the  bronchial  mucosa,  their  presence  there 
would  alford  a  complete  and  adeciuate  explanation  of  the  facts  observed 
during  a  paroxysm  of  i)ronchial  asthma  (Clark).     With  this  statement  I 
fully 'i'lLMTc,  but  the  ol)scrvations  of  Cursclmiann  have  directed  attention 
to  a  feature  in  asthma  which  has  been  neglected;    namely,  that  in  a  ma- 
jority of  the  cases  it  is  associated  with  an  exudation,  such  as  might  be 
supposed  to  come  from  a  turgescent  mucosa  and  which  is  of  a  very  charac- 
teristic and  peculiar  character.     The  hyperiemia  and  swelling  ol  the  mu- 
cosa iind  the  extremely  viscid,  tenacious  mucus  explain  well  the  hindrance 
to  inspiration  and  expiratiou  and  also  the  quality  of  the  rales.    An  (edemi 
of  the  angio-neurotic  ty]»e  has  been  described  in  the  hands  and  arms  in 
asthma  (J.  S.  J5illings,  Jr.).  .        ,      m. 

Some  general  facts  with  reference  to  etiology  may  be  nuMitioned.     J  lie 
affection  sometimes  runs  in  families,  particularly  those  with  irritable  and 
unstable  nervous  svstems.     The  attack  may  be  associated  with  neuralgia 
or    as  Salter  mentions,  even  alternate  with  e|)ilepsy.     Men  are  more  fre- 
(lu'cntlv  alVected  than  women.     The  disease  often  begins  in  childhood  and 
sometimes  lasts  until  old  age.     It  may  follow  an  attack  of  whooping-cough. 
One  of  its  most  striking  peculiarities  is  the  hizarre  and  extraordinary  variety 
of  circumst4Uices  which  at  times  induce  a  paroxysm.     Anu)ng  these  local 
conditions  climate  or  atmosphere  are  most  important.     A  person  may  be 
free  in  the  city  and  invariably  suffer  from  an  attack  when  he  goes  into  the 
country,  or  into  one  siiecial  part  of  the  country.     Such  cases  are  by  no 
means  ■uncommon.     Breathing  the  air  of  a  particular  room  or  a  dusty  at- 
mosphere may  bring  on  an  attack.     Odors,  particularly  of  flowers  and  of 
liav  or  emanations  from  animals,  as  the  horse,  dog,  or  cat,  may  at  once  cause 
nn  outbreak     Tright  or  violent  emotion  of  any  sort  may  bring  on  a  parox- 
ysm     rterine  and  ovarian  troubles  were  formerly  thought  to  induce  at- 
tacks and  may  do  so  in  rare  instances.    Diet,  too,  has  an  important  influ- 
ence and  in  persons  subject  to  the  disease  severe  paroxysms  may  be  induced 
by  overloading  the  stoma,  h,  or  by  taking  certain  articles  of  food.     Chronic 
cases    in  which  the  attacks  recur  year  after  year,  gradually  become  asso- 
ciated with  emphysema,  aiul  every  fresh  "  cold  "  induces  a  paroxysm.    And 
hi-tly  many  cases  of  bronchial  asthma  are  associated  with  affections  of  the 
luise". 'imrticularlv  with  hviiertrophic  rhinitis  and  nasal  polypi.     According 
to  some  specialists  of  hu-e  experience,  all  ca~.  s  of  bronchial  asthma  have 
scmie  affection  of  the  upper  air-passages,  but  I  mu  convinced  tn.in  personal 
observation  that  tnis  is  erroneous.     Still  physicians  must  acknowledge  the 
debt  which  we  owe  to  Voltoliui,  Hack,  Daly,  Koe,  and  others  who  have 


'.!r  ■ 


(530  UlSEASKS  OF  THE   KHSI'IUATUllY   SYSTEM. 

sliowii  the  close  (■oiinoclicii   wliicli   exists  between  all'eetioiis  ol'  the  iiaso- 
nharviix  and  inanv  eases  ol'  l)i(>iieliial  asthma. 

Jirielly  slated  tlieii,  broneliial  asthma  is  a  iieiirolie  allVetiuii,  eharaeter- 
ized  by  liypeneniia  and  tnrgeseenee  of  the  iniieosa  of  tlie  smaller  broneliial 
tul)es  and  a  peeidiar  exudate  of  mucin.  The  attacks  may  be  due  to  direet 
irritation  of  the  bronchial  mucosa  or  may  \>e  induced  retlexly,  by  irritation 
of  the  nasal  mucosa,  and  indirectly,  too,  by  rellex  inllueiices,  from  st;.iiiacli, 
intestines,  or  t^cnilal  organs. 

Symptoms.— Premonitory  sensations  precedi'  some  attaiks,  siieii  as 
chilly  J'eeling.s,  a  .sense  of  tigiitness  in  the  chest,  llatulcnce.  the  passage  of  a 
largJ  quantity  of  urine,  or  great  depression  of  spirits.     Nocturnal  attacks 
are  common.     After  a  few  hours'  sleep,  the  patient  is  aroused  with  a  dis- 
tressing sense  of  want  of  breath  and  a  feeling  of  great  oppression  in  the 
chest.  ""Soon  the  respiratory  ell'orts  become  violent,  all  the  accessory  mus- 
cles are  brought  into  i)lay.  and  in  a  few  minutes  the  patient  is  in  a  paroxysm 
of  the  most   intense  dy.<piura.      'JMie  face  is  jiale,  the  expression  anxious, 
speech  is  impossible,  and  in  spite  of  the  most  strenuous  inspiratory  ellorts 
very  little  air  enters  the  lungs,     ivxpiration  is  ])rolonged  and  also  wheezy. 
The  number  of  respirations,  however,  is  not  much  increased.     The  asth- 
matic lit  mav  last  from  a  few  minutes  to  several  hours.     When  severe,  the 
signs  of  defective  aeration  soon  appear,  tiie  face  becomes  bedewed  with 
sweat,  the  pulse  is  small  and  (juick,  the  extremities  get  cold,  and  just  as 
the  ])atient  seems  to  be  at  his  wor.'^t,  the  breathing  begins  to  get  easier,  and 
often  with  a  paroxysm  of  coughing  relief  is  obtained  and  ho  sinks  ex- 
hausted to  sleep,     the  relief  may  be  but  temporary  and  a  second  attack 
may  soon  come  on.     In  a  majority  of  the  cases  even  in  the  intervals  be- 
tween the  asthmatic  tits  the  respiration  is  somewhat  embarrassed.     Tho 
cough  is  at  first  very  tight  and  dry  and  the  expectoration  is  expelled  with 
the  greatest  ditliculty.  . 

The  jihysical  signs  during  an  attack  are  very  characteristie.  On  in- 
spection the  thorax  looks  enlarged,  barrel-.^baiied,  and  is  lixed,  the  amount 
of  cx]mnsioii  being  altogetlier  disproportionate  to  the  intensity  of  the  in- 
s])iratory  movements,  the  dia])hragm  is  lowered  and  moves  but  slightly. 
Insiiiration  is  short  and  quick.  ex]ii ration  ])rolonged.  Percussion  may  not 
reveal  uny  sjiecial  diiVerence,  but  there  is  sometimes  marked  hyperreso- 
nanee,  particularly  in  cases  which  have  had  repeated  attacks. 

On  auscultation,  with  insi)iration  and  expiration,  there  are  innumer- 
able sibilant  and  sonorous  rales  of  all  varieties,  piping  and  high-pitched, 
low-])itehed  and  grave.    Later  in  the  attack  there  are  moist  rales. 

The  sputum  in  bronchial  asthma  is  quite  distinctive,  unlike  that  which 
occurs  in  any  other  affection,     l-larly  in  the  attack  it  is  brought  up  with 
great  difficulty  and  is  in  the  form  of  rounded  gelaiinous  masses,  the  so- 
j,;  ealled  "perks"  of  Laennec.     Though  ball-like,  they  can  be  unfolded  and 

i  I  really  represent  moulds  in  mucus  of  the  smaller  tubes.     The  entire  expec- 

yi  ;  toration  may  be  made  up  of  these  somewhat  translucent-looking  pellets, 

■  floating  in  a  small  quantity  of  thin  mucus.     Some  of  them  are  opaijue. 

!'  Often  with  a  naked  eye  a  twisted  sjiiral  character  can  be  seen,  ]iartieularly 

if  the  sptitum  is  spread  on  a  glass  with  a  black  background.     Microscopic- 


ik 


)1'  the  iiaso- 

1,  ihuriK'tLT- 
or  bronchial 
liio  to  (lilTlt 
hy  irritation 

oin  ^tiiinach, 

iks,  t^iich  as 
jiassage  ol  a 
irnal  attacks 
1  witii  a  (lis- 
.'ssiun  in  the 
CL'ssory  nuis- 

I  a  paroxysm 
don  anxious. 
ratory  cll'orts 

also  whoezy. 
.  The  asth- 
in  severe,  the 
icdewed  with 
,  and  just  as 
et  easier,  and 
ho  sinks  ex- 
:econd  attack 
intervals  be- 
•rassed.  The 
expelled  with 

;tie.  On  in- 
I,  the  amount 
ity  of  the  in- 
i)ut  slightly, 
vsion  may  not 
ed  hyperreso- 

are  innumer- 
high-pitchod, 
'ales. 

ke  that  which 
iiight  up  with 
lasses,  the  so- 
unl'olded  and 
'  entire  expec- 
)oking  pellets, 

II  are  opaipie. 
n,  particularly 

Microseopic- 


HROXCniAL  ASTHMA. 


cm 


allv.  manv  of  these  pellets  have  a  spiral  structure,  which  renders  lluni 
among  the  most  rciuai'kalih'  liodics  met  with  in  .-pulum.  It  is  iml  a  little 
curious  that  ihcy  >h(iul(l  iiave  been  practieally  dvcrlnokcd  until  de-eribed  a 
few  years  ago  by  Curschmann.  I'nder  the  micros((i[ie  the  spiral.-  are  of 
tw(t  forms.  In  one  thci'e  is  simply  a  twi.-led.  spirally  arranged  mucin,  in 
which  arc  cntangh'd  leucocytes,  the  nuijority  nf  which  arc  eosino[iliiles. 
'I'lic  I  wist  may  be  loosi'  or  tight.  The  second  birm  is  much  nmre  pecidiai'. 
Ill  the  ceiilrc  of  a  tightly  coiled  skein  of  miuin  librils  with  a  few  scattered 
(■(lis  is  a  lilameiit  of  extraordimiry  clcanu'ss  and  translucency.  proliably 
comjxiscd  of  transformed  mucin.  As  C'urschnuinn  suggests,  tlicsc  s[(irals 
arc  doubtless  formed  in  the  liner  lironcliiolcs  and  constitute  the  product 
of  an  acute  bronchiolitis.  It  is  dillicult  to  cx[)lain  their  sjjiral  nature.  [ 
do  not  know  of  any  observations  uiion  the  course  of  the  currents  produced 
bv  the  ciliated  eiMtheliiim  in  the  bronchi,  but  it  is  ([uite  jio^sible  that  their 
action  may  l)e  rotatory,  in  which  case.  })articiilarly  when  combined  with 
s]iasm  of  the  bronchial  mu.-clcs.  it  is  possible  to  conceive  that  the  mucus 
formed  in  the  tube  might  be  compelled  to  assume  a  spiral  foiiii.  Williiu 
two  or  three  days  the  sputum  changes  entirely  in  character;  it  l)ec(!mes 
niuco-i)nrulent  and  ('urschmann's  spirals  arc  no  longer  to  lie  fumid.  'I'iiey 
occur  in  all  instances  of  true  Ijroiuhial  a>thma  in  the  early  ju'riod  of  the 
attack.  I  have  never  seen  the  true  s[)irals  either  in  bronchitis  or  [)iicu- 
monia.  There  are,  in  addition,  in  many  cases,  the  pointed,  octahedral  ciws- 
tals  described  by  Leyden  and  sometimes  called  asthma  crystals.  They  are 
identical  with  the  crystals  fouml  in  the  semen  and  in  the  blood  in  leu- 
kicmia.  At  one  time  they  were  sui)posi!d,  by  their  irritating  character  to 
induce  the  [laroxysms.  Eosinophilcs  in  the  blood  are  enormously  increased 
in  asthma — to  •-.*")  or  ;5.j  ])er  cent  of  the  leucocytes,  or  even  to  .");!. (!  per  cent 
in  one  case  (J.  S.  ]>illings.  Jr.). 

The  coiirf^c  of  the  di>ease  is  very  variable.  In  severe  attacks  llie  par- 
oxysms recur  for  three  or  four  nights  or  even  more,  and  in  the  intervals 
and  during  the  day  there  may  be  whcexing  and  cough.  Ivirly  in  the  disease 
the  patient  may  l)e  free  in  the  morning,  without  cough  or  much  distress, 
and  the  attacks  may  a|)pcai'  at  lii'st  to  be  of  a  ])urely  nervous  character.  Tn 
the  long-stamling  ca>es  cmpliys(,'ma  almost  invariably  develops,  and  while 
the  ])ure  asthmatic  lits  dinunish  in  frequency  the  chronic  bronchitis  and 
shortness  of  breath  bec(Uiie  aggravated. 

We  have  no  knowkxlgc  of  the  morbid  anatomy  of  true  asthma.  Death 
during  the  attack  is  unknown.  In  loiig-staiuling  cases  the  lesions  are  those 
of  chronic  lironchitis  and  cmi)hyscina. 

Treatment. — The  asthmatic  attack  usually  demands  immediate  and 
jirompt  treatment,  and  remedies  should  be  administered  which  experience 
has  shown  are  capable  of  relieving  the  condition  of  the  bronchial  muco>a. 
\  few  whiffs  of  chloroform  will  produce  ])rompt  though  temi)orary  relaxa- 
tion. In  a  child  with  very  severe  attacks,  resisting  all  the  usual  remedies, 
the  treatment  1)y  chloroform  gave  immediate  and  iinally  permanent  relief. 
Hypodermic  injections  of  pilocar]iin  (gr.  -J)  will  sometimes  I'clax  the  mu- 
cosa in  the  lU'ofuse  sweating.  Perlcs  of  nitrite  of  amyl  may  be  brok(Mi 
on  tile  handkerchief  or  from  two  to  five  drops  of  the  solution  may  be  i)laced 


]:• 


TOO  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

,,„tion-wool  an.l  inl.alc.l.     Slrnncr  stimulants  given  hot  or  a  dose  of 
spirits  of  ci.lorofonn  in  hut  whi.i<y  will  sn.netnnes  in.luoo  relaxation.     Mo 
uer.nanent  relief  is  given  bv  the  hyi.udernuc  n.jeetion  ot  niorplua  or  ot 
:;  ::::   Ind   eoeame   eomhined.     In   obstinate   -^,, -I-^^^  J:^ -;-;!:f 
attacks  this  has  proved  a  very  sat.slaetory  plan.      1  he  se  lat.  e  ant..pa> 
,,,o,lie.    sueh   as   belladonna,   henbane,  stranu.niuni,   and   lobelia,   iua>    lu 
gK.;;  in  sol.,ti..n  or  used  in  the  form  of  eigarettes.     Nearly  a  1  t-  popu  ar 
remedies  cither  in  this  form  or  in  pastilles  contain  some  plant  o    the  oid(  i 
;    L,mr,  with  nitrate  or  ehlorate  of  potash.     Excellent  e.garet  es  are  no 
;;iufaet;ired  and  asthnuUies  try  various  ^,rts,  since  one    -m  benet.     o  o 
patient    another  form  another  patient,     ^ltrc  paper  made  ^^ah  a  si.  in. 
Id    1   of  nitrate  of  potash  is  very  servicealdc.     Filling  the  room  wi  h    he 
nies  of  this  paper  prior  to  retiring  will  snnietinies  ward  oil  a  noetm.al 
attack.     I  have  known  several  patients  to  whom  tobacco  smoke  inhaled  wa. 
quite  as  potent  as  the  luvpared  eigarettes.  ,„.  i,..,u,(ipi.,l- 

The    ise  ot  cmupiv.M.d  air  in  tl..'  pneumatic  cabinet  is  ver.>  beneheial 
oxv<^en  inhalations  may  also  be  tried.     In   preventing  the  recurrence  of 
h  "^cks  there  is  no  imedy  so  nseful  as  iodide  ^'    l-^--"V:   ^  ""T 
times  acts  like  a  specilic.     From  10  to  -(>  grams  three  times  a  daj  i.  u.n- 

"^^' rarlicillar  attention  should  be  paid  to  the  diet  of  asthmatic  patients. 
\  rule  which  experience  generally  compels  them  to  make  is  to  ake  the 
ij!  meals  in  tie  <.arly  jl^irt  of  the  day  and  not  retire  to  bed  be  ore  gas- 
tr      digestion  is  completed.     As  the  attacks  are  often  uuluced  by  1  a  u- 

ncY  the  carbohvdrates  should  be  restricted.  Coffee  is  a  more  suitable 
ink  than  tea.     In  respect  to  climate  it  is  very  ditUcnlt  to  lay  down  rules 

"asthmatics.  The  pltients  are  often  much  better  in  the  -  -V  ^an  m 
the  countrv.  The  high  and  dry  altitudes  are  certainly  more  benel  cial  than 
the  sea-shm'c;  but  in  protracte.l  cases,  with  emphysema  as  a  secom  ary  com- 
plication, the  rarefied  air  of  high  altitudes  is  not  advant,ageons.  In  jming 
pions  i  have  known  a  residence  for  six  months  in  Honda  or  southern 
Oalifornia  to  be  followed  by  prolonged  freedom  irom  attacks. 


V.    FIBRINOUS    BRONCHITIS. 

.\n  acntc  or  chronic  affection,  characterised  by  the  formation  in  certain 
of  the  bronchial  tubes  of  fibrinons  casts,  which  are  expelled  in  paroxysms  of 

'T'^^li'dS-  fibrinons  moulds  of  the  bronchi  are  formed  as  in 
diphtheria  and  croup  (with  extension  into  the  trachea  and  bronchi  in 
remnonia,  and  occasionally  in  plithisis-conditions  which,  however  ha  e 
no  in.'  to  do  with  true  fibrinons  bronchitis.  These  casts  are  no  to  be 
confounded  with  the  blood-easts  which  occur  occasionally  in  hamioptysis 

Etiology.-Xothing  is  known  of  its  <.ausation.  It  occurs  more  fre- 
nnentlv  in  nudes.  It  is  met  with  at  all  periods  of  life,  but  is  more  common 
between  the  ages  of  twentv  and  forty.  It  has  been  known  to  at  ack  several 
numbers  of  tlic  same  family.     Instances  have  been  described  oocnrring 


■i1 


FinuiNous  nuoNcniTis. 


G33 


L)r  a  dose  of 
itioii.     More 
ji'phiii  or  ot 
ly   rcuurrini^ 
ivo  aiitispas- 
■liii,   may    lie 
,  the  popular 
of  tlic  order 
.'ttes  are  now 
L  benefits  one 
■itli  a  stron,!,' 
Doni  with  tlio 
[  a  nocturnal 
D  inlialed  was 

■ry  lieneficial; 
reeurreneo  of 
,  wliieh  sonic- 
a  day  is  usu- 

lalic  patients. 
s  to  take  the 
I'd  before  gas- 
iced  by  Uatu- 
niore  suitai)le 
ay  down  rules 
!  city  than  in 
beneticial  than 
econdary  com- 
us.  In  young 
la  or  southern 
;s. 


it  ion  in  certain 
n  paroxysms  of 

formed,  as  in 
id  bronchi),  in 
,  however,  have 
i  are  not  to  be 
.  hemoptysis. 
?curs  more  fre- 
s  more  common 
;o  attack  several 
ribed  occurring 


lo.retlier  as  if  due  to  some  endemic  inlluence  (i'icliini).    Tlie  case^  are  rare, 
nu'ticularlv  in  lu.spital  i-ractiee.     The  attacks  occur  most  commonly  in 
the  ^prin-'^noMths.     An  association  with  tidierculosis  has  heen  Irequently 
noted      Model,  in  an  article  from  I'.iinnder's  clinic,  states  that   tui.erculo- 
«!-  was  present  in  ten  of  twentv-one  post  niortems.     It  has  been  met  with 
uNo  in  comuvti.m   with  skin-diseases,  such   as  pemphigus,   unpetig",  am 
Ikti-cs     Tiie  attacks  ai.peared  to  he  related  in  some  cases  to  the  menstrual 
period      Several  instances  have  been  descrihed  with  heart-disease,  but  it 
ieems  prolmhle  that  in  all  these  c.mditions  the  connection  was  n<.t  causal. 
Symptoms.— .Veil te  cases  are  rare.     They  may  set  in  with  high  tever, 
rigors,  severe  paroxvsms  of  cough,   and    perhaps   with   lueinoi-tysis.      liie 
cHuical  picture  resemhles  that  of  acute  hronchitis,  and  only  the  expulsi.m 
of  the  ineiubranous  casts  gives  the  characteristic  features  to  the  case.     It  is 
„nich  more  serious  than  the  chronic  form  and  fatal  termination  is  not  un- 
common.    X.  S.  Davis  has  reported  two  fatal  ca.ses.     In  some  ot  the  acute 
cases  there  has  been  affection  of  the  tonsils,  and  it  is  possihle  that  the  dis- 
ease niav  have  been  trulv  diphtheritic  in  character  and  due  to  extension  ot 
the  niend.rane  into  the  "trachea  and  bronchi.     The  casts  in  these  cases  are 
not  onlv  more  extensive,  but  they  also  do  not  present  the  laminated  struc- 
ture characteristic  of  true  ].lastic  bronchitis.  ,    ,   •     ,, 

A  patient  inav  have  a  single  attack  without  any  recurren.e.  hut  m  the 
chronic  form  the' attacks  come  on  at  varying  intervals  and  the  disease  may 
last  f..r  ten  or  even  twenty  years.     Instances  are  on  record  in  which  the 
pan.xvsms  have  occurred  at  d.'iinite  intervals  for  many  months.      Ihi^^^t- 
tacks"mav  recur  weeklv  or  a  period  of  a  year  uv  more  may  intervene.      1  he 
onset  is  marked  bv  brouchitic  symi.t.ims,  not  necessarily  with  lever.      J  he 
cou-h  becomes  distressing  and  paroxysmal  in  character;  the  sputa  may  be 
blood-stained  and  the  patient  brings  up  rounded,  ball-like  masses,  which, 
when  disentangled,  are  found  to  be  moulds  of  hnnu'lii;  the  lucmorrhage 
mav  be  profuse.     In  one  of  the  two  cases  which  1  have  seen  it  mvarialily 
accompanied  the  attack,  and  the  whitish  dendritic  casts  of  the  tubes  were 
alwavs  entangled  in  the  blood  and  clots.     Urgent  dyspnu-a  and  cyanosis 
mav'be  iiresent  in  severe  attacks.     The  pluismil  signs  are  those  of  a  severe 
bronchitis.     It  mav  occasionallv  he  possible  to  determine  the  weakened  or 
suppressed  breath  sounds  in  the  affected  territory  and  there  may  be  deficient 
expansion  or  even  retraction  of  the  chest  wall  in  a  corresponding  area,  but 
this  is  in  reahty  very  dillicult,  and  twice  prior  to  the  expulsion  of  the  casts 
I  failed  to  determine  by  physical  examination  the  affected  region. 

As  mentioned,  the  casts  are  usually  rolled  up  and  mixed  with  mucus  or 
blood.  When  unravelled  in  water  they  present  a  complete  mould  of  a 
secondary  or  tertiarv  bronchus  with  its  ramifications.  The  size  of  the  cast 
mav  varv  with  different  attacks,  l)ut.  as  has  often  been  noticed,  the  form 
and  size'mav  be  identical  at  each  attack  as  if  precisely  the  same  bronchial 
area  was  involved  each  time.  The  casts  are  hollow,  laminated,  the  size  ot 
the  lumen  varving  with  the  number  and  thickness  of  the  lamina'.  Some- 
times thev  are  almost  solid.  Transverse  sections  slunv  a  beautiful  concen- 
tric arrangement.  The  casts  have  been  determined  by  Cirandy  to  be  com- 
posed of  mucus  and  not  of  fibrin.    He  regards  the  process  as  analogous  to 


r 


) , 


If 

w 


i! 

■  t 
I     1 


iH 


yi 


(53^  DISEASES  OF  Tilt',  IlESPIUATOHY  SYSTI'.M. 

,K,  .,n,.o,H  r.^litis.     TlH.  <Hnnn  Mpiu.-rs  in  phu-.s  lu  r.tai..  its  (ihrillary 
ru  i.>  .    iHTs,  ns   i„  aii.hih.ritic.   Hu.nhnuK,  it   has  u.ulorgouc     he 

I        n.     Inrn.a.^n..     UnLyW.  are  i,nln..l,lM  in  th.  uuslu..       n    W 
•      V   larlHularlv  in  tl...  Muallv  casts,  it  is  .ml  un.nuuaun  tu  s.o  ah.nla, 
;  ;;;Mii;::  wm,   nunK.n.us  ...l.-n  ,ar,i.l.s.     L.v<lcu-s  cnstal^  a,v  so.ne- 
times  louiul  and  oucasioiiallv  I'lUMlunaims  si'irals.  •     ■       r     i 

Ti  1     n,v  or  th.  .iiscas.  is  ohscun.     Tin.  m.mbran.  .s  M.n  ual 

,,„       J'    ,  ,huh  tlH.  wnn  .roupuus  ,s  a,rl-.l.  and  the  obsc.MM  y  v.la,., 
r.    nuuh  to  tl>e  nunhaMis.n  of  llu,  pn.hut.on    .huh  is  P'«  f  ^     ^^" 
no  as    u  otiuT  nuu.uus  surlm.s,  as  to  tlu.  curions  hnntafon  ot  the    lU   - 
,;;;;;\;,;,,,„i„  ,.,,„,Uial  territories  ana  th.  >vn,arkablo  munvnee  at  ..alul 
nr  iiT.-uiar  intervals  tlirou-lionl  a  luriod  ol  many  yuu>. 

u!'.  aento  cases  the  Inaln.n,  AunM  he  that  ol  onhnary  -"tc  hn  - 
,lntis  We  know  of  nothin-  \vhi.ii  can  prevent  the  reenrren.e  ol  tlu  al- 
:"in  tl  c  nnuc  fom.  In  the  uncon,plicalea  cases  there  .  rarely  any 
i  , te  1  rin.^  the  i.aroxvsnt,  even  thouj^h  the  sytnptonts  tnay  he  nu.st  1.^ 
u':,.  nUhe  .lspn.;-a  and  cou^h  very  severe.  Inhahi  .ons  ot  ether, 
^  ^^^o  a  mnixed  inte-water  aid  in  ll>e  separation  of  the  n.end.ranes 
r  f::  r  hu  nu,l>t  he  useftd.  as  in  some  instances  it  increases  t^-  '--;;; 
secretion.  The  enti-loytnent  of  emet.cs  may  he  nm»a>  and  m  son.e 
cases  they  are  elVective  in  promoting  the  removal  ol  the  ca.l.. 


IV.   DISEASES   OF  THE   LUXGS. 
1.    CIRCULATORY    DISTURBANCES    IN    THE    LUNGS. 

Congestion-There  are  two  forn.s  of  con.e.ti.m  of  the  lun.s-a.tive  and 

^'"O)'-  WlUr  Conyesfion  of  the  L».^s.-Mt,ch  donht  and  -"fnsion  still 
*    '  I  •     4-      i.Vrncli  writer^    follow  nii  ^^  odlez.  regard  it  a>  an 

•t'  "Mr,:n        val  M-  '^^  ^y"^""^-  ->'^  -  tlH-.au-tion- 

mdependent  piimaix   '"^'f""  .        y^,,,]\^],  and  American  an- 

(if  pneiinunna.      ll\e  eluel  sunpiouift  ul.^.  f,.„„  ioi'^  to  10;!°      The 


li 


%m 


its  (Ibrilliiry 
(Icigum;  the 
lies.  Ill  the 
I  (ruo  alvt'iilai' 
Is  an'  soiuc- 

I  is  iiR'iiticiil 
■rrity  rchitcs 
probiiljly  llio 
of  the  atVec- 
'lu-e  at  staU'cl 

\-  acute  l)niu- 
ice  i>i.  tlie  at- 
is  rari'ly  any 
be  iiuist  dis- 
(dis  ol'  ether, 
_'  iiu'nil)i'aiu's. 
the  ))V()iKhial 
ami   ill  some 


LUNGS. 

"s — active  and 

confusion  still 

eiiai'd  it  as  an 

iheir  dietlon- 

Ainerloan  au- 

Aetive  iUixioa 

when  very  hot 

nt erf ere  locally 

(1  portions  may 

llateral  fluxion, 

ulmonary  alTec- 

ronehitis,  pleu- 

110  means  defi- 
ch  writers  is  of 

or  larval  forms 
hill,  pain  in  the 
=■  to  103°.  The 
ctiines  bronchial 


Clia  TLATURY    DISTUIIBAXC'KS   IN   Till';    LCN'OS. 


c;',:. 


in  character,  and  line  rales.  A  mijority  of  clinical  physician^  wouM  nn- 
doubledlv  class  such  cases  under  inthimuiation  (d'  tlie  lun^r.  in  many  epi- 
deniics  tiie  alinormal  and  larval  forms  are  s[)ecially  prevalent.  This  is  no 
donl4  the  condition  to  whicii  I'orcher,  of  Charleston,  called  attention  a  >lioit 
time  a"(i  as  a  "  hitherto  uudcseribcd  all'ectioii  of  the  lunj;s." 

Tiu'  occurrence  of  an  inli'UM'  and  rapidly  fatal  conj:estioii  (d'  the  liuiLr. 
folluwinu-  extreme  heat  or  cold  or  sometinies  violent  exertion,  is  recoj:iii/.cd 
by  some  authors,  b'enfortli,  the  oar.-man.  is  said  to  have  died  from  this 
cause  during'  the  race  at  Halifax.  J.tuf  has  described  eases  in  which,  in 
association  with  drunkenness,  exposure,  and  cold,  death  occurred  suddenly, 
or  within  twenty-four  hours,  the  only  le-ion  found  luinj:-  an  extr.'me,  almo-t 
luemorrhaj'ie,  eongestiiui  o\'  the  lun-s.  It  is  by  no  means  certain  that  in 
these  eases  death  really  occurs  from  imlmonary  coiii:-e.-tion  in  the  absence 
of  siu'cille  statements  with  reference  to  the  coronary  arteries.  Several 
times  in  sudden  death  from  disease  (d'  these  vess.'l>  1  have  seen  -rreat  en- 
-oi-fiement  of  the  Inn-rs  thoueli  not  the  extreme  ;.n-ade  mentioned  liy  i.ful'. 
I  have  no  ])ersonal  kuowlcd-e  of  eases  such  as  he  describes. 

Ci)  rassiir,  <'<iii;irslinii. — Two  forms  of  this  nuiy  be  recoj^'nized.  I  lie  me- 
.hanical  and  the  hypostatic. 

{(i)  .Mechanical  con;jvstion  occurs  whenever  there  is  an  obstacle  to  the 
return  of  the  blood  to  the  heart.  It  is  a  common  event  in  many  aH'ci'tions 
of  the  left  heart.  The  lun.us  are  voluminous,  ru-^set  bi'owii  in  color,  cut- 
linu'  and  tcarinu^  with  .urcat  resistance.  On  section  they  >ho\v  at  iirst  a 
brownish-red  tin,i:e.  and  then  the  cut  surface,  exposed  to  the  air.  becomes 
rapidly  of  a  vivid  red  cnloi'  from  oxidation  of  the  abundant  Inemo.ulobin. 
This  is  the  conilition  known  as  hnnni  iinliinili-ni  cd'  the  lun.ir.  IlistoloLric- 
ally  it  is  characterized  by  (n)  .threat  distention  of  the  alveolar  capillaries; 
(^j  ineriMse  in  the  connective-tissue  elemeid---  (d'  the  hint:-;  (y)  the  pres- 
ence in  the  alveolar  walls  of  many  cells  containin--  allcred  blood-|Mi.nueid ; 
(8)  in  the  alveoli  numerous  epitlulial  cells  containinu-  blood-pi.Liineid  in  all 
sta-ics  of  alteration,  which  are  also  found  in  great  numbers  in  the  sputum. 

'"it  occasionally  happens  that  this  mechanical  hypera'inia  of  the  hinii; 
results  from  ]iressnro  by  tumors.  So  lonir  as  compensation  is  maintained 
tlie  mechanical  eon.uesticm  of  the  luii--  in  lieart-ilisca~e  do(s  not  produce  any 
symptoms,  but  with  enfeelded  heart  ai  lion  the  en<:-orgemeiit  becomes  marked 
and  there  are  dyspmea.  con,u-h.  and  ex[)eetoratioii,  with  the  characteristic 
alveolar  cells. 

(/))  Hypostatic  cnn.L'estion.  In  fevers  and  adynamic  states  jxenerally.  it 
is  very  common  to  llnd  the  base.^  of  the  lungs  deeply  conufcsted.  a  condition 
induced  partly  liy  the  elTect  of  gravity,  the  patient  lying  recumbent  in  one 
posture  for  a  long  time,  Init  chiefly  by  weakened  heart  action.  That  it  is 
not  an  effect  of  gravity  alone  is  shown  by  the  fact  that  a  healthy  person 
mav  remain  in  bed  an  indefinite  time  without  its  oeenrrenee.  The  term 
hypostatic  congestion  is  ap]died  to  it.  The  posterior  parts  of  the  lung  are 
dark  in  color  and  engorged  with  blood  and  serum;  in  some  instances  to 
sneh  a  degree  that  the  alveoli  no  longer  contain  air  and  portions  of  the  lung 
sink  in  water.  The  term  .■iii]i'in:<iti.,n  and  hypostatic  pneumonia  have  been 
uiven  to  these  advanced  grades.     It  is  a  common  alfection  in  protracted 


't 


m 


686 


DISKASKS  OF  THE   HESl'lKAToUY   SYSTKM. 


caHcs  of  tviiliniil  fiver  iind  in  l.iii-,'  dobililatiii-r  illmsscs.  In  nsiitcs.  inotcor- 
isiM.  !iii.riili(l(Mniniil  liunurrt  thu  Ijiists  vi  llic  lun-:s  may  lie  c.uninv.-.Md  mid 
i(iii;;r^tcd.  In  this  ninuoclion  must  In'  nicntiuni'd  {\\v  I'diMii  oT  |ias>iv.'  cmi- 
^'I'sUou  nu'l  with  in  injury  to,  and  or^'anic  disease  of,  the  I. ram.  In  eere- 
hral  ai>oi.h\v  tiie  hases  of'tlie  hmus  are  dei'iily  en;,'or^;ed,  not  (iiiite  airless. 
i)ut  heavv.  and  on  Mctioii  driii  with  l)lo(id  and  serum.  1  iiave  twiee  sei  ii 
tiiis  eon.lition  in  an  extreme  ^rade  throu-iuiut  liie  lung's  in  death  from  mor- 
jiina  |inis(inin'r.  In  some  instances  the  lun<i'  tissue  has  a  hhieldsli,  ^ielati- 
iitius,  infill  rated  apiiearanee,  almost  like  dilfiise  pulmonary  a|Miplexy.  Oeea- 
sionally  this  eonjicstion  is  ni(i>t  marked  in,  ami  even  ei.nlined  to,  the 
iiennitl"ej,Me  side.  In  prolon-ed  <niiia  the  hypostatic  eonnestion  may  be 
assoeiatt^l  with  patches  of  cunsolidalion,  due  to  the  aspiration  of  jiortions 
of  food  into  the  air-passages. 

The  symptoms  of  hypostatic  eon-estion  are  not  at  all  characteristic, 
and  the  condition  has  to"  l)e  .<oujiht  for  i)y  carel'ul  examination  of  the  basis 
of  the  lungs,  when  sliglit  dulncss,  feeble,  sometimes  blowing,  breathing  and 
litpiid  rales  can  bo  dctei'ted. 

The  liralnwnt  of  congestion  of  the  lungs  is  usually  that  of  the  condi- 
tion with  which  it  is  associated,  in  the  intense  ludiuoiiary  engorgement, 
which  nuiv  possiblv  occur  iirimarily.  and  which  is  met  with  in  hcart-di>ease 
and  ciiiph'vsema,  five  bleeding  should  bo  practised.  I'nnn  •.>()  to  ;)0  ounces 
of  blood  should  be  tiken  from  the  arm,  and  if  the  blood  does  not  ilow 
freely  and  the  coiidit  on  v[  the  patient  is  desperate,  aspiration  (d'  the  right 
auricle  mav  i)e  performed. 

(Edema!— In  all  forms  of  intense  c.iiigestion  of  the  lungs  there  is  a 
transiuhitioii  of  serum  from  the  engorged  capillaries  chietly  into  tho  air- 
cells,  but  also  into  the  alveolar  walls.  Not  only  is  it  very  freiiueiit  in  con- 
gestion, but  also  with  iiiilamiuation.  with  new  growths,  infarcts,  and  tuber- 
cles. AVheii  limited  to  the  neighborhood  of  an  alVoctod  part,  tho  namo 
collateral  ledcina  is  sometimes  ap|ilied  to  it.  (ieneral  icdoma  occurs  under 
conditions  verv  similar  to  those  met  with  in  congestion.  It  is  very  often, 
no  doubt,  a  terminal  event,  occurring  with  the  death  agony.  It  is  seen  in 
typical  form  in  tho  cachexias,  in  death  from  anu'inia,  also  in  chronic  r.right's 
disease,  disease  of  tho  heart,  and  cerebral  alfections. 

The  (edematous  lung  is  heavy,  looks  watery,  i)its  on  pressure,  and  from 
tho  cut  surface  a  largo  quantity  of  clear  and,  in  cases  of  congestion,  bloody 
serum  ilows  freely;  tho  tissiio  may  ovon  liavo  a  gelatinous,  infiltrated  ap- 
])earancc.  Tho  condition  is  much  more  common  at  tho  bases,  but  it  may 
exist  throughout  tho  entire  lung.  The  pathology  of  pulmonary  u'dema  is 
not  always  clear.  Two  factors  usually  prevail  in  extremo  cases— increased 
tension  within  tho  i^ulmonary  system  and  a  diluted  blood  plasma.  The 
increased  tension  alone  is  not  capa1)lo  of  producing  it.  Tho  experiments 
of  AVoleh  seem  to  indicate  that  the  essential  factor  lies  in  a  disproportion- 
ate weakness  of  the  loft  ventricle,  so  that  the  Idood  accumulates  in  the 
lung  capillaries  until  transudation  occurs,  a  view  which  satisfactorily  ex- 
plains certain  cases,  particularly  tho  terminal  OMlomas. 

The  si/mpfowi^  of  lodoma  of  the  lungs  are  often  only  an  aggravation  of 
those  alroadv  existing,  and  are  due  to  the  primary  disease,  whether  car- 


M 


■,%. 


o^W 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


// 


% 


Q- 


A 


i/.A 


1.0 


I.I 


1.25  nil  1.4 


6" 


M 

2.2 

IIM 

IM- 

1.6 


'4^%^ 


'/ 


Photographic 

Sciences 

Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


:^ 


^^Mta 


fc.=  : 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /Institut  canadien  de  microreproductions  historiques 


.J4 


rf^Ai 


CIRCULATORY   DISTURIJANCES  IN  THE   LUNGS. 


r.37 


(liao,  roiinl,  or  general.  There  are  usually  inereasing  dyspiKea  and  eough, 
and  on  examination  tliere  may  !)e  del'eetive  resonanee  and  large  liquid  rales 
iit  the  bases.  There  are  eases  in  wliieh  the  a'dema  cunies  on  with  great 
suddenness,  and  in  ehronie  iJrighfs  disease  it  may  i)rove  rai)idly  fatal. 

In  the  eases  of  so-ealied  iidlammatory  tedema  lever  is  always  i)resent, 
and  there  are  often  signs,  more  or  less  marked,  of  pneumonia. 

The  tmtliiinil  of  a'dema  of  the  lung  is  praetiealiy  that  of  tlie  eondi- 
tions  with  which  it  is  associated.  In  the  aeute  eases  active  catharsis,  and, 
if  tliere  is  cyanosis,  free  venesection  should  he  resorted  to. 

Pulmonary  HaemoiTliage. — This  ociurs  in  two  forms — hromlio-pul- 
moiiari/  hwinuvrhage,  sometimes  called  bronchorrhagia,  in  which  tlie  blood 
is  i)(Hircd  out  into  the  bronchi  and  is  expectorated,  ami  piiltnumni  apo- 
pJe.rii  or  pneunorrhagia,  in  which  the  luvmorrhage  takes  place  into  the 
air-cells  and  the  lung  tissue. 

1.  Bronclto-puhmmanj  IIa'iiiorrha;ic;  /Jrtwo/)//y.s'/s.— S])itting  of  blood, 
to  which  the  term  liivmoptysis  sluudd  be  restricted,  results  from  a  variety 
of  conditicnis,  among  which  tlie  f(dlowiiig  are  tiie  most  important:  (a)  In 
young  healtliy  persons  luemoptysis  may  occur  without  warning,  and  after 
continuing  for  a  few  days  disappear  and  leave  no  ill  traces.  There  may 
be  at  the  time  of  the  attack  no  ])hysical  signs  indicating  imlmonary  disease. 
Jn  such  cases  good  heallii  may  be  ]ir(>served  for  years  and  no  further 
trouble  occur.  These  cases  are  not  very  uncommon.  In  Ware's  impor- 
tant contril>ution  to  this  sul>ject,*  of  ;!S(;  eases  of  luemo]ifysis  noted  in 
])rivate  practice  G'2  recovered  and  pulmonary  disease  did  not  subsciiuently 
develop  in  them.  1  know  three  jind'essional  men  who  had  lucmoptysis  as 
students,  and  who  now.  at  periods  of  from  fifteen  to  eighteen  years  subse- 
quently, remain  in  perfect  health.  (/*)  lhvmoi>tysis  in  pulmonary  tubercu- 
losis, which  is  considered  in  pages  3()2-3(ti.  (c)  In  connection  with  cer- 
tain diseases  of  the  lung,  as  pneumonia  (in  the  initial  stage)  and  cancer, 
occasionally  in  gangrene,  abscess,  and  bronchiectasis,  luvmoptysis  occurs. 
(d)  IIa'mo]ttysis  is  met  with  in  many  heart  alVections,  particularly  mitral 
lesions.  It  may  bo  profuse  and  rei'ur  at  intervals  for  years.  {)')  In  ulcera- 
tive affections  of  the  larynx,  trachea,  or  bronchi.  Sometimes  the  ha-nior- 
rhage  is  jirofuse  and  rajiidly  fatal,  as  when  an  ulcer  erodes  a  large  branch 
of  the  pulmonary  artery,  an  accident  which  I  hiue  known  to  happen  in 
a  ease  of  chronic  bronchitis  with  emphysema,  (f)  Aneurism  is  an  occa- 
sional cause  of  luvnioptysis.  It  may  be  sudden  and  rai)idly  fatal  when  tlie 
sac  bursts  into  the  air-passages.  Slight  bleeding  may  continue  for  weeks  or 
even  longer,  due  to  pressure  on  the  mucous  membrane  or  erosion  of  the  lung; 
or  in  some  cases  the  sac  "  weeps  "  through  the  exposed  lamina'  of  fibrin. 
('/)  Vicarious  haimorrhage,  which  occurs  in  rare  instances  in  cases  of  inter- 
rujited  menstruation.  The  instances  are  well  authenticated.  Flint  men- 
tions a  case  which  ho  had  had  under  oliservation  for  four  years,  and  lliji- 
liocrates  refers  to  it  in  tlie  a])horisni,  "  IIa'mo|»tysis  in  a  woman  is  removed 
by  an  eruption  of  the  menses.''  Periodical  lurmoptysis  has  also  been  met 
with  after  the  removal  of  both  ovaries.     Even  fatal  hannorrhage  has  oc- 


♦  On  Iliumoptysis  as  a  Syiniiluni,  by  John  Ware,  M.  D. 


038 


DISEASES  OF  THE  KESPIRATOIIY  SYSTEM. 


ciirivd  from  ilu-  lim;,'  during  iiifiistriiation  wIrii  iin  lesion  was  found  to 
.loount  for  it.  (//)  'riiiMi'  is  a  form  of  rccurriujj;  lui'moptysis  in  arllirilic 
subjocts  to  wliicii  Sir  Andrew  ('lark  has  called  sjiecial  attention  and  wliieli 
also  is  descriix'd  by  J-'reneli  writers.  The  eases  oeeur  in  persons  over  lifty 
years  of  ago  who  usually  present  signs  of  the  artliritic  diathesis.  It  rarely 
leads  to  fatal  issue  and  sul)sides  without  inducing  pulmonary  changes,  (i) 
Ihenioptysis  recurs  sometimes  in  malignant  fevers  and  in  ])urp' ra  luenmr- 
rhagiea.  Lastly,  there  is  endemic  ha'moj)tysis.  due  to  the  Diiiloinnia  wcslcr- 
Duniid  in  the  bronchial  tubes,  an  all'ecli^'n  which  is  coniined  to  parts  of 
China  and  Japan. 

Symptoms. — Ilainoptysis  sets  in  as  a  rub  suddenly.  Often  witli- 
out  warning  the  i)atient  experiences  a  warm,  saltish  taste  as  tiie  inoulh 
fills  with  blood.  Coughing  is  usually  induced.  There  may  lie  only  an 
ounce  or  so  brought  up  before  the  hicmorrhagt"  stops,  or  the  bleeding  m:iy 
continue  for  <lays,  tlie  patient  bringing  up  small  cpiantities.  In  other  in- 
stances. ]iarticularly  when  a  large  vi'ssel  is  eroded  or  an  aneurism  bursts, 
the  amount  is  large,  and  the  ])atient  altera  few  atte?npts  at  coughing  siiows 
sicns  of  sull'ocation  and  death  is  produced  by  inundation  of  the  bronchial 
sy.>item.  Fatal  Invmorrhage  may  even  occur  into  a  large  cavity  in  a  patient 
d"el)ilitated  by  phthisis  without  the  production  of  ha'inoptysis.  I  dissected 
a  case  of  this  kind  at  the  rhiladelphia  Hospital.  The  blood  from  the  lungs 
generally  has  characters  which  render  it  readily  distinguislmblo  from  tlie 
blood  wiiich  is  vomited.  It  is  alkaline  in  reaction,  frothy,  and  mixed  witli 
mucus,  and  when  coagulation  occurs  air-bnbljles  are  i)resent  in  the  clot. 
IJlnod-moulds  of  the  smaller  bronchi  arc  sometime,?  seen.  Tatir- ts  can 
usually  tell  wiiether  the  blood  has  been  brought  up  by  coughing  or  by 
vomiting,  and  in  a  majority  of  cases  the  history  gives  important  indica- 
tions. In  jiaroxvsmal  luemoptysis  connected  with  menstrual  disturbances 
the  practitioner  should  see  that"  the  blood  is  actually  coughed  up,  since  de- 
ce]ition  may  be  ]iractised.  The  spurious  luvmoptysis  of  hysteria  is  consid- 
ered with  thai  disease.  Naturally,  the  jtatient  is  at  first  alarmed  at  tlio 
occurrence  of  blei'ding.  Imt,  unless  very  profuse,  as  when  due  to  rupture 
of  an  aortic  aneurism  in  a  jiulmonary  cavity,  the  danger  is  rarely  immedi- 
ate. The  attacks,  however,  are  apt  to  recur  for  a  few  days  and  the  sputa 
may  remain  blood-tinged  for  a  longer  period.  In  the  great  majority  of 
cases  ihe  Invmorrhage  ceases  s]iontaneously.  Tt  should  bo  icmembored 
that  some  of  the  blood  may  be  swallowed  and  produce  vomiting,  and, 
after  a  day  or  two,  the  stools  may  be  dark  in  color.  It  is  not  well  during 
an  attack  of  Im^optysis  to  examine  the  chest.  Tt  was  formerly  thought 
that  haMiiorrhage  exercised  a  prejudicial  clfect  and  excited  inflammation 
of  the  lungs,  but  this  is  not  often  the  case. 

{•i)  Puhivmnnj  Apoploxii;  Jhvmovrluvjie  Infarct. — In  this  condition 
the  blood  is  effused  into  the  air-cells  and  interstitial  tissue.  It  is  rarely 
indeed  dilTuse,  the  jiarenchyma  being  broken,  as  is  the  brain  tissue  in 
cerebral  apojdexy.  Sometimes,  in  disease  of  the  brain,  in  septic  condi- 
tions, and  in  the  maliixnant  forms  of  fevers,  the  lung  tissue  is  uniformly 
infiltrated  with  blood  and  has,  on  secti<m.  a  black,  gelatinous  ai)i)earance. 

As  a  rule,  the  lurmorrhage  is  limited  and  results  from  the  blocking  of 


EM. 

"ion  was  fouiul  tc) 
iptysis  ill  arlhriUc 
tentiuii  and  which 
])L'r.<uiis  over  lil'ty 
latht'sis.  It  rai'L'ly 
iiiary  chan^a'S.  (i) 
n  pui'p'.ra  ha'inor- 
!  Dialtiinniii  wcslcr- 
)iiiiiU'(l  to  partri  of 

'Illy.  Oi'toii  with- 
uste  as  the  mouth 
c  may  lie  only  an 
•  the  bleeding  iiriy 
ities.  In  other  iii- 
n  aneurism  hurst-;, 
at  coughing  shows 
n  of  the  hroncliial 
cavity  in  a  jiaticnt 
ptysis.  I  dissected 
ood  from  the  lungs 
^uisliahlo  from  the 
ly,  and  mixed  with 
resent  in  the  clot. 
ecn.  ratii- ts  can 
)y  coughing  or  by 
important  indica- 
strual  disturbances 
igliod  up,  since  de- 
hysteria  is  consid- 
rst  alarmed  at  tlio 
leii  due  to  rupture 
r  is  rarely  immedi- 
days  and  the  sputa 
'  great  majority  of 
Id  be  icmcmborod 
ico  vomiting,  and, 
is  not  well  during 
s  formerly  thought 
cited  inllammatiou 

-Tn  this  condition 
:issuo.  It  is  rarely 
he  lirain  tissue  in 
n,  in  septic  condi- 
tissuo  is  uniformly 
tinous  ai)])eai'ance. 
om  the  blocking  of 


ClllCULATOIiY    1)ISTURIJAN(;KS   in   TlIK   LUNdS. 


031) 


a  branch  of  the  pulmonary  artery  either  by  a  thrombus  or  an  embolus, 
'{"lie  condition  is  most  common  in  clironic  heart-diseaso.  Althougli  the 
pulmonary  arteries  are  terminal  ones,  blocking  is  not  always  followed  by 
infarction;  partly  because  the  wide  capillaries  furnish  sullicicnt  anasto- 
iiiusis,  and  partly  because  the  bronchial  vessels  may  k(!op  up  the  circula- 
tion. The  infarctions  are  chielly  at  the  jieripliery  of  the  lung,  usually 
wedge-shaped,  with  the  base  of  the  wedge  toward  the  surface.  When  re- 
cent, they  are  dark  in  color,  hard  and  linn,  and  look  on  section  like  an 
(iidinary  blood-clot-,  (iradual  changes  go  on,  and  the  color  becomes  a 
reddish  brown.  'J'lie  pleura  over  an  infarct  is  usually  inllamed.  A  lui- 
crosco]ii(iil  section  shows  the  air-cells  to  be  distended  with  red  blood-cor- 
puscles, which  may  also  he  in  the  alveolar  walls.  The  infarcts  are  usually 
multiple  and  vary  in  size  from  a  walnut  to  an  orange.  \  cry  large  ones 
may  involve  the  greater  jiart  of  a  lobe.  In  the  artery  jiassing  to  the 
ail'ected  territ(U'y  a  thrombus  or  an  embolus  is  found.  The  globular 
thrombi,  formed  in  the  right  auricular  appendi.x,  play  an  important  part 
in  the  production  of  ha'inorrhagic  infarction.  In  many  cases  the  source 
of  the  embolus  cannot  be  discovered,  and  the  infarct  may  have  resulted 
from  thrombosis  in  the  pulmonary  artery,  but,  as  before  mentioned,  it  is 
not  infre((uent  to  find  total  obstruction  of  a  large  branch  of  a  pulmonary 
artery  without  lia'morrhnge  into  the  corresponding  lung  area.  The;  fur- 
ther history  of  an  infarction  is  variable.  It  is  possible  that  in  some  in- 
stances the  circulation  is  re-established  and  tiic  blood  removed.  Jlorc 
(■tiiiimonly.  if  the  patient  lives,  the  usual  changes  go  on  in  the  extravasated 
blood  and  ultimately  a  pigmented,  puckered,  fibroid  patch  results.  Slough- 
ing may  occur  with  the  formation  of  a  cavity.  Occasionally  gangrene 
results.  In  a  ease  at  tlu!  T^^niversity  Hospital,  Philadelphia,  a  gangrenous 
infarct  ruptured  and  ]iroduccd  fatal  pneumothorax. 

The  syniploms  of  pulmonary  apoplexy  are  by  no  means  delinitc.  The 
condition  may  bo  suspected  in  chronic  heart-disease  when  luemoptysis 
occurs,  particularly  in  mitral  stenosis,  but  the  bleeding  may  be  due  to  the 
extreme  engorgement.  When  the  infarcts  are  very  large,  and  particularly 
in  the  lower  lobe,  in  which  they  most  commonly  occur,  there  may  be  signs 
of  consolidation  with  blowing  breathing. 

Treatment  of  Pulmonary  Haemorrhage. — In  the  treatment 
of  ha'moptysis  it  is  important  to  remember  the  condition  of  the  pulmo- 
nary circulation  and  the  nature  of  the  lesions  associated  with  the  luvnior- 
rliage. 

The  pressure  within  the  pulmonary  artery  is  considerably  less  than  that 
in  the  aortic  system.  Wv  have  as  yet  very  irnperrect  knowledge  of  the 
circunistances  which  inlluencc  the  lesser  circulation  in  man.  Kesearches, 
I'articularly  those  of  IJradford,  indicate  that  the  system  is  under  vaso- 
motor control,  but  our  knowledge  of  the  mutual  relations  of  pressure  in 
the  aorta  and  in  the  i>nliiionary  artery,  under  varying  conditions,  is  still 
very  imperfect.  Experiments  with  drugs  seem  to  show  that  there  may  be 
an  inlliience  on  systemic  blood-pressure  without  any  on  the  pulmonary, 
and  the  pressure  in  the  one  may  rise  while  it  falls  in  the  other,  or  it  may 

rise  and  fall  in  both  together.    In  Andrew's  Ilarveian  Oration  these  rela- 
40 


■AmA. 


Q40  DISEASES  OF  THE   RESIMllATOIlY  SYSTEM. 

tions  are  tl.oro.iKl.lv  doscril.o.l,  nnd  a  statf.nonl  i.s  lua.le  ba.sod  on  Brad- 
lonl's  oxiHTinuMits/as  lo  Uu-  action  on  tl.o  pulmonary  l.lood-prossure  ot 
nninv  of  the  .irugs  employ.'.!  in  hunm>ptysis.  Tims  crg..t,  the  remedy 
perhaps  most  cnnnonly  used,  causes  a  distinet  rise  m  the  puhuomuy 
blood-pivssure,  while  aconite  prod-  /es  a  delinite  iall.  .       .  ,, 

The  anatomical  con.iition   in  luemop.ysis  is  either  hyperaunuv  ot   the 
l.rone-.ral  mucosa  (or  of  the  lun-  tissu.')  or  a  perforated  artery.      In  the 
lattc  case  the  patient  often  passes  rapidly  l)ey..nd  treatment,  though  there 
are  instances  of  the  most  profuse  luvmorrhage,  which  must  have  come  ironi 
a  perforated  artery  or  a  ruptured  aneurism,  in  which  recovery  has  occurre.l. 
I'racticallv,  for  treatment,  we  should  separate  these  .-ases,  as  the  reuie.lies 
which  would  be  applicable  in  a  case  of  congested  and  bleeding  mucosa 
would  be  as  much  out  of  place  in  a  ease  of  Invnun-rhage  from  ruptured 
aneurism  as  in  a  cut  radial  artery.    When  the  Idood  is  brought  up  in  large 
miantities,  it  is  almost  certain  cither  that  an  aneurism  has  ruptured  or  a 
vessel  has  been  eroded.     In  the  instances  in  which  the  sputa  are  blood- 
tinired   or  when   the   blood   is   in   smaller   quantities,   bleeding   comes   by 
diapdesis  from  hypera<mie  vessels.    In  such  cases  the  h;em.,rrhage  may  be 
benelicial  in  relieving  the  congested  blood-vessels. 

The  indications  are  to  reduce  the  frcniueney  ol  the  heart-beats  an.l  to 
lower  the  blood-pressure.     I'.y  far  the  most  important  measure  is  absolute 
quiet  of  body,  such  as  can  only  be  secure.l  by  rest  in  bed  and  seclusion. 
In  the  majo'rity   of  cases  of   mild   luvmoptysis   this  is   sutbcien  .       hven 
when  the  patient  insists  upon  g..ing  about,  the  bUrd.ng  n.ay  stop  spon- 
taneously.    The  diet  should  be  light  and  unstimulating.     Alcohol  slunild 
not  be  used.      The  patient  may,  if  lie  wishes,  have  ue  to  suck,    ^mall 
doses  of  aromatic  sulplu.ric  acid  may  be  given,  but  unless  the  bleeding 
is  protracted   styptic  and  astringent   medicines  are   not   indicated.       l-.n 
ooiudi    which   is  -ilways  present  and  disturbing,  opium   should  be  f i en  1) 
.nv.m    and  is  of  all  medicines  most  serviceable  in  luemoptysis.     Digitalis 
should  not  be  used,  as  it  raises  the  blood-pressure  in  the  pulmonary  artery. 
Aconite,  as  it  lowers  the  pressure,  may  be  used  when  there  is  much  vascu- 
lar excitc-ment.      Ergot,  tannic  acid,  and  lead,  which  are  so  much  em- 
ploved  liave  little  or  no  influence  in  luvmoptysis;  ergot  probably  does  harm. 
One  of  the  most  satisfactory  means  of  lowering  the  bl..od-pressure  is  purgii- 
tion,  and  when  the  bleeding  is  protracted  salts  may  be  freely  S^^^^^ 
profuse  ha^moptysis,  such  as  om.^s  from  erosion  of  an  artery  or    he  rup- 
nre  of  an  aneurism,  a  fatal  n^sult  is  common,  and  yet  post-mortem  evi- 
dence shows  that  thrombosis  may  occur  with  healing  m  a  rupture  o    con- 
siderable size.     The  fainting  induced  by  the  loss  ot  blood  is  prol.ably  tl  e 
„,o,«t  eiTicient  means  of  promoting  thrombosis,  and  it  was  on  this  principle 
that  formerly  patients  were  bled  from  the  arm    or  from  b-.th  «""^^  •'^  '^ 
the  case  of  iJurence  Sterne.     Ligatures,  or  Ksmarch  s  bandages    placed 
Inmnd  the  legs  may  serve  temp.narilv  to  clicdc  the  b  ceding        ho  ic  - 
bag  on  the  sternum  is  of  doubtful  utility.     In  a  protnuted  ca>e  (  avkj  m 
duml  pneumothorax,  but  witlunit  oiTect.  „„,a,„.o  of 

Brielly,  then,  we  may  say  that  eases  "  /■---•^^-^^/■••'•':,    '^  \      ;,  ^ 
aneurism  or  erosion  of  a  blood-vessel  usually  prove  fatal.      The  fainting 


HIIONTIIO-PNEUMONIA. 


G41 


i.sed  on  Brad- 

jd-pi'L'sSlU'O    ul' 

;,   tlio   iviiK'ily 
lie  pulmonary 

.Tivniia  of  the 
■tory.  In  the 
,  though  there 
av(-  come  from 
y  has  oeeui're(l. 
,s  the  remedies 
ceding  mucosa 
from  ruptured 
flu  up  in  large 
rui)tured  or  a 
mta  are  blood- 
ling  comes  by 
)rrhage  may  be 

,rt-beats  and  to 
nire  is  absolute 
i  and  seclusion. 
Hieient.  Even 
may  stop  spon- 
Alcohol  should 

0  suck.  Snudl 
ss  the  l)leeding 
ndicated.  For 
hoidd  be  freely 
itysis.  Digitalis 
dmonary  artery. 

1  is  much  vascu- 
•e  so  much  em- 
Ijably  does  harm, 
ressure  is  pnrga- 
reely  given.  In 
tery  or  the  rup- 
)ost-mortem  ovi- 

ru])ture  of  con- 
1  is  ])robably  the 
on  this  ])rinciple 
both  arms,  as  in 
bandages,  phiced 
oding.  The  ice- 
d  case  Cayley  in- 

frotn  rujiture  of 
1.      The  fainting 


induced  i)y  tiie  loss  of  blood  is  bencfuial,  and,  if  the  patient  can  be  kept 
alive  for  twenty-four  hours,  a  tlirombus  of  sulhjicnt  streiigtli  to  prevent 
further  iileeding  may  form,  '{'he  chiel'  danger  is  the  iiuindalion  ol  tiie 
bronchial  system  with  the  blood,  so  that  while  tiie  liaiuorrliage  is  profuse 
the  coug'i  -hoiild  he  encouraged.  Opium  sliould  not  then  he  used,  and 
stimulants  should  lie  given  with  caution. 

In  the  otiier  group,  in  wiiicli  the  iucmorrliage  comes  from  a  congested 
area  and  is  limited,  the  patient  gets  well  if  kept  absolutely  quiet,  and 
fatal  luemorrhage  probably  never  oecnrs  from  this  source.  Rest,  reduc- 
tion of  the  Idood-prcssure  l)y  ihiuimuni  diet,  jmrging,  if  necessary,  and  the 
administration  of  opium  to  allay  tiie  cougli  are  the  main  indications. 


II.    BRONCHO-PNEUMONIA    (Cqnlhmj  rtrnuchifi.s). 

This  is  essentially  an  inflammation  of  the  terminal  bronchus  and  the 
air-vesicles  which  make  up  a  pulmonary  loliule,  whence  the  term  broncho- 
pneumonia. It  is  also  known  as  lobular,  in  contradistinction  to  lobar  pneu- 
monia. The  term  catarrlial  is  less  ai)i)licable.  The  process  begins  usually 
with  an  inflammation  of  tlie  ca])illary  bronchi,  which  is  a  condition  rarely, 
if  ever,  found  without  involvement  of  the  lobular  structures,  so  that  it  "is 
now  customary  to  consider  the  afl'ections  together.  All  forms  of  bronelio- 
IHieunionia  depend  upon  invasion  of  the  lung  with  microbes,  and  it  would 
have  been  more  consistent  to  place  them  with  loiiar  pneumonia  amon<^  the 
infectious  disorders,  but  it  is  well  perhajis  to  defer  this  nntil  the  bacteri- 
ology of  the  difl'erent  varieties  has  been  more  fully  worked  out. 

Etiology.— Broncho-pneumonia  occurs  cither  as  a  i)riniary  or  as  a  sec- 
ondary aifection.  The  relative  fre([Ucncy  in  41;}  cases  is  thus  (--iven  bv 
liolt:  Primary,  without  previou,s  bronchitis,  ].")4;  secondary  (/()  to  bron- 
chitis of  larger  tubes,  41;  to  measles,  S!);  to  wIioo]iing-cougli,  M;  to  diph- 
theria, 47;  to  scarlet  fever,  7;  to  intlucnza,  tl;  to  varicella,  ti;  to  erysipelas, 
2;  and  to  acute  ileo-colitis,  1!).  Tiie  ]iroportion  of  ]irimary  to  secondary 
forms  as  shown  in  this  list  is  ]irobably  too  low. 

Primary  acute  broncho-pneumonia,  like  the  lobar  form,  attacks  children 
in  good  health,  usually  under  two  years.  The  etiological  factors  are  very 
much  those  of  ordinary  pneumonia,  and  proliably  the  pncuiiio^oceus  is  more 
often  associated  with  it. 

Secondary  broncho-pneumonia  occurs  in  two  great  groups:  l.  As  a  se- 
quence of  the  infectious  fevers— measles,  dii-htheria,  wiroopinsr-cough,  scar- 
let fever,  and,  less  frecpiently,  small-pox,  erysipelas,  and  tvphoid  fever.  In 
children  it  forms  the  most  serious  comjilication  of  these  diseases,  and  in 
reality  causes  more  deaths  than  are  due  directly  to  the  fevers.  In  largo 
cities  it  ranks  next  in  fatality  to  infantile  diarrluea.  Following,  as  it  iloes, 
tlie  contagi(nis  diseases  which  ])rincipally  alfcct  children,  we  find  that  a 
large  majority  of  cases  occur  during  early  life.  According  to  Morrill's  Bos- 
ton statistics,  it  is  most  fatal  during  the  first  two  years  of  Fife.  The  numlier 
of  cases  in  a  community  increases  or  decreases  with  the  jirevalence  of 
measles,  scarlet  fever,  and  diphtheria.     It  is  most  prevalent  in  the  winter 


^^ 


,.^.2  DISKASKS  OP  THE  RESPIRATORY  SYSTEM. 

and  ^nriiK'  months.  In  tlic  k'hv\h'  afToctimis  of  adults  brondio-pnoumonia 
*i^  not  very  conunnn.  Tluiri  in  tvpliuid  IVxht  it  is  not  so  i\v>[mn\i  as  lol)ar 
i.ncunioiiia,  though  isohitcd  areas  of  consolidation  at  the  basos  are  by  no 
uu.ans  raro  in  protracted  cases  of  this  disease.  In  ohl  people  it  is  an  ex- 
treme] v  enmmon  ailVetion,  following  debilitating  causes  of  any  sort,  and 
superv'ening  in  the  course  of  chronic  Uright's  disease  and  varnms  acute  and 

chronic  maladies.  ,         ,  ii  e 

2.  In  the  second  division  of  this  aifectioii  are  embraced  tlie  cases  ot 
so-called  aspiration  or  deglutition  pneumonia.  Whenever  the  sensitiveness 
of  the  larvnx  is  benumbed,  as  in  tiie  coma  of  apoplexy  or  niwinia,  nunute 
l)articles  of  food  or  drink  are  allowed  to  pass  the  rimn,  and,  reaching  linally 
the  smaller  tubes,  excite  an  intense  inllaminatiuii  similar  to  the  vagus  pneu- 
monia which  follows  the  section  of  the  ].neumogastrics  in  the  dog.  Cases 
are  very  common  after  operations  about  the  mouth  and  nose,,  alter  tracheot- 
(,mv,  and  in  cancer  of  the  larynx  and  (esophagus.  The  aspirated  particles 
in  ^ome  instances  induce  such  an  intense  broncho-pneumonia  that  suppura- 
tion or  even  gangrene  supervenes.  The  ether  pneumonia,  already  described 
(p    l-vM»).  is  often  lobular  in  type. 

An  aspiration  broncho-pneumonia  may  follow  ha^noptysis  (which  has 
l,een  already  considered),  the  aspiration  of  material  from  a  br.mchiec 
tatie  cavity",  and  occasionally  the  material  from  an  empyema  which  has 
ruiitured  into  the  lung.  .     .    .,    .        •.    i  i     ^i  . 

A  common  and  fatal  form  of  broncho-pneumonia  is  that  exinted  by  the 
tubercle  bacillus,  which  has  already  been  consi.lered.  ,      •     , 

Amon"  "cneral  predisposing  causes  may  be  mentumed  age.  As  just 
roted  it  Fs  i)rone  to  attack  infants,  and  a  majority  of  cases  of  pneumonia 
in  children  under  live  years  of  age  are  of  this  ft.rm.  Of  370  cases  in  chil- 
dren under  five  years  of  age,  75  per  cent  were  broncho-pneumonia  (Il..lt).  At 
the  opposite  extreme  of  life  it  is  also  common,  in  association  with  various  (  e- 
bilitatincr  circumstances  and  with  the  chronic  diseases  incident  to  the  old. 
In  children  rickets  and  diarrluea  are  marked  predisposing  causes,  and  bron- 
cho-pneumonia is  one  or  the  most  frequent  post-mortem-room  lesions  ni 
infants'  homes  and  foun.lling  asylums.  The  disease  prevails  most  exten- 
sively among  the  jioorer  classes.  ,.     ,     ,     ,  wi 

Morbid  Anatomy.— On  the  i)leural  surfaces,  particularly  toward  the 
base  are  seen  depressed  bluish  or  blue-brown  areas  of  collapse,  between 
which  the  lun-'  tissue  is  of  a  li-btor  color.  Here  and  there  are  projectuig 
portions  over  which  the  pleura  may  be  slightly  turbid  or  granular.  The 
lun<^  is  fuller  and  llrmer  than  normal,  and,  though  in  great  part  crepitant, 
there  can  be  felt  in  places  throimbout  the  substance  solid,  nodular  bodies. 
The  dark  deju-essed  areas  mav  be  isolated  or  a  large  section  of  one  lobe  may 
be  in  the  condition  of  collapse  or  atelectasis.  Gradual  inflation  by  a  blow- 
pipe inserted  in  tlie  broncbus  will  distend  a  great  majority  of  these  col- 
lapsed areas  On  section,  the  general  surface  has  a  dark  reddish  color  and 
uiallv  drills  blood.  Projecting  above  the  level  of  the  section  are  ligbter 
r.-d  or  reddisb-grav  areas  representing  the  patches  of  broncho-pneumonia. 
Tbe^e  may  be  isolated  and  separated  from  each  other  by  tracts  of  unin- 
flimed  tissue  or  tliev  may  be  in  groups;  or  the  greater  part  of  a  lobe  may 


Kvpnoumonia 
uont  as  h)l)ai' 
?c'S  are  by  no 
L'  it  is  an  ex- 
:my  stirt,  and 
OILS  aciiti;  and 

I  the  casos  of 
}  stnsilivcness 
wniia,  minute 
■achinjii;  linally 
le  va.u'us  pnou- 
le  dog.  Cases 
after  traelieot- 
rated  i)ai'tieles 
that  su])])ui'a- 
eady  deseribed 

-is  (wliicli   lias 

a   l)roneliiec- 

nui  which  has 

exeited  by  the 

age.  As  just 
of  ])iieuinonia 
I)  eases  in  chil- 
iiia(Holt).  At 
,ith  various  de- 
ent  to  the  old. 
uses,  and  bron- 
oom  lesions  in 
lis  most  cxten- 

arly  toward  the 
llapse,  between 
!  are  projeetiug 
granular.  The 
])art  crepitant, 
nodular  bodies, 
jf  one  lobe  may 
tion  by  a  blow- 
:v  of  these  col- 
ddish  color  and 
tion  are  lighter 
cbo-pneumonia. 
tracts  of  unin- 
t  of  a  lobe  niav 


BRONCIIO-PXFA'MONIA. 


f.43 


])e  involved.  .Study  <if  a  favurable  section  of  an  isolated  patch  sliows:  (<;) 
A  dilated  icntral  bronchiole  full  nf  tenacious  purulent  nuicus.  A  i'ortu- 
nate  section  parallel  to  the  long  axis  may  show  a  racemose  ai'rangi  iiicut — 
tile  alveolar  i>assages  full  of  muco-pus.  (/')  Surrounding  tlu'  liroiicims  I'oi' 
from  '<\  to  .")  mm.  or  e\('U  more,  an  area  of  grayi>li-reil  ciui.-olidatioM,  usu- 
ally elevated  above  the  surface  and  linn  to  the  touch.  I'lilike  the  con- 
solidation of  loiiar  luicuuionia,  it  may  present  a  perlVctly  smooth  surface, 
tlujugh  in  some  instances  it  is  distinctly  granular.  In  a  late  stage  of  the 
disease  small  grayish-white  points  may  be  seen,  which  on  pressure  may  be 
sipieezed  out  as  purulent  droplets.  A  section  in  the  axis  of  the  lobule  may 
present  a  somewhat  grape-like  arrangement,  the  stalks  and  stems  repre- 
senting the  bronchioles  and  alveolar  passages  tilled  with  a  yelhnvish  oi' 
grayish-wl.ite  pus,  while  surrounding  them  is  a  reddish-brown  hepatized 
tissue.  ((■)  In  the  immediate  neighborhood  ot  this  periljronchial  iiiilaiii- 
mation  the  tissue  is  dark  in  color,  smooth,  airless,  at  a  somewhat  lower 
level  than  the  hepatized  portion,  and  diifers  distinctly  in  color  and  ap- 
l»carance  from  the  other  jjortious  of  the  lung.  This  is  i!ie  condition  to 
which  the  term  splniizatioii  has  been  given.  It  really  represents  a  tissue 
in  the  early  stage  of  inilammation,  and  it  perhaps  would  be  as  well  to  give 
u|)  the  use  of  this  term  and  also  that  of  caniifiralion,  which  is  onlv  a  niorc 
advanced  stage.  The  condition  of  collapse  probably  always  jirecedcs  this, 
and  it  is  dilUciilt  in  some  insiaiices  to  tell  the  difference,  as  one  shades  into 
the  other.  In  fact,  collapse,  spU'uization.  ami  eariiification  are  but  pivlim- 
iuary  steps  in  broncho-pneumuiiia. 

While,  in  many  cases,  the  areas  of  broncho-])neumoiiia  present  a  red- 
dish-brown color  and  are  indistinctly  granular,  in  others,  particularly  in 
adults,  the  nodules  may  resemble  more  closely  gray  hepatization  and  the 
air-eells  are  filled  with  a  grayish,  muco-purulent  material.  .Minute  liaMii- 
orrhages  are  sometimes  seen  in  the  neighborhood  of  the  inflamed  areas  or 
on  the  pleural  .surfaces.  Em])liysenia  is  commonly  seen  at  the  anterior 
borders  and  ujjper  portions  of  the  lung  or  in  lobules  adjacent  to  the  in- 
flamed ones.  In  many  cases  following  diphtheria  and  measles  the  ])rocess 
is  so  extensive  that  the  greater  part  of  a  lobe  is  involved,  and  it  looks  like 
a  case  of  lobar  hepatization.  It  has  not,  however,  the  uniformity  of  this 
alfcction,  and  collapsed  dark  strands  may  be  seen  between  extensive  areas 
of  hepatized  tissue. 

There  are  three  groups  of  cases:  (1)  Those  in  which  the  bronchitis  and 
bronchiolitis  are  most  marked,  and  in  which  there  may  be  no  definite  con- 
solidation, and  yet  on  microscopical  examination  many  of  the  alveolar  jias- 
sages  and  adjacent  air-eells  appear  tilled  with  inflammatory  j)roducis.  (•?) 
The  disseminated  broncho-pneumonia,  in  which  there  arc  scattered  areas 
of  peribronchial  hepatization  with  patches  of  collapse,  while  a  considerable 
])ro])ortion  of  the  lobe  is  still  cre])itant.  This  is  by  far  tlie  most  eommmi 
condition.  (3)  The  psendo-lobar  form,  in  which  the  greater  jiortion  of  the 
lobe  is  consolidated,  but  not  uniformly,  for  intervening  strands  of  dark 
congested  lung  tissue  separate  the  groups  of  hepatized  lobules. 

Microscopically,  the  centre  of  the  bronchus  is  seen  filled  with  a  i)hig 
of  exudation,  consisting  of  leucocytes  and  swollen  epithelium.     Section  in 


^■A 


('.44 


DISKASKS  OF  THE   liRSPIllATORY  SYSTEM. 


tlio  lonj:  a\is  inav  slmw  irrcjxuhir  ililahitiuiis  of  the  tuln'.  Tlic  broiuliial 
wall  is  sw.illni  and  iiililtraU'il  with  ccll:5.  rntkr  a  low  linwrr  it  is  mulily 
Krii  that  llif  air-cells  next  the  l.roiuliiis  are  im>.st  di'iisdy  tilled,  while 
loward  the  i>eri]iherv  of  the  I'oeiis  the  alveolar  oxudatiun  bceuines  less.  The 
contents  of  the  air-Irlls  are  made  up  of  leucocytes  and  swollen  endothelial 
cells  in  varvinu'  pnipoitions.  lied  corpuscles  are  not  often  ])rosent  and  a 
iil.rin  network  is  rarelv  seen,  Wnnv^h  it  may  l)e  present  in  some  alve  )li.  In 
the  swollen  walls  are'seen  distended  cai>illaries  and  numerous  leucocytes. 
As  Delaiield  has  pointed  out.  the  inter.-titial  intlammatiun  of  the  hroiiehi 
and  alveolar  walls  is  the  special  feature  of  lironcho-pneumonia. 

The  liistoluu-ical  chanties  in  the  aspiration  or  deglutition  broncho-pneu- 
monia dilfer  from  the  ordinary  post-febrile  form  in  a  more  intense  intiltra- 
tion  of  the  air-cells  with  leucocytes,  producing  supi>uration  and  foci  of 
softening;  even  gangrene  nuiy  bo  present. 

Bacln-iuhijij  (if  nroitchu-i>iicumonia.—i:hG  organisms  nu)st  commonly 
found  in  broncho-pneumonia  arc  the  micrucucrus  hiiurulatus,  the  stirpto- 
rnrciif  prMenci^  (either  alone  or  with  the  pneumoeoceus),  the  slnpln/loanrus 
iiinriis  'ft  alhiis,  and  Friedllin.ler's  hacilliin  piiaimonid'.  The  Klehs- 
LoeHlor  l)acill\is  is  not  infrequently  found  in  the  secondary  lesions  of 
diiibtheria.  Except  the  pneumoeoceus  these  microbes  are  rarely  found  m 
pure  cultures.  In  the  lobular  type  the  streptococcus  is  the  most  constant 
organism,  in  the  pseudo-lobar  ihe  pneumoeoceus.  Mixed  infections  are  al- 
most the  rule  in  broneho-pneunumia. 

.M.  Wollstein,  in  U  primary  cases,  found  tlie  mirromrus  lanreohdus 
alone  in  D,  with  the  streptococcus  in  7.  Of  1 1  secondary  cases  the  mirro- 
rocnis  hmrnhilHS  was  found  alone  in  'i  and  with  other  organisms  in  9.  The 
primary  form  is  the  result  of  infection  with  the  pneumoeoceus,  the  see- 
ondary'niost  often  with  the  streptococcus. 

Terminations  of  Bronclio-pnrun)oni(i.—{\)  In  resolution,  which  when  it 
once  be<Mns  goes  on  more  rapidlv  than  in  lilu'inous  pneumonia.  I'.rcuuho- 
pneumonia  of  the  apices,  in  a  child,  persisting  for  throe  or  more  weeks, 
particularly  if  it  follows  measles  or  diphtheria,  is  often  tuberculous.  In 
these  instances,  when  resolution  is  supposed  to  be  delayed,  caseation  has  m 
reality  taken  place.  ('?)  In  suppuration,  which  is  rarely  seen  apart  from 
the  aspiration  and  deglutition  forms,  in  which  it  is  extremely  common.^  (;5) 
In  (jnnqrenc,  which  occurs  under  the  same  conditions.  (I)  In  fihroid 
,.],„, ],,ef,'^rhronic  broncho-pneumonia— a  rare  termination  in  the  simple,  a 
common  sequence  of  the  tuberculous,  disease.  Formerly  it  was  thought 
tluit  one  of  the  most  common  changes  in  broncho-pneumonia,  particularly 
in' children,  was  caseation;  but  this  is  really  a  tuberculous  process,  the 
natural  termination  of  an  originally  s])eeific  broncho-pneumonia.  It  is  of 
course  quite  possible  that  a  broncho-pneumonia,  sim])le  in  its  origin,  may 
subsequently  be  the  seat  of  infection  by  the  haciUus  tulierculosis. 

Symptoms.— The  primarii  form  sots  in  abruptly  with  a  chill  or  a  con- 
yulsion.  The  child  has  not  had  a  previous  illness,  but  there  may  have  been 
slic-ht  exposure.  The  temi)erature  rises  rapidly  and  is  more  constant;  the 
physical  siixns  are  more  local  and  there  is  not  the  widespread  diffuse  catarrh 
of  "the  smaller  tubes.     :\Ianv  eases  are  mistaken  for  lobar  pneumonia.     In 


KUOXCIlO-rNErMoNIA. 


VA'> 


Thu  broiuliial 
or  it  is  R'liilily 
y  filled,  whilo 
uiL'S  less.  The 
leu  eiuldtlu'lial 
proHi'iit  Mini  a 
me  alvoli.  lu 
ous  li'iii'dcyli'S. 
(if  the  bruiRlii 

broiuho-pneu- 
iiUeiisi;  iiitillra- 
1)11  anil  I'ofi  of 

iiost   fDiiuuonly 
us,  the  dirplo- 

0  sliipliylociicciis 

Tiio  Klel)s- 
(lary  lesions  of 
rarely  lound  in 
3  most  constant 
ifections  are  al- 
ec hs  hiturohitus 
cases  the  niicro- 
lisnis  in  9.  The 
coccus,  the  sec- 

,  wliieh  when  it 

oiiia.     IW'diuho- 

or  more  weeks, 

uherculons.     In 

caseation  has  in 

seen  apart  from 

ly  common.     (3) 

(4)    In   fihroid 

n  the  simple,  a 

it  was  tliouglit 

iiiia,  particularly 

ous  process,  the 

imonia.     It  is  of 

1  its  origin,  may 
■ulosis. 

.  a  chill  or  a  con- 
■e  may  have  been 
)re  constant;  the 
id  diffuse  catarrh 
pneumonia.     In 


others  the  piilinoiiary  feiitiircs  are  in  tiie  liackgniiind  or  aie  overlooked  in 
I  Ik  intensity  of  the  general  or  cereliral  syiiijitoriis.     'riio  terniination  is  olteii 
liy  crisis,  and  the  recovery  is  prompt.    'I'lie  niortalily  of  this  form  is  slight. 
S.  West  has  recently  (ISritisii  Medical  .loiiinal,  ISKS,  i)  called  atteiilion  to 
the  iiiiportance  of  recognizing  these  primary  cases  and  to  their  resemldance 
in  clinical  features  witii  acute  lohar  imeiimonia.     The  sccdnildn/  form  begins 
ii>iially  as  a   lii-oiichitis  of  the  smaller  tidies.     Much  confusion   has  arisen 
from  the  description  (d'  capillary  lu'oiichitis  as  a  separate  ail'ection,  whereas 
it   i-  only  a  part,  though  a  primary  and  important  one,  of  broncho-pneu- 
monia.    .\t  the  outset  it  may  be  .slid  that  if  in  convalescence  from  measles 
or  in  whooping-cough  a  child  has  an  accession  of  fever  with  cough,  rapid 
pulse,  and  rapid  breathing,  and  if,  on  auscultation,  line  rales  are  heard  at 
the  liases,  or  widely  sjiread  throughout  the  lungs,  even  though  neither  ciui- 
solidation  nor  blowing  breathing  can  lie  detected,  the  diagnosis  of  broncho- 
pneumonia may  safely  lie  made.     I  have  never  seen   in  a   fatal  case  after 
diphtheria  or  measles  a  cajiillary  bronchitis  as  the  sole  lesion.     The  onset 
is  rarely  sudden,  or  with  a  distinct  chill;  but  after  a  day  or  so  of  imlispo- 
siti'iii  the  child  gets  feverish  and  begins  to  cough  and  to  get  short  of  breath. 
The  fever  is  extremely  variable;  a  range  of  from   10".3"  to  101"  is  common. 
The  skin  is  very  dry  and  pungent.     The  cough  is  hard,  distressing,  and 
may  be  painful.     Dyspmea  gradually  becomes  a   prominent    feafun.      lv\- 
]iiratioii  may  be  jerky  and  grunting.     The  respii'ations  may   ri.se  as  high 
as  (10  or  even  80  per  niiniite.     Within  the  first  forty-eight  hours  the  per- 
cussion resonance  is  not  iiniiaircd;  the  note,  indeed,  may  be  very  full  at  the 
anterior  borders  of  tlu'   lungs.     On   auscultation,   many   rales  are   heard, 
chieily  the  tine  subcrepitant  variety,   with   sibilant   rhoiichi.     There   may 
really  be  no  signs  indicating  that  the  ])arenchyina  of  the  lung  is  involved, 
and  yet  even  at  this  early  stage,  within  forty-eight  hours  of  the  onset  of  the 
pulmonary  symptoms,  I  have  repeatedly,  after  di[ilitlieria.  found  scattered 
nodules  of  lobular  liei)atizati(in.     Xortlirup,  in  a  case  in  which  death  oc- 
curred within  the  first  twenty-four  hours,  in  addition  to  the  e.\tensive  in- 
volvement of  the  smaller  bronchi,  found  the  intralobular  tissue  also  in- 
volved in  places.     The  dyspno'a  is  constant  and  progressive  and  .soon  signs 
of  deficient  aeration  of  the  blood  are  noted.     The  face  becomes  a  little  slif- 
fused  and  the  finger-tips  bluish.     The  child  has  an  anxious  expression  and 
gradually  enters  ujion  the  most  distressing  stage  of  asphyxia.     At  first  the 
urgency  of  the  symptoms  is  marked,  but  soon  the  benumbing  influence  of 
the  carbon  dioxide  on  the  nerve-centres  is  seen  and  the  child  no  longer  makes 
strenu<ius  efforts  to  breathe.     The  cough  subsides  and,  with  a  gradual  in- 
crease in  lividity  and  a  drow^sy  restlessness,  the  right  ventricle  becomes  more 
and  more  distended,  the  bidnchial  rales  become  more  liquid  as  the  tubes 
fill  with  mucus,  and  death  occurs  from  heart  paralysis.     These  are  symp- 
toms of  a  severe  case  of  broncho-pneumonia,  or  what  "the  older  writers  called 
svfffirafire  rafarrh. 

The  physical  siipis  may  at  first  be  those  of  capillary  bronchitis,  as  in- 
dicated by  the  absence  of  dulness,  the  presence  of  fine  subcrepitant  and 
whistling  rales.  In  many  cases  death  takes  place  before  any  definite  pneu- 
monic signs  are  detected.     "When  these  exi.st  they  are  much  more  frequent 


^■i^ 


VA{> 


DISKASKS  OK   TIIK   IlKSriUATOllY   SYSTKM. 


at  I  he  ])iis('s,  wlim-  tlicrc  may  ln"  aivas  c.f  iiiiiiaircil  rc^^uiuinco  ur  even  oi 
positive  (iuliicss.  Wlioii  numerous  i'oci  involve  tlie  greater  part  of  u  lolie 
the  bmitliinf,'  miiv  hecome  tubular,  l)ut  in  tlie  scattered  i)atehes  of  ordi- 
nary broneho-pneumonia.  iollo\vin<,'  tlie  fevers,  the  breathin^^  is  more  eom- 
monly  liar^h  than  bluwiuj;.  in  ^rave  eases  there  is  relraetlon  of  the  ha^e 
of  the  sternuiu  ami  of  the  lower  eostal  cartihiges  duriuy  inspiration.  i)nint- 
ing  to  deiicient  lung  expansion. 

Diagnosis.— With  lobar  jmeumonia  it   may  readily  be  confounded  if 
the  areas  of  consolidation  are  large  and  merged  together.     It  is  to  be  re- 
mendiered.   as    lioll's   ligurew   well   show,   that   broncho-i)ncuiuonia   occurs 
ehielly  in  children  under  one  year,  whereas  hibar  pneumonia  is  more  common 
alter  tlu'  third  year.     No  writer  has  so  clearly  brought  out  the  dill'erence 
between  pneumonia  at  these  periods  as  (ierhard,'"  of  J'liila.lclphia,  whoso 
papers  on  this  sid)ject,  though  published  nearly  sixty  years  ago,  have  the 
livshness  and  accuracy  which  characterize  all  the  writings  of  that  eminent 
j)liysician.     Uetween  lobar  pnenmoiiia  and  the  secondary  form  of  broncho- 
pneumonia the  diagnosis  is  easy.     The  mode  of  onset  is  essentially  dill'erent 
in  the  two  infections,  the  one  developing  insidiously  in  the  course  or  at  the 
conclusion  of  another  disease,  the  other  setting  in  abruptly  in  a  child  in 
good  health.     In  Iol)ar  ])nenmonia  the  disease  is  almost  always  unilateral, 
hi  bronclio-pneumonia  bilateral.     The  chief  trouble  arises  in  eases  of  pri- 
mary broncho-pneumonia,  which  by  aggregation  of  the  foci  involves  the 
greater  part  of  one  lobe.     Here  the  dilllculty  is  very  great,  and  the  jdiysical 
signs  may  be  practically  identical,  but  in  broncbo-i)neumonia  it   is  luuch 
more  likt'ly  that  a  lesion",  however  slight,  will  be  found  on  the  other  side. 

A  still"  more  diflicnlt  cpicstioii  to  decide  is  whether  an  existing  broncho- 
pneumonia is  simple  or  tuberculous.  In  many  instanec<  the  decision  can- 
not he  made,  as  the  circiimstanees  under  which  the  disease  occurs,  the 
mode  of  onset,  and  the  physical  signs  may  be  identical.  It  has  often  been 
mv  experience  that  a  ease  has  been  sent  down  from  the  chihlreirs  ward  to 
the  dead-house  with  the  diagnosis  of  p'ost-febrile  broncho-pneumonia  in 
which  there  was  no  suspicion  of  the  existence  of  tuljcrculosis;  hut  on  sec- 
tion there  were  found  tuberculous  bronchial  glands  and  scattered  areas  of 
broiicho-]meumonia.  soiiie  of  which  were  distinctly  caseous,  while  others 
showed  si>viis  of  softening.  I  have  already  si)oken  fully  of  this  in  the  sec- 
tion on  tuberculosis,  but  it  is  well  to  emphasize  the  fact  that  there  are 
many  cases  of  hroncho-i.ncumoiiia  in  children  which  time  alone  enables 
us  to  distinguish  from  tulierculosis.  The  existence  of  extensive  disease 
at  the  apices  or  central  regions  is  a  suggestive  indication,  and  signs  of  soft- 
enimr  may  l)0  detected.  In  the  vomited  matter,  which  is  brought  up  after 
severe  spells  of  coughing. 'sputum  may  be  ])icked  out  and  elastic  tissue  and 

bacilli  detected. 

Tt  is  a  superfluous  refinement  to  make  a  diagnosis  hotwcen  capillary 
bronchitis  and  catarrhal  pneumonia,  for  the  two  conditions  are  j-art  and 
parcel  of  the  same  disease.  In  simple  bronchitis  involving  the  larger  tubes 
urgent  dysimcca  and  pulmonary  distress  are  rarely  pre.H'iit  and   the  rales 


American  Journal  of  tt  -  Mclical  Scicneos,  vols,  xiv  ami  xv. 


ll. 

laiiL'c  or  c'VLMi  of 
r  itart  of  a  luhu 
l>iit(hos  of  oidi- 
u^i  is  iMuro  cMiiii- 
■tl>m  of  llio  bufO 
i>l)ii'atiuii.  piiiiit- 

)('  confoiunlccl  if 
it  is  tu  Iju  ro- 
luuiiioiiia   occurs 
I  is  more  ctiiiiiiKin 
ut  the  (litl'crciico 
ihidi'lphia,  whoso 
irs  a>;(>,  iiavi'  the 
;  of  that  cuiiiieiit 
f(irm  nl'  hroncho- 
scutially  dillVrcnt 
L'  course  or  at  the 
itly  in  a  chihl  in 
always  unilateral, 
s  in  cases  of  pri- 
fooi  involves  the 
.  and  the  i)liysical 
uonia  it   is  much 
the  otlicr  side, 
exist iui;'  lironcho- 
tlie  decision  can- 
iseasc  occurs,  tlio 
It  has  often  been 
.-jiildren's  ward  to 
L'ho-pneumonia  in 
ilosis;  l)ut  on  sec- 
scattered  areas  of 
•ous,  while  othei's 
of  this  in  the  sec- 
ret that  there  are 
ime  alone  enables 
extensive   disease 
and  sij:ns  of  soft- 
s  brou^-ht  up  after 
I  elastic  tissue  and 

between  capillary 
lions  are  ]iart  and 
ijf  the  larger  tubes 
=ent  and   the  rales 

V  ami  XV. 


IJUOXfllo-I'NF.UMOXrA. 


r.n 


are  coarser  and  more  sibilant,  ll  inu-t  not  be  I'orirotlcn  that,  as  in  lobar 
jineumonia,  cerebral  symplums  may  ma-k  the  true  nature  ot  the  disease. 
and  may  even  lead  to  the  dia-nosis  ..)'  Muiiin<,ntis.  1  recall  more  than  one 
iiHtaiice  ill  which  it  cnald  not  lie  .sitislactorily  determined  whether  the 
infant  bad  tuliertulons  menii'-itis  or  a  cerebral  compl. cation  of  an  acute 
juilmonary  albction. 

Prognosis.— in  the  primary  form  the  outlook  is  ^.'ood.  In  children 
cnfecbhMl  by  const ilutioiial  disease  and  prolonged  fevers  bruneho-pneuinoniu 
is  terribly  fatal,  but  in  cases  coming'  on  in  connection  with  wlioopini;-- 
c<'U,i.;h  or  after  measles  recovery  may  take  plm  e  in  the  most  desperate  case's. 
It  is  in  this  disease  that  the  truth  of  the  old  maxim  is  shoun—"  Never 
despair  of  a  sick  child."  'i'he  (bath-rale  in  children  under  live  has  been 
variously  estimated  at  from  ;J0  to  .Mi  per  ,rnt.  Alter  diphtheria  and 
measles  thin,  wiry  children  .<ecm  to  stand  broncho-jaieumonia  much  belt'  r 
than  fat,  llabby  ones.  Jn  adults  the  a-piration  or  de-lutition  pneumonia 
is  a  vt'cy  fatal  disease. 

Prophylaxis. -M  uch  can  be  done  to  reduce  the  probabiiitv  of  attack 
after  febrile  albrtion-.  'i'juis.  in  the  convalescence  from  mVasles  ami 
whoopin.L-cou-h.  it  is  very  important  that  the  child  should  not  be  exposed 
to  cold,  jiartieularly  at  ni-ht,  when  the  temperature  of  the  room  naturally 
falls.  In  a  nocturnal  visit  to  the  nursery— sometimes,  too,  1  am  sorrv  to 
say.  to  a  children's  hospital— how  olten  one  sees  children  almost  naked, 
bavinn-  kick((l  aside  the  bedclothes  and  having'  the  nij:ht-clothes  up  about 
the  arms!  The  use  of  light  llannel  -combinations"  obviates  this  noctur- 
nal chill,  which  is.  1  am  sure,  an  important  factor  in  the  coMs  and  pulmo- 
nary anVetions  of  young  children.  b,)th  in  privat.'  houses  and  in  institu- 
tions. The  (atarrhal  troubles  of  the  no.-e  and  throat  should  be  carefullv 
attended  to.  and  during  fevers  tlic  mouth  should  be  washed  two  or  three 
times  ii  (lay  with  an  antiseptic  solution. 

Treatment-.— The  fre(|ueney  and  the  seriousness  of  broncho-iuieu- 
monia  render  it  a  disease  which  taxes  to  the  utmost  the  n-sources  of  the 
practitioner.  There  is  no  acute  pulmonarv  aU'ection  over  which  he  at  times 
so  greatly  despaiis,  On  the  other  hand,  there  it  not  one  in  which  he  will 
be  more  giatiiicd  m  .saving  cases  which  have  seemed  jiast  all  succor.  'J'he 
general  arrangements  should  receive  sp(;cial  attention.  The  room  should 
be  kept  at  an  even  temperature— about  (i.^  t<;  (;«'— and  the  air  slnaild  be 
Ke])t  moist  with  vajior. 

At  the  out.et  tlie  bowels  should  be  oiumed  bv  a  mild  i.iiroe.  either 
castor  oil  or  small  doses  of  calomel,  one  twelfth  to  one  sixth  n(  a  -rain 
hourly  until  a  movement  is  obtained,  and  care  should  he  taken  thnundiout 
the  attack  to  secure  a  daily  movement.  The  common  saline  fever  mixture 
of  citrate  of  imfash.  li(pior  ammonii  acctatis.  and  aromatic  spirit^  of  am- 
monia may  be  giv(Mi  (>very  two  or  ihroo  h.nirs.  If  the  diseiise  comes  on 
abru|.tly  with  high  fever,  minim  or  minim  and  a  half  dose.,  of  the  tinctur.- 
of  aconite  may  be  given  with  it.  The  pain,  the  distressing  svmptonis.  and 
the  incessant  cough  often  demand  opium,  which  must  of  course  be  used 
with  care  and  judgment  in  the  case  of  young  children,  but  which  is  cer- 
tainly not   contra-indicated   and   may   be  usefully  given    in   the   form   of 


I 


I 


648 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


]hnn<  imwHcr.     lUisters  are  now  rarely  if  over  emjiloycd,  and  oven  tlio 
jacket  pcultice  lias  g..no  <.ut  oi  fasliion.     For  the  latter,  however    1  eon- 
fe«<  to  a  strong  prejudiee,  and  when  liirhtly  made  and  I'lTqiiently  changed 
it  imdonl)tedly  j^ives  ^M'eat  relief.      Mueh   more  commonly   wo   now   see, 
hoth   in   i.rivatc  and   in    hospital   practice,   the   jacket   of   cotton-battmg. 
Ice-ponltices  to  the  chest   I  have  seen  nsed  apparently  with  groat  bene- 
lit    and  thcv  are  warndv  recommended  by  many  German  phyicians  as 
well  as  by  "(ioodhart   and  others   in   Kn;;land.     The  diet   should   consist 
of  milk,  broths   and  egg  allmmen.     .Milk  often  curds  and  i^  disagreeable 
lMr<^-white  is  particularly  suitable  and  very  acceptable  when  given  in  cold 
mxtvv  with  11  little  sugar.     It  forms,  indeed,  an  excellent  medium  for  the  ad- 
ministration of  the  stimulants.    If  the  pulse  shows  signs  of  failing  it  is  best 
to  be-in  early  with  brandv.     As  in  all  febrile  all'octions  ot  cliiUlren,  cold 
^vaterslKudd  1)0  constantlv  at  the  bedside,  and  the  child  should  bo  enconr- 
ao-cd  to  drink  freely.    ^Vith  those  measures,  in  many  cases  the  disease  pro- 
gresses to  a  favorable  termination,  but  Uh)  often  other  and  more  serious 
symptoms  arise.     Cough  becomes  more  distressing,  dyspn.oa  increases,  the 
,;,ninous  rattling  of  the  mucus  can  be  heard  in  the  tubes,  the  child  s  color 
is  not  so  good,  and  there  is  greater  restlessness.      Under  these  circum- 
stances stimulant  expectorants— ammonia,  squills,  and  senega— should  be 
.riven       Together  they  make  a  very  disagreeable  dose  for  a  young  child, 
vartieularly  with  the  carbonate  of  ammonia.     The  aromatic  spirits  of  am- 
monia is  somewhat  bettor.    Jf  the  carbonate  is  employed,  it  must  be  given 
in  small  doses,  not  more  than  a  grain  to  an  infant  of  eighteen  months,     it 
the  child  has  increasing  diiliculty  in  getting  up  the  mucus,  an  emetic 
should  be  given-oithor  the  wine  of  ipecac  or,  if  necessary,  tartar  emetic. 
There  is  no  nocossity,  hosvovor,  to  keep  the  child  constantly  nauseated. 
Enou-h  should  be  given  to  cause  prompt  emesis,  and  the  beneht  results  in 
the  expulsion  of  mucus  from  the  larger  tubes.     In  this  stage,  too,  strych- 
nine is  u'Kloubtedly  helpful  in  stimulating  the  depressed  respiratory  cen- 
tre.    With  commencing  cyanosis,  inhalations  of  o.xygen  may  be  employed, 

sometimes  with  groat  benefit.  •     ,,      ,i        <.    .,„.i 

Wit'^  rai.id  failure  of  the  heart,  loud  mucous  rattles  in  the  throat,  and 
increasing  lividity,  evory  measure  should  bo  used  to  arouse  the  clu  d  and 
excite  '.niohing.  Alternate  douches  of  hot  and  cold  water,  electricity, 
which  I  have  seen  ap].liod  with  good  re.sults  at  Wiederhofor  s  clinic  in 
Vienna,  and  hypodermic  injections  of  ether  may  be  tried.  For  the  reduc- 
tion of  temperature,  particularly  if  cerebral  symptoms  are  prominon  ,  there 
is  nothing  so  satisfactory  as  the  wet  pack  or  the  cold  bath.  In  the  case 
of  childrcm.  when  the  latter  is  used  it  should  be  graduated,  beginning  with 
a  temperature  which  is  pleasantly  warm  and  gradua  ly  reducing  it  to  .o 
or  80°.  Even  when  the  temperature  is  not  high,  the  cerebral  symptoms 
arc  greatly  relieved  by  the  bath  or  the  jiack. 


CHRONIC   INTERSTITIAL   PNEUMONIA. 


crj 


,  ami  oven  the 
owover,  1  c(tn- 
iiuntly  cliaugod 
y  wo  now  soo, 
cotloii-batting. 
til  groat  bono- 

I  pliy^ieiaiis  a.s 
should  coiif-ist 
i>  di^agrooablc. 

II  givon  ill  cold 
iuni  for  the  ad- 
ailing,  it  is  best 
f  childron,  cold 
onld  bo  cnconr- 
tho  disease  pro- 
id  more  serious 
■a  increases,  the 
Aic  child's  color 
r  these  circum- 
loga — slionld  be 

a  young  child, 
[c  spirits  of  am- 
t  must  be  given 
ecu  months.  If 
ucus,  an  emetic 
y,  tartar  emetic, 
intly  nauseated, 
jenelit  results  in 
age,  too,  strycli- 

respiratory  cen- 
ay  be  employed, 

I  the  throat,  and 
so  the  child  and 
:ater,  electricity, 
hofer's  clinic  in 
For  the  roduc- 
prominent,  there 
ith.  In  the  case 
[,  beginning  witli 
;dncing  it  to  75° 
irebral  symptoms 


III.    CHRONIC    INTERSTITIAL    PNEUMONIA 

(Cirrhusia  of  the  Luiii/ — Filimid  I'hthi.  ig),  '^ 

This  consists  in  the  gradual  sul)stitMtinn  to  a  greater  or  less  extent  of 
connective  tissue  for  the  normal  lung.  It  is  a  iibroid  change  which  may 
have  its  starting-point  in  the  ti.-sue  about  the  bronchi  and  blood-vess..'ls, 
the  interlobular  se]ita,  the  alveolar  walls,  or  in  the  pleura.  So  diverse  are 
the  diU'erent  forms  ami  so  varied  the  conditions  under  which  this  chan"-o 
occurs  that  a  jirojier  classiiieation  is  extremely  dillicult.  We  nuiy  recog- 
nize, however,  two  chief  forms — the  hinil,  which  involves  only  a"  limited 
area  of  the  lung  substance,  and  the  dijjnsc,  invading  either  both  lungs  or 
an  entire  organ. 

Etiology. — Local  fibroid  change  in  tiu'  lungs  is  common.  It  is  a 
constant  aecom])animent  of  tul)er(le  ami  in  every  case  of  phthisis  the 
chronic  interstitial  changes  jilay  a  very  important  rule.  In  tumors,  ab- 
scess, gummata,  hydatids,  and  cmphyse'iua  it  also  occurs.  Fibroid  pro- 
cesses are  freipiently  met  with  at  llu'  apices  of  the  lung  and  may  bo  due 
either  to  a  linuted  healed  tuberculosis,  to  lil)roid  induration  in  conse- 
quence of  pigment,  or,  in  a  few  instances,  may  result  from  thickening  of 
the  i)leura.     They  have  been  desca'ibcd  at  page";j;!l. 

Diffuse  iiilcrslilial  pnriinionia  is  nuit  with  umler  the  following  cir- 
cumstances: 1.  As  a  sequence  of  acute  librinous  pneununiia.  Altiiou!,di 
extremely  rare,  this  is  recognized  as  a  jKissible  termination.  From  un- 
known causes  resolution  fails  to  take  place.  A  gradual  jjrocess  of  organ- 
ization goes  on  in  the  fibrinous  plugs  within  the  air-colls  and  the  alv(H)lar 
walls  become  greatly  thickened  by  a  new  growth,  lirst  of  nuclear  and 
subsequently  of  flbrillated  connective  tissue.  :\lacroscopically  there  is  pro- 
duced a  smooth,  grayish,  homogeneous  tissue  whieli  has  the  p(>euliar  trans- 
lucency  of  all  new-formed  connective  tissue.  This  has  been  called  gray  in- 
duration. A  majority  of  the  cases  terminate  within  a  few  mouths,  and  in- 
stames  which  have  lieen  followed  from  the  outset  are  very  rare. 

'•.'.  Chronic  Broucho-l'ncumonia. — The  relation  of  broncho-pneumonia 
to  cirrhosis  of  the  lung  has  been  specially  studied  by  Charcot,  who  states 
that  it  may  follow  the  acute  or  subacute  form  of  this  disease,  particularly  in 
children.  The  fibrosis  exten.ls  from  the  bronchi,  which  are  usually  found 
dilated.  Bronchiectasis  itself  may  be  followed  by  fibrosis  of  the  lung. 
'I'he  alveolar  walls  are  thickened  and  the  lobules  converted  into  firm  gray- 
ish masses,  in  which  there  is  no  trace  of  normal  lung  tissue.  This  process 
may  go  on  and  inv(dve  an  entire  lobe  or  even  the  whole  lung.  Many  of 
these  cases  are  tuberculous  from  the  outset. 

3.  Pkiinii/citous  Jiilcrslilid}  Pnciiinonid. — Charcot  apjdies  this  term 
to  that  form  of  cirrhosis  of  the  lung  which  follows  invasion  from  the  pleura. 
])oul)t  has  l)een  exin-esscd  by  some  writers  whether  this  really  occurs. 
^^hile  A\  ilson  Fox  is  ])robably  correct  in  (piestioniug  whether  an  eiitirt! 
lung  can  liecome  cirrhosed  by  the  gradual  invasion  from  the  pleura,  there 
can  be  no  donljt  that  there  are  instances  of  primitive  dry  pleurisy,  which, 


1 


li 


J 


«^ 


(350  DISEASES  OF  THE  RESPIRATOKY  SYSTEM. 

.,.  Sir   \,uln.w  Clark  has  poinU.d  out,  gnulually  compve.scs  the  lung  ami 
:     U  '  i    0     .a.  leads  to  nUer^titial  einhosis.      Tin.  .nay  be  duo  m  p    t 

ht^  t        t  a.-e   ..f   involveuK.nl    o{   the    pleura,      lu   man:    other   ca.e> 
V    ,h     exten^ion  <een,s  to  he  so  .lelinitelv  assoeiated  ^vUh  pleun.v 
h.Avevei,  thecxten.o     .c    m  ,„nneeti<m    between    the    two 

''-"'    ''"'"   ;;  tho^  '  i   'a     e      1      lun'is  ren.oved  with   great  ditUeulty, 
:;;:qi:;   til:;  llneLr: nd    elose   adhe.ou   ot   the    pleura    to   the   ohe. 

'"'4    Chronic  u,le,.lUial  ,.nnnnnnia,  due  to  inhalation  ut  dust,  ^vhieh  is 

^""f  ^^i/i;;.:  ^t^:;;:  U.^  P^seuts  tl.  features  ot  a  ehronie  hbrosis  of  the 

"T  hl'aule^'ehan^es   iu    the   lung   n>ay   follow   the   compression   by 
,,u    ;.i  m  or  new  growth  or  the  irritation  of  a  foreign  body  m  a  bronehu. 
iinrW^AnatomV  -There  are  two  chief  forms,  the  massive  or  lo   u 

dhe-  ;:^\;:t:!:^:'th;;ienral   m'm^anes  may  1.  -tre.ne^  ^e^  atu^ 

thiek,  particularly  in  the  pleurogemu.s  cases;    but  ^^^7^,   ^^^^^^'^  ^^ 

V  li,  ..  ed  in  the  lun'>-  there  mav  be  little  thickening  of  the  p  ouia.     iht 

'ntai     s     fim,  and  hard,  'it  strongly  resists  cutting,  and  on  section 

TT      '   ivS  iibroid  tissue  ..f  variable  anu.unt,  through  wdneh  pass  the 

;;;:a-;S      nd  b    ncili.     The  latter  n.ay  be  either  slightly  or  onor- 

i-l  I,       There  -ire  instances  in  whieh  the  entire  lung  is  converted 

""V'Z.,«r  f.,r,»  of  f.1>ro.i.  o!  the  U,„g  l,»s  been  dccHbod  by  Tcroy 


■s  the  lung  and 
be  due  iu  part 
jioii.  lu  soiiiu 
L'  greatly  thiek- 
iig  I'rom  it  into 

or  the  greater 
iving  tc  tlio  iu- 
,hieh  may  oxit^t 
my  other  ea>es, 
A  with  l)U,■uri^y 
(.■tweeu    ihe    two 

greiil  (linieiilly, 
ini   to   the   ohe^t 

A  dufft,  wiiieh  is 

iiie  fil)rosis  of  the 

compression   hy 

in  a  broneluis. 
\i  massive  or  h)l)ar 
;sive  type  the  dis- 
lefornied,  and  tb.e 
Mirt  is  seen  drawn 
iphysematons  and 
•areely  credible  in 
ng  may  lie.     The 
remely   dense  and 
n  tlie  disease  has 
:  the  plenra.     The 
ng,  and  on  section 
gh  wliich  pass  the 

slightly  or  enor- 
>  Inng  is  converted 
s  is  api)arent  only 
can  nsually  he  dif- 
n-onchieetatic,  and 
ffhows  tuberculous 
tlie  cavities.  The 
ous.  The  heart  is 
■re  may  Ik'  marked 

amyloid   condition 

Her,  often  centrally 

0  deeply  pigmented, 

Ijy  emphysematous 

described  by  Tercy 


CDRONIC  INTERSTITIAL  I'NEUMONIA. 


r.r.i 


Kidd  and  W.  McCollinn,  in  wliieh  tiu'  lungs  are  inlerseeled  by  grayish 
iihroid  strands  following  the  lines  of  tiie  iiiterhibiUar  septa. 

Symptoms  and  Course.— 'i'lie  disease  is  essentially  cliroiiic,  ex- 
lending  oMT  a  ])erio(l  of  many  years,  and  when  once  the  condition  is  estab- 
lished the  health  may  be  fairly  good..  In  a  well-inarked  ease  the  jialieiit 
coiiiplaiiis  only  of  his  chronic  cough,  jierhajts  a  slight  shortne-s  of  breath. 
In  other  respects  he  is  (piite  well,  and  is  usually  able  to  do  light  work. 
The  eases  ai'e  commonly  regarded  as  phthisical,  though  there  may  be 
scarcely  a  symptom  of  that  ail'ection  e.\cept  the  cough.  There  are  in- 
stances, however,  of  fibroid  phthisis  which  cannot  Ite  distinguished  from 
cirrhosis  of  the  lung  except  by  the  presence  of  tubercle  bacilli  in  the 
expectoration.  As  the  bronchi  are  usually  dilated,  the  sym])toms  ami 
]ihysical  signs  may  be  those  of  bronchiectasis.  The  cough  is  ])aroxysmal 
and  the  expectoration  is  generally  co])ious  and  of  a  niuco-])urulent  or  sero- 
jiurulent  nature.  It  is  sometimes  fetid.  Ibemorrhage  is  l)y  no  means 
infre([uent,  and  occurred  in  more  than  one  half  of  the  cases  analyzed  by 
Bastian.  Walking  on  the  level  and  in  the  ordinary  affairs  of  life  the  patient 
may  show  no  shortness  of  breath,  but  in  the  ascent  of  stairs  and  on  exer- 
tion there  may  be  dj'spna'a. 

Physical  Signs. — Ini^pcrtiou. — The  aifected  side  is  immobile,  retracted, 
and  shrunken,  and  contrasts  in  a  striking  way  with  the  voluminous  sound 
side.  The  intercostal  spaces  are  obliterated  and  the  rrl)s  may  even  over- 
lap. The  shoulder  is  drawn  down  and  from  l)ehiiul  it  is  seen  that  the 
spine  is  bowed.  The  heart  is  greatly  displaced,  being  d.'awn  over  by  the 
shrinkage  of  tlio  lung  to  the  affected  side.  When  the  left  lung  is  affected 
there  may  he  a  large  area  of  visible  impulse  in  the  second,  third,  and 
fourth  interspaces.  ]\rensuration  shows  a  great  diminution  in  the  affected 
side,  and  with  the  saddle-tape  the  expansion  may  bo  seen  to  be  negative. 
The  percussion  note  varies  with  the  condition  of  the  bronchi.  It  may  be 
absolutely  flat,  particularly  at  the  base  or  at  the  apex.  In  the  axilla 
there  may  be  a  flat  tymjjany  or  even  an  amphoric  note  over  a  large  sac- 
cidated  bronchus.  On  the  opposite  side  the  percussion  note  is  usually 
hyperresonant.  On  avsntltalinn  the  breath-sounds  have  either  a  cavern- 
ous or  amphoric  quality  at  the  apex,  and  at  the  base  are  feeble,  with 
mucous,  bubbling  rales.  The  voice-sounds  are  usually  exaggerated.  Car- 
diac murmurs  are  not  uncommon,  ])articularly  late  in  the  disease,  wlion 
the  right  heart  fails.  These  are,  of  course,  the  ]>hysical  signs  »f  the  dis- 
ease when  it  is  well  established.  They  naturally  vary  considerably,  ac- 
cording to  the  stage  of  the  process.  The  disease  is  essentially  chronic, 
and  may  persist  for  fifteen  or  twenty  years.  Death  occui's  sometimes  from 
haemorrhage,  more  commonly  from  gradual  failure  of  the  right  heart  with 
dropsy,  and  occasionally  from  amyloid  degeneration  of  the  organs. 

The  (Uafjnnsis  is  never  diflicult.  It  may  be  impossible  to  say,  without 
a  clear  history,  whether  the  origin  is  pleuritic  or  pneumonic.  Between 
cases  of  this  kind  and  fibroid  phthisis  it  is  not  always  easy  to  discriminate, 
as  the  conditions  may  be  almost  identical.  When  tuberculosis  is  present. 
however,  even  in  long-standing  cases,  bacilli  are  nsually  present  in  the 
sputa,  and  there  may  be  signs  of  disease  in  the  other  lung. 


^^ 


052 


DISEASES  OF  THE   UESPIUATORY   SYSTEM. 


Treatment.— Tt  is  only  for  nn  iiitcMvuvrciit  iiilVction  or  for  an  aggra- 
vatioii  of  tlu'  coiigli  iluil  the  iialiciU  socks  relief.  Nothing  can  Ijo  done 
for  tiie  condition  itself.  Wiien  possiljle  tiie  patient  shoidd  live  in  a  mild 
eliniate,  and  should  avoid  exposure  to  eold  and  damp.  A  distressing 
feature  in  some  eases  is  the  putrei'ac:li(tn  of  the  contents  of  the  dilated 
tubes,  for  which  the  same  measures  may  be  u>ed  as  in  fetid  bronehitis. 


IV.    PNEUMONOKONIOSIS. 

I'nder  this  term,  introduced  by  Zenker,  are  embraced  those  forms  of 
fibrosis  of  the  lung  due  to  the  inhalation  of  dusts  in  various  occupations. 
Thoy  have  received  various  names,  according  to  the  nature  of  the  inhaled 
p.„.t'i(.le^_r,/(////Y;r(<,s'(.s',  or  coal-miner's  dis(.'ase;  .vi'(/c;vAsi.s,  due  to  the  inhala- 
tion of  metallic  dusts,  particularly  iron;  chulicosi)!,  due  to  the  inhalation 
of  mineral  dusts.  ])roducing  the  so-called  stone-cutter's  phthisis,  or  the 
'•  <n'inder's  rot  "  of  the  Shellield  workers. 

"^  The  dust  particles  iiduiled  into  the  lungs  are  dealt  with  extensively  l)y 
the  ciliated  epithelium  and  by  the  phagocytes,  which  exist  normally  in  the 
respiratory  organs.     The  ordinary  mucous  corimscles  take  in  a  large  num- 
ber of  the  jiarticles,  which  fall  upon  the  trachea  and  main  ))ronchi.     The 
cilia  sweep  the  mucus  out  to  a  jioint  from  which  it  can  be  expelled  by 
coughing.     It  is  doubtful  if  the  par' ides  ever  reach  tlie  air-cells,  but  the 
swollen  alveolar  cells  (in  which  liiey  are  in  numl)ers)  i)ro!)ab!y  pick  them 
up  on  the  way.     The  muc(nis  an'  the  alveolar  cells  are  the  normal  respira- 
tory scavengers.     Jn  dwellers  in       ••  country,  in  which  the  air  is  pure, 
they  are  able  to  i)revent  the  access  of  dust  particles  to  the  lung  tissue, 
so  that  even  in  adults  these  organs  present  a  rosy  tint,  very  diiferent  from 
the  dark,  carbonized  appearance  of  the  lungs  of  dwellers  in  cities.    "When 
the  imimrilies  in  the  air  are  very  abundant,  a  certain  proportion  of  the 
dust  particles  escajjcs  these  cells  and  penetrates  the  mucosa,  reaching  the 
lymph  spaces,  where  tliev  are  attacked  at  once  by  the  cells  of  the  connec- 
tive-tissue stroma,  which  are  capable  of  ingesting  and  retaining  a  large  quan- 
tity.    In  coal-miners,  coal-heavers,  and  others  whose  occu])ations  neces- 
sitate the  constant  breathing  of  a  very  dusty  atmosphere  even  these  forces 
are  insufT'cient.     "Manv  of  the  particles  enter  the  lymph  stream  and,  as 
Arnold  has  shown  in  his  beautiful  researches,  are  carried  (1)  to  the  lymph 
nodules  surrounding  the  bronchi  and  blood-vessels;   (2)  to  the  interlobular 
eepta  beneath  the  idetira.  where  th(>y  lodge  in  and  between  the  tissue  ele- 
ments- and  (;?)  alouir  the  lar-rer  Ivmph  channels  to  the  substernal,  bronchial 
and  ti'acheal  glands,  in  which  the  stroma  cells  of  the  follicular  cords  dis- 
pose of  them  iiermanently  and  i)revent  them  from  entering  the  general 
circulation.     Occasionallv  in  anthracosis  the  carbon  graitis  do  reach  the 
iiencral  circulation,  and  the  coal  dust  is  found  in  the  liver  and  s].leen.    As 
Weigert  has  shown,  this  occurs  when   the  densely   i)igmented    brmichial 
glands  closelv  adhere  to  the  ])ulmonary  veins,  through  the  walls  of  which 
the  carbon  ^iarticles  pass  to  the  general  circulation.     The  lung  tissue  has 
a  remarkable  tolerance  for  these  particles,  probably  1)ecanse  a  large  proper- 


PXEUMUNOKONIOSIS. 


053 


for  an  aggra- 
cau  be  done 
ive  ill  a  iiiilil 
A  distressing 
j1'  the  dilated 
)rouchitis. 


hose  forms  of 
IS  occupations. 
1)1'  the  inhaled 
to  the  inhala- 
the  inhalation 
itliisis,  or  the 

extensively  hy 
ornially  in  the 
1  a  large  nuin- 
l)ronclii.    The 
be  expelled  by 
r-cells,  but  the 
il)]y  pick  them 
iiornial  respira- 
le  air  is  pure, 
lie  lung  tissue, 
ditl'erent  from 
1  cities.     When 
jjiortion  of  the 
I,  reaching  the 
of  the  connec- 
ig  a  large  (juan- 
u])ations  neees- 
■en  these  forces 
stream  and,  as 
)  to  the  lymph 
the  interlobular 
1  the  tissue  ele- 
criial,  bronchial 
cular  cords  dis- 
ing  the  general 
is  do  reach  the 
and  spleen.     As 
_Mited    bronchial 
M-alls  of  which 
lung  tissue  has 
a  large  propor- 


tion of  them  is  warehoused,  so  to  speak,  in  protoplasmic  cells.  I'.y  con- 
stant exposure  a  limit  is  rcachi'd,  and  there  is  hroiight  ai)()Ut  a  vt  ry  definite 
pathological  condition,  an  interstitial  sclerosis.  In  coal-miners  this  may 
occur  in  patches,  even  iietore  the  lung  tissue  is  unit'ormly  inliltrated  witli 
the  dust,  in  others  it  appears  only  after  the  entire  organs  have  beeomo 
so  laden  that  iliey  are  dark  in  I'olor,  and  an  ink-like  juice  Hows  from  the 
cut  surface.  The  lungs  of  u  miner  may  he  hiack  throughout  and  yet  show 
no  local  lesions  and  be  everywhere  crepitant. 

As  already  mentioned,  the  ])articlcs  are  deposited  in  large  numl)ers  in 
the  follicular  cords  of  the  tracheal  and  bronchial  glands  and  of  the  peri- 
bronchial and  jieri-arterial  lymph  nodules,  and  in  these  they  linally  excite 
])rolil'eration  of  the  connective-tissue  elements.  It  is  by  no  means  un- 
common to  find  in  persons  whose  lungs  are  only  moderately  carbonized 
the  bronchial  glands  sclerosed  and  hard.  In  anthracosis  the  iiltroid 
changes  usually  begin  in  the  jieri-bronchial  lymph  tissue,  and  in  the  early 
stage  of  the  process  the  sclerosis  may  be  largely  conilned  to  these  regions. 
A  Nova  Scolian  miner,  aged  thirty-six,  died  under  my  care,  at  tiie  :Mont- 
real  General  ]lospilal,  of  black  small-pox,  after  an  illness  of  a  few  days. 
In  his  lungs  (externally  coal-black)  there  were  round  and  linear  jiatches 
ranging  in  size  from  a  pea  to  a  hazel-nut,  of  an  intensely  black  color,  air- 
less and  firm,  and  surroumhMl  by  a  crepitant  tissue,  slate-gray  in  color. 
In  the  centre  of  each  of  these  areas  was  a  small  bronchus.  Many  of  them 
were  situated  just  beneath  the  pleura,  and  formed  typical  examples  of 
limited  fibroid  broncho-pneumonia.  In  addition  there  is  usually  thicken- 
ing of  the  alveolar  walls,  jiarticularly  in  certain  areas.  liy  tlie  gradual 
coalescence  of  these  filjroid  ])atclies  large  portions  of  the  lung  mav  be 
converted  into  firm  grayish-black,  in  the  case  of  the  coal-miner — .steel- 
gray,  in  the  case  of  the  stone-worker — areas  of  cirrhosis.  In  the  case  of  a 
Cornish  miner,  aged  sixty-three,  who  died  under  my  care,  one  of  these 
fibroid  areas  measured  18  by  (I  cm.  and  i.'>  cm.  in  depth. 

A  second  imjiortant  factor  in  these  cases  is  chronic  bronchitis,  which 
is  ])resent  in  a  large  jn-oixirtion  and  really  causes  the  chief  symptoms.  A 
third  is  the  occurrence  of  em])hysema,  which  is  almost  invariably  associ- 
ated with  long-standing  cases  of  imeumonokoniosis.  With  the  changes  so 
far  described,  unless  the  cirrhotic  area  is  unusually  extensive,  the  ca.^e  may 
l)resent  the  features  of  chronic  bronchitis  with  emphysema,  but  finally 
another  element  conies  into  play.  In  the  fibroid  area.s  softening  occurs, 
probably  a  ])rocess  of  necrosis  similar  to  that  by  which  softening  is  pro- 
duced in  nbro-myomata  of  the  uterus.  At  first"  the.H-  are  small  and  eon- 
tiiin  a  dark  li.piid.  Charcot  calls  them  niches  dii  pintniim.  They  rarely 
attain  a  large  size  unless  a  communication  is  formed  with  the  bronchus, 
in  which  case  they  may  liecome  converted  into  sup])urating  cavities.  Tiie 
(luestion  has  been  much  discussed  of  late  as  to  what  part  the  tubercle  bacil- 
lus plays  ill  these  cases  of  pneumonokoniosis  with  cavity  formation.  In 
some  instances  there  is  certainly  a  tulierculous  process  ingrafted,  but 
that  large  excavations  may  occur,  or  in  other  instances  bronchiectasis 
without  the  presence  of  bacilli,  I  have  convinced  myself  by  the  examina- 
tion of  several  characteristic  specimens. 


i 


f 


3 

1,3 


^^ 


054 


DISEASES   OF  THE   HESPIUATOllY   SYSTEM. 


Tlip  fiiilrrosis  imhicod  liy  tlif  dxido  of  iron  oaiisos  nn  interstitial  pnoii- 
nioiiia  similar  to  anllnii(('>is.  W'niktTs  in  brat-s  and  in  iironze  aio  lial)lo 
to  a  iiUo  allVction. 

Chfilirdsis,  dill'  to  the  dciio.-it  of  particlos  of  silcx  and  alumina,  is 
found  in  tlic  mal<i'rs  of  niiil-stones.  )iai1i(ulaiiy  the  J-'reneii  mill-stones, 
and  also  in  knife  and  axe  jzrindeis  and  stone-cutters.  Anatouiieally,  this 
form  is  charaeterized  liy  the  ]iro.lneti(ni  of  n«  .lules  of  various  sizes,  .vhieh 
are  eut  witii  tiie  greatest  dillienlty  and  sometimes  present  a  curious  gray- 
isii,  even  f:litterin<r,  crystalloid  appearance. 

Worki'rs  in  llax  and  in  cotton,  and  j;rain-shovellers  are  also  sid)jeet  to 
these  elironic  interstitial  eiuin.<:es  in  the  luii<;s.  in  all  these  oceupatioi'=, 
as  shown  by  Cireenhow,  to  wMiose  careful  studies  we  owe  so  much  of  our 
knowledfic  of  these  diseases,  the  condition  of  the  lung  may  ultimately  be 
almost  identical. 

The  si/iiiiildins  do  not  come  on  until  the  iiatient  has  worked  for  a  vari- 
able number  of  years  in  the  dusty  atmosphere.  As  a  nde  there  are  cough 
and  failing  health  for  a  ]>rolonged  ]ieriod  of  time  before  .complete  disa- 
hility.  The  coincident  emphysema  is  rcsponsil)le  in  great  part  fo'"  the 
shortness  of  breath  and  wheezy  condition  of  these  patients.  The  expec- 
toration is  usually  muco-pundent,  often  i)rofuse;  in  a  case  of  anfhra- 
cosis,  very  dark  in  color — the  so-called  "  black  spit  "  ;  in  a  case  of  ciuilicosis 
there  may  he  seen  under  the  microscope  the  Ijright  angular  particles  of 
silica. 

Even  when  there  are  physical  signs  of  cavity,  tuljcrele  bacillus  are  not 
necessarily,  and  indeed  in  my  experience  they  are  not  usually  jiresent.  It 
is  remarkable  for  how  long  a  time  a  coal-miner  may  continue  to  bring  up 
sjiutum  laden  with  coal  ])arlicles  even  when  there  are  only  signs  of  a 
ciironic  brotichitis.  ]\Iany  of  the  jiarticles  arc. contained  in  the  cells  of  the 
alveolar  epithelium.  In  these  instances  it  appears  that  an  attempt  is  made 
by  the  leucocytes  to  rid  the  lungs  of  some  of  the  carbon  grains. 

Tlie  diagnosis  of  the  condition  is  rarely  dillicult;  the  exi)ectoration  is 
tisually  characteristic.  It  must  always  be  borne  in  mind  that  chronic 
bronchitis  and  emphysema  form  essential  jiarts  of  the  process  and  that  in 
late  stages  there  may  be  tul)ercidous  infection. 

The  hrdlnieui  of  the  condition  is  practically  that  of  chronic  bronchitis 
and  einpliy:-enia. 


V.    EMPHYSEMA. 

Definition. — The  comlition  in  which  the  infundibular  passages  and 
the  alveoli  are  dilated  and  the  alveolar  walls  atrophied. 

A  practical  divisi(m  may  be  made  into  compensatory,  hypertrophic, 
and  atrojihic  forms,  the  acute  vcsicidar  em])hysema,  and  the  interstitial 
forms.  The  last  two  do  not  in  reality  come  under  the  above  definition,  but 
for  convenience  they  may  be  considered  here. 


rstitial  pnou- 
izc  iiie  lial)lo 

nlunrma,  is 
1  iiiill-i^lom's, 
Jink-ally,  this 
«  sizes,  '.vliii'U 
curious  gray- 

Iso  siil)jet't  to 
I  occupatioi's, 
imieli  of  our 
ultiniuloly  be 

cd  for  a  vari- 
oro  are  cough 
oMipk'te  (lisa- 
part  I'o^  the 
The  expec- 
?c  of  anthra- 
c  of  ciuilicosis 
r  particles  of 

icillus  are  not 
V  present.  It 
e  to  bring  up 
ly  signs  of  a 
le  cells  of  the 
:ompt  is  made 

;S. 

pectoration  is 

that  chronic 

;s  and  that  in 

nic  bronchitis 


passages  and 

hypertrophic, 
he  interstitial 
definition,  but 


EMPIIYSKMA. 
I.     ('(I.MI'KNSATnliV      IvM  I'll  YSKMA. 


i!55 


Wlu'iu'ver  n  region  nf  the  lung  does  not  exiiand  fully  in  ins|iiration, 
either  anollu'r  |i(uliiin  of  tlie  lung  nnist  exiiand  or  the  elu'st  wall  sink  in 
order  to  oeeupy  the  s|iaee.  The  fornu'r  almost  invarialily  oecurs.  We 
iiave  already  nientioiieil  tiial  in  lironeho-iuieuinonia  there  is  a  vicarious 
(lislenlion  ol'  the  air-vesii'les  in  tiu'  adjaeeiit  healthy  lolinlcs,  iiiul  the  same 
hajipens  in  tlii'  neighborhood  of  tuberculous  areas  and  eicatiiees.  in  gen- 
eral jileural  adhesions  there  is  ol'ten  eoinpensatory  emphysema,  |iartieu- 
larly  at  the  anterior  margins  ol"  the  Inng.  The  most  advanced  example  of 
this  form  is  sei'n  in  cirrhosis,  when  the  unall'ected  lung  increases  greatly 
in  size,  owing  to  (li.-tentinn  of  the  air-vesieles.  A  similar  thnu<,;h  less 
niaiked  condition  is  ^e^■n  in  i-xteiisive  pleurisy  with  ell'usidn  and  in  [uieii- 
mothorax. 

At  lirst,  this  distention  of  the  air-vesicles  is  a  simple  plivsiologieal 
]iro(('>s  and  the  alveolar  walls  are  stivtched  hut  not  atrophiiMl.  I'lti- 
mately.  however,  in  many  cases  they  waste  and  the  contiguous  aii-cells 
fuse,  jiroducing  true;  cmiihysenia. 

ir.    TTYl'KIiTliOI'inC    Kjri'IIYSKMA. 

The  large-lunged  emphysema  of  Jeiiner,  also  known  as  substantive  or 
idiopathic  em]ihysema,  is  a  well-marked  clinical  alVcction,  charaeterized  hy 
cidargenu'nt  of  tiie  lungs,  due  to  dist^'iition  of  the  air-cells  ami  atro|)liy  of 
tluir  walls,  and  clinically  by  imjierfiet  aeration  of  the  blood  and  nu)re  or 
less  marked  (lyspn(ea. 

Etiology. — Kmphysema  is  the  result  of  persistently  high  intra- 
alvi'(dar  tension  acting  up(m  a  congenitally  weak  Inng  tissue.  If  the 
mechanical  views  as  to  its  origin,  which  have  prevailed  so  long,  were  true, 
the  disease  would  certainly  be  much  more  coniuu)n;  since  violent  respira- 
tory elforts,  believed  to  be  the  essential  factor,  are  performed  by  a  majority 
of  the  working  classes.  Strongly  in  favor  of  the  view,  that  the  nutritive 
change  in  the  air-cells  is  the  primary  factor,  is  the  markedly  hereditary 
character  of  the  disease  and  the  fre(|uency  with  which  it  starts  early  in 
life.  Tlu'se  are  two  points  npon  which  scarcely  snllicient  stress  has  been 
laid.  'I'o  James  Jackson,  Jr.,  of  Boston,  we  owe  the  first  observations 
on  the  hereditary  character  of  cmiihysema.  Working  under  T.ouis'  direc- 
tions, he  found  that  in  IS  out  <  f  v'S  cases  one  or  both  parcnl>  were  af- 
fected. 

I  have  been  imiu'cssed  by  the  freijuency  of  its  origin  in  cliildluKHl.  It 
may  f(dlow  recurring  asthmatic  attacks  due  to  adenoid  vegetations.  It 
may  develoj),  too,  in  several  mendiers  »{'  the  same  family.  We  are  still 
ignorant  as  to  the  nature  of  this  congenital  ]iulmonary  weakness.  Cohn- 
heini  thiid<s  it  proI)ably  due  to  a  defect  in  the  development  of  the  clastic- 
Tissue  fibres — a  statement  which  is  borne  out  by  l'",])piiiger"s  observations, 

ircightened   jtressure  within   the  air-cells  may  be  due   to   fm-cilde   in- 
spiration or  expiration.     Much  discussion  has  taken  place  as  to  the  jiart 
played  by  these  two  acts  in  the  lu-oduction  of  the  disease.    The  inspiratory 
41 


i 


^^ 


(550  DISKASES  OF  THE  RESPIRATORY  SYSTEM. 

Ilicorv  was  julviiiiiod  liy  Liicmior  and  subsoqiiontly  moililii'il  liv  CJiiirdiicr, 
wIh)  lu'lil  tliiit  ill  clinmii'  l.roiichiti;;  areas  ol'  collaiise  wiTc  indiiml,  and  com- 
pensatory distention  took  place  in  the  adjacent  lohnles.  Tliis  nnipies- 
tionalily"  does  oeenr  in  tlie  viearious  or  eoniiu'nsatory  emphysenui,  l>ut 
it  |.rol.al)ly  is  not  a  factor  of  inncli  moment  in  the  form  now  nnder  con- 
sideration." The  e.\i)iratory  tlieory.  whicli  was  sujiported  by  Mendelssohn 
and  .lenner.  accounts  for  the  comlition  in  a  mncii  more  satisfactory  way. 
Jn  all  straining  etl'orts  and  violent  attacks  of  conj^liin.ir,  the  glottis  is  dosed 
and  the  chest  walls  are  strongly  comprcsised  hy  muscular  eiVor'.s,  so  that 
the  strain  is  thrown  ujion  those  parts  of  the  lung  least  protected,  as  the 
apices  and  the  anteiior  margins,  in  which  we  always  lind  the  emi)hy- 
sema  most  advanced.  The  sternum  and  costal  cartilages  gradually  yield 
to  the  heightened  intrathoracic  iiressnre  and  are,  in  advanced  cases,  pushed 
forward,  giving  the  characteristic  rotundity  to  the  thorax.  The  cartilages 
graduaU'ritecome  calcilied.  One  theory  of  the  disease  i.s  that  there  is  a 
gradual  "enlargement  of  the  thorax  and  the  lungs  increase  in  vohime  to 
till  up  the  space.  . 

Of  other  etiological  factors  occupation  is  the  most  important,  iho 
disease  is  met  with  in  players  on  wind  instruments,  in  glass-hlowers,  and 
in  occupations  necessitating  heavy  lifting  or  straining.  \Vhooping-cough 
and  hronchitis  i)lay  an  important  ivli\  not  so  much  in  the  changes  winch 
they  induce  in  the  bronchi  as  in  consequence  of  the  prolonged  attacks  of 

cou'^hini^. 

Morbid  Anatomy.— The  thorax  is  capacious,  nsnally  barrel-shaped, 
and  the  cartilages  are  calcilied.     On  removal  of  the  sternum,  the  anterior 
mediastinum  is  found  comiiletcly  occupied  by  the  edges  of  the  lungs,  and 
the  jtericardial  sac  may  not  be  visible.      The  organs  arc  very  large  and 
have  lost  their  elasticity,  so  that  they  do  not  collapse  either  in  the  thorax 
or  when  i)laced  on  the  table.     The  iileura  is  iiale  and  there  is  often  an 
absence  of  ))igment,  sometimes  in  patches,  termed  by  Virchow  albinism  of 
the  lunix.     To  the  touch  they  have  a  ]H'cnliar,  downy,  feathery  feel,  and 
])it  reacfily  on  ])ressure.      Th'is  is  one  of  the  most  marked  feature  .      be- 
neath the  i)lenra  greatly  enlarged  air-vesicles  may  be  readily  seen.     They 
vary  in  size  from  i  to "3  mm.,  and  irregular  bulhr.  the  size  of  a  walmxt 
or  larger,  mav  ]iroject  from  the  free  margins.      The  best  idea  of  the  ex- 
tremo^'rare  fact  ion  of  the  tissue  is  obtained  from  sections  of  a  lung  dis- 
tended and  dried.     At  the  anterior  margins  the  structure  may  form  an 
irrcnilar  series  of  air-chambers,  icscmbling  the  frog's  lung.     On  careful 
insirection  with  the  hand-lens,  remnants  of  the  interlobular  septa  or  even 
of  the  alveoli  mav  lie  seen  on  these  large  emphysematous  vesicles.    Though 
c^eneral  throuudimit  the  organs,  the  distention  is  more  marked,  as  a  rule, 
at  the  anterior  margins,  and  is  often  specially  developed  at  the  inner  sur- 
face of  the  lobe  near  the  root,  where  in  extreme  cases  air-spaces  as  large 
as  an  e.r<^  may  sometimes  be  found.    :Microscopically  there  is  seen  atro].hy 
of  the  aU'Milar  walls,  by  which  is  produced  the  coalescence  of  neighboring 
air-cells      ju   this   pro'cess  the   cajtillary   network   disappears   before  the 
walls  are  comidetelv  atrophied.     The  loss  of  the  clastic  tissue  is  a  special 
feature      It  is  stated,  indeed,  that  in  certain  cases  there  is  a  congenital 


wim 


EMPilYSKMA. 


c,:>7 


liy  Giiinliier, 
'Oil,  and  com- 
riiis  un<iiu's- 
iliysi'iiia,  hut 
,v  iiikIct  con- 

st'iictoi'v  way. 
lit  lis  is  flosL'd 
I'or's,  so  that 
(■(■ti'd,  as  the 
tlu!  I'lnjiliy- 
adually  yield 
cases,  pushed 
riie  cartilages 
lal  there  is  a 
ill  viiliiine  to 

lortant.  The 
-Idowers,  and 
iooi>iiig-eou.^'h 
hauges  wliich 
^ed  attacks  of 

Ijarrel-shapcd, 
,  tlie  anterior 
lie  lungs,  and 
ery  large  and 
in  the  thorax 
[■e  is  often  an 
iw  aJbiniam  of 
liery  feel,  and 
'eature-.      Be- 
y  seen.     They 
e  of  a  walnut 
:lea  of  the  ex- 
jf  a  lung  dis- 
may form  an 
r.     On  careful 
septa  or  even 
ioles.    Though 
ked,  as  a  rule, 
the  inner  sur- 
;paces  as  large 
s  seen  atro]ihy 
of  neighboring 
u's   before  the 
Hie  is  a  special 
is  a  congenital 


defect  in  the  development  of  tiiis  tissue.  Tlie  epitlieliiun  of  the  air-cells 
undergoes  a  fatty  change,  but  the  large  disteiideil  air-siiaccs  retain  a  pave- 
iiieiit  layi'r. 

Tliu  Ijrniiciii  show  inipnrtant  changes.  In  the  larger  tul)es  tlie  mucous 
membrane  may  be  rough  and  thickened  from  ciinmic  liioiichitis;  often  tiie 
longitudinal  lines  of  submucous  elastic  tissue  stand  out  |)r()minently.  in 
the  advanced  cases  many  of  the  smaller  tidies  are  dilated,  particularly 
wiieii,  in  aililition  to  em|ihyscma,  there  are  peri-broncliial  lilivoid  changes, 
lironchiectasis  is  not,  however,  an  invarialile  aceompaiiiment  of  empiiy- 
senia,  but,  as  Laennec  remarks,  it  is  dilliciill  to  understand  wliy  it  is  luit 
more  common.  Of  associated  morliid  ciianges  the  most  inijiortant  are 
found  in  the  heart.  The  right  cliauibers  are  dilated  and  liypertro|iliied. 
the  (riciis|)id  orifice  is  large,  and  the  valve  segments  are  often  thickened 
at  tlie  edges.  In  advanced  cases  tlie  cardiac  hy])ertropliy  is  general.  The 
pulmonary  artery  and  its  branches  may  be  wide  and  show  marked  atluM'om- 
atous  ciianges. 

^J'he  changes  in  the  other  organs  are  those  commonly  associated  with 
prolonged  venous  congestion. 

Symptoms. — The  disease  may  lie  tolerably  advanced  before  any  spe- 
cial symiitums  develoj).  A  child,  for  instance,  may  be  somewhat  short  of 
breath  on  going  up-stairs  or  may  be  unable  to  run  and  play  i.s  other  ehil- 
dreu  without  great  discomfort;  or,  perhajis,  has  attacks  of  slight  lividit}-. 
Doubtless  much  dejjends  upon  the  completeness  of  cardiac  compensation. 
"When  this  is  perfect,  there  may  be  no  special  iiiterrii]>tion  of  the  puliiKinary 
circulation  and,  excejjt  with  violent  exertion,  there  is  no  interl'erence  witli 
the  aeration  of  tlie  blood.  Tn  well-develo]ied  cases  the  following  are  tiie 
most  imiHirtant  symptoms:  Dijspna'a,  which  may  be  felt  only  on  slight 
exertion,  or  may  l)e  persistent,  and  aggravated  by  intercurrent  attacks  of 
bronchitis.  The  resjiirations  are  often  harsh  and  wheezy,  and  expi  ion 
is  distinctly  i)i'olonged. 

Cijnnosis  of  an  extreme  grade  is  more  common  in.  emphysema  than  in 
other  affections  with  the  exception  of  congenital  heart-disease.  So  far  as  I 
know  it  is  the  only  disease  in  which  a  patient  may  be  able  to  go  al)out  and 
even  to  walk  into  the  hospital  or  consulting-room  with  a  lividity  of  star- 
tling intensity.  The  contrast  between  the  extreme  cyanosis  and  the  com- 
parative comfort  of  the  jiaticnt  is  very  striking.  In  other  atfections  of  the 
heart  and  lungs  associated  with  a  similar  degree  of  cyanosis  the  patient  is 
invariably  in  bed  and  usually  in  a  state  of  orthopna>a.  One  condition  must 
be  here  referred  to,  viz..  the  extraordinary  cyanosis  in  cases  of  poisoning 
by  aniline  products,  which  is  in  most  part  due  to  the  conversion  of  the 
ha.'moglobin  into  methtenioglobin. 

Bronrliilis  with  associated  cough  is  a  frequent  symptom  and  often  the 
direct  cause  of  the  pulmonary  distress.  The  contrast  betwi'en  emphy- 
sematous patients  in  the  winter  and  summer  is  marked  in  this  respect. 
In  the  latter  they  may  be  comfortable  and  alile  tc  attend  to  their 
Mdrk,  but  with  the  cold  and  changealile  weather  they  are  laid  up  with 
attacks  of  bronchitis.  Finally,  in  fact,  the  two  conditions  become  in- 
separable and  the  patient  has  ])crsistently  more  or  less  cough.     The  acute 


i.'i 


I 


058 


DISKASES  OF  TllK  UESl'IUATOllY  SYSTEM. 


hromliitis  iiiny  prndmr  altucks  not    unlike  iistlniui.     Tii  snuw   instances 
tliis  is  true  sim.-inudiu  a.tlunii,  witli  wliifh  I'lni.lijscnm  is  I'miiU'Ully  ass..- 

aJ  iv^v  iKlvniKrs,  and  with  succcssiv.'  attacks  of  l.rondiitis.  the  condi- 
tion* "cts  slowlv  worse.  In  hospital  practice  it  is  toMunou  to  admit  lui- 
ticiits"ovcr  sixty  with  weil-niarked  si-iis  of  advanced  emphysema.  Iho 
alVeeti<.n  can  jrenerally  he  told  at  a  glance— the  rounded  shoulders,  '-arrel 
chest,  the  thin  vet  oftentimes  muscular  i'orm,  and  sometimes,  1  tinnk,  u  very 
characteristic  facial  expression.  ,        .     ,• 

There  is  another  group,  however,  of  younger  patients  from  twenty-livo 
to  fcn-tv  years  of  age  who,  winter  -fter  winter,  have  attacks  <d'  intense  cya- 
nosis in"conse(pience  of  an  aggravated  liroiuhial  catarrh.  Un  in(iuiry  wo 
lind  that  these  patients  have  heen  short-breathed  from  infancy,  and  they 
helong.  1  helieve,  t(.  a  categoiT  in  which  there  has  heen  a  primary  defect 
of  structure  in  the  lung  tissue.  ,  •      , 

Physical  Signs.— //(.n'/"''//'*/).— The  th'irax  is  nuirkedly  altered  m  sliape; 
the  antero-po.sterior  diameter  is  increa>ed  and  may  be  even  greater  than 
the  lateral,  so  that  the  chest  is  barrel-shaped.  The  ai)pearaiiee  is  sonie- 
w  liat  as  if  the  chest  was  in  a  ])erinanent  inspiratory  position.  The  sternum 
and  costal  cartilages  are  prominent.  The  lower  zone  of  the  thorax  looks 
larnv  aiul  tiie  intercostal  sillies  are  much  widened,  particularly  m  the  hypo- 
ilioudriac  re-ions.  The  sternal  f.is^a  is  deep,  the  clavicles  stand  out  witli 
.rrciit  prominence,  aii.l  the  neck  look-  shortened  from  the  elevation  of  the 
^liorax  and  tiie  sternum.  A  /.one  of  dilated  venules  may  be  seen  along  the 
line  of  altai-hment  of  the  diaphragm.  Tliough  this  is  common  in  emphy- 
sema, it  is  hv  no  means  iieculiar  to  it  or  indeed  lo  any  special  alfection. 
Andrew,  of  liarlholomew's  llosiutal,  and.  according  to  Duckworth.  Layeock 

called  attention  to  it.  ,    n  i    i 

The  I  urve  of  the  spine  is  increased  and  the  liack  is  remarkably  rounded, 
so  that  the  scapuhe  seem  t.)  l)e  almost  horizontal.  Mensuration  shows  the 
rounded  form  of  the  chest  and  the  very  slight  I'xpausion  on  dee})  inspira- 
tion The  respirat(M'v  movements,  which  may  look  energetic  and  foreiijle, 
exercise  little  "or  no  influence.  The  chest  does  not  expand,  but  tlierc  is  a 
.^fiieral  elevati(.n.  The  inspiratory  elVort  is  short  and  (piick;  the  expiratory 
niovement  is  proloui^ed.  There  may  be  retraction  instead  of  distention 
ii,  the  upper  abdominal  regi.m  during  inspiration,  and  there  is  sometimes 
.ceil  a  tninsverse  curve  crossing  the  abdomen  at  the  level  of  tlu'  twolllh 
rib  Til.'  apex  beat  cd'  the  heart  is  not  visilde.  and  there  is  usually  marked 
pulsation   in   the  epigastric  region.     The  cervical   veins  stand  out  promi- 

neiitlv  and  may  luilsate.  ,    ,  ,    i   i  ^   i     ^ 

r'alpalinii.—'Vhv  vocal  fremitus  is  somewhat  enfeebled  liut  not  Io>t. 
The  apex  beat  can  rarelv  be  felt.  There  is  a  marked  shock  in  tlie  lower 
<ternal  re.'ion  and  verv  distinct  j-ulsation  in  the  epigastrium.  Pcrcusswii 
..■ives  -M'eatlv  increase.!  resonance,  full  and  drum-like— what  is  sometimes 
cal!ed"hvperres(manee.  The  note  is  not  often  distinctly  tympanitic  in 
.lualitv.  "  The  percus-^ion  note  is  greatly  extended,  the  heart  dulness  may 
be  obliterated,  the  upper  limit  of  liver  dulaess  is  greatly  lowered,  and  the 
resonance  niav  extend  to  the  costal  margin.     Behind,  a  clear  percussion  note 


EMIMIVSKMA, 


♦;5'j 


10  instances 
iH'ntly  usMi- 

i,  till'  fundi- 

0  admit  lui- 
)-seum.  The 
ildcrs,  %arr(.'l 
lliiidc,  a  VL'iy 

1  twonty-livo 
intonso  cya- 

1  inquiry  wo 
(V.  and  tlioy 
iniary  dot'oct 

red  in  sliapo; 
fii'oatcr  than 
iiico  is  t-onio- 
Tho  stornuni 
thorax  look:5 
in  the  liypo- 
and  out  with 
vation  of  tho 
oon  ak)n^^  tho 
on  in  onii)hy- 
cial  aUVctitin. 
oith,  liaycock 

ahly  rounded, 

ion  slu)W!5  the 

deep  inspira- 

and  forciblo, 

hut  tlierc  is  a 

tho  oxpiratory 

of  distontioa 

;  is  soniolimcs 

jf  tho  twelfth 

sually  marked 

h1  out  pronii- 

hut  not  lost, 
c  in  tho  lower 
[1.  Pcirussiou 
t  is  sonictimos 
tyni])auitic  in 
t  dulness  may 
ivorod,  and  the 
percussion  unto 


extends  to  a  niueli  lower  level  than  normal,  'i'he  level  of  sjilenie  dulne.ss. 
too,  may  lie  lowered. 

On  aiit'iiiUiiHiiii  the  hi'ealh-sounds  are  usually  enfeehled  and  may  ho 
inafl\ed  liy  lironehitie  I'ales.  The  most  eharneteristic  fealiire  is  the  pro- 
lon;:a!ioM  of  the  expiration,  and  tho  normal  ratio  may  l)o  reversed — 1  to  I 
iiisteail  of  1  to  1.  It  is  often  whee/.y  and  iiar>li  and  assoeialed  with  coarse 
rales  and  siliilant  rhonelii.  It  is  said  that  in  iiitoi.-titial  emphysema  there 
may  he  a  friction  sound  heard,  not  unlike  that  of  pleuri>y.  'i"he  heart- 
i^oiinds  are  usually  clear;  i)Ut  in  ad\aiu'ed  cai-es.  when  tiiero  is  marked 
cyanosis,  a  tricuspid  re^iir^^itant  murmur  may  ho  heard,  .\ceoutiiation  uf 
the  pulmonary  second  sound  i>  present. 

The  niKisc  of  the  disease  is  slow  hut  ]iro,u'ressive,  tho  reeurrinir  attac  ks 
of  hroncliitis  ajr^n'avatini,'  tho  condition.  Death  may  occur  from  intercur- 
rent pm'umoiiia,  either  lohar  or  lolnilar,  ami  dropsy  imiy  su|)orveno  from 
cardiae  failure.  Occasionally  death  r<'sults  from  overdislontion  of  the  heart, 
with  extreme  cyanosis.  Duckworth  has  callid  attention  to  the  occasional 
oeuurronco  uf  fatal  luemorrhaji;o  in  ciuphy.-onui.  In  an  old  emphysematous 
j)atient  at  the  Montreal  (Jcneial  ll(s|iilal  death  followed  tho  erosion  of  a 
main  branch  of  tho  [udmonary  artery  hy  an  ulcer  mar  the  hifurcatioii  of  tho 
traihca. 

Treatment. — l*ractically.  the  nua-ures  uu'utioiu'd  in  connection  with 
bronchitis  should  he  employed.  In  children  with  asthma  and  developiiiLr 
cm|ihysenia  tho  nose  should  ho  carefully  oxamiiu'd.  No  remedy  is  known 
which  has  any  inlluenco  over  tho  pro^foss  of  the  condition  it.self.  bron- 
chitis is  the  great  danger  of  these  patients,  ami  therefore  when  possible  they 
should  live  in  an  e(|uahle  climate.  In  conso(|uonee  of  tho  voiHins  engorge- 
ment they  are  liaiile  t(j  gastric  ami  intestinal  disturbance,  and  it  is  par- 
ticularly important  to  keep  the  bowels  regulated  and  to  avoid  flatulency 
which  often  .seriously  aggravates  the  dyspiuea.  Tationts  who  come  into  the 
hos])ital  in  a  state  of  urgent  dyspntea  and  lividity,  with  groat  ongoi'gomont 
of  tho  veins,  particularly  if  they  are  y<aing  and  vigorous,  should  i)e  bled 
freely.  On  more  than  one  occasion  I  have  saved  tlu'  lives  of  persons  in  this 
condition  by  venesection.  Inhalation  of  oxygon  may  he  used  ami  tho  renu'- 
dies  given  already  mentioned  in  connection  with  bronehitis.  tSlrychnino 
will  be  found  specially  useful. 

IJI.   At1K)1'1IIC   Emi'iivsema. 

This  is  really  a  senile  change  ami  is  called  by  Sir  William  Jenner  small- 
lunged  eniphysenia.  Jt  is  really  a  primary  atrophy  of  tho  lung,  coming 
on  in  advanced  life,  and  scarcely  constitutes  a  special  afTection.  It  oecur.s 
in  "withered-looking  old  i)ersons  "  who  may  perhaps  have  had  a  winter 
cough  and  shortness  of  breath  for  years.  In  striking  contrast  to  tho  essen- 
tial or  hypertrophic  emphysema,  the  chest  in  this  form  is  small.  The  ribs 
are  ohliciuely  ]ilacod,  tho  decrease  in  tho  diameter  being  duo  to  greatly  in- 
creased ol)li(|uity  in  tho  position  of  the  ribs.  The  thoracio  muscles  are 
usually  atrophied.  In  advanced  cases  of  this  affection  the  lung  jjirsents  a 
remarkable  appearance,  being  converted  into  a  series  of  large  vesicles,  on 


;  1 


I 
I 


•11 


H 


H 


600 


DISKAiiKS  UK  TlIK  RKSl'IUATOUY  SYSTKM. 


tlip  wnlls  of  wliicli  tlu'  rcmiiuiits  of  uir-ei'lU  may  bu  st-en.     It  is  a  condition 
l'(ir  which  iiothiiiL'  can  l)c  done. 


i'i 


IV.  AcTTi-:  Vi:si(i[-AK  Kmi-hyskma. 

\Vlicii  (U'ath  occurs  i'roni  l)ronchitirt  of  the  smaller  tniics.or  from  cyanosis 
when  >tion;:  inspinitorv  cIVorts  liavc  Inrn  nunh'.  the  liinjis  are  lai-e  in  v.il- 
uine  and  the  air-cells  arc  iiiucii  distended.  Clinically,  this  contlition  may 
develop  rapidiv  in  cases  of  cardiac  asthma  and  an;;ina  pectoris.  The  lungs 
uro  voluminous,  the  area  of  pulmonary  resonance  is  much  increased,  and  on 
auscultation  there  are  heard  everywhere  pipin^r  rales  and  prolonj^ed  expira- 
tion. It  is  the  condition  to  which  von  I'.asch  has  jzivcn  the  names  lAinijni- 
xrliirclhniif  and  LitiKjciislnrrliiil.  A  sinalar  condition  may  follow  pressure 
(in  the  vagi. 

V.    INTI'.IISTITIAI.   KmIMIYSKMA. 

In  this  form  heads  of  air  arc  seen  in  the  interlohular  and  suhpleural 
tissue;  sometimes  thev  form  large  hulhe  heiicath  the  pleura.  A  rare  event 
is  rupture  close  to  tlie  root  of  the  lung,  and  the  pa>sage  of  air  along  the 
trachea  into  the  suhcutancous  tissues  of  the  neck.  After  tracheotomy  ju^t 
the  reverse  mav  occur  and  the  air  nuiy  pass  from  the  tracheotomy  wuii'.d 
along  the  wind-pipe  and  !)ronchi  and  appear  beneath  the  surface  of  the 
pleura.  From  this  interstitial  emphysema  spontaneous  pneumothorax  may 
arise  in  healthy  persons. 

VI.   GANGRENE   OF   THE   LUNG. 

Etiology.— <iangreiie  of  the  lung  is  not  an  affection  per  se,  but  occurs 
in  a  variety  of  condHions  wIumi  necrotic  areas  undergo  imtrefaction.     It 
it  not  easy'to  sav  whv  sphacelus  should  occur  in  one  case  and  not  in  an- 
other, as  the  germs  of  ])utrefaction  are  always  in  the  air-passages,  and  yet 
necrotic  territories  rarely  become  gangrenous.     Total  obstruction  of  a  pul- 
monary artery,  as  a  rule,  causes  infarction,  and  the  area  shut  oil"  does  not 
often  "thomrii  it  mav,  sphacelate.     Another  factor  would  seem  to  be  neces- 
sary-^proiial)ly  a  lowered  tissue  resistance,  the  result  of  general  or  local 
causes.     It  is  "met  with  (1)  as  a  sequence  of  lobar  pneumonia.     Tins  rarely 
occurs'  in  a  previously  healthy  person— more  commonly  in  the  debilitated 
or  in  the  diabetic  subject,     (-i)  Chmgrene  is  very  prone  to  ^-ollow  the  as- 
piration pneumonia,  since  the  foreign  particles  rapidly  undergo  putrefac- 
tive changes.     Of  a  similar  nature  are  the  cases  of  gangrene  due  to  perfora- 
tion of  cancer  of  the  (esophagus  into  the  lung  or  into  a  bronchus.     (:?)  The 
l)utrid  contents  of  a  bronchiectatic.  more  commonly  of  a  tuberculous,  cav- 
ity may  excite  gan<,^rcne  in  the  neighboring  tissues.     The  pressure  broncln- 
ec'tasis'following  aneurism  or  tumor  may  lead  to  extensive  sloughing.     (-1) 
Gangrene  may  follow  simide  embolism  of  the  pulmonary  artery.     Move 
commonly,  Imwever,  the  embolus  is  derived  from  a  part  which  is  morti- 
lied  or  comes  from  a  focus  of  bone  disease.     In  typhus  and  in  typhoid  fever 


is  a  cuudition 


■  Irmii  cyanosis 
•i'  la !•;:»■  in  vol- 
('(indilinn  may 
is.  'riic  lungs 
rcasi'd,  and  on 
il()n;.'f(l  t'xpirn- 
ll;UIU'S  Luuijcii- 
I'oUow  press uro 


and  sul)|ilt'iiral 
A  raru  ovi'iit 
I'  air  along  the 
aclu'otoiny  ju^t 
u'dtuMiy  w'UU'.d 
surface  of  the 
uuiutliorax  may 


'r  se,  but  occurs 
utrcfaction.     It 
and  nut  in  an- 
iissagos,  and  yet 
uction  of  a  pul- 
lul  oir  does  not 
'cui  to  be  neces- 
gcneral  or  local 
ia.     T!iis  rarely 
I  Hie  debilitated 
I)  A)ll(nv  the  as- 
idergo  putrefac- 
3  due  to  perfora- 
nchus.     (;?)  The 
;iil)erculous,  cav- 
)ressiire  bronchi- 
sloughing.     (-1) 
•y  artery.     ^lorc 
which  is  niorti- 
in  typhoid  fever 


(iAN(UlENK  OF  TFIK   LrXO. 


(101 


gangrene  <if  the  lung  may  fnlldw  ilir<imlMij.is  of  one  of  the  larger  i)ran(  lies 
of  the  jpulmonary  artery.  A  <  a>e  nciurred  in  my  wards  in  Octoljcr,  1S!»T, 
in  connection  wilii  a  typhoid  septica-mia.  Typhoid  imcilli  \\v\v  isolated 
from  the  lung.  Lastly,  gangrene  (if  the  lung  may  nccur  in  conditions  of 
dcliilitv  during  convalescence  from  protracted  fever — occasionally,  indeed, 
\\itliout  our  heing  aide  to  assign  any  reasonahle  caii^c 

Morbid  Anatomy.^ — Lacnucc,  who  tlisl  acimatcly  descrihed  pul- 
nioiiaiv  gangrene,  iccogiiizcd  a  diiViiM'  and  a  circuiiisci  ilicd  form.  The  I'or- 
nuT,  though  rare,  is  sometimes  seen  in  connection  witli  pneumonia,  more 
rarelv  after  iililitciation  of  a  large  ln'aru  h  of  tiie  |iuluioiiai'y  artery.  It  may 
involve  the  erealer  part  of  a  lohe.  and  the  lung  tissue  is  coiiveited  into  a  hor- 
ribly olVeic-'  ve  greeiiish-hlack  mass,  torn  and  ragged  in  the  centre.  In  the 
circ'umscrii...  form  there  is  \vell-niarke(l  limitation  hetween  the  gangrenous 
area  and  tlie  surroumling  tissue.  The  focus  may  be  single  or  there  may  he 
two  or  more.  The  lower  lolie  is  more  Kunmonly  alVected  than  the  upper, 
and  the  peripheral  more  than  the  central  portion  of  the  lung.  \  gan- 
grenous area  is  at  lirst  uniforndy  greenish  hrown  in  color;  hut  softening  rap- 
idly takes  place  with  the  formation  of  a  cavity  with  shreddy,  irregui.ir  walls 
and  a  girenish,  oll'i'nsive  iluid.  The  lung  tissue  in  the  immediate  lU'igh- 
borhood  shows  a  zone  of  deep  con;.;estion,  (d'ten  consolidation,  and  outside 
this  an  inti'use  (cdciiia.  In  the  endiolie  cases  the  |ilugged  artery  c^'u  some- 
times he  found.  When  rapidly  extending,  vessels  may  he  opeiieo  and  a 
copious  hieniorrhage  ensue.  Perforation  (d'  the  pleura  is  not  uncommon. 
The  irritating  decomposing  material  usually  excites  the  most  intense  hron- 
chitis.  Kmholic  processes  are  not  iiifre(|ueiit.  There  is  a  reinarkahle  asso- 
ciation in  some  eases  between  circiimscrihcd  gangrene  (d'  the  lung  and 
abscess  of  the  hrain.  It  has  been  referred  to  under  the  section  on  hnm- 
chieetasis. 

Symptoms  and  Course. — rsunlly  definite  symptoins  of  local  pul- 
monary disease  precede  the  characteristic  features  of  gangrene.  These,  of 
course,  are  very  varied,  depending  on  the  nature  of  the  trouble.  The  sputum 
is  very  characteristic.  It  is  intensely  feti<l — usually  pr(d'use — and.  if  ex- 
pectorated into  a  conical  glass,  separates  into  three  layers — a  greenish-brown, 
licavy  sediment;  an  intervening  thin  li(piid,  which  sometimes  has  a  greenish 
or  a  brownish  tint;  and,  on  top,  a  thick,  frothy  layer.  Spread  on  a  glass 
])late,  the  shreddy  (Khris  of  lung  tissue  can  readily  lie  ])icke<l  out.  Kven 
large  fragments  of  lung  may  be  coughed  u|i.  Uoliertson,  of  Onaneock, 
Va.,  sent  nie  one  several  centimetres  in  length,  which  had  been  expecto- 
rated by  a  lad  of  eighteen,  who  had  severe  gangrene  and  recovered.  Mi- 
croscopically, elastic  lilires  are  found  in  altindance,  with  granular  matter, 
pigment  grains,  fatty  crystals,  bacteria,  and  leptothrix.  It  is  stated  that 
elastic  tissue  is  sometimes  absent,  but  I  have  never  met  with  such  an  in- 
stance. The  peculiar  plugs  of  sputum  which  occur  in  bronchiectasy  are  not 
found.  Blood  is  often  present,  and,  as  a  rule,  is  much  altered.  The  spu- 
tum has,  iu  a  majority  of  the  cases,  an  intensely  fetid  odor,  which  is  com- 
municated to  the  breath  and  may  ])ermeate  ihe  entire  room.  It  is  much 
more  olfensive  than  in  fetid  bronchitis  or  in  abscess  of  the  lung.  The 
fetor  is  particularly  marked  when  there  is  free  communication  between  the 


6C2 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


il 


n 

'.  i 


il 


11 


giin^rronoiis  cavities  and  the  Ijroiulii.  On  sovoral  occasions  I  have  found, 
posr luorlcni,  localized  gangrene,  wiiieli  had  been  unsuspected  during  life, 
and  in  which  there  had  been  no  fetor  of  the  breath. 

'i'lie  ])h\sical  signs,  wlien  extensive  destruction  has  occurred,  are  those 
of  cavitj-,  but  the  limited  circumscribed  areas  may  be  dilliculfto  detect. 
Brondiitis  is  always  present. 

Among  the  general  symptoms  may  l)c  mentioned  fever,  usually  af  mod- 
orate  grade;  the  i)ulse  is  rapid,  and  very  often  the  constitutional  depression 
is  severe.  But  the  only  special  features  indicative  of  gang  ene  are  the 
sputa  and  the  fetor  of  the  breath.  The  patient  generally  sinks  from  exhaus- 
tion.    Fatal  ha'inorrluige  may  ensue. 

Treatment.— The  treatment  of  gangrene  is  very  unsatisfactory.  Tlie 
indications,  of  course,  are  to  disinfect  the  gangrenous  area,  but  this  is  often 
impossible.  An  antiseptic  spray  of  carbolic  acid  may  be  employed.  A 
good  plan  is  for  the  [)atient  to  use  over  the  mouth  and  nose  an  inhaler, 
which  may  be  charged  witli  a  solution  of  carbolic  acid  or  with  guaiacol; 
the  latter  "drug  has  also  been  used  hypodermically,  with,  it  is  said,  happy 
results  in  renu)ving  the  odor.  If  the  signs  of  cavity  are  distinct  an  attemi)t 
should  be  nuide  to  cleanse  it  by  direct  injections  of  an  antiseptic  solution. 
If  the  patient's  condition  is  good  and  the  gangrenous  region  can  be  local- 
ized, surgical  interference  may  be  indicated.  Successful  cases  have  been 
reported.  The  general  condition  of  the  i)atient  is  always  such  as  to  demand 
the  greatest  care  in  the  matter  of  diet  and  nursing. 


VII.    ABSCESS    OF    THE    LUNG. 

Etiology. — Suppuration  occurs  in  the  lung  under  the  following  con- 
ditions: (1)  As  a  sequence  of  intlamnuition,  either  lobar  or  lobular.  Apart 
from  the  purulent  infiltration  this  is  luuiuestionably  rare,  and  even  in 
lobar  pneumonia  the  abscesses  are  of  small  size  and  usually  involve,  as 
Addison  renuirked,  several  jjoints  at  the  same  time.  On  the  other  hand, 
abscess  formation  is  extremely  frequent  in  the  deglutition  and  aspiration 
forms  of  loljular  pneumonia.  After  wounds  of  the  neck  or  operations 
upon  the  throat,  in  supi)urativc  disease  of  the  nose  or  larynx,  occasionally 
even  of  the  ear  (V(dkmann),  infective  particles  reach  the  bronchial  tubes 
by  aspiration  and  excite  an  intense  inllammation  which  often  ends  in 
al)scess.  Cancer  of  the  irsophagus,  perforating  the  root  of  tlie  lung  or  into 
the  bronchi,  may  i)roduce  extensive  suppuration.  The  abscesses  vary  in 
hize  from  a  walnut  to  an  orange,  and  have  ragged  and  irregular  walls,  and 
purulent,  sometimes  necrotic,  contents. 

(2)  Embolic,  so-called  metastatic,  abscesses,  the  result  of  infectious 
emboli,  are  extremely  common  in  a  hirge  proiiortion  of  all  cases  of  pya'mia. 
They  may  occur  in  enormous  numbers  and  present  very  definite  char- 
acters. As  a  rule  they  are  superficial,  beneath  the  ideura,  and  often 
wedge-shaiied.  At  first  firm,  grayish  red  in  color,  and  surrounded  by  a 
zone  of  intense  hypera>mia,  sup])uration  soon  follows  Mith  the  forma- 
tion of  a  definite  abscess.     The  pleura  is  usually  covered  with  greenish 


A 


I  have  found, 
(1  during  lite, 

■red,  iii'p  tliDso 
.■ulf  to  dfloct. 

jually  Df  mod- 
lual  depression 
gene  are  the 
3  from  exhaus- 

ifaetory.  Tlie 
it  this  is  often 
employed.  A 
)se  an  inliakT, 
with  guaiacol; 
is  said,  happy 
net  an  attem])t 
;e})tie  solution. 
1  ean  he  local- 
ises have  been 
1  as  to  demand 


following  con- 
obular.  Apart 
,  and  even  in 
tly  involve,  as 
lie  other  hand, 
and  aspiration 
or  operations 
IX,  occasionally 
jronchial  tubes 
often  ends  in 
lie  lung  or  into 
scesses  vary  in 
:ular  walls,  and 

t  of  infectious 
ases  of  pyo-'mia. 

definite  char- 
ura,  and  often 
irrounded  by  a 
itli   the   forma- 

witli  greenish 


NEW  GROWTHS  IN  TUE  LUNGS. 


G63 


lymph,  and  perforation  sometimes  takes  place  with  the  jirodiiction  of 
pneumothorax. 

(3)  IVrforatiou  of  tlie  lung  from  without,  lodgment  of  foivign  l)odies, 
and,  in  the  right  lung,  perforation  from  abscess  of  the  liver  or  a  suppurat- 
ing echinococcus  cyst  are  occasional  causes  of  pulmonary  abscess. 

(1)  Suppurative  processes  play  an  imi)ortaiit  part  in  chronic  pulmonary 
tulxrculosis.  many  of  the  symptoms  of  which  are  due  to  them. 

Symptoms. — Abscess  following  pucuuionia  is  easily  recognized  by 
an  aggravation  of  the  general  symptoms  and  by  tiie  i)liysical  signs  of  cavity 
and  the  characters  of  the  exi)ectorati()n.  Embolic  al)scesses  cannot  often 
be  recognized,  and  the  local  symptoms  are  generally  masked  in  the  gen- 
eral pya'uiic  manifestations.  The  characters  of  the  si)utiim  are  of  great 
importance  in  determining  the  presence  of  abscess.  The  odor  is  oll'ensive, 
yet  it  rarely  has  the  horrible  fetor  of  gangrene  (U-  of  putrid  l)roiHliitis. 
Jn  the  pus  fragments  of  lung  tissue  ean  be  seen,  and  the  elastic  tissue  may 
be  very  abundant.  The  jiresence  of  this  with  the  physical  signs  rarely 
leaves  any  (luestion  as  to  the  nature  of  the  trouble.  Kniltolic  cases  usually 
run  a  fatal  course.  Recovery  occasionally  occurs  after  pneumonia.  In  a 
case  following  typhoid  fever  which  I  saw  at  the  (iariicld  Hospital,  Kerr 
removed  two  ribs  and  found  free  in  the  pus  of  a  hjcalized  empyema  a 
sequestrated  piece  of  lung,  the  size  of  the  palm  of  tin?  hand,  which  had 
sloughed  olf  clearly  from  the  lower  lobe.  The  patit'ut  made  a  good  re- 
covery. 

]\iedicinal  treatment  is  of  little  avail  in  abscess  of  the  lung.  When 
well  defined  and  superficial,  an  attem])t  should  always  l)e  made  to 
ojien  and  drain  it.  A  nuinl)er  of  successful  cases  have  already  been 
treated  in  this  way. 


VIII.    NEW   GROWTHS    IN    THE    LUNGS. 

Etiology  and  Morbid  Anatomy. — While  primary  tumors  are 
rare,  secondary  growths  are  not  uncommon. 

The  primary  growths  of  the  lung  are  either  eiicephaloid,  scirrhus  or 
epithelioma.  Recent  observations  show  that  the  last  is  the  most  common 
form.  Sarcoma  also  is  occasionally  found  as  a  primary  growth,  and  still 
more  rarely  enchondroma. 

The  secondary  growths  may  be  of  various  forms.  ]\Iost  commonly  they 
follow  tumors  in  the  digestive  or  genito-urinary  organs;  not  infre(piently 
also  tumors  of  the  bone.  There  may  be  ence])haloid,  scirrhus,  epithelioma, 
colloid,  melano-sarcoma,  enchondroma,  or  osteoma. 

Primary  cancer  or  sarcoma  usually  involves  only  one  lung.  The  sec- 
ondary growths  are  distributed  in  both.  The  ])rimary  growth  generally 
forms  a  large  mass,  which  may  occupy  the  greater  iiart  of  a  lung.  Occasion- 
ally the  secondary  growths  are  solitary  and  confined  chiefiy  to  the  ])]eura. 
The  metastatic  growths  are  nearly  always  disseminated.  Occasionally  they 
occupy  a  large  portion  of  the  pulmonary  tissue.  Tn  a  case  of  colloid  cancer 
secondary  to  cancer  of  the  pancreas,  1  found  both  lungs  voluminous,  heavy, 


r—  J^ 


n 


:  * 


V 

'■J 


V] 


COi 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


only  slightly  eroiiitant,  and  occupiod  l)y  circular  traiitfluceiit  inast-cs,  vary- 
iug  iu  size  iroiu  a  pea  to  a  large  walnut. 

There  are  numerous  accessory  lesions  in  the  pulmonary  new  growths. 
There  may  be  jileurisy,  either  cancerous  or  sero-librinous.  The  ell'usion 
nuiy  be  hicmorrhagic,  "but  in  'iOO  cases  oi  cancer,  primary  or  secondary,  of 
the  lungs  and  pleura  analyzed  by  Moutard-Martin,  luemorrhagic  eil'usion 
occurred  iu  only  12  per  cent.  The  tracheal  and  bronchial  glands  arc  usu- 
ally ail'ccted,  the  cervical  glands  not  inlrcciuentJy,  and  occasionally  even 
the  inguinal. 

The  disease  is  most  common  in  tiie  middle  period  of  life.  The  pri- 
mary form  all'ects  the  sexes  equally,  but  secondary  cancer  is  much  more 
freipient  in  women  than  in  men.  The  conditions  which  predispose  to  it 
are  quite  unknown.  Jt  is  a  remarkable  fact  that  the  workers  in  the 
Schneeberg  cobalt  mines  are  very  lialile  to  primary  cancer  of  the  lungs. 
It  is  stated  that  in  this  region  a  considerable  proportion  of  all  deaths  in 
l)ersons  over  forty  are  due  to  this  disease. 

Symptoms.— Th  clinical  features  of  neoplasms  of  the  lungs  are  by 
no  means  distinctive,  particularly  in  the  case  of  primary  growths.  The 
.  i)atient  may,  indeed,  as  noted  by  Walshe,  present  no  symptoms  pointing 
to  intrathoracic  disease.  Among  the  more  important  symptoms  are  pain, 
particularly  when  the  pleura  is  involved;  dyspniea,  which  is  apt  to  be 
paroxysmal  when  due  to  pressure  upon  the  trachea;  cough,  which  may  be 
dry  and  painful  and  accompanied  by  the  expectoration  of  a  dark  mucoid 
sputum.  This  so-called  i)rune-juice  expectoration,  which  was  jiresent  10 
times  in  18  cases  of  primary  cancer  of  the  lung,  was  thought  by  Stokes 
to  be  of  great  diagnostic  value. 

In  many  instances  there  are  signs  of  compression  of  the  largo  veins, 
producing  lividity  of  the  face  and  ui)per  extremities,  or  occasionally  of 
only  one  arm.  Comi)ression  of  the  trachea  and  bronchi  may  give  rise  to 
urgent  dyspiuea.  The  heart  may  be  pushed  over  to  the  opposite  side. 
The  pneumogastric  and  recurrent  laryngeal  nerves  are  occasionally  in- 
volved in  the  growth. 

Physical  Signs.— The  ])atient.  according  to  Walshe,  usually  lies  on 
the  airccted  side.  On  inspection  this  side  may  be  enlarged  and  immo- 
bile and  the  intercostal  spaces  are  obliterated.  This  is  more  commonly 
duo  to  the  eil'usion  than  to  the  growth  itself.  The  external  lymph- 
glands  may  l)e  enlarged,  i)articularly  the  clavicular.  The  signs,  on  per- 
cussion and  auscultation,  are  varied,  depending  much  ujion  the  pres- 
ence or  absence  of  fluid.  Signs  of  consolidation  are,  of  course,  ])rcsent; 
the  tactile  fremitus  is  ab.-;ent  and  the  breath-sounds  are  usually  dimin- 
ished in  intensity.  Occasionally  there  is  typical  bronchial  breathing. 
Among  other  symptoms  may  be  mentioned  fever,  which  is  present 
in  a  certain  mimbcr  of  cases.  Emaciation  is  not  necessarily  extreme. 
The  duration  of  the  disease  is  from  six  to  eight  months.  Occasion- 
ally it  runs  a  very  acnte  course,  as  noted  l)y  Carswell.  Cases  are  re- 
ported in  which  death  occurred  in  a  month  or  six  weeks,  and  in  one  in- 
stance (Jaccoud)  the  patient  died  in  a  week  from  the  onset  of  the  symp- 
toms. 


11 

1 


t  inassfos,  vary- 

,'  new  growths. 
The  ell'usion 
r  seeondary,  of 
rliagic  etl'usioii 
trlands  'ire  iis^u- 
L'a!:^iuiuilly  even 

life.  The  pri- 
iti  much  more 
iredispot-e  to  it 
kvorkers  in  the 
r  ol'  the  hing!?. 
)!'  all  deaths  in 

le  lungs  are  hy 
growths.  The 
ptouis  pointing 
itoms  are  pain, 
li  is  apt  to  be 
.  which  may  be 
a  dark  mucoid 
was  j)resent  10 
ught  by  Stokes 

the  large  veins, 
occasionally  of 
nay  give  rise  to 
i  opjwsite  side, 
accasionally  in- 

usually  lies  on 
gcd  and  inuno- 
nore  commonly 
■xtcrnal  lyniph- 
;  signs,  on  per- 
npon  the  pres- 
course,  present; 

\isually  diniin- 
:'hial  breathing, 
lich  is  present 
ssarily  extreme, 
iths.  Occasion- 
Cases  are  re- 

and  in  one  in- 
;et  of  the  symp- 


ACUTE  PLEURISY. 


6f55 


Diagnosis. — Tn  secondary  growths  this  is  not  dilTicult.  Tiie  develop- 
ment of  pulmonary  symjitoms  witliin  a  year  or  two  alter  tlic  removal  of 
a  cancer  of  the  breast,  or  after  the  amputation  of  a  lind)  for  osteo-sarcoma, 
or  the  onset  of  similar  symptoms  in  connection  with  cancer  of  tht;  liver, 
or  of  the  uterus,  or  of  the  rectum,  would  be  extremely  suggestive.  Jn 
jirimary  cases  the  unilateral  involvement,  the  anomalous  characttn-  of  the 
lihysical  si>:tis,  the  occurrence  of  pruiu-jiicc  expectoration,  the  progressive 
wasting,  and  the  secondary  involvement  of  the  cervical  glands  are  the  im- 
portant jxiints  in  the  diagnosis. 

Xew  growths  are  occasionally  primary  in  the  pleura  (Harris,  Journal 
of  Pathology,  vol.  ii). 


V.    DISEASES  OF  TIIE  PLEURA. 
I.    ACUTE    PLEURISY. 

Ana  cally,  the  cases  may  be  divided  into  dry  or  adhesive  pleurisy 
and  pleurisy  with  eifusion.  Another  classification  is  into  primary  or  sec- 
ondary forms.  According  to  the  course  of  the  disease,  a  division  may  l)e 
nuule  into  acute  and  chronic  ])leurisy,  and  as  it  is  im[)ossiblc,  at  present, 
to  group  the  various  forms  etiologieally,  this  is  perhaps  the  most  satisfac- 
tory division.    The  following  forms  of  acute  pleurisy  may  be  considered: 

I.  FmuiNois   OH    Plastic    Plkiiusy. 

In  this  the  pleural  membrane  is  covered  by  a  sheeting  of  lymph  of 
variable  thickness,  which  gives  it  a  turbid,  granidar  appearance,  or  tlie 
fibrin  may  exist  in  distinct  layers.  It  occurs  (1)  as  an  independent  alfec- 
tion,  following  cold  or  exposure.  This  form  of  acute  jiiastic  jilcurisy 
without  fluid  exudate  is  not  common  in  ])erfectly  liealtiiy  individuals. 
Cases  arc  met  with,  however,  in  wliich  the  disease  sets  in  with  the  usual 
symptoms  of  jtain  in  the  side  and  slight  fever,  and  there  are  tlu'  physical 
signs  of  pleurisy  as  indicated  by  the  friction.  After  ]iersisting  for  a  few 
days,  the  friction  murmur  disajjpears  and  no  exudation  occurs.  I'nion 
takes  place  between  the  membranes,  and  possibly  the  pleuritic  adhesions 
M-hich  are  found  in  such  a  large  percentage  of  all  l)odies  examined  after 
death  originate  in  these  slight  fibrinous  pleurisies. 

Fibrinous  pleurisy  occurs  {'i)  as  a  secondary  process  in  acute  diseases 
of  the  lung,  such  as  jmeumonia,  which  is  always  accom])anicd  by  a  certain 
amount  of  iileurisv,  usuallv  of  this  form.  Cancer,  abscess,  and  ixanirrcne 
also  cause  plastic  pleurisy  when  the  surface  of  the  lung  becomes  involved. 
This  condition  is  specially  as.sociated  in  a  large  number  of  cases  with 
tuberculosis.  Pleural  pain,  stitch  in  the  side,  and  a  dry  cough,  with 
marked  friction  sounds  on  auscultation  are  the  iin'tial  phenomena  in 
many  instances  of  phthisis.  Tiie  signs  are  usually  l)asic.  but  P)urney  Yeo 
has  recently  called  attention  to  the  frequency  with  which  they  occur  at 
the  apex. 


fT 


nor. 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


M 


5 ; 

I: 


i! 


ii 


11.  Si;uo-riuRixous    Plkuiusy. 

In  a  iimjority  of  cases  of  iniliimmaticn  of  th^  pleura  there  is,  with  the 
lihrin,  a  variable  aiiuniiil  of  Uuid  exiuh.te,  whieli  produces  tlie  condition 
Ivnowii  as  pleurisy  with  etl'usion. 

Etiology.— For    generations    j)liysicians    have    considered    cold    the 
potent  factor  in  inducing  pleurisy.     This  may  l)e  true  in  many  c.ses,  but 
modern  views  of  serous  intlammations  scarcely  recognize  cold  as  anything 
more  than  a  predisjiosiug  agent,  which  permits  the  action  of  various  micro- 
organisms.    We  have  not  yet,  however,  brought  all  the  acute  pleurisies  into 
the  category  of  microliic  atVections,  and  the   fact   renuiins  that   pleurisy 
does  follow  with   great   rapidity  a   sudden   wetting   or   a   chill.      Of   bite 
years  an  attempt  luis  been  made,  ])artieularly  by  Frencli  writers,  to  show 
that  the  majority  of  acute  pleurisies  are  tidjerculous.     In  this  connection 
tlie  following  facts   may   l)e  admitted:    (1)    In  a  hirge   nund)er  of  cases 
of  ])leurisy  coming  on  aliru]itly  in  liealtlty  persons  the  disease  luis  been 
j;],n\vii — ((/)  iiy  jiost-mortem.  in  cases  of  accidental  or  sudden  death,  (/))  l)y 
the  sul)se(iuent   history— to  i)e  tul)ercub)us;    C^)  in  a  birger  proportion  of 
those  cases  which  come  on  insidiously  in  persons  wlio  have  been  in  failing 
health  or  who  are  delicate  the  disease  is  tul)erculous  from  the  outset;    (3) 
the  acute  pleurisy,  wiiich  occurs  as  a  secondary,  often  a  ternunal,  event  in 
chronic  allVctions,  sucli  as  cirrhosis  of  the  liver,  IJrighfs  disease,  and  can- 
cer, is  very  freci^R'Htly  tuberculous.     I  confess  that  the  more  carefully   1 
have  studied  the  question  the  larger  does  the  prop(Hlion  ajtpear  to  ])C  of 
])rinuiry  i)leurisies  of  tul)ercnlous  origin.     The  subsecpient  history  of  cases 
of  acute  pleurisy  forces  us  to  conclude  that  in  at  least  two  thirds  of  the 
cases  it  is  a  curable  all'ection.     This  may  well  be  so,  according  to  our  pres- 
ent ideas  of  local  tuberculous  disease.     Several  years  ago  I  looked   over 
the  i)ost-mortem  records  of  101  successive  cases  which  had  died  in  my  wards 
with  ])leurisy— fibrinous.sero-tibrinous.  hannorrhagic.or  ]iurulent.   Of  these, 
there  were  oidv  '.Vi  in  winch  the  ideurisy  was  definitely  tuberculous.     One 
of  the  most  interesting  contributions  to  this  question  has  been  made  from 
the  records  of  llenrv  1.  l^owditch.  of  I'.oston,  to  whom  we  are  indebted  for 
so  nuinv  important  additions  to  (mr  knowledge  of  pleurisy.*     Of  !)0  cases 
of  acute  jtleurisv  which   had   been  under  observation  between   18-19  and 
IST'J,  ;3-3  died  of  or  had  i)lithisis— a  percentage  large  enough  to  indicate 
what  an  imi)ortant  rdic  tuberculosis  plays  in  the  etiology  of  this  disease. 

Bactcriol„ini  of  Aciih  rinirisi/.—Vrom  a  bacteri(dogical  standpoint  wo 
may  recognize' three  gron])s  of  cases  of  acute  pleurisy:  the  tuberculous,  the 
jineumococcus,  and  the  strei)tococcus. 

The  harilhis  itihnrithisl!^  is  iiresent  in  a  very  large  ]iroportion  of  all 
cases  of  jirimary  or  so-called  idiopathic  pleurisy.  The  exudate  is  usually 
sterile  on  cover-slips  or  in  the  cidture  and  inoculation  tests  made  in  the 
"ordinary  wav.  as  the  bacilli  are  very  scanty.  It  has  been  demonstrated 
clearly  "that  a  large  amount  of  the  exudate  must  be  taken  to  make  the  test 
comiiiete.  either  in  cultures  or  in  the  inoculation  of  animals.     Kichhorst 


•  Vincent  Y.  Bowditch,  in  Boston  Medical  and  Surgical  Journal.  1889. 


ACUTE   PLEL'UISY, 


r.G. 


LM'o  i:^,  witli  the 
5  tlio  ooiulition 

orcd    cold    the 
iiany  c,l!^os,  but 
)1(1  as  anytiiing 
['  various  iiiicro- 
;'  pUnirisics  into 
s  that   pleurisy 
dull.      Of   late 
vritors,  to  show 
this  conni't'tiou 
unil)C'r  ol'  cases 
iseaso  has  hocn 
■n  (leatli,  ('')  by 
r  proportion  of 
been  in  i'ailinsf 
the  outset;    (3) 
•luinal,  event  in 
isease,  and  caii- 
lore  carefully  I 
ajtpear  to  be  of 
bistory  of  cases 
,0  tbirds  of  the 
in<I  to  our  pres- 
)  T   looked   over 
ied  in  my  wards 
uleiit.   ()f  these, 
lu'rculous.     One 
been  made  from 
are  indelited  for 
,'.*     Of  !)0  eases 
ween   LSI!)  and 
tuirb  to  indicate 
'  this  disease, 
il  standpoint  wc 
tuberculous,  the 

irojtortion  of  all 
:udate  is  usually 
'sts  made  in  the 
en  demonstrated 
to  make  the  test 
mals.     Eichhorst 

irnal.  1889. 


found  that  more  that  V,-2  per  cent  were  demonstrated  as  tubereulous  wlu  ii 
as  much  as  15  cc.  of  tbe  exudate  was  inoculated  iulo  test  animal.-,  while 
less  than  lo  |)tT  cent  of  the  ca^es  showed  tiibereulnsis  when  nnlv  1  cc.  of  the 
exudate  was  u>v(].  'i'his  is  a  jioint  to  which  oliMMvers  >hoiil(l  pay  vcrv 
special  attention,  hi  Damaiiy  has  rect'iitly  in  '>'>  priuiaiy  pli'Uri.-ic.-  dciiioii- 
strate'l  the  tui)erculous  character  of  all  hut  1.  lie  has  used  lar^c  (piauiiiies 
uf  the  fluid  for  his  inoculation  experiments. 

'J'he  pneuniococcus  pleurisy  is  almost  always  secondary  to  a  focus  of 
inilamuiation  in  the  luiiy.  Jt  may,  however,  be  primary.  The  e.xudate  is 
usually  purideiit  and  the  outlook  is  very  favorable. 

The  slrei)tococcns  pleurisy  is  the  typical  septic  form  which  may  occur 
either  frt)ni  direct  infection  of  the  pleura  throu<:h  the  lun^f  in  broucho- 
])neumonia,  or  in  cases  of  streptococcus  ])neunionia;  in  other  instances  it 
follows  infection  of  more  distant  parts.  'J'he  acute  streptococcus  pleurisy  is 
the  most  serious  and  fatal  of  all  forms. 

Among  other  bacilli  which  have  been  found  arc  the  staphylococcus, 
Frii'dliinder's  bacillus,  the  typhoid  bacillus,  aiul  the  di|ihtbcria  bacillus. 

Morbid  Anatomy. —  In  sero-ilbrinous  |ileurisy  the  scrims  exudate  is 
abundant  and  the  fibrin  is  found  on  tbe  pleural  surfaces  aiul  >cattercd 
throu<;'h  the  fluid  in  the  form  of  llocculi.  The  proportion  of  these 
constituents  varies  a  great  deal,  in  somi'  in-taiices  there  is  very  little 
mendu'anous  fibrin;  in  others  it  forms  thick,  creamy  layers  ami  exists 
in  the  depenih'iit  ]iart  of  the  fluid  ar-  whitish,  curd-like  masses.  The 
fluid  of  scro-fihrinoiis  pleurisy  is  of  a  h'lnon  color,  either  clear  or  slightly 
turbid,  depending  on  the  number  of  formed  elements.  In  .some  instances 
it  has  a  dark-brown  color,  'i'he  microsco])ical  examination  of  the  fluid 
shows  leucocytes,  occasional  swollen  cells,  which  nriy  possibly  be  derived 
from  the  pleural  endothelium,  shreds  of  fihrillated  fibrin,  iind  a  variable 
nund)er  of  red  blood-corpuscles.  On  boiling,  the  fluid  is  found  to  be  rich 
in  albumin.  Sometinu's  it  coagulates  s|)ontaneously.  Its  composition 
closely  rescnd)les  that  of  blood-serum.  Cholesteriu,  uric  acid,  and  sugar 
are  occasionally  found.  The  amount  of  the  effusion  varies  from  \  to  1 
litres. 

'j'he  lung  in  acute  scro-flbrinous  pleurisy  is  more  or  les,-  eompre-sed.  If 
the  exudation  is  limited  the  lower  lobe  abuu'  is  atelectatic:  but  in  an  exten- 
sive effusion  which  reaches  to  tbe  clavicle  the  entire  lung  will  be  found 
lying  close  to  the  spine,  dark  ami  airless,  or  even  bloodless — i.  e.,  car- 
nified. 

In  large  exudations  the  adjacent  organs  are  displace(l.  In  large  riglit- 
sided  pleurisies  the  liver  is  much  dei)ressed.  IJather  varying  statements 
are  made  with  reference  to  the  jiosition  of  the  heart  and  as  to  whether  or 
not  it  rofaft's  <m  its  axis.  In  a  number  of  post-mortems  I  have  carefully 
studied  its  ])ositio7i,  both  in  ])neumotb(uax  and  in  large  effusions,  and  can 
s]ieak  with  some  degree  of  certainty  on  the  following  points:  (1)  Even  in 
the  most  extensive  left-sided  exudation  there  is  no  rotation  of  the  apex 
of  the  heart,  which  in  no  case  was  to  the  right  of  the  mid-sternal  line; 
(•2)  the  relative  position  of  the  a]iex  and  base  is  usually  maintained;  in 
eonie  instances  the  apex  is  lifted,  in  others  the  whole  heart  lies  more  trans- 


rtlA 


fT 


QQg  DISEASES  OF  THE  RESPIllATOIlY  SYSTEM. 

ver-clv  (3)  the  r\<:U  (•luiiul)crs  of  the  heart  occupy  the  greater  portion  of 
th.'  front  so  that  the  displaccnicnt  is  rather  a  (U-finite  dislocation  ol  tlio 
„,,  -tio'iim,  Willi  the  i.ericardiuin,  to  tiie  ri-iit,  than  any  special  twisting 
ot  'art  itself;  (4)  the  kink  or  twist  in  tiie  inferior  vena  cava  described 

l,v   ,        ,ls  was  not  present  in  any  of  the  cases. 
'   Symptoms.— I 'roil roines  are  not  unconmion,  hut  the  disease  may  set 
in  al„,n.tly  with  a  chill,  followed  l.y  fever  and  a  severe  pain  in  the  side 
In  very  many  cases,  however,  the  onset  is  insidious.    Washhoiirn  has  called 
attention  to'the  freipiencv  with  wliich  the  pneumococcus  p.eunsy  sets  in 
witii  the  features  of  pneumonia.    The  pain  in  the  side  is  the  most  distress- 
ing symptom,  and  is  usually  referred  to  the  nipi.lc  or  axillary  re-ions     It 
,uu4"he  ivineinl.ered,  however,  that  i)leuritic  pain  may  be  felt  m  tlie  abdo- 
„H.„  or  low  down  in  the  hack,  particularly  when  the  diaphragmatic  sur- 
face of  the  i)leura  is  involved.     It  is  lancinating,  sharj),  and  severe,  and  is 
a-nrnnated  l.v  cough.     At  this  early  stage,  on  auscultation,  sometimes  in- 
deed on  palimtion,  a  drv  friction  rub  can  be  detected.     The  fever  rarely 
ri-^e^  so  rai>idly  as  in  i.neumonia,  and  does  not  reach  the  same  gra.le.     A 
trmi)erature  of  fr..m  \or  to  W.]°  is  an  average  pyrexia.     It  may  drop  to 
normal  at  the  end  of  a  week  or  ten  days  without  the  ai)pearance  of  any 
(kfmite  change  in  the  physical  signs,  or  it  may  persist  for  several  weeks. 
The  temi.erature  of  the  affected  is  higher  than  that  of  the  sound  side. 
Cou'-h  is  an  early  symptom  in  acute  ])leurisy,  but  is  rarely  so  distressing  or 
«o  fretnient  as  in  pneumonia.     There  arc  instances  in  which  it  is  absent 
The  expectoration  is  usually  slight  in  amount,  mucoid  in  character,  and 
occasionallv  streaked  with  blood.  ,        ,, 

At  the  outset  tlu're  may  be  dvs,m(ra,  due  partly  to  the  fever  and  partly 
to  tiie  pain  in  tiie  side.  Later  it  results  from  the  compression  of  the  lung, 
..articularlv  if  the  exudation  has  taken  place  rapi.Uy.  When,  however 
the  lluid  is  effused  slowlv,  one  lung  may  be  entirely  compressed  without 
inducing  shortness  of  breath,  except  on  exertion,  and  the  patient  will  he 
cuietiv  in  bed  without  evin.MUg  the  slightest  resi.iratory  distress.  ^\  hc;n  the 
effusion  is  large  the  patient  usually  prefers  to  lie  upon  the  affected  side 

Physical  Signs.— T„sporl!on  shows  some  degree  of  immobility  on  the 
affectcHl  side,  depcu.liug  upon  the  amount  of  exudation,  and  in  large  effu- 
sions an  increase  in  volume,  which  may  appear  to  be  mucli  more  than  it 
rcallv  is  as  determined  by  mensuration.  The  intercostal  spaces  are  obliter- 
ated" In  right-sided  effusions  the  a,.ex  heat  may  be  lifted  to  the  fourth 
interspace  or  be  pushed  bevond  the  left  nipple,  or  may  even  bo  seen  in  tiie 
axilla.  When  the  exudation  is  on  the  left  side,  the  heart's  impulse  may 
not  be  visible;  but  if  the  effusion  is  large  it  is  seen  in  the  third  and  fourth 
spaces  on  the  right  side,  and  sometimes  as  far  out  as  the  nipple,  or  even 

'''Talmtinn  enables  us  more  successfully  to  determine  the  deficient  move- 
ments on  the  affected  side,  and  the  obliterati.)n  of  the  intercostal  spaces, 
and  more  accuratelv  to  define  the  position  of  the  heart  s  impulse.  In  sim- 
ple sero-fibrinous  effusion  there  is  rarely  any  oedema  of  the  chest  walls. 
It  is  scarcely  ever  possible  to  obtain  fluctuation.  Tactile  fremitus  is  greatly 
diminished'or  abolished.     If  the  effusion  is  slight  there  may  be  only  en- 


L. 

eater  portion  of 
jlocatiou  of  tho 
special  twisting 
a  cava  described 

disease  may  set 
)ain  in  tlic  side. 
Ixmrn  lias  called 

pleurisy  sets  in 
lie  most  distress- 
lary  re<ri()ns.  It 
felt  in  tlie  abdo- 
ipbragmatic  sur- 
iid  severe,  and  is 
n,  sometimes  in- 
Tiie  fever  rarely 

same  <;ra<le.     A 

]t  may  drop  to 
)pearance  of  any 
or  several  weeks. 

tbe  sound  side. 
■  so  distressing  or 
inch  it  is  absent, 
in  character,  and 

?  fever  and  partly 
ssion  of  the  lung, 
When,  however, 
mpressed  without 
le  ])atient  will  lie 
stress.    When  the 
le  affected  side, 
nimobility  on  tlie 
and  in  large  efVu- 
lucli  more  tlum  it 
spaces  are  ol)litcr- 
fted  to  the  fourtli 
ven  be  seen  in  tlie 
art's  impulse  may 
e  third  and  fourth 
lie  nijjple,  or  even 

:ho  deficient  move- 
intercostal  spaces, 

1  impulse.    In  sim- 

)f  the  chest  walls, 
fremitus  is  greatly 

c  mav  be  only  cn- 


ACUTE  PLErULSY. 


(Ki!) 


feeblement.  Tiie  absence  of  the  voice  vil)i'ations  in  elTusions  of  any  size 
constitutes  one  of  tiic  most  valual)le  of  pliysical  t-igiis.  Jn  chihlren  there 
may  be  much  elfiision  with  retention  of  fremitus.  In  rare  cases  tlie  vibra- 
tions may  be  coniiminicatud  to  the  chest  walls  througii  locali/cd  ideiiral 
adhesions. 

Mcnsiinitiiin. — With  tiie  cyrtometer,  if  llie  eiVusioii  is  excessive,  a  dif- 
ference of  from  half  an  inch  to  an  inch,  or  even,  in  large  elVnsions,  an 
imii  and  a  half,  may  be  found  lietween  the  two  sides.  Allowance  must 
be  made  for  the  fact  that  the  right  side  is  naturally  larger  than  the  left. 
With  the  saddle-tape  tlie  dill'ereiice  in  expansion  between  tiie  two  siiles 
can  lie  conveniently  measured. 

J'nritssidii. — luirly  in  the  disease,  when  the  pain  in  the  side  is  severe 
and  the  friction  muriiiur  evident,  there  may  be  no  alteration,  but  with 
the  grailiial  accuiimlation  of  the  iluid  the  resonance  becomes  defective, 
and  iinally  gives  place  to  absolute  ilatness.  From  day  to  day  the  gradual 
increase  in  iieight  of  the  iluid  may  be  studied.  In  a  jileuritic  eti'usion 
rising  to  tlic  fourth  rib  in  front,  the  percussion  signs  are  usually  very 
suggestive.  In  the  subclavicular  region  the  attention  is  often  aroused  at 
once  by  a  tympanitic  note,  the  so-called  Skoda's  resonance,  which  is  heard 
Jierhaps  more  commonly  in  this  situation  with  ]ileiiral  effusion  than  in 
any  other  condition.  Jt  shades  insensibly  into  a  Hat  note  in  the  lower 
mammary  and  axillary  regions.  Skoda's  resonance  may  be  olitaiiied  also 
behind,  just  above  the  limit  of  etfusion.  The  duliiess  has  a  peculiarly 
resistant,  wooden  (piality,  differing  from  that  of  pneumonia  and  readily 
recognized  by  skilled  lingers.  It  has  long  been  known  that  when  the 
])atient  is  in  the  erect  posture  the  upper  line  of  duliiess  is  not  liorizontiil, 
but  is  higher  liehind  than  it  is  in  front,  forming  a  parabola.  The  curve 
marking  the  intersection  of  the  ]>lane  of  contact  of  lung  and  fluid  with 
the  chest  wall  has  been  variously  descrilied.  The  '"  Kllis  lino  of  ilatness," 
which  (.'arland  has  verified  clinically  and  t)y  animal  experiments,  is  per- 
haps the  most  characteristic.  With  meiliuni-sixed  elVusions  "  this  line  bt'gins 
lowest  behind,  advances  ujuvard  and  forward  in  a  letter-S  curve  to  the 
axillary  region,  whence  it  proceeds  in  a  straight  decline  to  the  sternum." 
Such  a  curve  is  ]iresent  only  when  the  ])atient  is  in  the  erect  position, 
when  the  lung  is  in  fairly  normal  condition,  since  then  by  its  elastic  ten- 
sion it  contnds  the  jiosition  and  shajie  of  the  mass  of  fluid, "even  supporting 
the  entire  weight  of  a  considerable  exudate,  and  when  tlie  pleura'  are  free 
from  adhesions.  With  larger  exudates  the  curve  flattens  much,  but  the  S  can 
l)e  detached  with  tho  fluid  as  liigh  as  tho  third  ril).  Garland  emphasi/ces 
that  the  line  can  be  accurately  determined  only  by  light  ])ercussion.  (Gar- 
laiid"s  exhaustive  work  on  Pnenmo-dynamics.) 

On  the  right  side  tlie  dulne.^s  passes  without  change  info  that  of  the 
liver.  On  the  left  side  in  the  nipple  line  it  extends  to  and  may  obliterate 
Traube's  semilunar  space.  If  tho  effusion  is  nioderafe.  the  phenomenon 
of  movable  duliiess  may  bo  obtained  by  marking  carefully,  in  the  sitting 
])osture.  the  upjier  limit  in  the  mammary  region,  and  then  in  the  rceuni- 
bent  posture,  noting  the  change  in  the  height  of  duliiess.  This  infallil)le 
sign  of  fluid  cannot  always  be  obtained.     In  very  copious  exudation  tho 


^m^ 


fT 


u 


■■; 


n 


670 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


dulncss  limy  vcaili  tla'  chivklf  an.l  (.■veil  oxtoml  beyond  llic  sUTiial  margin 
of  the  oiiiMisito  .-idL'.  ,,     ,     ,        i 

.li/.srH/^//M//(.— Karlv  ill  tlie  di^^oa.<c  a  irutum  rub  can  iisuailN  be  lieard, 
wliicii  disapiieaiH  as  the'  tluid  aeemuuhites.  It  is  a  t..-aiid-lm  dry  rub,  cduso 
to  tiie  ear,  and  has  a  leatlierv,  erealdn-  eharaeter.  Tliere  is  another  pleiua 
I'rietion  f^uiiiid  wiiieli  ei.iselv  resenil)les,  and  is  seareely  to  be  distin^iuislied 
from,  tlie  line  eraeldiiig  erepitiis  of  iineumonia.  Tliis  may  be  heard  at  tlie 
commeneenient  ol'  tlie  disease,  and  also,  as  [.ointed  out  in  IS  II  by  Mae- 
Donnell,  Sr.,  ol'  Montreal,  when  the  ell'usiun  has  receded  and  the  pleural 

layi'i'.*  ('oii'i-'  together  again. 

'  With  even  a  slight  exudation  there  is  weakened  or  di>taiit  breathing. 
Often  insjiiration  and  expiration  are  distinetly  audible,  though  di>taiit,  and 
have  a  tubular  (pialilv.  Sometimes  only  a  pulling  tubular  expiration  is 
heard  whieh  iiiav  have  a  metallie  or  amphoric  quality.  Loud  resonant 
rales  aeeomimnying  this  may  forcibly  s:uggest  a  cavity.  These  pseudo- 
cavernous  signs"  are  met  with  more  frcpiently  in  children,  and  olleii  lead 
to  error  in  diagnosis.  Above  the  line  of  dulness  the  breath-sounds  arc  usu- 
allv  harsh  and  exagirerated,  and  mav  have  a  tubular  (juality. 

■  The  vocal  resonance  is  usually  diminished  or  absent.  The  whispered 
voice  is  said  to  lie  transmitted  through  a  serous  and  not  through  a  puru- 
lent exudate  (liaecelli's  sign).  This  author  advises  direct  auscultation  m 
the  antero-lateral  region  of  the  chest.  There  may,  however,  lie  intensihca- 
tion— bronchophonv.  The  voice  sometimes  has  a  curious  nasal,  squeaking 
character,  which  was  termed  bv  Lacniiec  a'unphmuj,  from  its  suj.poscd  re- 
semblance to  the  bleating  of  a  goat.  In  tyi.ical  form  this  is  not  conunnn, 
but  it  is  by  no  means  rare  to  hear  a  curious  twang-like  quality  m  the  voice, 
particularlv  at  the  outer  angle  of  the  scapula. 

In  the'examination  of  the  heart  in  cases  of  pleuritic  elfusum  it  is  well 
to  bear  in  mind  that  when  the  apex  of  the  heart  lies  beneath  the  sternum 
there  mav  be  no  impulse.  The  determination  of  the  situation  of  the  orga 
nriv  re^t'with  the  position  of  maximum  loudness  of  the  sounds.  Over  the 
displaced  or-an  a  svstolic  murmur  may  be  heard.  When  the  lappet  of  lung 
over  the  pei^eardiiim  is  involved  on  cither  side  there  may  be  a  pleuro-pen- 
eardial  friction.     A  Icucocytosis  is  usually  present. 

The  cnuv^e  of  acute  sero-fibrinous  pleurisy  is  very  variable.     Alter  per- 
ci.tin.'  for  a  wi'ek  or  ten  davs  the  fever  subsides,  the  cough  and  pam  dis- 
appeai-,  and  a  slight  elVusion  may  be  (p.ickly  abs.n-bed.     In  cases  in  which 
the  elTusion  reaches  as  high  as  the  fourth  rib  recovery  is  usually  slower. 
:^ranv  instances  come  under  obscrvatiim  for  the  first  time,  after  two  or  three 
wcek'^'  indisi)osition,  with  the  fluid  at  a  level  with  the  clavicle.      J  ho  fever 
mav  la<t  from  ten  to  twentv  davs  without  exciting  anxiety,  though,  as  a 
rule,  in  ordinarv  pleurisy  from  .•ohl.  as  we  say,  the  temperature  m  easo,  oi 
modc.rate  severi'tv  is  normal  within  c'lght  or  ten  days.     Left  to  itse  f  t he 
natural   teiuh'iicv  is  to  resolution:  but  this  may   take  j.lace   very   slowly. 
With  the  absorption  of  the  fluid  there  is  a  rcdux-friction  crejutus,  either 
leatherv  and  creaking  or  crackling  and  rale-like,  and  for  nirmtlis,  or  oven 
lon-HT'the  defective  res.manco  and  feeble  breathing  are  heard  at  the  base. 
Hare  modes  of  termination  are  perforation  and  discharge  through  the  lung. 


ACUTE   PLKURISY, 


(•.71 


sternal  margin 


iially  1)0  heard, 
dry  nil),  oloso 
umtlKT  |)k'urul 
.'  dislin^Liuislail 
JO  hoard  at  the 
IS  11  by  Mao- 
nd  tho  ploural 

tiiiit  hriathinLj. 
-h  distant,  and 
r  o.\i)iration  is 
\j>iu\  rosonant 
Tho.'^e  ])?oudo- 
and  olton  load 
troiinds  aro  usU- 

Tho  whisperod 
liroiigh  a  puru- 
aus-oultation  in 
■,  1)0  inton^ilica- 
lasal,  scjuoaking 
ils  sujjposod  ro- 
is  not  oununon, 
ity  in  the  voico, 

rn^ion  it  is  well 
ith  tho  litorniun 
on  oi  tho  orjza 
iuid.<.  Ovor  the 
10  lai)i)ot  of  king 
JO  a  pk'uro-pori- 

ihio.     Aftor  por- 
di  and  pain  di^- 
1  casos  in  whioh 
5  usually  slower, 
ftcr  two  or  three 
,ielo.     Tho  fevor 
ty,  though,  as  a 
aturc  in  cases  ol' 
.oft  to  itself  tho 
lace  very  slowly. 
1  oro])itus,  eitlur 
months,  or  even 
eard  at  tho  base, 
hrough  the  lung, 


.ind  oxternally  through  the  clKst  wall,  examples  of  whiili   have  been   ro- 
(orded  by  Saidi, 

A  soro-liltrinor.s  exudate  may  ])ersist  for  months  willioiit  change,  jiar- 
tieidariy  in  Inherciiloiis  casos,  and  will  sometiinos  reaeeiuiiidalf  aller  a^pi- 
ration  a  d  resist  all  treatment.  After  lu^rsistoiioo  for  more  than  twelve 
months,  in  spite  of  repeated  ta|)ping,  a  serous  elfusioii  was  cured  hy  inci- 
sion without  deformity  of  the  chest  (S.  Wist).  'i"he  chai«go  of  the  exudate 
into  pus  will  be  si)ol<en  of  in  connection  with  empyema.  l>oath  is  a  rare 
leriuiiuition  of  sero-lihrinous  olfusion.  When  one  |)leura  is  full  and  the 
heart  is  greatly  dislocated,  the  condition,  although  in  a  majority  of  cases 
|)roducing  remarkably  little  disturbance,  is  not  without  risk,  t^inldcii  dvalh 
may  occur,  and  its  possibility  under  those  cireunistanees  should  always  be 
considered.  1  have  seen  two  instances — one  in  right  and  the  other  in  left 
sided  e'Vusion — Ijoth  duo,  ap])arontly,  to  syncope  fidlowing  slight  exertion, 
sueh  as  getting  out  of  bed.  In  neither  ease,  however,  was  the  amount  of 
fluid  e.xeessive.  Weil,  who  has  studied  carefully  this  accident,  concludes 
as  follows:  (1)  That  it  may  bo  duo  to  thrombosis  or  emholisni  of  the  iieart 
or  [lulnionary  artery,  (odema  (d'  the  opposite  lung,  or  degeneration  of  the 
heart  muscle;  (2)  such  alleged  causes  as  mechanical  inipedinu'ut  to  the  cir- 
culation, owing  to  dislocation  of  the  heart  or  twisting  of  tho  groat  vessels, 
require  further  investigation.  Death  may  occur  without  any  i)rcmonitory 
sym|)tonis. 

III.  Priu'i.ENT  Pleurisy  {Empyema). 

Etiology. — Pus  in  the  ])]eu;Ti  is  met  with  under  the  following  condi- 
tions: («)  As  a  sequoiu'o  of  acute  sero-iibrinous  jdourisy.  It  is  not  always 
easy  to  say  why,  in  certain  cases,  the  exudate  becomes  j)urulont.  It  rarely 
does  so  in  the  acute  pleurisies  of  healthy  individuals.  In  children  many 
cases  are  ])robably  purulent  from  tho  onset.  Asi)iration,  which  is  said  to 
favor  the  occurrence  of  empyema,  in  my  ex|)erience  does  so  very  rarely. 
(/;)  Purulent  i)leurisy  is  comiiujn  as  a  secondary  inilanunation  in  various 
infectious  diseases,  among  which  scarlet  fever  takes  the  first  j)lace.  It  luis 
long  been  known  that  the  pleurisy  supervening  in  the  convalescence  of  this 
disease  is  almost  always  i)urulent.  It  sliould  bo  remembered  that  it  is  latent 
in  its  onset,  and  that  there  may  be  no  pulmonary  symptoms.  The  pleurisy 
following  typhoid  fevor  is  also  usually  ;)urulenl.  Other  infectious  diseases 
— measles  and  whooping-cough — are  more  rarely  followed  by  tliis  compli- 
cation. Of  late  years  especial  attention  has  been  paid  to  the  connection 
of  pneumonia  with  empyema,  and  it  has  been  shown  that  very  many  cases 
come  on  insidiously  either  in  the  course  of  or  during  convalescence  from 
this  disease;  and,  lastly,  a  limited  number  of  tuberculous  pleurisies  early 
become  purulent,  (r)  l']mp\ema  results  from  local  causes — fracture  of  the 
rib,  penetrating  wounds,  malignant  disease  of  the  lung  or  tosopliagus,  and, 
jjorhaps  most  frequently  of  all,  the  perforation  of  the  pleura  by  tuberculous 
cavities. 

The  bacteriology  of  empyema  is  of  great  importance.  A  sterile  exudate 
suggests  tuberc-dosis.  In  many  cases  the  pneumococci  are  present, and  these 
cases,  as  a  rule,  run  a  very  favorable  course.  The  streptococci  are  found 
43 


m^ 


ff 


M 


SI 


iS 


072 


DISKASKS  OK   TIIK   KKSlMISAToKY   SYSTKM. 


mo>\  cniMiiinnly  in  1 1."  s.ruiMlary  lascs  in  (•-.niu<<ti..ii  willi  x'l'tic  processo.-. 

Ill   11    few    ill>tnm<'>   |i-n|n>|(rrillS   liaVO   lu'Cll   IUH'St'llt. 

Morbid  Anatomy.^On  npcnin-r  an  (•iniiy"iiia  post  ninrtcm,  we  usu- 
allv  liiid  thai  \\\>'  .irusioii  lias  s.'|mratf(l  into  a  .l.ar.  ;ri(ri>isli-ycllnw  siTiiiii 
alM.vi-  aii.l  Iliv  llii(l<.  nvam-Iiki'  |.ii<  l.cl-w.  'V\w  lliii.l  may  l)e  scarcely 
more  lliaii  liirlii«l.  willi  llnc.uli  of  til)riii  tlinm;rli  it.  In  tlic  pnciimococcud 
(.inpycma  tlic  |mis  is  usually  thick  and  crcaiuy.  It  usually  has  a  heavy, 
sweetish  n.lnr.  hut  in  some  instauec^— |»arti(ularly  those  followinj,'  \V(mn»U 
_it  is  fetiil.  1m  eases  ol"  ;;aii;ireMe  of  the  luiii.'  or  i.leura  I  lie  pus  has  a 
iion-ihly  stiukiu;:  odor.  Mieruseopieally  it  has  the  charaet.Ts  of  onliimry 
pus.  the  i)leural  meuiliranes  are  ^Mcatly  thiek.'M.d.  and  jireseiil  a  ^.'rayish- 
white  laver  from  1  to  'l  mm.  in  thickness.  On  the  costal  pleura  iIumc  iiuiy 
lie  erosions,  and  in  old  eases  fistulous  eonimunieations  are  coininon.  'i'he 
lun-r  may  In'  couipresscd  to  a  very  small  limit,  and  the  visceral  pleura  also 
niav  show  perforations. 

Symptoms.-— rurulent  pleurisy  may  he;ri„  ahruptly,  with  the  symp- 
toms alreadv  deseril)ed.  More  fre.piently  it  comes  on  insidiously  iii^  the 
course  of  other  diseases  or  follows  an  ordinary  sero-lihrinous  pleurisy.  There 
may  he  im  pain  in  the  chest,  very  little  c(Hij.di,  and  no  dyspno'a,  unless  the 
Hdi'  is  verv  full.  Syiiii>toms  of  sei.tie  infection  are  rarely  wantin-,'.  If 
in  a  child,  there  is  a  jiVadually  developin.i:  pallor  ami  weakness;  sweats  occur, 
and  there  is  irrenuhir  fever.'  .\  eoii-h  is  hy  no  means  constant.  The  leu- 
cocytes arc  usually  much  increased;  in  one  fatal  case  they  numbered  11.),- 
(I(l(»  |ier  eul)ie  millimetre. 

Physical  Signs.— I'raetically  they  are  those  already  considorea  in  pleu- 
risv  with  elVusion.  There  are,  Jiowcver,  one  or  two  additional  points  to  bo 
mentioned.  In  eiiipvema,  partieidarly  in  children,  the  disproporti(m  be- 
tween the  sid.'s  may'he  extreme.  The  intercostal  spaces  may  not  only  be 
obliterated,  but  may  l)ulj;e.  Not  infrequently  there  is  (edema  of  the  chest 
\\all<  The  network  of  subcutaneous  veins  may  be  very  distinct.  It  must 
not  be  for-'-otten  that  in  chil.lren  the  breath-sounds  may  bo  hnid  and  liihuJnr 
over  a  puruleut  ciVusion  of  considerable  size.  Wliisporod  pectoriloquy  is 
tisually  uot  heard  in  omi)yema  (liaccelli's  sifjn).  The  dislocation  of  tho 
licart  and  the  disidacement  (d'  the  liver  are  more  marked  in  emiiyema  than 
in   sero-!il>rinous   eiVusion— prol)ably,   as   Senator   su<rgests,   owing   to   the 

greater  weight  of  the  ihiid.  ,    ,      ,  •  , 

\  curious  i)lienomenon  ass.xiated  generally  with  om|)ycma,  but  which 
mav  occur  in  the  sero-fibrinous  exudate,  is  piilsalinn  plntrisn,  first  described 
bv  ^lacDonncll.  Sr.,  of  Montreal.  Of  Vi  cases  39  occurred  on  tho  left  .side. 
In  all  but  one  case  the  nuid  was  purulent,  rneumothorax  may  be  present. 
There  are  two  groups  of  eases,  the  intrapleural  pulsating  ].leurisy  and  the 
Pulsatilla'  nnpiii'nm  necessitatis,  in  which  there  is  an  external  pulsating 
tumor.  ""Xo  satisfactory  exi)lana1ion  has  bwii  offered  how  the  heart  im- 
pulse is  thu^  forciblv  c'ominunicated  through  the  elfusion. 

Kmpvema  is  a  chronic  alfecthui,  which  in  a  few  instances  terminates 
naturally  in  recovery,  but  a  majority  of  cases,  if  left  alone,  end  m  death. 
The  following  are  some  modes  of  natural  cure:  {a)  By  absorption  of  tiie 
iluid.     In  siaall  effusions  this  mav  take  place  gradually.     The  chest  wall 


'l)tic  procesgo!". 
)rteiii,  wr  usu- 

l-yt'llnw   SITU  111 

iiy  l)e  scartt'ly 

|»lU'llllltH'0(('\lS 

,'  lias  ii  hiiivv, 
lowing'  woiiiiils 
till'  |iii.s  lias  a 
•rs  of  ordinary 
sent  a  ;rrayisli- 
cma  t licit'  may 
I'oiniiioii.  'I'iii' 
■ral  pliiira  also 

ivith  tlic  syiiip- 
idioiisly  ill  tlio 
Iciirisy.  TluTC 
iKpa,  uiik'ss  tlio 
y  wanting.  If 
s;  sweats  occur, 
taut.  The  Icu- 
iiuiiibcrcd  1 1">,- 

sidorcd  in  jilcu- 
iial  points  to  bo 
spropnrtion  be- 
lay  not  only  bo 
Ilia  of  tlio  chest 
stiiict.  It  must 
'uiul  and  luhuhir 
pectoriloquy  is 
-location  of  tho 
1  empycnui  than 
,   owing   to   tho 

cnia,  but  which 
//,  lirst  described 
on  the  left  side, 
may  be  present, 
pleurisy  and  tho 
ternal  pulsating 
iv  the  heart  ini- 

ances  terminates 

le,  end  in  death. 

bsorption  of  the 

The  chest  wall 


ACUTE   PLF.IUISV. 


♦;7;? 


sinks.  The  pleural  layers  become  greatly  tliiekcned  and  enclose  between 
them  the  inspissated  pus,  in  which  lime  salts  are  gradually  dc|iosited.  Such 
a  condition  may  be  neeii  once  or  twice  a  year  in  the  post-mortem  room  nf 
any  large  hospital,  (h)  l>y  perforation  of  the  lung.  Although  in  lliis 
event  death  may  take  place  rapidly,  by  siilVocatioii,  as  .\reta'us  says,  yet 
in  cases  in  which  it  octurs  gradually  recovery  may  follow.  Since  l,S7;i, 
when  1  >av\  a  case  (d'  this  kind  in  'I'raube's  clinic,  and  heard  his  remarks 
on  the  >uliject,  I  have  seen  a  nuinber  of  instances  of  the  kind  and  can 
corroliorate  his  statement  as  to  the  favorable  ti'i'iiiiiiatioii  of  many  of  them. 
Kinpyema  may  discharge  cither  by  opening  into  the  bronchus  and  forming 
a  (i>tula,  or,  as  Traiibe  pointed  out,  by  prndiuing  necrosis  of  the  pidmonarv 
pleura,  siilbcieiit  to  alhiw  the  Miakage  (d"  the  pus  tliroiigh  the  spongy  lung 
tissue  into  the  bidiichi.  in  the  lirst  way  pneumothorax  usually,  though 
not  always,  develops.  In  the  second  way  the  pus  is  discharged  without 
formation  cd'  pneumothorax,  i'lveii  with  a  bronchial  iistula  recovery  is  pos- 
sible, (r)  \\\  perforation  of  the  chest  wall — ciiiiii/niKi  iirrrssllalis.  'J'liis 
is  by  no  means  an  unfavorable  method,  a^  many  ca>es  reco\er.  '{"lie  per- 
foration may  occur  anywhere  in  the  chest  wall,  but  is,  as  Cnncilhier  re- 
marked, more  common  in  front,  it  may  be  anywhere  from  the  third  to 
the  sixth  interspace,  usually,  according  to  Marshall,  in  the  fifth,  it  may 
jicrforate  in  more  than  one  place,  and  there  may  be  a  (istulous  cominunica- 
tion  which  opens  into  the  pleura  at  some  distance  from  the  external  orifice. 
The  lunior,  when  near  the  heart,  may  pulsate.  The  discharge  may  jiersist 
for  years.  In  Coficland's  Dictionary  is  mentioned  an  instance  of  a  lia- 
varian  physician  who  had  a  jdeural  Iistula  for  thirteen  years  and  enjoyed 
fairly  good  health. 

An  empyema  may  ])erforate  the  neighboring  organs,  the  (esophagus, 
jieritoiia'iim.  iiericardium,  or  the  stomach,  ^'ery  remarkable  cases  are  those 
which  pass  down  the  spine  and  along  the  psoas  into  the  iliac  fossa,  and 
simulate  a  psoas  or  lumbar  abcess. 

IV.  TrnKHcri.ovs  Pr,i;i:RisY. 

This  has  already  been  considered  (p.  "^HA.),  and  the  syni])tonis  and  phys- 
ical signs  do  not  recjuire  any  deseri[>tion  other  than  that  already  given  iu 
connection  with  the  sero-dbrinous  and  ])urulent  forms. 

Y.  Otiiicu  A'aiuktiks  or  Pr.Ki'RisY. 

HaBmoirhagic  Pleurisy.— A  bloody  efrusion  is  met  with  under  the  fol- 
lowing conditions:  (a)  In  the  pleurisy  of  asthenic  states,  such  as  cancer, 
liright's  disease,  and  occasionally  in  the  malignant  fevers.  It  is  interest- 
ing to  note  the  frequency  with  which  ha'inorrhagic  pleurisy  is  found  in 
cirrhosis  of  the  liver.  It  occurred  in  the  very  patient  in  whom  T.aeniiec 
first  accurately  described  this  disease.  While  this  may  be  a  simple  hamior- 
rhagic  ](leurisy.  in  a  majority  of  the  cases  which  T  have  seen  it  has  been 
tuberculous,  (h)  Tu1)erculous  ]ileurlsy,  in  which  the  bloody  effusion  may 
result  from  the  rupture  of  newl^.  formed  vessels  in  the  soft  exudate  accom- 


ff 


r 


674 


DISICASKS  OF  TllK  IlKSPIRATOUY  SVSTKM. 


.  I 


nnnvin-  tho  crui.tion  ..f  miliary  tubcnlcs.  or  it  may  romc  from  mr>r(«  slowly 
iurm.Ml  tiiluTclfs  in  a  pleurisy  Mrou.lary  to  vMv\m\v  imlmoi.ary  jIi-v.im. 
(r)  I'aiurro.is  pleurisy,  svlu'tlu'r  primary  ..r  Heeoiulary.  18  friMpiontly  luvmor- 
rhamc.  {<!)  OccaHionully  lunuuirha^ie  cxu.latiou  is  met  \Mlh  n.  perleelly 
l.ealtl.v  imlivi.luals,  in  whom  there  is  not  the  sli-htest  suspieiun  ol  lul.er- 
,.ulo<i'<"  or  eaneer.  In  one  HUeh  ease,  a  lar^e,  able-bodied  man,  the  jmtient 
was  to  mv  knowlediio  healthy  and  Btron^  c'it;ht  years  afterward.  And, 
histlv  it  must  lie  remend.ered  that  <luriiiK  aspiration  the  Umi;-  may  bo 
wouiided  and  blood  in  this  wav  ^^et  mixed  with  the  ser..-librimms  exu.lato. 
The  condition  of  hiumorrhagic  pleurisy  is  to  be  distinguished  from  luvmo- 
thorax,  due  to  the  rupture  of  aneurism  or  the  juessure  of  a  tumor  on  the 

thoracie  veins.  ,■     •,    ■         ,i 

Diaphragmatic  Pleuri.^y.— Tho  innammation  may  be  limited  partly  or 
ohielly  to  the  diapliragiiii'.tic  surface.  This  is  often  a  dry  ]>leurisy,  but 
there' may  be  elfiision,  ei'her  sero-libriiious  or  purulent,  which  is  eir(um- 
scriluMl  on  the  diaphragmutic  surface.  In  these  eases  the  pain  is  low  in 
the  zone  of  the  diaphragm  .iiid  may  simulate  that  of  acute  abdominal  dis- 
rate it  mav  be  iiiteiisilied  bv  pressure  at  the  point  of  insertion  ot  the 
diai.hragm  at  the  tenth  ril.  The  diaphragm  is  lixed  and  the  respiration 
is  thoracic  and  short.  An  Iral  noted  in  certain  cases  severe  dyspn.ea  and 
attacks  simulating  angina.  As  mentioned,  the  elfusion  is  usually  plastic, 
not  <er<uis.  Serous  or  jmrnlent  otViisioiis  (d"  any  size  limited  to  the  dia- 
pliragmatic  surface  are  extremely  rare.  Intense  subjective  with  trilling 
obicAive  features  are  always  suiggestive  of  diaphragmatic  j.lcurisy. 

Encysted  Pleurisy.— The  eiVusion  may  lie  circumscribed  by  adhesions  or 
separated  into  two  or  more  pockets  or  loculi.  which  communicate  witli  each 
other.  This  is  most  common  in  emi)ycma.  in  these  rases  there  have 
nsualiv  been,  at  dilferent  parts  of  the  pleura,  multiple  adhesions  by  which 
the  iluid  is  limited.  In  other  instances  the  recent  false  membranes  may 
encapsulate  the  exudation  on  the  diaphragmatic  surface,  for  examide.  or  tho 
part  of  the  ]deura  posterior  to  the  mid-axillary  line.  The  condition  may 
be  very  pu/zling  during  life,  and  present  special  difficulties  in  diagnosis. 
In  soine  cases  the  tactile  fremitus  is  retained  along  certain  lines  of  adhe- 
sion.    The  exploratory  needle  should  be  freely  used. 

Interlobar  Pleurisyj  forms  an  interesting  and  not  uncommon  variety. 
In  nearly  everv  instance  of  acute  i.leurisy  the  interlobular  serous  surfaces 
are  also  involved  and  closely  agglutinated  together,  and  sometimes  the  iluid 
is  encysted  lietween  them.  In  this  position  tubercles  are  to  be  carefully 
looked  for.  In  a  case  of  this  kind  following  i)nenmonia  there  was  between 
the  lower  and  U])i)er  and  middle  lobes  of  the  right  side  an  enorin.ms  puru- 
lent collection,  which  looked  at  first  like  a  large  abscess  of  the  lung.  These 
collections  may  perforate  the  bronchi,  and  the  cases  present  special  diih- 
cnlties  in  diagnosis.  , 

Diagnosis  of  Pleurisy.— Acute-  i)lastic  pleurisy  is  readily  recog- 
nized In  tbe  diaLmosis  of  pleuritic  effusion  the  first  question  is,  Does  a 
fluid  exudate  exist?  the  second.  What  is  its  nature?  In  large  effusions 
the  increase  in  the  size  of  the  affected  side,  the  immobility,  the  absence  of 
tactile  fremitus,  together  with  the  displacement  of  organs,  give  infallible 


Ill  iMoro  slowly 
Kiiiury  UisviiM-. 
ui'iitly  luvmur- 
h  ill  iHTl'fctly 
Uitui  111'  liiher- 

Ul,   tlu'    jliltit'llt 

(.rwanl.  Aiul, 
liiiig  may  lie 
riiKnis  fxuiiato. 
•d  I'rom  liiuinu- 
i  tuimir  nil  the 

iiitt'd  partly  or 
\:  jiit'iirisy,  Itut 
lich  is  (.•ii'cum- 
pain  is  lusv  in 
al'idoiniiial  dis- 
nscrtioii  uf  tlio 
llu'  respiration 
V  (lyspini'a  and 
iisiiiilly  plastic, 
ted  to  tliL'  dia- 
•L"  with  trilling 
li'urisy. 

by  adlic'sions  or 
lifato  witli  each 
iiscs  there  have 
esioiis  by  which 
im'iii1)ranes  may 
cxanijile,  or  the 
3  eoiidition  may 
ies  in  diagnosis, 
n  lines  of  adhc- 

■oniiiion  variety. 
•  serous  surfaces 
letiines  the  lluid 

to  be  carefully 
ere  was  l)etweeii 

enormous  puru- 
the  luiiff.  These 
eiit  special  dilll- 

s  readily  recog- 
estion  is,  Does  a 
1  large  effusions 
y,  the  absence  of 
IS,  give  infallible 


ACUTE  PLKL'UISY. 


indications  of  the  ]»resence  of  fluid.  The  chief  diilieulty  arises  in  elTusions 
of  UKjdeiiUi'  extent,  when  the  dnlness,  the  presence  of  liroin  lioph(jiiy,  and, 
perliajw,  tubular  lireathing  may  simulate  itiifiinKJiiin.  'I'he  chief  points  to 
he  borne  in  mind  are:  (ii)  Ditl'ereiiees  in  the  onset  and  in  the  gnicinl  char- 
acters of  the  two  alfections,  more  partiiuhirly  the  initial  chill,  the  higher 
fever,  more  urgent  dyspmea,  and  the  rusty  exptutoralion,  which  charac- 
terize pneumonia.  .\s  already  mentioned,  some  (d'  the  ca>es  of  pneuino- 
cocciis  pleurisy  set  in  liUi'  pncninoiiia.  (/<)  Certain  physical  signs — the  more 
wooden  character  of  the  tlulmss,  the  greater  resistance,  and  the  marked 
(liminutiiin  or  the  absence  of  tactile  fremitus  in  pleurisy.  The  au>eullatoiy 
signs  may  lie  de(c|)tive.  It  is  usually,  iiideeil,  the  persistence  of  tubular 
breathing,  particularly  the  high-|iitclied,  even  amphoric  e\|iiiati(in,  beard 
in  some  cases  (d'  pleurisy,  which  has  raisc(l  the  doubt.  The  iiilcrcoslal 
spaces  are  more  couimoidy  obliterated  in  pleuritic  elfusioii  than  in  pneu- 
monia. .\s  already  mi'iilioiied.  the  disphi'i'mciit  of  organs  is  a  very  valualilc 
sign.  Nowadays  with  the  hypo(|eriuie  needle  the  (|uesti()!i  is  easily  settled. 
A  se]iarate  small  >yriiige  with  a  capacity  (d'  tuo  di'acliius  should  be  reserved 
for  exploratoi'y  purposes,  and  the  needle  shoidd  be  longer  and  firmer  than 
in  the  ordinary  hypodermic  instrument.  With  (arcful  preliminary  <lisin- 
fection  the  instrument  can  be  used  with  impunity,  and  in  cases  of  doubt 
the  exi)loratory  puncture  should  be  made  witluuit  hesitation.  I'neiimo- 
thoi'ax  is  an  occasional  seipience.  The  hypodermic  needle  is  es|iecially 
useful  in  those  cases  in  which  there  are  pseudo-cavernous  signs  at  the  base. 
in  cases,  too,  of  massive  pneumonia,  in  which  tiie  bronchi  are  plugged  with 
lihrin,  if  the  patient  has  not  been  seen  from  the  outset,  the  diagnosis  may 
be  im])ossil)le  without  it. 

On  the  left  side  it  may  be  dillicult  to  differentiate  a  very  large  peri- 
cardial from  a  pleural  elfusion.  The  retention  of  ii'sonance  at  the  base, 
the  lu'eseiice  of  Skoda's  resonance  toward  the  axilla,  the  absence  id'  dis- 
location of  the  heart-beat  to  the  right  of  the  sternum,  the  b'cblcness  (d' 
the  pulse  and  of  the  heart-sounds,  and  the  urgency  of  the  dyspmea.  out 
(d'  all  proportion  to  the  extent  of  the  effusion,  are  the  chief  i)oiiits  to  lie 
considered,  rnilateral  hydndhorax,  which  is  not  at  all  uneonimun  in 
heart-disease,  presents  signs  identical  with  those  of  sero-fibrinous  elfusion. 
Certain  tumors  within  the  chest  may  simulate  ))leural  elfusion.  It  should 
he  remembered  that  many  intrathoracic  growths  are  aec()m])anied  by  exu- 
dation. Malignant  disease  of  the  lung  and  of  the  i)leura  and  hydatids  of 
the  i)leura  ])roduce  extensive  dulness,  with  suppression  of  the  breath-sounds, 
simulating  closely  effusion. 

On  the  right  side,  abscess  of  the  liver  and  hydatid  cysts  may  rise  high 
into  the  jilenra  and  produce  dulness  and  enfeebled  breathing.  Often  in 
these  cases  there  is  a  friction  sound,  which  should  excite  suspicion,  and 
the  upper  outline  of  the  dulness  is  sometimes  iilainly  convex.  In  a  case  of 
cancer  of  the  kidney  the  growth  involved  the  diaphragm  very  early,  and  for 
months  there  were  signs  of  pleurLsy  before  our  attention  was  directed  to  the 
kidney.     In  all  these  instances  the  exploratory  puncture  should  be  made. 

The  second  f{uestion.  as  to  the  nature  of  tlie  fluid,  is  quickly  decided 
by  the  use  of  the  needle.     The  persistent  fever,  the  occurrence  of  sweats. 


t  . 


■^] 


U-' 

i  1 

i  1 


'  ! 


'ii] 

.if' 


^1 


676 


DISEASES  OF  THE  RESPIRATOIIY  SYSTEM. 


a  Ic'Ufocvtosis,  iiiid  tlu'  iiuTcasf  in  llio  ])all<)r  siippest  tlio  pro^oncc  of  pus. 
In  chihrirn  the  comploxiun  is  ul'ton  sallow  and  earthy.  In  pvotrack'd  cases, 
even  in  liiildivn,  wlion  the  oemTal  symptoms  and  the  appearance  of  the 
patient  has  been  most  stronf.dy  suo-jreslive  of  pus.  tlie  syringe  has  withdrawn 
ilear  Ihiid.  On  the  other  hand.  eUusions  of  short  duration  may  he  puru- 
lent, even  wlu'u  tlie  j^eneral  symptoms  do  not  sufijiest  it.  The  following 
statement  mav  be  made  with  reference  to  the  prognostic  import  of  the  bac- 
teriological examination  of  the  aspirated  ihiid:  The  presence  of  the  pneumo- 
coccus^is  of  i'avoraljle  signiiicance,  as  such  cases  usually  get  well  rai)idly, 
even  with  a  single  aspiration.  The  streptococcus  emi)yenui  is  the  most 
serious  form,  and  even  after  a  free  drainage  the  patient  may  succundj  to  a 
general  septicu-nna.     A  sterile  fluid  indicates  in  a  majority  of  instauces  a 

tuberculous  oi'igin. 

Treatment.— At  the  onset  the  severe  pam  may  demand  leeciics,  which 
usually  give  relief.  l)ut  a  hvpodermic  of  uiorphia  is  more  elVective.  The 
I'a.pu'lin  cauterv  mav  be  lightly  but  freely  applied.  It  is  well  to  adminis- 
ter a  mercurial  or  saline  purge.  Fixing  the  side  by  careful  strapping  with 
long  strips  of  adhesive  plaster,  which  should  ])ass  well  over  the  middle  line, 
drawn  tisihtlv  and  evenly,  gives  great  relief,  and  I  can  corroborate  the 
statement  of  V.  T.  J{oberts  as  to  its  ellicacy.  Cupping,  wet  or  dry,  is  now 
seldom  emploved.  lilisters  are  of  no  special  service  in  the  acute  stages, 
although  thev'  relieve  the  iiaiu.  The  ice-bag  may  he  used  as  in  pneumonia. 
The  general  treatment  at  the  early  stage  should  be  rest  in  bed  and  a  liquid 
diet.  .Medicines  are  rarely  retpiired.  A  Dover's  powder  may  he  given  at 
night.     ]Mercurials  are  not  indicated. 

When  the  eil'usion  has  taken  iilace,  mustard  plasters  or  iodine,  pro- 
ducing slight    counter-irritation,  appear  useful,  particularly  in  the  later 
stages?    Tlie  following  rational  plan  is  successful  in  some  cases.     It  is  ])ased 
upon  the  idea  that  if  the  l)lood  serum  is  depleted  or  if  it  is  kept  concen- 
trited    the  ]i(iuid  will  be  absorbed  from  the  lymph  spaces,  of  which  the 
pleura  is  one.  to  equalh.-  the  loss.     To  do  this  the  patient  should  have  the 
dailv  amount  of  liquid  food  greatly  restricted.     If  there  is  no  fever,  a  meat 
diet",  with  an  eug  and  drv  ])read  and  S  to  10  ounces  of  liquid  in  the  form  of 
milk  or  water.' sdiould  he  given.     Salt  articles  of  food  may  he  used,  but  I 
do  not  think  it  nccessarv  to  give,  as  some  do,  doses  of  salt.     The  second 
element  in  the  treatment  is  the  active  dei)letion  of  blood  serum,  which  is 
eil'ected  in  the  wav  introduced  hy  iMatthew  Hay.     Every  morning,  if  the 
patient  is  robust,  otherwise  every  second  morning,  from  half  an  ounce  to 
an  ounce  and  a  half  of  Kpsom  salts  is  given  an  hour  before  breakfast,  m  as 
concentrated  a  form  as  is  iiossible.    This  produces  copious  liquid  discharges. 
I  have  seen  lar<;c  exudations  disajqiear  raiiidly  vlien  this  plan  was  fol- 
lowed     lU-  acting  upon  the  skin  and  kidneys,  the  same  end  may  be  ob- 
tained   l)ut   with  much  less  certainty.     The  vapor  or  hot  bath   may  bo 
u^ed  and  an   occasional  dose  of  pilocarpin.     Diuretics,  such  as  digitalis, 
s,,uills  and  acetate  of  potash,  may  sometimes  be  re<|uired.     I  rarely  resort, 
however  to  diuretics  or  diaphoretics  in  the  treatment  of  pleurisy  with  effu- 
sion.    Iodide  of  potassium  is  of  doubtful  benefit.     By  some  the  salicylates 
are  believed  to  be  of  special  efficacy. 


ACUTE  PLEURISY. 


077 


syneo  of  pus. 
)triick'(l  cast's, 
iiraiR't.'  of  the 
las  withdrawn 
may  Ijc  puru- 
rho  foUowiiig 
)i't  of  I  ho  1)ac- 
f  tlie  pnoinno- 
,  well  rai)itlly, 
1  is  tho  must 
succumb  to  a 
of  instances  a 

leeches,  wliich 
■iVective.  The 
■11  to  adminis- 
strapping  with 
10  middle  line, 
orroborato  the 
or  dry,  is  now 
c  acute  stages, 
in  pneumonia, 
'd  and  a  li(iuid 
ly  be  given  at 

)r  iodine,  pro- 
V   in   the  Uiter 
es.     It  is  ])ascd 
Is  kept  coneen- 
,  of  which  the 
hould  have  the 
0  fever,  a  meat 
in  the  form  of 
1)0  used,  but  I 
t.     The  second 
ernm.  which  is 
norning,  if  the 
df  an  ounce  to 
breakfast,  in  as 
piid  discharges. 
;  jihin  was  fol- 
ind  may  be  ob- 
b  bath  may  be 
ch  as  digitalis, 
I  rarely  resort, 
urisy  with  effu- 
3  the  salicylates 


As[)iration  of  the  fluid  is  the  most  thorough  and  satisfactory  nu.thod 
and  should  be  resorted  to  whenever  the  ell'usion  becomes  large  or  if  it  re- 
sists tho  ordinaiT  methods  of  treatment.  Tho  credit  of  introducing  aspi- 
ration in  pleuritic  clVusions  is  due  to  Morrill  Wyman,  of  t'andnidge,  Mass., 
and  Jlenry  1.  Bowditcli,  of  Uoston.  Years  prior  to  Dioulafoy's  work,  as- 
piration was  in  constant  use  at  tho  Massacluisctts  tioncral  llospital  and 
was  advocated  repeatedly  by  r>o\v(litch.  As  the  (piestion  is  one  of  some 
historical  interest,  I  give  Txiwditch's  conclusions  concerning  as|>iratioii, 
ex]irosso(l  nearly  iifty  years  ago,  and  wiiicli  practically  ro])i('sent  the  opinion 
of  to-day:  "  (1)  The  operation  is  perfectly  simi)lo,  but  slightly  painful,  ami 
can  lie  done  with  case  upon  any  jiatient  in  however  advanced  a  stage  of 
the  disease.  C^)  it  should  be  performed  forthwith  in  all  cases  in  which 
there  is  complete  tilling  \ip  of  one  side  of  tho  chest.  (:5)  lie  had  deter- 
mined to  use  it  in  any  case  of  even  moileraic  ell'usion  lasting  more  than  a 
few  weeks  and  in  wliich  there  should  seem  to  be  a  disiiosition  to  resist 
ordinary  modes  of  treatment.  (4)  lie  urged  this  practice  upon  the  profes- 
sion as  a  very  imjiortant  measure  in  jiractical  medicine;  believing  that  by 
this  method  death  may  frecpiontly  be  ])reveiitod  from  ensuing  cither  1)V 
sudden  attack  of  dys|)na'a  or  subse(|uont  jihthisis.  and,  iinally.  from  the 
gradual  wearing  out  of  the  powers  of  life  or  inability  to  absorb  the  iluid. 
(o)  He  believed  that  this  operation  would  sometimes  iirevent  the  occurrence 
of  those  tedious  cases  of  spontaneous  evacuation  of  purulent  fluid  and  those 
great  contractions  of  the  chest  which  occur  after  long-continued  effusion 
and  the  subsequent  discharge  or  absorption  of  a  fluid." 

There  is  scarcely  anything  to  lie  added  to-day  to  these  observations. 
When  the  fluid  reaches  to  the  clavicle  the  indication  for  aspiration  is  ini- 
]ierative,  even  though  the  patient  be  comfortable  and  present  no  signs  of 
pulmonary  distress.  Tho  presence  of  fever  is  not  a  contra-indication;  in- 
deed, sometimes  with  serous  exudates  the  tomi)erature  falls  after  aspiration. 

The  operation  is  extremely  simple  and  is  jiractically  without  risk.  The 
spot  selected  for  puncture  should  be  either  in  the  seventh  interspace  in  the 
mid-axilla  or  at  the  outer  angle  of  the  scapula  in  the  eighth  intersjiace. 
The  arm  of  the  jiatient  should  be  brought  forward  with  the  hand  on  the 
opposite  shoulder,  so  as  to  widen  tho  interspaces.  The  needle  should  be 
thrust  in  close  to  tho  n]i]ier  margin  of  the  rib,  so  as  to  avoid  the  intercostal 
artery,  the  wounding  of  which,  however,  is  an  exco;;sivoly  rare  accident. 
The  fluid  slnmld  be  withdrawn  slowly.  Tho  amount  will  de|)on(1  on  the 
size  of  tho  exudate.  If  tho  fluid  roaches  to  tho  clavicle  a  litre  or  more  may 
be  withdrawn  with  safety.  In  chronic  cases  of  serous  pleurisv  after  re- 
peated tapi)ings  S.  West  has  shown  the  groat  value  of  free  iiicision  and 
drainage.  He  has  reported  cases  of  recovery  after  elfusions  of  (ifteen  and 
eighteen  months'  standing. 

Symptoms  and  Accidents  during  Paracentesis.-— Pa i«  is  usually  com- 
l)laincd  of  after  a  certain  amount  of  fluid  has  been  withdrawn;  it  is  sharp 
and  cutting  in  character.  Coui/liiiuj  occurs  toward  the  close,  and  mav  be 
severe  and  paroxysmal,  riicnmolhorax  may  follow  an  exploratory  puncture 
with  a  hyjiodermic  needle;  it  is  rare  during  aspiration.  Subrutaneovs  em- 
physema may  develop  from  the  point  of  puncture,  without  the  })roduction 


f¥ 


i 


\\ 


m 


I 


C7S 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


of  pneumothorax.  Alhinniuoitfi  crprdoration  is  a  romnrkablo  phenomenon 
deseribcd  l)y  Freiicli  writers.  Jt  u>iially  develops  ai'ler  llie  tapping,  is  asso- 
ciated Willi' dyspna'a,  and  many  prove  suddenly  fatal.  Vcirbral  suinploins. 
— Faintness  is  not  uncommon.  Epileptic  convulsions  may  occur  either 
during  the  withdrawal  or  while  irrigating  the  pleura.  1  have  seen  but  a 
single  instance.  'J'hey  are  very  dillicult  to  explain  and  arc  regarded  by  nio.^l 
authors  as  ol'  rellex  origin;  and  lastly  sudden  death  may  occur  cither  from 
syncope  or  during  the  convulsions. 

Kinjiiienia  is  really  a  surgical  affection,  and  1  shall  make  only  a  few 
general   remarks  upon  its  treatment.      When  it  has  been  determined  by 
cxi)loratory  ])uncturc  that  the  lluid  is  purulent,  aspiration  should  not  bo 
jierformed,  except  as  jtrcliminary  to  operation  or  as  a  temporary  measure. 
J'erhaps  it  is  l)etter  not  to  have  an  exception  to  this  rule,  although  the 
empyemas  of  children  and  the  ]ineumonic  empyema  occasionally  get  well 
rapidly  after  a  single  tapiiing.     Jt  is  sad  to  think  of  the  number  of  lives 
which"  are  sacriliced  annually  by  the  failure  to  recognize  that  empyema 
should  lie  treated  as  an  ordinary  abscess,  by  free  incision.     The  oiu'ration 
dates  from  the  time  of  Ilipjiocrates  and  is  by  no  means  serious.     A  ma- 
jority of  the  cases  get  well,  iiroviding  that  free  drainage  is  obtained,  and 
it  makes  no  dilference  practically  what  measures  are  followed  so  long  as 
this  indication  is  met.      The  good  results  in  any  method  depend  upon 
the  thoroughness   with   which   the   cavity  is  drained.      Irrigation  of   the 
cavity  is  rarely  neces.sary  unless  the  contents  are  fetid.     In  the  subsequent 
treatment  a  point  of  great  importance  in  facilitating  the  closure  of  the 
cavity  is  tlie  distention  of  tiie  lung  on  the  aifeeted  side.     This  may  be 
accomiilishcd  ])y  the  method  advised   by   Ralston  James,  which  has  been 
practised  with  great  success  in  the  surgical  wards  of  the  Johns  Hopkins 
Hospital.    The  ])atient  daily,  for  a  certain  length  of  time,  increasing  gradu- 
ally with  the  increase  of  his  strength,  transfers  by  air-])ressuro  water  from 
one  bottle  to  another.    The  bottles  should  be  hirge,  Indding  at  least  a  gallon 
each,  and  l)y  the  arrangement  of  tubes,  as  in  the  Wolff's  bottle,  an  expira- 
tory elfort  of  the  patient  forces  the  water  from  one  bottle  into  the  other. 
In  "this  way  expansion  of  the  comi>ressed  lung  is  systematically  ])ractiscd. 
The  abscess  cavity  is  gradually  closed,  ])artly  by  the  falling  in  of  the  chest 
wall  and  nartly  i)y  tlie  expansion  of  the  lung.      In  some  instances  it  is 
necessary  to  resect  ])ortions  of  one  or  more  ribs. 

The'physician  is  often  asked,  in  cases  (  f  empyema  with  emaciation, 
hectic  and  "feeble  rapid  jndse,  whether  the  ])atient  could  stand  the  opera- 
tion. Even  in  the  most  desperate  cases  the  surgeon  should  never  hesitate 
to  make  a  free  incision. 


II.    CHRONIC    PLEURISY. 

This  affection  occurs  in  two  forms:  (!)  Chronic  pkuris;/  vilh  effusion, 
in  which  the  disease  may  set  in  insidiously  or  may  follow  an  acute  .sero- 
fdjrintms  jileurisy.  There  are  cases  in  which  the  liquid  ])crsists  for  months 
or  even  vears  without  undergoing  any  special  alteration  and  without  bcconi- 


CnilONIC  PLEURLSY. 


079 


!  phenomenon 
pping,  is  asso- 
ral  a  [/ in  pi  (I  ins. 
occur  eitlior 
ve  seen  but  a 
iirdod  by  nio.^l 
ir  citbcr  I'roni 

CO  only  a  few 
lotorniinud  l)y 
gliould  not  Ijo 
)riiry  nioasurc. 

although  the 
nally  got  well 
unbor  of  lives 
tliat  onipyonia 
Tlio  operation 
rious.     A  nia- 

obtained,  and 
:ed  so  long  as 

depend  npnn 
igation  of  the 
the  snbso(piont 
closure  of  the 

'JMiis  may  bo 
hich  has  been 
rohns  Hopkins 
■roasing  gradu- 
u'o  water  from 
t  least  a  gallon 
Ltlo,  an  expira- 
into  the  other. 
?ally  ])ractised. 
in  of  the  chest 
instances  it  is 

th   emaciation, 

and  the  opera- 

nover  hesitate 


//  vilh  effusion, 

an  acute  sero- 

ists  for  months 

without  becom- 


ing purulent.  Such  eases  have  the  characters  which  wo  liav(>  described 
under  pleurisy  with  olfusion.  (•-?)  Clirniiir  dri/  iilciirisi/.  '\'hr  cases  are  mot 
with  ((()  as  a  seipu'nce  of  ordinary  |)loural  clfusiiui.  Wbeii  the  exudate  is 
alisorheil  and  the  layers  of  tlie  pleura  comio  together  tiiere  is  left  lietwecn 
them  a  variahle  anu)unt  of  lilu'inous  material  which  gradually  undergoes 
organization,  and  is  converted  into  a  layer  of  linn  connective  tissue.  'J'liis 
jirocess  goes  on  at  the  base,  and  is  re])resenteil  clinically  liy  a  sliglit  grade  of 
llattening,  deficient  expansion,  defective  resdnanee  on  percussion,  and  en- 
feebled breathing.  After  recovery  from  emiiyema  tin  llattening  and  re- 
traction may  be  still  more  marked.  Jn  both  cases  it  is  a  condition  which 
can  be  greatly  benefited  by  ])ulnionary  gymnastics.  In  these  firm,  fibrous 
membranes  calcification  may  occur,  ])articularly  after  empyema.  It  is 
not  very  uncommon  to  find  between  the  false  membranes  a  small  pocket 
of  lluid  forming  a  sort  of  jileural  cyst.  In  the  groat  majority  of  those 
cases  the  condition  is  one  which  need  not  cause  anxiety.  There  may  bo 
an  occasional  dragging  ])ain  at  the  base  of  the  lung  or  a  stitch  in  the  side, 
but  patients  may  remain  in  ])erfoctly  good  health  for  years.  The  most 
advanced  grade  of  this  secondary  dry  pleurisy  is  i^wn  in  tbo>e  cases  of  em- 
pyema which  have  been  left  to  themselves  and  have  perb>rated  and  ulti- 
mately healed  by  a  gradual  alisorption  or  discharge  of  the  ])us.  with  retrao 
tion  of  the  side  of  the  chest  aiul  jiermancnt  carnilieation  of  the  lung. 
Traumatic  lesions,  such  as  gunshot  wounds,  nuiy  be  lollowed  by  an  identical 
condition.  J'ost  nu)rtoni,  it  is  quite  im[)ossiblo  to  separate  the  layers  of  the 
pleura,  wbich  are  greatly  thickened,  particularly  at  the  Iiase.  and  surround 
a  com])resse(l,  airless,  fiiiroid  lung,  bronchiectasis  may  grailually  develo]), 
ami  in  oiio  remarkable  case  which  I  have  seen  (m  several  occasions  with 
Dr.  lilackader,  of  ^Montreal,  not  only  on  the  afl'octod  side,  but  also  in  the 
lower  lobe  of  the  other  lung. 

(h)  Primitive  lirij  pkurisi/.  This  condition  i)\\\\  directly  follow  the 
acute  ])Iastic  pleurisy  already  deseribod;  but  it  may  set  in  without  any 
acute  symptoms  whatever,  and  the  ))atient's  attention  nuiy  l)o  called  to  it 
by  feeling  the  ])loural  friction.  A  constant  cirect  of  this  primitive  dry 
pleurisy  is  the  adhesion  of  the  layers.  This  is  jirobably  an  invariable  result, 
whether  the  ])leurisy  is  primary  or  secondary.  Ilio  organization  of  the  thin 
layer  of  exudation  in  a  })neumonia  will  unite  the  two  surfaces  by  delicate 
bands.  Pleural  adhesions  are  oxtromoly  common,  aiul  it  is  rare  to  oxainino 
a  body  entirely  free  from  them.  They  may  bo  limited  in  extent  or  univer- 
sal. Thin  fdtrous  adhesions  do  not  produce  any  alteration  in  the  jjorcussion 
characters,  and,  if  limited,  there  is  no  special  change  beard  on  ausculta- 
tion. "When,  however,  there  is  general  synechia  on  both  sides  the  cxi)ansile 
movement  of  the  lung  is  considerably  impaired.  We  should  naturally 
think  that  nniversal  adhesions  would  interfere  materially  with  the  func- 
tion of  the  lungs.  l)ut  practically  we  sec  many  instances  in  which  tlioro 
has  not  liecn  the  slightest  disturbance.  The  physical  signs  of  total  adhe- 
sion are  by  no  moans  constant.  It  has  been  stated  that  tli(>re  is  a  marked 
dispro]iortion  between  the  degree  of  expansion  of  the  cbest  walls  and  the 
intensity  of  the  vesicular  murnuir,  but  the  latter  is  a  very  variable  factor, 
and  under  perfectly  normal  conditions  the  breatli-.sounds,  with  very  full 


^^ 


ti  , 


8 


'•,  r  i 


680  DISEASES  OF  THE  RESPIRATORY  SYSTEM. 

chof^t  oxpansion,  may  ho  extremely  feeble.    The  diaphragm  phonomonou— 

Litteii's  sign— is  absent.  -,     „     ,     i    .  wi  ■  i 

Is  there  a  primitive  drv  ].leiirisv  which  pradually  leads  to  great  thiek- 
eiiin-'  of  the  membranes,  and  which  nltimately  may  invade  tiu'  lung  and 
indueo   cirrhotic   change?      Upon   this   question   neither   pathologists   nor 
clinicians  agree.     I  think  that  Sir  Andrew  Clark,  in  his  T.undeiaii  lectures 
at  the  IJoval  College  of  rhvsicians  (IHHo),  has  made  good  his  claim  that 
such  a  disease  does  exist.     Clinically  the  cases  are  of  great  irterest,  and 
«hould    1  think,  be  separated,  on  the  one  hand,  from  the  condition  ulueli 
follows  a  healed  empvenia  or  old  pleurisy  witli  elTusion,  and,  on  the  other 
from  the  rare  instances  of  i)rimitive  cirrhosis  of  the  lung.     However,  m  all 
three  states  there  may  ultinuitely  be  an  almost  identical  climcal  picture. 
Anatomieallv  in  these'ph'uritie  cases  the  i)leura,  particularly  that  surround- 
in"  the  lower  lobe,  sometimes  the  entire  membrane,  is  thickened,  the  two 
layers  are  intimately  united,  and  fibrinous  bands  passing  from  the  pleura 
tr'  a>rse  the  lung  tissue,  sometimes  dividing  it  in  a  remarkable  way  into 
sections.     The  bronchi  may  present  marked  dilatations,  though   this  is 
not  alwavs  the  ease,  and  the  lung  tissue  is  more  or  less  sclerosed,      iho 
rases  belong  to  tlie  gnuip  of  chronic  pneumonias  called  by  Charcot  pleu- 

rogenous.  .   .        j     •*- 

Lastly  tlu're  is  a  i.rimitive  drv  ideurisy  of  tuberculous  origin.  In  it 
both  parietal  and  costal  layers  are  greatly  thickened-i.erhaps  from  2  to 
3  „j„,  each— and  i.rcseiit  iirm  lil)roid,  caseous  masses  and  small  tul)crcles 
while  uniting  these  two  greatly  thickened  layers  is  a  reddish-gray  hbroid 
tissue,  sometimes  infiltrated  with  serum.  This  may  be  a  local  process  con- 
fined to  one  pleura,  or  it  may  be  in  both.  These  cases  are  sometimes  associ- 
ated wilh  a  similar  condition  in  the  pericardium  and  peritonanim. 

Occasionally  remarkable  vaso-motor  phenomena  occur  in  chronic  pleu- 
risy whether  simple  or  in  connection  with  tuberculosis  of  an  apex,  llush- 
in-V'or  sweating  of  one  cheek  or  dilatation  of  the  pupil  are  the  common 
manifestations.  They  appear  to  be  due  to  involvement  of  the  first  thoracic 
ganglion  at  the  toj)  of  the  pleural  cavity. 


III.  HYDROTHORAX. 

ITvdrothorax  is  a  transudation  of  simple  non-inflammatory  fluid  into 
the  nieural  cavities,  and  occurs  as  a  secondary  process  in  many  alVections. 
The  fluid  is  clear,  witlumt  anv  floeculi  of  fibrin,  and  the  membranes  are 
cmooth  It  is  met  with  more  particularly  in  connection  with  general 
dropsy,' either  renal,  cardiac,  or  hannic  It  may,  however,  occur  al.me.  or 
with  mdv  slight  .ed.Mua  of  the  feet.  A  child  was  admitted  to  the  Mont- 
real General  Hospital  with  urgent  dyspn.ea  and  cyanosis,  and  dietl  the 
ni.dit  after  admission.  She  had  extensive  bilateral  hydrothorax,  which 
had  come  on  earlv  in  the  nepi'vitis  of  scarl.-t  fev(.r.  Tn  renal  diseasehydro- 
thorax  is  almost  alwavs  bilateral,  but  in  heart  atfections  one  pleura  is  more 
commonlv  involved.  "The  physical  signs  are  those  of  pleural  etfusion,  but 
the  exudation  is  rarely  excessive.    In  kidney  and  heart-disease,  even  when 


lenomcnou — 

i  groat  thick- 
llic  lung  ami 
liologisls  nor 
li'inii  Ircturi's 
is  claim  that 
irteiT-t.  and 
idition  uliifli 
on  the  other, 
owever,  in  all 
iiieal  i)ict\ire. 
hat  surroiind- 
ened,  the  two 
)m  the  pleura 
able  way  into 
hough   this   is 
'Icrosed.     The 
Charcot  pleu- 

origin.  In  it 
(jis  from  'i  to 
mall  tul)ercles, 
ih-gray  iibroid 
il  process  con- 
net  imes  assoei- 
nanim. 

.  chronic  ])leu- 

a]H'x.    riush- 

c  the  common 

e  first  thoracic 


tory  fluid  into 
laiiy  alVections. 
membranes  are 
1  with  general 
occur  alone,  or 
1  to  the  Mont- 
,  and  died  the 
othorax,  which 
1  disease  hydro- 
I  pleura  is  more 
al  eiVusion,  but 
.'ase,  even  when 


PNEUMOTHORAX. 


C8l 


tiiere  is  no  general  dro])sy,  the  occurrence  of  dy^pmea  should  at  once 
direct  attention  to  the  pleura,  since  many  ])aticnts  aic  carried  olT  by  a 
rapid  elfusion.  I'ost-nmrtem  records  siiow  the  frei|neMiy  with  which  this 
condition  is  overlooked.  The  saline  i)urges  will  in  many  cases  ra|)i(ily 
reduce  the  cll'usion,  but,  if  necessary,  asjiiration  should  rejieatedly  be 
practised. 


IV.    PNEUMOTHORAX   {Hydro- Pneumothorax  and  Pijn- Pneumothorax). 

Air  alone  in  the  ])lcural  cavity,  to  which  the  term  piieuiiKithorax  is 
strictly  ap|ilicable,  is  an  extrenu'ly  rare  condition,  it  is  alm<ist  invariably 
assoi'ialcd  with  a  serous  lluid — hydro-pneuniothorax,  or  with  [lus — jiyo- 
pneumothorax. 

Etiology. — There  exists  normally  within  the  pleural  cavity  of  an  adult 
a  neg^Uive  pressure  of  several  millimetres  of  mercury,  due  to  the  recoil  of 
the  distended,  perfectly  elastic,  lung.  Hence  through  any  opening  con- 
necting the  ])lcural  cavity  with  the  external  air  we  should  expect  air  to 
rush  in  until  this  negative  pressure  is  relieved.  To  explain  the  absence  of 
])neumolhorax  in  a  few  cases  in  which  it  would  be  expected,  S.  West  has 
assumi'd  the  existence  of  a  cohesion  between  the  ])leura'  which  overcomes 
the  tendency  of  the  chest  to  this  condition,  but  this  force  has  not  as  yet 
been  satisfactorily  demonstrated. 

In  a  case  of  ])neumothorax,  if  the  opening  causing  it  remain  ])atent, 
the  intrathoracic  pressure  will  be  that  of  the  at nuis]»hcre,  the  lung  will  be 
found  to  have  collajtsed  by  virtue  of  its  own  elastic  tension,  the  intercostal 
grooves  obliterated,  the  heart  displaced  io  the  other  side,  and  the  diaphragm 
lower  than  normal,  because  the  lu'gative  pressure  by  reason  of  which  these 
organs  are  retaiiu'd  in  their  ordinary  ])osition  has  been  relieved.  If  the 
opening  becomes  closed  the  intrathoracic  ])ressure  may  rise  above  the  at- 
mospheric and  the  al)ove-mentioned  displacements  l)e  much  increased. 
Some  of  the  reasons  for  this  rise  of  i)rcssure  are,  the  valvular  action  of  the 
ojiening  during  violent  expiratory  efforts,  the  rise  of  temjierature  of  the  im- 
]irisoned  gas,  and  the  com])ression  of  the  air  by  the  usual  elfusion  into  the 
cavity. 

rnenmothorax  arises:  (1)  In  perforating  w(uinds  of  the  chest,  in  which 
case  it  is  sometimes  associated  with  exten.sive  cutaneous  emphysema.  It 
has  followed  exjiloratory  ])unctnre.  Herman  I'.iggs  has  i'e]iiirte(i  two  cases 
and  I  have  seen  it  twice,  rnenmothorax  rarely  follows  fracture  of  the  rib, 
even  tliough  the  hing  may  be  torn.  (2)  In  perforati(m  of  the  pleura 
through  the  diaphragm,  usually  by  malignant  disease  of  the  stomach  or 
C(don.  The  jilenra  may  also  be  perforated  in  cases  of  cancer  of  the  (esoph- 
agus. (.1)  When  the  lung  is  ])erl'orated.  This  is  by  far  the  nmst  com- 
mon cause,  and  may  occur:  {a)  In  a  normal  lung  from  rupture  of  the 
air-vesicles  during  straining  or  even  when  at  rest.  S|)ecial  attention  has 
been  called  to  this  accident  liy  S.  West  and  De  II.  Hall.  The  air  may  be 
absorbed  and  no  ill  effect  follows.  It  does  not  necessarily  excite  jdeurisy, 
as  pointed  out  many  years  ago  by  Gairdner,  but  inflammation  and  effusion 


^^^ 


fW 


; 


i' 


li 


I': 


i: 


1 

1 


ggo  DISEASES  OP  THE  RESPIRATORY  SYSTEM. 

nro  tho  ii^^iiiil  result.  Tn  a  rcronl  case  tho  coii.liticn  dovi'lopcd  as  tlie  pa- 
'tient  was  -..in-  .l..wn-stairs;  no  otl'usion  MUnsvd;  he  did  not  react  to 
tul.L-ronlin.  (h)  I'l-ni  lu'iloiation  due  to  local  disease  of  the  lung,  either 
the  s.d'ti.nin-  of  a  caseous  I'ocus  or  the  breaking  of  a  tul.erculous  cavity. 
AcoordiiK'  to  S.  West,  !)U  per  cent  of  all  tlie  cases  are  due  to  this  cau.e. 
Le<<  conmion  are  the  cases  due  to  septic  broncho-pneumonia  and  t,.  gan- 
grene A  rare  cause  is  the  breaking  of  a  lueinorrhagic  infarct  ui  chronic 
lieart-di<eiiM",  of  which  I  met  an  instance  a  few  years  ago.  (0  1  crlora- 
tion  of  the  lung  from  the  pleura,  which  arises  in  certain  cases  of  empyema 
and  produces  a  plenro-bronchial  fistula.  {<!)  Spontaneously,  by  the  de- 
velopment in  pleural  exu-lates  of  the  gas  bacillus  [B.  acrojcncs  rai,.nlaliis 

'pneumothorax  occurs  chielly  in  adults,  though  (ascs  are  met  with  in 
verv  voung  ehildren.     It  is  more  frcpient  in  males  than  m  lema  es.  . 

Morbid  Anatomy.— If  a  trocar  or  blow-].ipe  is  inserted  between 
the  ribs,  there  may  be  a  jet  of  air  of  sutlicient  strength  to  blow  out  a 
li.vjited  match.  On  opeiiiuu'  the  thorax  the  mediastinum  and  pericardium 
a^e  -cell  to  b.'  pushe.l,  or  rather,  as  Douglas  Powell  pointed  out,  drawn 
over  to  tiie  opposite  side;  but,  as  before  menthmed,  the  heart  is  not 
rotated,  and  the  relation  of  its  parts  is  maintained  much  as  in  the  normal 
condition.  A  serous  or  purulent  iluid  is  usually  i.resent,  and  the  mem- 
branes are  inllamed.  The  canse  of  tho  imeumothorax  can  usually  be 
found  without  diilicultv.  In  the  great  majority  of  instances  it  is  tho 
perforation  of  a  tubercnhms  cavity  or  a  breaking  of  a  sui.erficial  caseous 
focus  The  oriliee  of  rupture  may  be  extremely  small.  In  chronic  cases 
there  may  be  a  listula  of  considerable  size  communicating  with  the  bron- 
chi    The  lung  is  usuallv  compressed  and  carnilled. 

Symptoms. -The  onset  is  usuallv  sudden  and  characterized  by  severe 
pain  in  the  side,  urgent  dvspna-a,  and  signs  of  general  distress,  as  indicated 
bv  slioht  lividity  and  a  verv  rapid  and  feeble  pulse.  There  may,  lioweyer, 
i;  n.;  ur-cnt  sVmpt.nns,  ]mrticularly  in  cases  of  long-standing  ph  hisis. 
On  more'than  one  occash.n  I  have  found,  post  mortem,  a  pneumothorax 
which  was  unsuspected  during  life.  West  states  that  even  m  healthy 
adults  this  latent  pneumothorax  may  occasionally  occur.  „,    ,     „     , 

\  remarkable  recurrent  variety  has  been  descrilied  by  S  ^^est,  ,oo(l- 
hart.  and  Furney.  In  Ooodharfs  case  the  pneumotliorax  develojied  lirst 
in  one  side  and  then  in  the  other. 

The  phislral  sh/n.^  are  very  distinctive.  Tn.'^pectum  shows  marked  en- 
larcrement 'of  the  aiT(.cted  side  with  immobility.  The  heart  nnpulse  is 
n.uallv  much  disi^laced.  On  palimlion  the  fremitus  is  greatly  diminished 
or  more  commoulv  abolished.  On  percussion  tho  resonance  may  be  tym- 
panitic or  even  have  an  amphoric  quality.  This,  however,  is  not  always 
the  ca<e  It  mav  he  a  flat  tvmpany.  resembling  Skoda  s  resonance.  In 
some  instances  it  mav  he  a' full,  liy].erresonant  note,  like  emphysema: 
while  in  others-and  this  is  very  decei.tive-there  i^  «1"I'H'^;^-  i'"^^° 
extreme  variations  dep.'iid  douhlless  upon  the  degree  of  mtraidcural  ten- 
sion On  several  occasions  I  have  known  an  error  in  diagnosis  to  resu  t 
from  ignorance  of  the  fact  that,  in  certain  instances,  the  percussion  note 


;|r. 


PNEUMOTIIOIIAX. 


083 


I'd  as  tlie  pa- 
not  roait  to 
•  lung,  oithcr 
.'iiloiis  cavity, 
to  tliis  cau>o. 
I  and  to  gan- 
•ct  in  chronio 
(,  )  rfvl'oni- 
>;  of  empyema 
y,  l)y  the  (le- 
ncs  (iiih-iitlalus 

>  met  with  in 
emaks.  < 

erted  l)et\\een 
:o  l)lo\v  out  a 
d  pericardium 
L'd  out,  drawn 
I  heart  is  not 
in  tlic  normal 
and  the  niem- 
an  nsually  be 
nces  it  is  the 
I'rficial  caseous 
1  chronic  cases 
witli  the  bron- 

■rized  by  severe 
ss,  as  indicated 

may,  however, 
iiding  i)lithisis. 

pnenmothorax 
^■en  in  healthy 

S.  West,  r.ond- 
develo])ed  first 

1WS  marked  en • 
cart  impnlse  is 
atly  diminished 
?e  may  be  tym- 
r,  is  not  always 

resonance.  Tn 
l<e  emphysema: 
lulness.  "These 
utraiilenral  ten- 
i<''nosis  to  result 

percussion  note 


may  be  "  mullled,  tonelc-^s,  aluiost  dull"  (Walr-he).  'i'licre  is  usually  dul- 
ness  at  the  base  I'rom  etl'iiscd  lluid,  wliicli  can  readily  lie  made  to  change 
the  level  by  altering  the  position  of  the  ]iatient.  Movable  dulness  can 
be  obtained  much  nmre  readily  in  pneumothorax  than  in  a  simple  jilcii- 
risy.  On  (nisciilldlKni  the  breath-sounds  arc  sii|)prcssed.  Sonu'limes 
there  is  oidy  a  distant  i'ecble  inspii'atory  murmur  of  marked  am|ihoric 
(juality.  The  contrast  between  the  loud  exaggerated  breath-sounds  on 
the  m)rnuil  side  ami  tlie  absence  of  the  breath-soniuls  on  the  other  is 
very  suggestive.  The  rales  have  a  peculiar  metallic  quality,  and  on 
coughing  or  deep  insjiiration  there  may  be  what  LaeniU'c  tt'rmed  the 
metallic  tiidvling.  The  voice,  too,  has  a  curious  metallic  echo.  What  is 
sometimes  called  the  coin-sound,  termed  by  Trousseau  the  /)/•////  (I'diniin, 
is  very  characteristic.  To  obtain  it  the  auscultator  should  place  one  ear 
on  the  back  of  the  chest  wall  while  the  assistant  taps  one  coin  on  another 
on  the  front  of  the  chest.  The  metallic  echoing  sound  wiiich  is  produced 
in  this  way  is  one  of  the  most  constant  and  characteristic  signs  of  pncunu)- 
thorax.  And.  lastly,  the  liippocratic  succnssioii  may  be  obtained  when 
the  auscultator's  head  is  placed  upon  the  chest  while  the  patient's  body  is 
shaken.  A  si)lashing  sound  is  produced,  which  may  be  audible  at  a  dis- 
tance. A  ])atient  may  himself  notice  it  in  making  abrupt  changes  in 
po.sture.  Of  other  ;ym])toms  disi)lacement  of  organs  is  most  constant. 
As  already  mentioned,  the  heart  may  be  drawn  over  to  the  opposite  side, 
and  the  liver  greatly  displaced,  .so  that  its  npper  surface  is  below  the  level 
of  the  costal  margin,  a  degree  of  dislocation  never  seen  in  simple  eifnsion. 
The  >-Ii(U/iiiisis  of  pneiMnolhorax  rarely  offers  any  dilliculty,  as  the  signs 
are  very  characteristic.  In  cases  in  which  the  percussion  note  is  dull  the 
condition  may  be  mistaken  for  effusion.  I  made  this  mistake  in  a  case  of 
jiidsating  ]ilenrisy,  in  which  the  i)neiimothorax  followed  lu'avy  lifting,  and 
it  was  not  until  several  days  later,  after  some  of  the  fluid  had  ln'cn  with- 
drawn, that  a  tympanitic  note  developed.  Diaphragmatic  hernia  follow- 
ing a  crush  or  other  accident  may  closely  simulate  pneunu)thorax. 

In  ca.ses  of  very  large  jihthisical  cavities  with  tympanitic  percussion 
resonance  and  rales  of  an  am])horic,  metallic  cpuility,  the  question  of  pneu- 
mothorax is  sometinu's  raised.  In  those  rare  instances  of  total  excava- 
tion of  one  lung  the  amphoric  ami  metallic  phenomena  may  lie  most  in- 
tense, but  the  absence  of  dislocation  of  the  organs,  of  the  succussion  sjilash, 
and  of  the  coin-sound  suflice  to  diirerentiate  this  condition.  While  this  is 
true  in  the  great  majority  of  cases,  I  have  recently  heard  the  hniit  d'airain 
over  large  cavities  of  the  right  up])er  lobe.  The  condition  of  pyo-pneu- 
mothorax  subphrcnicus  may  simulate  closely  true  pnctimothorax. 

The  prof/nosis  in  cases  of  jjueumothorax  dei)emls  largely  upon  the  cause. 
S.  West  gives  a  mortality  of  TO  j)er  cent.  The  tuberculous  cases  usually 
<lie  within  a  few  weeks.  Of  39  cases,  'i\)  died  within  a  fortnight  (West); 
10  jiatients  died  on  the  fir.st  day,  2  within  twenty  and  thirty  minutes  re- 
spectively of  the  attack.  Tneumothorax  developing  in  a  healthy  individual 
often  ends  in  recovery.  There  are  tuberculous  cases  in  which  the  pneu- 
mothorax, if  occurring  early,  seems  to  arrest  the  ])rogress  of  the  tubercu- 
losis.   This  appeared  to  be  the  case  in  a  man  with  chronic  pneumothorax 


^^ki 


V 


ggj  DISEASES  OF  THE   KESPIUATORY  SYSTEM. 

wlm  was  under  n.v  ciur  in  niihuli'lpliia  for  lu.tw.M.n  tluvr  and  r.uir  years. 
ll  may  hr  a  cl.nmie  condition,  as  m  tlie  case  jii>l  nientione.l,  an.l  a  lair 
measinc  of  hcaltii  niav  lie  enjoyed. 

Treatment.— l^Mclicallv  tliose  cases  slioul<l  l.e  .lealt  with  as  ordinary 
ldeiiri<v   vvitli   etViision.     Of  course,   wlieii    piieiiniotliorax   develops   in   ad- 
vanced" |.iitiii>is  the  indicati..n  is  to  relieve  the  pain  and  distress  eitlier  l.y 
,„„,,;,  „,  ,|,loroforni;    hut  in  cases  which  develo,,  early  the  ilnid  shoid.l 
Ik-  withdrawn  l.v  aspiration,  or.  if  piirnlcnt,  pc>rniaiient  drama-.,  should  he 
(.l)tained       Kven   when  the  condition  has  .seemed  to  lie  most   desperate   1 
have  known   rccoverv   t<.  take   place  after  thormi-h  draniajre  of  the  sac. 
I'ortions  of  rihs  mav  liave  to  he  excised,  and  durinj?  convalescence  it  is 
well    for  the   |.aticnt    to    i.ractise   expansion   of  the   Inn-  m   the   manner 
nlreadv  mentioned.     There  are  cases  of  pneumothorax  in  phthisis  m  which 
the  -cneral  condition  is  so  -ood  and  the  inconvenience  so  shght  tiiat  to 
let  well  eiion-h  alone  seems  the  hest  course.     In  such  an  occasional  as- 
piration  mav  he   perfornie.l    if  tlie   lluid   increases.       In   some  ol  the  in- 
stances the  mere  tappin-  of  the  chest  with  a  fine  needle,  so  as  to  al  ow 
the  escape  of  some  of  the  air,  seems  to  -ive  relief  hy  n..luein-  the  in  ra- 
thoracic  pressure.      (iood  results  are  stated  to  have  followed  the  method 
introduced  hy  I'otain,  of  replacing  the  air  and  lluid  within  the  thorax  by 
sterilized  air. 


V.    AFFECTIONS   OF  THE   MEDIASTINUM. 

(1)     Simple    Lymphadenitis.— In    all    intlammatory    aiVedions    of    the 
bronclii  and  of  the  lun-s  the  groups  of  lymph-glands  in  the  mediastinum 
become  swollen.     Jn  the  hronchitis  of  measles,  for  example,  and  in  simple 
broncho-pneumonia   tlie   bronchial   glands   are   large   and   mliltrated     the 
tis.ue  is  engorged  and  (edematous,  s.u.ictimes  intensely  hypera>mic     Much 
stress  has  been  laid  by  some  writers  on  this  enlargement  ol  the  glands  in 
the  posterior  mediastinum,  and  De  Mussy  held  that  ,t  was  an  important 
factor  in   inducing  paroxysms  of  whooping-cugh.      1  hey  may  attain  a 
size  sutTicicnt  t<.  induce  dulness  beneath  the  manuhrium  and  m  the  upper 
part  ..f  the  interscapular  regions  behind,  though  this  is  often  dU  icult  to 
Il.termine.     In  reality  the  glands  lie  chietly  upon  the  spine,  and  unless 
tlio^e  wh-  ■    are  deep  in  the  root  of  the  lung  are  large  enough  to  induce 
compre.   ■   n  of  the  adjacent  lung  tissue,  I  doubt  if  the  ordinary  bronchial 
adeilopathv  ever  .-an  be  determined  by  percussion  in  the  u,,per  ^^^^^ 
lar  re'non:     I  have      ever  met  with  an  instance  m  which  the  compression 
of  either  bronchus  s.emcd  to  have  resulted  from  the  glands,  however  large. 
Tuberculous  allVction  of  these  glands  has  already  been  consi.lere.l. 

C^)  Suppurative  Lymphadenitis.-Occasionally  abscess  m  the  bronchia 
or  t\.a!.heal  lymph-glands  is  found.  It  may  follow  the  simple  ^^^^^^^}^ 
is  most  freipientlv  associated  with  the  presence  of  tubercle,  lie  luiuid 
portion  mav  graduallv  bee.nnc  absorbed  and  the  inspissated  contents  un- 
dergo calcification.  Serious  accidents  ocoasionally  occur,  as  perforation 
into  the  tesophagus  or  into  a  bronchus,  or  in  rare  instances,  as  in  the  ca,~e 


■\l 


Ml 


^^ 


AFFKCTIONS  OF  TIIK  MHDIASTINTM. 


•586 


(I  four  years. 
il,  ami  a  I'air 

li  as  ordinary 
;v\o[)S  in  ail- 
ivss  either  liy 
•  lliiid  shoiiltl 
iljrc  slioilld  lie 
t   desperate  I 
e  ol'  the  sac. 
ilosfonce  it  is 
the   manlier 
liisis  in  wliieh 
sli<j;lit  that  to 
ot'easional  as- 
110  ol'  the  in- 
<o  as  to  aUow 
inji  tlio  iiitra- 
(I   the  metlind 
tiio  thorax  hy 


JNI. 

■elions  of  the 
e  mediastinum 
and  in  simple 
ntiltrated,  the 
'ra'iiiic.  iliK'h 
'  the  plands  in 
•  an  important 
may  attain  a 
d  in  the  ui)per 
ton  dinioidt  to 
no,  and  unless 
)ngh  to  induce 
inary  hronchial 
iper  interscapu- 
lie  eomprossion 
iiuwevor  large, 
dered. 

1  the  hronchial 
tie  adenitis,  hut 
lo.  The  litiuid 
hI  contents  Un- 
as perforation 
!,  as  in  the  case 


reported  l)y  Sidney  Phillips,  porl'oration  of  the  aniia.  as  well  as  a  hn.nchtis. 
whieh,  it  is  reiiiarkahle  to  say.  did  not  prove  latal  rapidly,  hut  caused  iv- 
jicatcd  attacks  of  lia'niopty>is  during  a  period  nf  sixteen  months. 

(;i)  Tumors ;  Cancer  and  Sarcoma.- -I  n  HaivV  elahoniie  study  ..f  .v.'o 
cases  of  ilisease  of  the  iiiediastinum '"  there  were  J;!l  (•a>es  of  eaneer.  !l.S 
cases  of  sarcoma,  ".' I  cases  of  lymphoma.  T  cases  ,,f  (ihnuna,  ]!  cases  of 
deniHiid  cysts,  ,s  cases  of  hydatid  cysts,  and  in>tanc.'s  of  lipoma,  giniima, 
and  cndioiidioma.  From  this  we  ,>-ce  that  cancer  is  the  most  niimiioii 
form  of  growth.  The  tumor  occurred  in  tiie  anterior  mediastinum  alone 
in  IS  of  the  cases  of  cancer  and  in  ;;;i  of  the  cases  of  sarcoma,  'i'here  are 
three  chief  |.oin(s  of  origin,  the  thymus,  the  lymph-glands,  and  tlie  pleura 
and  lung.  Sarcoma  is  more  freciiicnlly  primary  than  cancer.  .Males  are 
more  ficpienlly  aircetcd  than  females.  'I'lir  age  ui'  onset  is  most  com- 
monly iietwcen  thirty  and  forty. 

Symptoms.— The  signs  of  iiu'diastinal  tumor  are  those  of  intra- 
thoracic pressure.  Di/spiiua  is  one  (.f  the  earliest  and  most  constant 
sympt(uns.  and  may  he  duo  cither  to  pressure  on  the  trachea  or  on  the 
recurrent  laryngeal  nerves.  It  may  indeed  he  cardia.'.  due  to  lavssuro 
upon  the  heart  or  its  vessels.  In  a  few  cases  il  ivsults  from  the  pleural 
ciriision  which  so  fre(picntly  accompanies  intrathoracic  growths.  Asso- 
ciated with  the  dyspiKca  is  a  cough,  often  .-cvore  and  paroxysmal  in  char- 
acter, with  the  hrazeii  (piality  (d'  the  so-called  aiieiirisnial  cough  when  a 
recurrent  nerve  is  involved.  The  voice  may  also  he  aireeled  from  a  simi- 
lar cau.-c.  Fressnre  on  the  vessels  is  common.  The  superior  vena  cava 
may  ho  compressed  and  ohliterated.  and  when  the  iirocoss  goes  on  slowly 
the  collateral  circulation  may  he  com|)letoly  oil'octod.  Loss  commonly  the 
inferior  vena  cava  or  one  or  other  of  the  suhclavian  veins  is  com|)ressed. 
The  arteries  are  much  less  rarely  ohstructed.  It  is  ivmarkahlo  how  little 
the  aorta  may  he  involved,  though  entirely  surrounded  hy  a  sarcomatous 
or  cancerous  mass.  There  may  he  dysphagia,  due  to  compression  of  the 
lesoiihagus.  In  rare  instances  there  are  i.npillary  changes,  cither  dilatation 
or  contraction,  due  to  involvement  of  the  syin])atlietie. 

Physical  Signs.— On  inspox'tion  there  niav  he  orthoi)no«a  and  marked 
cyanosis  of  the  upper  part  of  the  hody.  In  such  instances,  if  of  long 
duration,  there  are  signs  of  ccdiateral  circulation  and  the  superficial  niann 
inary  and  epigastric  vimiis  arc  enlarged.  In  those  cases  of  chronic  ohstriic- 
tion  the  finger-tips  uiay  lie  cluhhod.  There  may  ho  hulging  of  the  ster- 
num or  the  tumor  may  erode  the  hone  and  form  a  prominent  suiicnfaneous 
growth.  The  rapidly  growing  lyniiihoid  tumors  more  conimonly  than 
others  iiorforatc  the  chest  wall.  In  I  of  13  ca.ses  of  llodgkin's  diseas.-. 
there  was  mediastinal  growth,  and  in  3  in.stances  the  sternu'm  was  eroded 
and  perforated.  The  perforation  may  lie  on  one  side  of  the  hroast-liono 
The  jirojecting  tumor  may  pulsate;  the  heart  mav  he  dislocated  and  its 
ini|)ulse  miicji  out  of  place.  Contraction  of  one  side  of  the  thorax  has  hoon 
noted  in  a  few  instances.  On  palpation  the  fremitus  is  ahsent  wherever 
the  tumor  readies  tlio  chest  wall.     If  pulsating,  it  raivlv  has  the  foreihlo 


'  Fotliorgillinn  Prize  Essay  of  tlie  Medical  Society  of  Lonrlon,  Philadelphia.  1889. 


080 


DISKASES  OF   THE  RKSIMRATOIIY   SYSTEM. 


hoavin-  iiuP.ilM'  nf  ;.M  nn.M.risnial  s,.<-.     On  aiisoultntiun  \\u'vv  K  imwlly 
Hk.m.cw.vc.r  tl...  .lull   n-i..n.     Th.  hrart-soniuls  a,v  nut   tn.u>H..tt...    an, 
tlR.  r.snirat..rv   n>nrnnir  is  f(rl.h'  nr   inaudiMr.   raivly   hmnclual.      \  ncal 
r,-..nnnco  is,  as  a  rnlo,  al.sc-nt.     Sij^ns  of  pleural  dVusi-n  u.-.ur  ,n  a  gnat 
many  instances  ..f  mediastinal  gr-.wth.  and  in  (l.ud)trul  eases  the  aspirator 

iieeifk'  siiouia  be  used.  ,,     •      ., 

Tumors  of  the  anterior  mediastinum  originate  usually  m  the  myinus, 
the  sternum  i«  pushed  iorward  and  often  eroded.  The  grov.th  may  bo 
IVlt  in  the  suprasternal  fossa;  the  cervieal  ghinds  are  usually  mvlved. 
The  pressure  symptoms  are  ehielly  upon  tiie  venous  trunks.     Dyspn.eii  is 

a  iironiinent  feature.  ,.      .  •   •     i 

InlralluM'a.Me  tumors  in  the  middle  and  posterior  mediastinum  originate 
mu^t  eommonlv  in  the  lymph-glands.  The  symptoms  aiv  out  ol  all  pr<.- 
,„Hlion  to  the'pi'vsieal  signs;  there  is  urgent  dysim.ea  and  e.nigh  wlueli 
I  sometimes  loud'  ami  ringing.  The  pressure  symptoms  are  ehielly  upon 
the  .nillet,  the  reeurrent  larvngval.  and  sometimes  npon  tiie  a/.ygos  vein. 

fn  a  tliird  group,  tumors  originating  in  the  pleura  and  the  lung,  the 
r,re-ure  svniptoms  are  not  so  marked.  Pleural  exudate  is  very  nnie  i 
more  eomnion;  the  patient  beeomes  amemie  and  enia.Mat.on  is  rai-id. 
There  may  be  seeondary  involvement  of  the  lymph-glands  in  the  neek. 
For  a  discussion  of  the  symptomatology  of  these  ditVerent  groups  see 
l>,,,,,,,r  and  Stengel,  Transactions  of  the  Association  of  American  1  hysi- 

''"''Thvilimiiiosis  of  mediastinal  tumor  fr.mi  aneurism  is  sometimes  ex- 
tremely dillicult.     An  interesting  case  reported  and  figured  by  Sokoh.sski, 
in    r.d'    1!)    of    the    Deutsch.'S    Areliiv    fiir    klinische    Medicin.    in    Nvlueh 
O.mol/er   diagnosed    aneurism   and    Skoda    mediastinal    tumor,    illustrates 
1,,,'v   in  some  instances  th.-  uiost  skilful  ..f  observers  may  be  miable  to 
•i.rree      Scarcely  a  sign  is  found  in  aneurism  \vliich  may  not  be  duplicated 
lu  mediastinartumor.     This  is  n.)t  strange,  since  the  sympt^mis  ui  both 
•n-o  lar-elv  due  to  pressure.     The  time  element  is  imi.ortant.     I     a  case 
has  pei^sisted  for  uuu'e  than  eighteen  months  the  disease  is  probably  ane.t- 
in     There  are,  however,  exceptions  to  this.     V,y  far  the  most  yaluablo 
M.n  of  aneurism  is  the  diastolic  shock  so  often  to  bo  felt,  and  m  a  majority 
of^-ases  to  he  heard,  over  the  sac.    This  is  rarely,  if  ever,  present  m  medias- 
tinal -rowths,  even  when  they  perforate  the  sternum  and  have  communi- 
cated ^pulsaticm.     Tracheal  tugging  is  rarely  presetrt  in  tumor.     Another 
point  of  importance  is  that  a  tumor,  advancing  from  the  mediastm  .  n, 
Jrodin-  the  sternum  and  ai^pcaring  externally,  if  aneurismal,  has  lorcib  e, 
;;:.;yhi,  and  distinctly  expansile  pulsati<ms.     The  radiating  pam  in     he 
hack  and  arms  and  neck  is  rather  in  favor  of  aneurism,  as  is  also  a  bene 
ficial  influence  on  it  of  iodide  of  i-otassium.  v    .•     i  + 

The  frciucncy  of  ideural  elTusion  in  connection  with  mediastinal  tumor 
i.  to  be  constantly  borne  in  mind.  Tt  may  give  curiously  complex  char- 
acters to  the   physical   signs-characters  which   are   profoundly   modified 

after  a«i"iiration  of  the  liipiid.  ,        t 

U)  Abscess  of  the  Mediastinum.-IIare  collected  115  cases  of  medi- 
astinal abscess,  in  77  of  which  there  were  details  sufricicnt  to  permit  the 


uismiltcil  ami 
ichiiil.  Vocal 
L'lir  in  a  griat 
■;  \\\v  a-piialnr 

II  the  liiyimis; 
rowtli  may  bo 
lally  invdlvid. 
.     J)ysi)iiii'a  is 

iinnii  (irij;iiiato 
(lilt  (if  all  pro- 
l  coii^li,  which 
re  chictly  upon 

azyijos  vein. 
1  the  Uing,  the 

if!  very  nnieli 
iition  i:<  rai)i(l. 
Is  in  the  neek. 
Mit  jri'()U)).s,  SCO 
incrii'an  I'liys-i- 

sonietimes  cx- 
I  hy  Sokolosski, 
liein.  in  whieh 
inor,  illustrates 
y  l)e  uiiahle  to 
)t  be  (lu])lieated 
nptonis  in  both 
lant.  11'  a  ease 
1  probably  aneu- 
e  most  valuable 
nd  in  a  majority 
•esent  in  niedias- 

have  eoninumi- 
uuior.  Another 
lie  mediastinum, 
iial,  has  forcible, 

iiijr  pain  in  the 
IS  is  also  a  bene- 

lediastinal  tumor 
ly  complex  char- 
:oundly   modified 

15  cases  of  mcdi- 
nt  to  permit  the 


AFFECTIONS  OF  THE  MEDIASTINUM.  ,;s7 

analysis.  Of  these  cases  the  great  niajoiity  oci  lined  in  males.  Korty-foiir 
were  iiK-laiices  of  aeiitc  alisicss.  'i'iie  anteiior  meilia.-tiniim  is  most  com- 
iiioiily  tlie  .-eat  of  the  siip|iiiiiition.  The  lases  are  iiio.-t  freipieiitly  as.-oeiated 
with  tiaiima.  Some  liave  followed  erysipelas  or  o(cmred  in  a.-,«oeiation 
with  eriiiitive  levers.  .Many  eases,  particularly  the  elironie  absccsser-,  are 
of  tiilieiciilons  origin.  Of  ,v////////(-///.v,  pain  luhiml  the  .•.terniim  is  the  mo>t 
common.  It  may  he  of  a  ihrohhing  eharacter,  and  in  the  aiiite  eases  is 
as.-oeiated  with  fever,  sometimes  with  chills  and  sweats.  If  the  abscess  is 
large  there  may  be  dyspmea.  The  pus  may  burrow  into  the  aiidoiiieii, 
perforate  through  an  intereo>tal  space,  or  it  may  erode  the  sttriium.  lii- 
stanees  are  on  record  in  which  the  aiiscess  has  discharged  into  the  trachea 
or  (c.-iophagiis.  in  many  ca.<es,  particularly  of  (hionie  ai)scess,  the  pus 
becomes  inspissated  and  |)rodiic'es  no  ill  ell'ect.  'I'lie  ///(//.s/Vr//  sii/ns  may 
be  very  indelinite.  A  piil>ating  and  iliictiiating  tumor  may  appear  at  the 
iiorder  of  the  sternum  or  at  the  sternal  m^tch.  The  ahseiice  of  hndl,  of 
the  diastolic  shock,  and  of  the  expansile  pulsation  usually  eiiaiiles  a  i(ir- 
reet  diagnosis  to  lie  made.  Wiien  in  doiiht  a  liiU'  hypodermic  needle  mav 
be  inscrtctl. 

(■))  Indurative  Mediastino-Pericarditis.— Harris  has  ivdntly  reviewed 
the  subject.  In  one  form  there  is  adherent  perii'ardium  and  great  increase 
in  the  fibrous  ti.^sues  of  the  mediastinum;  in  another  there  is  adherent  peri- 
cardium with  union  to  surrounding  parts,  but  \ery  little  niediastinitis;  in 
a  third  the  ]iericardiiim  may  lie  uninvolved.  The  disease  is  rare;  of 
'■I'i  cases  i;  were  in  males;  only  2  were  aiiove  thirty  years  of  age.  The 
symptoms  are  es.>;t'iitially  those  of  that  form  of  adhesive  pericardium  which 
is  associated  with  great  hypertroiihy  and  dilatation  of  the  heart,  and  in 
which  the  patients  jOTsent  a  picture  of  cyanosis,  dyspncea,  anasarca,  etc. 
The  pulsus  jiaradoxns,  descriiied  by  Kiissniaul,  is  not  distinctive.  Occa- 
sionally there  is  also  a  jiroliferative  peritonitis.  ;\iediastiiial  friction  is 
sometimes  heard  in  patients  with  adhesive  mediastino-pcricarditi.';— drv, 
coarse,  crackling  rales  heard  along  the  sternum,  particularly  when  tlie 
arms  are  rai.^ed. 

(<■')  Miscellaneous  Affections.— In  Hare's  monograidi  there  were  7  in- 
stances of  ''liroma,  11  ca.^es  of  dermoid  cy.<t,  8  ea.^es  of  hydatid  cvst.  and 
cases  of  lipome  and  gumma. 

(T)  Emphysema  of  the  Mediastinum.— .\ir  in  the  cellular  tissues  of  the 
mediaslimini  is  met  with  in  cases  of  trauma,  and  occasionally  in  fatal  cases 
of  dijihtheria  and  in  whooping-cough.  It  may  extend  to  the  sulM'Utane(yns 
tissues.  Champneys  has  called  attention  to  its'fre.iuency  after  traclieotoniv, 
m  which,  he  says  the  conditions  favoring  the  imidiiction  are  divisicm  of  the 
deep  fascia,  obstruction  in  the  air-pa.^sages,  and  inspiratorv  efforts.  The 
deep  fascia,  he  says,  should  not  be  raised  from  the  traclK-a.  It  is  often 
asi^ociated  with  pneumothorax.  The  condition  seems  liv  no  means  uncom- 
mon. Angel  Money  found  it  in  If.  of  28  eases  of  traclieotoniv,  and  in  3 
of  these  pneumothora.x  also  was  prtsetit. 


43 


iW 


1- 

'ii 


1^^ 


SKCTION    VII. 

pt8I<:asI':s  of  the  ciuculatouy  system. 


I.    DISEASES   OK  THE   l>EKI('AIiI)irM. 
I.    PERICARDITIS. 

rKnirMn.iTis  is  \hv  vosult  cf  inf.-tiv.  pnur-cs,  i.rimary  or  socnndary, 
or  iivi-.'<  l.v  I'xti-nsi.ui  of  intlnniniatioii  fnun  .niiti-imus  ci-ans. 

Etiology.-/V/».,n/,  so...all..l  i.lio,.a.l.i-.  inllannna,,-,,  of  tin.  UH;.n- 
l.va..  is  ratvlhut  casos  are  n,.!  uiti,,  .u-st  .unuuunlv  ,„  .Inidn.M.  m  .hul, 
tl  ■'.',  is  no  ..vi.lrn....  of  rlMMunatisn,  or  of  ntluT  n.n.lU.uns  wuh  wlnrh  the 
>1Uo-i<.^i>  is  iwiialiv  associatt'il. 

^^     ICril^niitll  rro.n  injury  usnally  ..onu.  un,l.r  tlu.  .ar.  n,  ,1...  sur.-ou 

in  c-onn.vtion   ^vi^l.   ti.o  i-rin.ary   uoun.l.      Intm.stln^^  casrs  ar.   thus,   u 

Ul     1.0  trann.atiMn  i^  fn-n,  within,  du..  to  tho  ,.assa,e.  o    son.e  lorn,- 

;;;,iv-su.h  as  a  n.c..lle.  a  pin.  or  a  l.nu-throu.rh  tho  a-so,,hagus  into  tho 

'''tT:^>.'l^n-,,  vroooss  porioanlitis  is  n.ot  with  in  tho  followin,  a^..^ 
iion«-  (0)  A  major itv  of  th..  .'asos  oo.nr  in  oonnoot.on  ^v.th  rhouniatiMU. 
Tr;>omM  ta"o  iiv.-  Lv  dilToron.  an.hors  ran.os  from  thirty  to  sovonty. 
T    .  ula,-  trouhlo  niay  ho  slight  ..r.  indoo.l.  tho  d.soaso  n.ay  bo  asso- 

ci    od  r  *h  aouto  tonsilliUs  in  rhoun.atio  suhjoots.     Casos  an-  m.ordod  ,n 

d  to  rho.unatisn.     In  tho  aonto  nooros.s  ..f  ho„o  and  ,n,o  - 
I  .  is  not  nncommon.    (r)  Tnhoroulo.is,  in  whuh  tho  d.soaso  may 

,,rv  or  part  of  a  ;ronoral  invdvonuMit  of  tho  sorous  saos  ';';;^-";;>''  ;"' 
,        oxtonsivo  vuln.onary  disoaso.     UD  Ernptivo  fovors.     In  olnldron     ho 
ai^caso  is  not  infroquont  aftor  scarlatina.     It  is  raroly  n.ot  w.th  >n  n.    .lo> 
';    H-ox.  or  tvrh'd  fovor.    In  othor  infootivo  d.soasos.  suoh  as  d,ph  ho, 
n  d  pununonia    it  is  raro.     Porirarditis  soniotnnos  conip  .oa  os  o  o,oa,  it 
wa    n   V       in    0  of  r^  autopsios  .hioh  I  oollootod:  in  only  S  of  thoso  wa 
nrthSi^  procont      0')  Cortain  alt.>rod   conditions  of  tho  systom   soom   to 
S    ho   ,0  ^^rd  n  n  n.oro  suseoptihlo  to  infection.     Of  thoso  ,out  takes 
f^,r«      h.co.    In  chronic  Priohfs  disoaso  pericarditis  is  by  no  n.oans  ra^^^ 
TCprraM  ln-n,l,Hr,ur  of  tl,e  Frcu.h  for.ns  one  of  the  most  nnportant 
pronps  of  the  disease  in  persons  over  fifty  years  of  ago,  most  frequently 
088 


SYf^TEM. 


JM. 


irv  or  si'ioiulary, 

:aiis. 

oil  of  this  iiHin- 

lildrrn,  in  which 

i  with  whiili  tlif 

V  ol  the  sur^'coii 
iscs  all'  those  in 
'  of  soiiii'  l'oi'('i<.Mi 
:o|ihagus  into  tlio 

2  follinvin;:  alTcc- 
ivitli  rliciunatisin. 
lliirty  to  sevonty. 
>ase  may  Ijo  asso- 
'S  arc  ri'conli'd  in 
.  {h)  Si'ptic  ]>ro- 
)[  hone  anil  pucr- 
■\\  the  (liswiso  may 

sacs  or  assoeiati'il 
In  chiMri'n,  thi> 
■t  witli  ill  incash's, 
-nch  as  iliphtlicria 
jdicatcs  clioiva;  it 
lily  S  of  these  was 
0  system  seem  to 
If  tiicse  pout  takes 

by  110  means  rare, 
he  most  important 
0,  most  frequently 


PKKICAUDrriS. 


tvsu 


occoiiipnnyinK  Hie  diruiiie  iiitei>iilial  foi„i  of  ncpluitis.     IVrieanlitis  has 
hern  met  with  al,-o  in  scurvy  and  dialictcs. 

rniranlilis  hij  (.rini.si,,,,  „(  diM'a>c  from  (•(.iiti^'iioiis  or^mis.  In  pleiiro- 
I'liemiioiiia  it  forms  one  .d'  the  most  serious  complications,  and  was  present 
111  .■  ci.cs  of  100  |„,.«t  moiteins  in  liii>  disease  wliich  I  ma.le  at  the  Mont- 
real (leiieral  llo>pii;,h     ll  is  most  .dlcii  met  with  in  the  pleiiio-pueu ia 

ot  cliildren  iind  .d  alcoholics.  The  association  with  simple  pleuri>v  i.>  niucii 
less  common.  In  uherative  endocarditi.s,  purulent  mvocanliiis,  and  in 
imeurism  .d'  the  aorta  pericarditis  is  occasionally  found,  "it  niav  also  resiill 
from  extension  (d'  di,-.eii.<e  from  the  liroiichial  -lands,  the  rihs.  st.'rnum,  verte- 
hra',  and  even  from  the  ahdominal  viscera.  Of  loo  con-ecutive  casesat  the 
j;o.«toii  City  Jiospita!  analyzed  l.y  Sears,  in  :.  I  the  cMidale  was  dry,  in  II 
serous,  in  I  haiiiorrha-ic,  and  in  :>  purulent,  'i'liiit v-foiir  eases '.■lliowed 
H^iis  of  ,dd  valvular  .li.<ea.-e;  rheumali-m  was  a  factor  in  .',1;  pneumonia 
in  IS;  and  in  7  ehronie  ne|.liritis.     Of  the  loo  cases  i;i  died. 

i'ericarditis  occurs  at  all  a-es.  Ca^es  are  reported  in  the  f,Ptus.  In 
the  new-horn  it  may  result  from  septic  infection  throii-h  the  navel. 
Tlirou.uhoiit  childhood  the  incidence  of  rheumatism  and  .scarlet  fever  nial<es 
It  a  rrcpient  air.'.'tion.  whereas  late  in  life  it  is  most  often  a.-^soeiated  with 
tuhen'iih.sis,  liri-hf.s  disease,  and  -out.  .Males  are  .Hunewhat  more  f,v- 
Mn..ntly  attai  ked  than  females.  Climatic  and  ,-easonal  inlliiene..s  have  heen 
"lentioned  h_\  some  writers.  The  .<o-called  epidemics  of  p.-ricardilis  have 
iKrii  onihreaiss  i,\'  piieiii lia  with  this  as  a  freipieiit  complical  ion. 

Anatomically  as  w.dl  as  clinically  the  di>ea.-e  may  he  considered  under 
the  iollowinp  divisions: 

1.  Acute.  i)laslic.  or  dry  pericarditis. 

•-'.  IVricrditis  with  eiriisioii— sero-lihriiious.  ha'morrhaiiie,  or  ]airulent. 

3.   Chronic  ailliesive  pericarditis  (adherent  pericardium). 

Acute  Plastic  Pericarditis. -This,  the  most  common  form,  neenrs  usu- 
ally as  a  secondao-  proecs,  ami  is  di>tinj^ui^he.l  hy  the  small  amount  of 
luid  e.xudatn.n,  which  does  not,  as  in  th,.  next  variety,  .ive  special  charac- 
ters to  the  disease.    It  i.s  a  heni-n  form  and  never  of  itself  proves  fatal 

Anat<.mieally  ,t  may  he  partial  or  j,ri,,H,,,,l.  j,,  ,i„,  ,,,1,,,,,,^  ^^.^  j,j^. 
serous  memhraiie  looks  lustreless  and  ron-hened.  This  is  .hie  to  the  i.res- 
ence  ot  a  thin  fihnnous  sheetin-  which  can  he  lifted  with  the  knife,  showin- 
the  niemhrane  iK.iu.ath  to  he  injected  or  in  places  ecchymotie.  As  the 
til)rin..iis  .^heetin-  increases  in  thickne.s.s  the  constant  movement  of  the 
adjacent  surfaces  frivol  l,,  it  sometimes  a  rid-e-like,  at  others  a  honey- 
comhed  appearance.  With  more  ahun.lant  lihrinous  exudation  the  mem- 
l.ranes  present  an  ai.pearance  resemhlin-  hiittered  surfaces  which  have  heen 
drawn  apart.  The  fihnn  is  in  Ion-  shreds,  and  the  heart  presents  a  curiously 
sha^joy  appearance-the  so-called  hairy  heart  of  ,dd  writer,s-r«r  rillosum 

\n  mild  o-nides  the  subjacent  muscle  looks  normal;  but  in  the  more 
prolonged  and  severe  cases  there  is  myocarditis,  and  for  "^  or  ;i  mm  be- 
neath the  visceral  layer  the  muscle  i)rcsents  a  pale,  turhi.l  api.earancc. 
-Many  of  these  acute  cases  arc  tuberculous;  eovere.l  bv  the  lavers  of  lymph 
the  granulations  arc  easily  overlooked  in  a  superficial  examination 


ggO  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

Sli.ht  ili-ia  exudation  i.  invariably  rro.cnt,  entangled  in  the  moBhos 
of  libnnjn.t  tiu^e  nu.y  be  very  thick  librinuu.  layer.  wUhout  nu.eh  .e,uu. 

'^""S^ptoms.-The  n.ajority  of  ca.e.  of  .inu^le  pla.t^ic  l-i-r^Uis^llk. 
tho!?^.f  .nu.lc  endocarditis,  present  no  syn.pt.nns,  ^";  ^ -;  ^^'^  ^^  ]  ^ 
there  arc  no  object i^e  siums  indicating  its  existence  In  the  po.t-n.o  tern 
nlnn  ft  is  not  i.nconunon  to  find  it  in  cases  in  which  its  presence  nas  been 

""1:r!:'  vS^^nptoni,  not  usually  intense,  and  in  this  form  rardy 
oxcUed  1  ;  V^sure.  U  is  more  marked  in  the  early  stage^  and  niay  bo 
vc'e  red  either  to  the  pr.vcordia  or  to  the  region  of  the  xiphoid  cartilage. 
i^^«.o  recorded  <.f  pain  of  an  aggravated  and  most  distressing  chai^ 
J";;^;  nimbi ing  angina.  Fever  is  usually  present,  but  it  is  not  aUvays  e  .y 
t  o"  u.u.h  defends  upon  the  primary  febrile  alVection.  and  how  much 

Ln  the  pencardit^is.     It  is  as  a  rule  not  high,  rarely  exceeding  10>.o  . 
Tn  rbinimatir  cases  livperpyrexia  has  been  ob,.erved. 

Phy  ^a   Signs.-/LF'/i'-  i^  -gative;  palpation  m.y  reveal  the  pre  - 
encoora  distinct  frcmilus  caused  by  the  rubbing  of  the  roughened  pei- 
c.^rdial Surfaces     This  is  usually  best  marked  over  the  right  ve.ilric  o.     It 
;  no    .1      V    to  be  felt,  even  when  the  friction  sound  on  auscultation  is 
om     ud      ear      AnscuUali.n:  The  friction  sound,  due  to  the  movement 
^  fliM    1    a  dial  surfaces  upon  each  other,  is  one  of  the  most  distinctive 
o      hv       1    i-nis.     It  is  double,  corresponding  to  the  systole  and  d.astol  , 
b  /    e  "ncl  ;>nism  with  the  heart-sounds  is  not  accumte   ami  the  to-.nd- 
f  innr    n.uallv  outlasts  the  time  occupied  by  the  hrst  and  scnond 

rire  in-fuur.  the  friction  i.  single;  more  fre.iuently  it  ap- 
::;"  to  e  t  ;;  e  n  c  a^ictlr-a  sort  of  canter  rhythm.  The  sounds  ha^. 
Tp^    i  >•     ullbing,  grating  cpiality,  characteristic  when  once  recogmzed 

:i-tr;tf:::^kS^ 

St     4ac  s  and  adjacent  portions  of  the  sternum.    There  are  instanc  . 
In  wh    h  tl  e  friction    s  most  marked  at  the  base,  over  the  aorta,  and  a 

T  "  ™::;tt:.s;i  ::zi!:,.x::z.  :!z.r^r-;z 

en  "7r?lrv  p.ri,,„,li.b.  tor  the  fiction  „,,„„1.  ^^^  ^^'Zlo^ 
mT    The  constant  ckivactc-  of  the  aortic  murmur,  the  d.reet.on  of  trans 


in  the  mcslios 
it  niUL'h  seruuij 

n'icarditis,  like 
It'ss  ^;()llght  I'or 
le  po^^t-luovtom 
isencc  luis  been 

his  form  rarely 
;(.',  and  may  bo 
|)h()id  cartilage, 
listressiiig  char- 
not  always  easy 
,  and  how  much 
:ceeding  10'^. o°. 

reveal  the  prcs- 
roughcned  peri- 
ht  veiilricle.     It 
1  auscultation  is 
-}  the  movement 
most  distinctive 
i)le  and  diastole; 
,  and  the  to-and- 
lirst  and  second 
veciuently  it  aj)- 
The  sounds  have 
once  recognized, 
[imes    instead    of 
—the  new-leather 
:  superficial,  very 

I  the  stethoscope, 
art  which  is  most 
n  the  fourtli  and 
here  arc  instances 
the  aorta,  and  at 
,•  it  is  best  heard 
narrow  area,  or  it 

arc,  however,  no 
ir.  An  important 
(piality;  they  may 

II  of  intensity  will 

rn\ining  the  pres- 

di^tin(•tive.     The 

'loscly  the  to-and- 

■h  this  mistake  was 

direction  of  trans- 


PEllK'AUDITIS. 


<;oi 


mission,  the  phenomena  in  the  arteries,  and  tiie  associated  conditions  of 
the  disease  should  he  sullicient  to  prevent  this  error. 

1  iiave  never  known  an  instance  in  which  pericarditis  was  mistaken  for 
acute  endocarditis,  tliougii  writers  refer  to  siicli,  and  give  tlie  (lin'erential 
diagnosis  in  the  two  all'ections.  The  only  possiijle  mistake  couhl  he  made 
in  those  rare  instaiues  of  single  soft,  systolic,  pericardial  friction. 

J'Iciiru-pcriccirdial  f  rid  am  is  very  common,  and  may  be  as.sociate<l  witli 
en(h»-pericarditis,  jiarticularly  in  cases  of  iileuro-pneunionia.  It  is  fre- 
quent, too,  in  i)lithisis.  It  is  best  heard  over  the  left  border  (jf  tiiu  lieart, 
ami  is  imieii  alfectcd  by  the  respiratory  movement.  Holding  the  breatii 
or  taking  a  dee])  inspiration  may  annihilate  it.  The  rhythm  is  nut  the  sim- 
I)le  to-and-fro  diastolic  and  systolic,  but  the  resjiiratory  rJiyihm  is  super- 
added, usually  intensifying  the  inurniur  during  expiration  and  les.~eniiig 
it  on  inspiration.  In  phthisis  there  are  instances  in  whicji,  with  the  fric- 
tion, a  loud  .systolic  click  is  heard,  due  to  tlic  comj.rer.sion  of  a  thin  layer 
of  lung  and  the  exiiulsiou  of  a  bubble  of  air  from  a  small  softening  focus 
or  from  a  bronchus. 

And,  lastly,  it  is  not  very  uncommon,  in  the  rcgidii  of  the  ajjcx  beat,  to 
hear  a  series  of  fine  crepitant  sounds,  systolic  in  time,  often  very  distinct, 
suggestive  of  ])ericardial  adhesions,  but  heard  too  frequently  for  this  cause.' 

Course  and  Tcnnin(iti.jn.—H[m])\(i  fil)rinous  j.ericarditis  never  kills,  but 
it  occurs  so  often  in  connection  with  serious  all'ections  that  we  have' fre- 
quent opportunities  to  see  all  stages  of  its  j.rogress.  In  the  majoritv  of 
cases  the  jnllammation  sul^sidcs  and  the  thin  fibrinous  lamimc  gradually 
l.ccome  converted  into  connective  tissue,  wliicli  unites  the  ])cricardial  leavt^ 
firmly  together.  In  other  instances  the  inilammation  progresses,  with  in- 
crease of  tlie  exudation,  and  the  condition  is  changed  from  a  '•  dry  "  to  a 
'•  moist  "  pericarditis,  or  the  pericarditis  with  effusion. 

In  a  few  instances— probably  always  tuberculous— the  simi.le  ]daslic 
pericarditis  becomes  chronic,  and  great  thickening  of  botli  visceral  and 
jiarietal  layers  is  gradually  induced. 

Pericarditis  with  Eflfusion.— Though  commonly  a  direct  sequence  of 
the  dry  or  ].lastic  ].ericarditi.«,  of  which  it  is  sometimes  called  the  second 
stage,  t^his  lorm  presents  special  features  and  deserves  separate  considera- 
tion. It  IS  found  most  frequently  in  association  with  acute  rheumatism, 
tuberculosis,  and  septicaemia,  and  sets  in  usually  with  the  symptoms  above 
dcscrihc.l,  namely,  pra^'ordial  pain,  with  slight  fever  or  a  distinct  chill 

In  children  the  disease  may,  like  pleurisy,  come  on  without  local  symp- 
toms and.  after  a  week  or  two  of  failing  health,  slight  fever,  shortness  of 
breath,  and  increasing  pallor,  the  physician  mav  find,  to  his  astonishment 
signs  of  most  extensive  pericardial  effusion.  These  latent  causes  arc  often 
tuherculous.  ^\ .  Kwart  has  called  special  attention  to  latent  and  ephemeral 
l)ericardial  effusions,  which  he  thinks  are  often  of  short  duration  and  of 
nu.derate  size,  with  an  absence  of  the  painful  features  of  pericarditis  The 
effusion  may  be  sero-fibrinous.  hn^morrhagic,  or  purulent.  The  amount 
vanes  from  200  or  300  cc.  to  2  litres.  In  the  cases  of  scro-fibrinous  exuda- 
tion the  pericardial  membranes  arc  covered  with  thick,  ercamv  fibrin,  which 


I 


693 


DISEASES  OF  THE  CIUCULATORY  SYSTEM. 


inav  bo  in  ri.!-.'.^  or  l,on..vc.nnl.f.l,  nv  may  i-ir^ent  long,  villous  extensions. 
The  varietal  layer  inav  lie  several  n.iUinietres  in  thiekness  an-l  niay  iorm 
a  linn,  leathery  inenilM-ane.  The  Invinorrhagie  exudation  is  usua  ly  associ- 
ated with  tuherenlnns.  or  with  caneer..us  i.ericarditis,  or  with  the  (lisease 
in  the  a-ed  The  Ivniph  is  less  al.iuulant,  but  both  surfaces  are  injected 
and  ol'ttm  show  nun.erous  lueni.irrhages.  Thick,  cur.ly  masses  ol  lympii 
are  usnallv  f.nmd  in  the  depen.lent  part  of  the  sac.  In  the  purulent  ellu- 
.ion  the  fluid  has  a  creamy  consistency,  i-articularly  ni  tuberculosis.  In 
many  eases  the  etVusion  is  really  scro-purulent,  a  thin,  turlnd  exudation  cou- 
taininir  ilocculi  of  lilirin.  . 

TlR.  pericardial  lavi-rs  arc  greatly  thickened  and  covered  with  fibrin. 
When  the  iluid  is  pus,  they  present  a  grayish,  rough  granular  surface. 
Sometimes  there  are  distinct  er-^sions  on  tlie  visceral  membrane,  ihe 
heart  muscle  in  these  cases  becomes  involved  to  a  greater  or  less  extent, 
and  on  s(rtion,  the  tissue,  for  a  dei)th  of  from  2  to  3  mm.,  is  pale  and 
turbid,  and  slmws  evidence  of  fatty  and  granular  cl.ange  hndocarditi» 
cMH'xisIs  frequently,  but  rarely  results  fnnii  the  extension  of  the  mllamnui- 

tion  throu-:li  the  wall  of  the  heart.  ,  ^        i 

Symptoms.— I'.ven  with  copious  elTusion  the  onset  and  course  may 
be  so  insidious  that  no  susjiicion  of  the  true  nature  of  the  disease  is  aroused 
\s  in  the  simple  ].ericarditis,  pain  may  be  present,  either  sharp  and 
stabbing  or  as  a  sense  of  distress  and  discomfort  in  the  cardiac  region  It 
i<  more  frcnient  with  elTusion  than  in  the  plastic  form.  Pressure  at  the 
lower  end  of  the  sternum  usually  aggravates  it.  Dyspnea  is  a  common 
and  important  svmptom.  <me  which,  perhaps,  more  than  any  other,  excites 
snspieion  of  graVe  disorder  and  leads  to  careful  examination  of  heart  and 
h,n-s  The  patient  is  restless,  lies  upon  the  left  side  or,  as  the  eifusion 
iiKiva^es,  sits  np  in  bed.  Associated  with  the  dyspnoea  is  in  many  cases  a 
IKH-uliarlv  duskv.  anxious  countenance.  The  ].ulse  is  rapid,  small,  some- 
Ji.no.  re.n.lar.  and  may  present  the  characters  known  as  puhus  parado.vii>,, 

in  which  during  each' inspiration  the  I'^l^^'-^^f  ^^^^^^V"'?' ^I'lnlal 
l.wt  Tiu«se  svmi.toms  are  due,  in  great  part,  to  the  direct  mechanical 
oifect  of  the  iluid  within  the  pericardium  which  embarrasses  the  heart, 
action  Other  pressure  elTeets  are  distention  of  the  veins  of  the  neck, 
dvsligia.  which  mav  be  a  marked  symptom,  and  irritative  cough  from 
cmnpre^>i.>n  of  the  trachea.  Aphonia  is  not  nncommon  owing  Jo  C'ompre.- 
sion  or  irritation  of  the  recurrent  laryngeal  as  it  winds  round  the  aoiia 
\nother  important  ].ressnre  elToct  is  exercised  npon  the  left  hing  n 
massive  elTulion  the'pericardial  sac  occnpies  such  a  ^■•\-^%VOvinmo^^^^J^ 
Intero-lateral  re.ion  of  the  left  side  that  the  condition  has  frequently  been 

is    ken  for  pleurisv.    Even  in  moderate  grades  the  left  lung  is  somew b 
"on.pressed.     This   is   an   additional   element   in   the   production   of   the 

^''On^t  restlessness,  insomnia,  and  in  the  later  stages  low-  deliriiirn  and 
coma  are  svmptoms  in  the  more  severe  cases.  Delirium  and  marked  cere- 
bra!  svmpioml  are  associated  with  the  hyperpyrexia  of  rheumatic  ease  . 
Init  apart  from  the  ordinary  d.dirium  there  may  be  peculiar  mental  symp- 
tom^.   The  patient  may  become  melancholic  and  show  snicidal  tendencies. 


I^Mi^^MM 


PEUICAUBITIS. 


693 


us  extensions, 
md  nmy  form 
usually  associ- 
tli  the  (lii-ease 
.'ri  are  injected 
sses  of  lynii)ii 
purulent  ell'u- 
bereulosis.  In 
exudation  cou- 

hI  with  fibrin, 
mular  surface, 
'nibrane.  The 
or  less  extent, 
n.,  is  pale  and 
Endocarditis 
'  the  inilanmia- 

nd  course  may 
jcase  is  aroused, 
ther  sharp  and 
iliac  region.  It 
Pressure  at  the 
a  is  a  common 
ly  other,  excites 
jn  of  heart  and 

as  the  eifusion 
in  many  cases  a 
id,  small,  some- 
ihus  paradoxus, 
very  weak  or  is 
rect  mechanical 
isses  the  heart's 
ns  of  the  neck, 

ive  cough  from 
i'ing  to  compres- 
ronnd  the  aorta. 
!  left  lung.  In 
3  portion  of  the 

frequently  been 
uug  is  somewhat 
oduction   of   the 

ow  delirium  and 
nd  marked  core- 
rheumatic  cases, 
iar  mental  symp- 
icidal  tendencies. 


Ju  nther  cases  the  condition  rcsenililcs  closely  delirium  tri'uuns.  Sibson, 
who  has  specially  describt'd  this  condition,  states  that  the  niajoiity  of  such 
cases  recover.  Chorea  may  also  occur,  as  was  jjointed  out  iiy  IWigJit.  Kpi- 
lejisy  is  a  rare  complication  which  has  occurred  during  paracentesis. 

Physical  Signs. — InspcrUun. — In  children  the  [UU'cordia  bulges  and 
with  copious  exudation  the  autero-lateral  region  of  the  left  chest  becomes 
enlargeil.  'i'he  intercostal  s|)aces  are  prominent  and  there  may  be  marked 
tedema  of  the  wall.  The  epigastrium  may  be  more  prominent.  Perfora- 
tion externally  thnmgli  a  sjiace  is  very  rare.  Owing  to  the  comiire.-sion 
of  the  lung,  the  ex|)ansion  of  the  left  side  is  greatly  diminished.  The  dia- 
phragm and  left  lobe  of  the  liver  may  be  pushed  ilown  and  may  proiUue 
a  distinct  |iroiniiu'nce  in  the  epigastric  region. 

J'lilpitlioii. — A  gradual  diminution  aiul  iiiial  obliteration  of  the  i^ardiae 
shock  is  a  striking  feature  in  [)rogressive  elfusion.  The  position  of  the 
apex  licat  is  not  constant.  In  large  effusions  it  is  usually  not  felt.  In  i-hil- 
dren  as  the  fluid  collects  the  pulsation  may  l)e  best  seen  in  the  fourth  s[)ace, 
but  this  may  not  be  the  apex  itself.  Ewart  maintains  that  the  position  of 
the  apex  beat  is  unaltered,  or  even  dejiressed.  The  jiericardial  friction  may 
lessen  with  the  elfusion,  though  it  often  persists  at  the  base  when  no  longer 
palpable  over  the  right  ventricle,  or  may  be  felt  in  the  erect  ami  not  in  the 
recumbent  posture.    Fluctuation  can  rarely,  if  ever,  be  detected. 

rcirussion  gives  most  imi)ortant  indications.  The  gradual  distention 
of  the  ])ericardial  sac  pushes  aside  the  margins  of  the  lungs  so  that  a  large 
area  comes  in  contact  with  the  t'hest  wall  and  gives  a  greatly  increased 
percussion  dulness.  The  form  of  this  dulness  is  irregularly  pear-shaped; 
the  base  or  broad  surface  directed  downward  and  the  stem  or  ajiex  directed 
u])ward  toward  the  manubrium.  A  valuable  sign,  to  which  Kotch  called 
attention,  is  the  absence  of  resonance  in  the  right  fifth  intercostal  space. 
In  the  left  infrascapular  area  there  may  be  a  patch  of  dimini.-hed  resonance 
or  even  flatness  (Ewart). 

Aiisrullalioii. — The  friction  sound  heard  in  the  early  stages  nuiy  dis- 
appear when  the  elTusion  is  copious,  but  often  persists  at  the  base  or  at 
the  limited  area  of  the  apex.  It  may  be  audible  in  the  erect  and  not  in 
the  recundient  ])o,>iture.  With  the  absorption  of  the  lliud  the  friction  re- 
turns. One  of  the  most  imi)ortant  signs  is  the  gradual  weakening  of  the 
heart-souiuls,  which  with  the  increase  in  the  eil'usion  may  become  so  muf- 
fled and  indistinct  as  to  be  scarcely  audible.  The  heart's  action  is  usually 
increased  and  the  rhythm  disturbed.  Occasionally  a  systolic  endocardial 
murmur  is  heard.  Early  and  persistent  accentuation  of  the  puhnonary 
second  sound  may  be  present  (Warthin). 

Important  accessory  signs  in  large  effusion  are  due  to  ]U"essure  on  the 
left  lung.  The  antero-lateral  margin  of  the  lower  lobe  is  pushed  aside  and 
in  sonic  instances  compressed,  so  that  percussion  in  the  axillary  region, 
in  and  just  below  the  transverse  nipple  line,  gives  a  modified  percussion 
note,  usually  a  flat  tymi)any.  Variations  in  the  position  of  the  patient 
may  change  materially  this  modified  percussion  area,  over  which  (Ui  auscul- 
tation there  is  either  feeble  or  tubular  breathing. 

Course. — Cases  vary  extremely  in  the  rajiidity  with  which  the  effusion 


I'' 


A 


094 


DISEASIiS  OF  THE  CIRCULATORY  SYSTEM. 


Mkos  pliK-c.     In  ovorv  instan.T,  whrn  n  poricanlii.l  fiictinn  inunuur  lias 
Loon  (lotcotocl,  ll.o  pn.otiticnor  should    i.nnio.liatoly  oullino   ^vith   care- 
„<in.'  the  aniline  porcil  or  nitrate  of  silver-the  upper  and  lateral  l.nuts 
of  canliae  dniness,  sinee  he  will  in  this  way  have  certain  positive  guides  in 
detoruiining  the  rate  and  grade  o£  the  elf usion.     In  many  instances    he 
exudation  is  slight  in  amount,  reaches  a  maximum  witiun  lorty-cnght  lioui., 
and  then  gradually  sul.sidos.    In  other  instances  the  accumulation  is  more 
.rvadiful  and  progressive,  increasing  for  several  weeks         ..  such  eases  the 
term  clironic  has  l.oen  ai.,.liod.     The  rapidity  with  which  a  sero-libnnou 
ofl-u.ion  may  he  ahsorhed  is  surprising.     The  possibility  ol  the  absorption 
of  a  purulent  exudate  is  shown  by  the  cases  in  which  the  pencardu.ni  con- 
tain^^  semi-solid  gravish  masses  in  all  stages  of  calc.lication.     ^\  ith  sero- 
lil,rinous  eifiision,  if  moderate  in  amount,  recovery  is  the  rule    with  in- 
evitable union,  however,  of  the  pericanlial  layers.     In  some  ot  the  septic 
ca«es  there  is  a  rapid  forination  of  pus  and  a  fatal  result  may  fol  ow  in  three 
or  four  davs.    :^lore  conimontv,  when  death  occurs  with  large  effusion,  it  is 
not  until  t'he  second  or  third  week  and  takes  place  by  gradual  asthenia. 

Prognosis.— In  the  sero-fibrinous  elTiisions  the  outlook  is  good,  and 
a  lar^e  majoritv  of  all  the  rheumatic  cases  recover.  The  inirulent  elTusions 
arc,  of  coursc'more  dangerous;  the  septic  cases  are  usually  fatal,  and  re- 
covery is  rare  in  the  slow,  insidious  tuberculous  forms 

Diagnosis. -Probably  no  serious  disease  is  so  frequently  overlooked 
bv  the  practitioner,  rost-morteni  experience  shows  how  often  pericarditis 
is'  not  recosuized,  or  goes  on  to  resolution  and  adhesion  without  a  trac  ing 
notice.  In  a  case  of  rheumatism,  watched  from  the  outset,  with  the  atten- 
tion directed  daily  to  the  heart,  it  is  one  of  the  simplest  ol  diseases  o  diag- 
,,ose;  but  when  one  is  called  to  a  case  for  the  first  tunc  and  finds  perhaps  a 
increased  area  of  ,,nccordial  dulness,  it  is  often  very  hard  to  determine  \Mth 
certainty  whether  or  not  elVusion  is  present. 

The'dillieultv  usuallv  lies  in  distinguishing  l)e(ween  dilatation  of  tic 
heart  and  pericardial  eifusion.  Although  the  diflercntial  signs  are  simple 
oiiou.-h  on  paper,  it  is  not,unously  difficult  in  certain  cases,  particularly  in 
sloun-ersons:  to  say  which  of  the  conditions  exists.     The  points  which 

deserve  attention  are:  .  .•     i    i     • 

(a)  The  character  of  the  impulse,  which  in  dilatation,  particularly  m 

thin-chested  i)eople,  is  commonly  visible  and  wavy.  ,     ,  ,    •     i-i 

ih)  The  shock  of  the  cardiac  sounds  is  more  distmctlv  palpable  in  d.la- 

^"*'(")  The  area  of  dulness  in  dilatation  rarely  has  a  triangular  foruj: 
nor  d..es  it,  exce].t  in  cases  of  mitral  stenosis,  reach  so  high  along  the  left 
.ternal  marunn  ov  so  low  in  the  fifth  and  sixth  interspaces  ../,.»/  r,s,hh  or 
'palpahle  impulse.  An  upper  limit  of  dulness  shifting  with  change  of  posi- 
tion speaks  strongly  for  efl'usion.  v.1v„l.ir 
01)  Tn  dilatation  the  heart-sounds  are  clearer,  often  sharp,  ^alullaT 
or  fo-tal  in  character;    whereas  in   eifusion  the  sounds  are  distant  and 

"'"(.o'Earelv  in  dilatation  is  the  distention  sumdent  to  compress  the  lung 
and  produce  the  tympanitic  ikUc  in  the  axillary  region. 


PERICARDITIS. 


695 


imumur  has 

with  cure — 
hilenil  hmits 
tivu  guides  ill 
iii:-lauces  the 
y-cight  hours, 
liitioii  is  nioro 
uc'h  oases  the 

sero-libriuous 
lie  al)S(iri)tion 
ieai'diuui  eou- 
,.  With  sero- 
rule,  with  in- 
'  of  the  septic 
foUow  in  three 
?  efl'usion,  it  is 
.  asthenia, 
k  is  good,  and 
ulent  elTusions 

fatal,  and  re- 
dly overlooked 
ten  pericarditis 
liout  attracting 
with  the  atten- 
iseases  to  diag- 
iiids  perhaps  an 
determine  witli 

ilatation  of  the 

igns  are  simi)le 

particularly  in 

e  points  which 

particularly  in 

lalpahle  in  dila- 

riangular  fomi: 

h  along  the  left 

cHhout  visible  or 

change  of  posi- 

sharp,  valvular, 
are  distant  and 

impress  the  lung 


The  number  of  excellent  observers  who  liave  acknowledged  that  tliev 
have  failed  sometimes  to  discriminate  between  tiicsc  two  conditiniis,  luid 
•who  have  indeed  jierformed  paracentesis  cordis  instead  of  [laraccnte.-is  prri- 
canlii,  is  j)erliaps  tiie  best  connncnt  on  the  dilbcultics. 

Ikhassive  (U  to  2  litre)  exudations  luive  been  coni'oundi'd  with  a  pleural 
cfTusion.  On  more  than  one  occasion  the  ])ericardium  has  l)een  ta^lped 
under  the  impression  that  the  exudate  was  jjleuritie.  The  Hat  tympany 
in  the  infrascai>ular  region,  tlie  absence  of  well-dellned  moval)lo  dulness, 
and  the  feel)le,  mulllcd  sounds  are  indicative  ])oints.  Jf  tlu'  case  has  been 
followed  from  day  to  day  there  is  rarely  mucii  dilliculty;  but  it  is  dill'ercnt 
when  a  case  ])rcsents  a  large  area  of  dulness  in  the  auteri)-lateral  region 
of  the  left  chest,  and  there  is  no  to-and-fro  jiericardia!  friction  murmur. 
Many  of  the  cases  have  been  regarded  as  encapsulat  m1  ph-iiral  (•tl'usious. 

The  nature  of  the  fluid  cannot  positively  be  determined  without  aspira- 
tion; but  a  fairly  accurate  o])inion  can  be  fornu'd  from  tiie  nature  of  the 
prinuiry  disease  and  the  general  coiulition  of  the  patient.  Jn  rheumatic 
cases  the  exudation  is  usually  sero-iibrinous;  in  .sejitic  r  ul  tuberculous 
cases  it  is  often  purulent  from  the  outset;  in  senile,  nephritic,  and  tuber- 
culous cases  the  exudation  is  sometimes  luvmorrhagic. 

Treatment.— The  patient  should  have  absolute  quiet,  mentally  and 
bodily,  so  as  to  reduce  to  a  minimum  the  heart's  action.  Drugs  given  for 
this  purpose,  such  as  aconite  or  digitalis,  arc  of  dmditful  utility.  Local 
bloodletting  l)y  cupping  or  leeches  is  certainly  advantageous  in  robust 
subjects,  particularly  in  the  cases  of  extension  in  pleuro-pneumonia.  The 
ice-bag  is  of  great  value.  It  may  be  aj)plicd  to  the  ])rax'ordia  at  first  for  an 
hour  or  more  at  a  time,  and  then  continuously.  It  reduces  the  frecpu'ucy 
of  the  heart's  action  and  seems  to  retard  the  i)rogress  of  an  ell'usion.  Blis- 
ters are  not  indicated  in  the  early  stage. 

When  effusion  is  present,  the  following  measures  to  jiroiiiotc  absorption 
may  be  adopted:  Blisters  to  the  pra^cordia,  a  practice  not  so  much  in  vogue 
now  as  formerly.  It  is  surprising,  however,  in  some  instances,  how  (piickly 
an  eilusion  will  subside  on  their  ajjidication.  If  the  patient's  strength  is 
good,  a  purge  every  other  morning  may  be  given.  The  diet  should  Ije  light, 
dry,  and  nutritious.  In  cases  in  which  the  ])ulse  is  strong  and  the  consti- 
tutional disturbance  not  great,  lide  of  potassium  may  be  of  service,  and 
the  action  of  the  kidneys  may  be  jn'omoted  by  the  infusion  of  digitalis  and 
acetate  of  potash. 

When  the  effusion  is  large,  as  soon  as  signs  of  serious  impairment  of 
t)ie  heart  occur,  as  iiulicated  by  dys]ma\n.  small  rapid  i)ulse,  dusky,  anxious 
countenance,  surgical  measures  should  be  resorted  to,  and  jiaracentcsis,  or 
incision  of  the  pericardium,  at  once  be  ])erformed.  With  the  sero-fibrinoiis 
exudate,  such  as  commonly  occurs  after  rheumatism,  aspiration  is  suili- 
cient;  but  when  the  exudate  is  purulent,  the  pericardium  should  be  freely 
incised  and  freely  drained.  The  i)uucture  may  be  nuide  in  the  fourth  inter- 
space, either  at  the  left  sternal  margin  or  2..")  cm.  (an  iiu'b)  from  it.  If 
made  in  the  fifth  interspace  it  is  well  to  jiuncture  an  inch  and  a  half  from 
the  left  sternal  margin.  In  large  eil'usions  the  ])ericardium  can  also  be 
rcadilv  reached  without  danger  by  thrusting  the  needle  upward  and  back- 


(596  DISEASES  OP  THE  ClllCULATOliY  SYSTEM. 

v-u.!  cln^o  to  the  costal  ma.-in  in  tl>c  left  costo-xii-hnul  an^lo  The  rc- 
lu  s  o  ,1  u..nt.sis  ot  the  ^n.ardnnn  have  .o  far  nut  he.n  satisfactory. 
^V  h  an"  IkT  ,.,.cration  in  uuuw  instances  an.l  a  n>orc  nuhcal  one  m 
Ota  s^i  ee  incilion  and  not  aspiration  ^vhcn  the  iUnd  is  purulent-tho 
;  '  ;;ta  e  of  recovenes  will  he  ,reatiy  .ncreascjl.  ^l]^^^:;^^;^^Z 
live  pericarditis  treated  hy  incision  lo  recovered  and  .'U  died  (KoLul.,  Am. 

'"'■"ctoii^'Sesi^rPeSanlitis  i-UlhraU   /'r,-uan/un.).-Two   groups 

of  cases  may  l)e  recognized:  ^       •       vii       .        Tl,i  •  i*  -woni- 

(„)  Simple  adhesion  of  tlie  pen-  and  ep.cardial  layers      Ihi.  i.  a  con 
n.on    e.,uem.e  of  pericarditis,  and  is  frequently  n-.t  .Uh  post  nu>r  em    s 
Z  accidental  lesion.     It  is  not  necessarily  assocmted  ^nth  ^^^-^^l 
the  function  of  the  heart,  and  in  a  large  proportion  of  the  ca.i.  thcu.  i. 
neitlier  dihitation  nor  hypertrophy. 

(6)  Adherent  pericardunn  with  chronic  n>ed>astnut.s  and  u.non  of  tie 
outLT  laver  of  the  pericardium  to  the  pleura  and  to  the  chest  walls       Lhis 
on    i  u    s  ..ne  of  Ihe  most  serious  forms  of  cardiac  disea^,  V-^^^^^fy^ 
V  life,  and  mav  lead  to  an  extren.e  grade  of  hypertrophy  and  drlatatioi 
rl.e  heart.     Even  with  partial  adhesion  hetween  the  ep.cardium  and 
or    mlium  there  n>av  he  enorn.ous  hypertrophy  under  the  conditions  just 
tU    ed.     The  .y.niUo.ns  of  adherent  pericardium  are  nncerta.n  and  ,n- 
S  In  the  second  group  the  features  are  those  of  hypertrophy  and 

d  1  tat  mi  of  the  heart,  later  cardiac  insulliciency.  and  ni  a  few  ins  ances 
^  o'xtension  of  the  mediastinitis  to  the  peritoneum,  causnig  chn.n  c 
ix-liferative    peritonitis,    with    perihepatitis    and    pensplen.t.s.*      Sudden 
I,;,;;;,'  luay  ociu-  after  an  unusual  exertion  or  during  parturition  (Uejnold. 

^^'^Tho' following  are  important  points  in  the  'diagnosis:  /..F^^o^.-A 
iinio  V  of  the  sFgns  of  value  come  under  this  lieading.  (a)  'I  he  pra-corduv 
i  Tm  in  n  and  there  mav  he  marked  asymmetry,  owing  to  the  enormous 
1.  piomuKiu  a.  ^_^^,^^.,^^  nnpulso  is  greatly 

•  ; S':^:^  m;:v':^;:^ti.!ui  he  seen  ^om  the  third  to  the  sixth  in^r 
^^,  and  in  extreme  cases  from  the  right  parasternal  hue  ^ -ui.^  ^ 
eft  n  ni.le      (c)  The  character  of  the  cardiac  impulse.     It  is  nndulatory, 
vv       d  hi  t  e  apex  region  there  is  marked  systolic  retraction.     (,/)  Diu- 
;    ■  1.  n.    ,e,  •       J  W   r,roadl,ent  has  called  attention  to  a  very  vahi- 

:;  rS^nt  Z;  t  ^,^ic!;;d!mn.     AVhen  the  heart  is  adherent  over  a  largo 
't    f    he    lapliragm  there  is  with  each  ptdsation  a  ^Pt"l-tiig,  winch 
2v  t  ^.mnumica^^d  through  the  diaphragm  to  the  P-!^^  "^  ^^^^^^^ 
„t  on  the  wall,  causing  a  visihle  syst..lic  tuggn,g._    ^  ^   ^^ j^^^    :^^ 
•ecooni/ed  in  the  region  of  the  seventh  or  eighth  rihs  in  the  left  P;"'!^'^'";^ 
i;^l       Dr.  r.roadhent  called  attention  to  the  fact  that  it  was  fre^iuent  y 
i'     .n  on  the  left  side  hehind,  hetween  the  e  eventh  and  twei  - 

Wi  h  each  svstole  there  n,ay  he  here  a  distinct,  visihle  retraction  of  the  chest 
111  This'is  a  very  valuahle  and  .luite  common  sign  Sir  ^^  dhan  B  oad- 
W  cal  littentioif  also  to  the  fact  that  owing  to  the  attachment  of  the 


*  For  illustrative  cases  see  Arch,  of  Pediatrics,  1806. 


-lo.  The  ru- 
11  sitisfuetory. 
•udiiiil  uno  ill 
puruk'iil — the 
es  oi  suppura- 
(Koherts,  Am. 

—Two   grou[)S 

This  is  a  coiii- 

o.st  murleiu  as 

disturbance  in 

cases  there  is 

1  union  of  the 
^t  walls.  This 
particularly  in 
and  dilatation 
picardiuin  and 
conditions  Just 
certain  and  in- 
vpertrophy  and 
:i  few  instances 
causing  chronic 
litis.*  Sudden 
•ition  (Reynolds 

Inspection. — A 
)  The  prsecordia 
[o  the  enormous 
ipulse  is  greatly 
the  sixth  intcr- 
,e  to  out.-'  '"  the 
t  is  nndulatory, 
iction.     ((/)  Dia- 
1  to  a  very  valu- 
rent  over  a  large 
tolic  tug,  which 
Its  of  its  attach- 
is  has  long  been 
e  left  parasternal 
it  was  fre<iuently 
iind  twelt  h  ribs, 
etion  of  the  chest 
r  William  Broad- 
ttachment  of  the 


[)6. 


OTIIEK  APFECTIOXS  OP  THE  PERlC.\RDirM. 


(197 


heart  to  the  ceutnil  temldn  of  the  dia]>hriigm  this  p;irt  docs  imt  descend 
with  inspiration,  iluring  which  act  tiicre  is  not  tlie  visible  ninveinciit  in  the 
epigastrium,  {r)  Diastolic  collajise  of  the  cervical  veins,  the  so-caUcd  Fried- 
reich's  sign.    Tiiis  is  not  oi'  much  moment. 

I'alpnHiin. — The  n\)v\  beat  is  (i\cd.  and  turning  the  patient  on  the  left 
side  does  not  alter  its  position.  This  1  have  found,  however,  somewhat  un- 
certain. On  i>lacing  the  liand  over  the  licart  there  is  felt  a  diastolic  shock 
or  rcliound,  wliich  sonn'  have  regarded  as  the  most  rclialilc  of  all  signs  of  ad- 
herent pericardium. 

l'rrntssinii.—'V\\v  area  of  cardiac  duhu'ss  is  usually  much  iiurea-cd.  In 
a  majority  of  instances  there  are  adiiesioiis  between  tlie  pleura  aud  ihe  peri- 
cardium, and  the  limit  of  cai'diac  dulnc'S  aliove  and  to  the  left  may  be 
iixed  and  is  uninllueiiced  l)y  ileep  inspiratimi.  Tliis,  too,  is  an  uncertain 
sign,  inasmuch  as  there  may  lie  close  adhesions  l)i'twcen  the  pleura  and  the 
pericardium  and  between  tlie  jilciira  and  the  chest  wall,  which  at  the  same 
time  allow  a  very  considerable  degree  of  mobility  to  the  edge  of  tiie  lung. 

Au.sniJIiiliiin. — The  phenomena  are  variable  and  uncertain.  In  the 
cases  in  children  with  a  history  of  rheumatism,  endocarditis  has  usually 
been  present.  Even  in  the  absence  of  chronic  endocarditis,  when  the  dila- 
tation reaches  a  certain  grade  there  are  murmurs  of  relative  insuincieiicy, 
which,  as  in  one  case  1  have  recorded,  may  be  present  not  only  at  the  mitral 
but  also  at  the  tricuspid  and  puliiKUiary  orifices.  Hale  White  has  called 
attcTition  to  the  fact  tliat  tliero  may  l)e  a  well-marked  ])resystolic  murmur 
in  connection  with  adherent  pericardium.  This  was  present  in  one  of  my 
cases. 

The  ])ulsus  jiaradoxus,  in  which  during  inspiration  the  ]iulsc-wavc  is 
small  and  feelile,  is  sometimes  ])resent,  but  it  is  not  a  diagnostic  sign  of 
cither  simple  pericardial  adhesion  or  of  the  cicatricial  mediastino-peri- 
carditis. 

In  children,  chronic  adhesive  ])ericarditis  and  mediastinitis  may  be  asso- 
ciated with,  proliferative  peritonitis,  ])erihepatitis,  and  perisplenitis,  in 
which  condition  ascites  may  recur  for  months,  or  even  for  years. 


II.    OTHER   AFFECTIONS   OF   THE    PERICARDIUM. 

(1)  Hydropericardiura. — Xaturally  there  are  in  the  jicricardial  sac  a  few 
cubic  ceiilimetros  of  clear,  citron-colored  fluid,  which  probalily  represents 
a  ]iost-mortem  transudate.  In  certain  conditions  during  life  there  may  bo 
a  large  secretion  of  serum  forming  what  is  known  as  dro]isy  of  the  peri- 
cardium. It  occurs  usually  in  connection  with  general  drojisy.  due  to  kid- 
ney or  heart  disease;  more  commonly  the  former.  It  rarely  of  itself  jiroves 
fatal,  though  when  the  effusion  is  excessive  it  adds  to  the  embarrassment  of 
the  heart  and  the  lungs,  particularly  when  the  pleural  cavities  are  the  seat 
of  similar  exudation.  There  are  rar(>  instances  in  which  cfVusion  into  the 
liericardium  occurs  after  scarlet  fever  with  few.  if  any.  other  dro]isical 
symptoms.  The  physical  signs  are  those  already  referred  to  in  connection 
with  pericarditis  with  efl'usion.     It  is  frequently  overlooked. 


I  ', 


Ji 


1 


G93 


DISHASKS  OP  THE  CIRCULATORY  SYSTEM. 


T„  rare  rii^.s  tlu>  s.-nnn  lias  a  inill<y  clKiractn— (•l.yl..-i.eT.canlmm. 

(V)  Hffiino-pericardium.-Tlns  fon.lilinnj.y  no  means  .incnn,m..n,  i«  met 
^vith  n  ancurLu  of  the  iir.t  part  of  ih.  aorta,  of  tho  canhac  wall  or  ot  t lie 
:!:;•;  artenes,  and  in  ruplure  and  .ounds  of  the  lu.rt  ^-tl. ^.ud  y 
follows  before  there  is  tin.e  for  t!>e  prodvuUon  o  synu-lon  ^  fZ  Z 
th.se  of  rapid  heart-failure  due  to  eon.pression.  Partieularlj  i.  thib  the 
ie  in  aneLrisn.  In  rupture  of  the  heart  the  patient  n,ay  hve  for  many 
hours  or  even  days  with  symptoms  of  progressive  lieart-ladure,  dyspncoa, 
1111(1  (he  nhvsical  sijins  of  elVusion. 

\sal.'eadv  mentioned,  the  iniUunmatory  exudate  of  tuherele  or  cancer 
is  oi'le.i  hhuKl-stained.     The  same  is  true  of  the  elTusion  m  the  perieardilis 

of  J'.ri"ht*s  disease  and  of  old  people.  •       v  i       „ 

(:5fPneumo-pericardiuin.-tias  is  rarcdy  f.n.nd   in  the   pericardial  sac, 
and  is  due,  as  a  rule,  to  perforation  from  witlnuit,  as  m  the  ease  ol  stab 
wounds,  or  is  the  result  of  ,.erforati,m  from  the  lungs,  tvsophagus,  or  stom- 
•idi     IVrforation  from  a  tuberculous  cavity  is  a  not  uncommon  cause,    in 
those  cases,  forn.erlv  so  puzzling,  in  which  the  gas  is  i.resent  shortly  attcT 
death  (a  few  hours),' the  gas  bacillus  (//.  armonic.  capsulalus)  will  be  f.nmd 
In  a  case  at  the  IJoyal  Victoria  Hospital,  in  which  the  gas  bac.  Ins  was 
isolated,  the  diagnosis  was  made  during  life  (Nichols).    As  a  result  of  pe- 
foratioi,  acute  pericarditis  is  always  excited,  and  the  e   us.on  rapu  Iv   be- 
o      s  purulent.^     The  physical  signs  are  remarkable.     ^\  hen  the  el lusion 
is  copious  the  fluid  and  gas  together  give  a  movable  arc.i  .d  l-^;-  !     '^    " 
IH.SS  with  marked  tympany  in  the  region  of  the  gas.     (  n  "--^^f  ^  '^^ 
markable  c,,lashin-,  churning,  metallic  phenomena  arc  heard  w  th  fuction 
ib  V  feeble    distant  heart-sounds.     Death  follows  rapidly,  even  in 
, v-:ix  hours,  as  in  a  ease  (the  only  one  which  I  have  seen)  o    perforation 
''    K >  pericardium  in  cancer  of  the  stomach,     l^xcept  as  a  resu     of  .n^u^ 
the  condition  is  not  one  for  which  treatment  is  available.     In  a  ca.e  ot 
p;;f::"i.m  Jrom  without  with  signs  of  eirusion,  to  enlarge  the  wound  by 
free  incision  would  be  justiliable. 


II.    DISEASES  OF  THE  IIEAr.T. 

I.    ENDOCARDITIS. 

Tnnammation  of  the  lining  membrane  of  the  heart  is  usually  confined  to 
the  va    es  so  that  the  term  is  practically  Bynonymonsvvith  valvular  endo- 
ard  It  occurs  in  two  fon.^arvtr,  characterized  by  the  Fosonce  of 

v'^at  ons  with  loss  of  continuity  or  of  substance  in  the  vahe  tis  ues, 
^In.!;',  a  slow  sclerotic  change,  resulting  in  thickening,  puckering,  and  do- 
formitv.  _ 

ACI-TE   En'BOCAUDITIS. 

Thi«  occnr=;  in  rare  instance?  as  a  primary,  independent  affection;  but 
in  th  great  maioritv  of  eases  it  is  an  accident  in  various  infective  processes, 
so  that  in  reality  the  disease  does  not  constitute  an  etiological  entitv. 


'i-icanlium. 
•(iiiimon,  is  met 
•  Willi,  or  vi  the 
Duath  usually 
)ins  other  than 
irly  is  this  the 
V  live  for  many 
liliire,  dyspnuea, 

lien'le  or  cancer 
the  periearditis 

pericardial  sac, 
the  casic  of  !-tab 
phagus,  or  stom- 
uinon  canse.  In 
ent  shortly  after 
s)  will  he  found, 
gas  IjacilUis  was 
s  a  result  of  per- 
ision  rapidly  he- 
hen  the  elfusion 
f  percussion  did- 

auscultation.  re- 
ard  with  friction 

lapidly,  even  in 
LMi)  of  perforation 
I  result  of  injury, 
le.  In  a  case  of 
ge  the  wound  hy 


if?ually  confined  to 
ith  valvular  endo- 
)y  the  presence  of 
"tlie  valve  tissues; 
puckering,  and  dc- 


lent  affection;  hut 
infective  processes, 
igical  entity. 


ENDOCARDITIS. 


(100 


Tor  convenience  of  description  we  sjicak  of  a  siiniile  or  hcuign.  and  a 
malignanl  or  ulcerative  i-ndot  iirditis.  he;  ween  which,  hdwrver,  there  is  no 
essential  anatomical  diU'erciice.  as  all  gradations  can  he  traced,  and  they 
represent  hut  dilVerent  degrees  of  inteu.-ity  of  the  same  [irocess. 

Etiology. — Siiii/ilf  niihirdnlilis  does  imt  C(in>titute  a  disease  of  itself, 
hut  is  invariahly  fouiul  with  souh'  other  aU'eetion.  The  genera!  e\|)erieiue 
of  tile  profession  has  cunlirnu'd  tiie  original  ohservation  of  r.ouillaud  as  to 
the  frecjuency  of  association  of  simple  endocarditis  with  acute  aitieular 
rheuniatisui.  J'ossihiy  it  is  nothing  in  the  (li>ease  itself,  hut  simply  an 
altered  state  of  the  lluid  media — a  reduction  perha,  of  the  lethal  inllu- 
enees  which  they  normally  exert — permitting  the  invasion  of  the  hlood  hy 
certain  micro-organisms.  Tonsillitis,  which  in  some  forms  is  nganled  as 
a  rheumatic  atl'ection,  may  he  complicated  with  endocarditis.  Of  the  sjie- 
eific  diseases  of  childhood  it  is  not  uncommon  in  scarlet  fever,  \vliile  it  is 
rare  in  measles  and  chicken-pox.  In  diphtherir.  siniple  endocarditis  is  rare. 
In  small-pox  it  is  not  connuon.  In  typhoid  fever  1  have  met  with  it  twice 
in  8(1  autopsies. 

In  pneumonia  hoth  simple  and  nutlignant  endocarditis  are  common. 
In  lun  aulopsii-s  in  this  disease  made  at  the  Montreal  (Jeueral  Hospital  there 
were  -j  instances  of  the  I'ornu'r.  Acute  endocarditis  is  hy  no  means  rare  in 
phthisis.    1  have  met  with  it  in  Vi  eases  in  'U(>  jiost  niortems. 

In  chorea  simple  warty  vegetations  are  found  on  the  valves  in  a  large 
majority  of  all  fatal  cases,  in  &l  of  To  cases  collected  hy  nu'.  There  is  no 
disease  in  which,  post  nu>rtem.  acute  endocarditis  has  been  so  fre(|uently 
fouml.  And,  lastly,  simple  endocarditis  is  met  with  in  diseases  associated 
with  loss  of  ilesh  aiul  progressive  debility,  as  cancer,  and  such  disorders  as 
g(mt,  diabetes,  and  Bright's  disease. 

A  very  common  form  is  that  which  occurs  on  the  sclerotic  valves  in  old 
heart-disease — the  so-called  recurring  endocarditis. 

MttJiiimiiit  cnihicdrdilis  is  nu't  with:  (n)  .\s  a  primary  disease  of  the 
lining  membrane  of  the  heart  or  of  its  valves. 

(b)  As  a  secondary  affection  in  acute  rheumatism,  pneumonia,  and  in 
various  specific  fevers;  or  as  an  associated  condition  in  septic  processes. 

It  is  also  known  hy  the  names  of  ulcerative,  infectious,  or  diphtheritic 
endocarditis,  but  the  term  maligiuuit  seems  most  ap[iroi)riate  to  charac- 
terize the  essential  clinical  features  of  the  disease. 

The  existence  of  a  primary  endocarditis  has  been  doubted;  but  there 
are  instances  in  which  persons  previously  in  good  lu'alth,  withcuit  any  his- 
tory of  affections  with  which  eiulocarditis  is  usually  associated,  have  been 
attacked  with  symptoms  resembling  severe  ty))luis  or  typhoid.  In  one  case 
which  I  saw,  deatli  occurred  on  the  sixth  day  and  no  lesions  were  lound 
other  than  those  of  malignant  emlocardltis. 

The  simple  endocarditis  of  rheumatism  rarely  develops  into  the  malig- 
nant form.  In  only  24  of  'iW  cases  the  symiitoms  of  severe  eiulcKarditis 
arose  in  the  progress  of  acute  or  subacute  rheumatism.  In  only  3  of  my 
^lontreal  cases  was  there  a  history  of  rheunuitisin  either  before  or  during 
the  attacks. 

Malignant  endocarditis  is  extremely  rare  in  chorea.     Of  all  acute  dis- 


rsM 


Yoo  DISKASKS  OF  THE  CIUCULATOUY  SYSTKM. 

,,wr^  .(mn.liciit.Ml  Willi  scv.MT  (.iid.Miir.litis  i.ncum.mia  prolmbly  liciuls  the 
li.t  Tl.i^  I'li.t.  wln.h  liii.l  Inrn  ntVnc.l  t..  l.y  several  ..f  tlie  ol.ler  writers, 
wa-i  l.ruihrht  Mill  in  a  Mrikin-  iiianiu'r  l.v  llie  tl-uivs  mi  wliH'h  my  (iiil- 
.tuniMM  Urt.ires  w..ir  l.a.e.l.  !..  H  ni  the  -y.l  Montreal  .ases  the  disease  eamo 
„„  with  l..l.ar  i-iieiinioniM.  wliile  it  .leveh-iH-l  with  this  .lisease  m  ..I  ot  the 
'.,).,  ,,,.,.^  aiialv/e.l—in.lee.l.  the  en.hxanlitis  which  ueeiirs  m  iineiiinoiua 
s.riiis  t..  he  or  an  iiiiusiiailv  mali-nant  typ...  as  in  Ki  eases  of  iny_  l<Mt  ai.top- 
<ies  i„  this  disease  in  wliieh  this  l.-ion  was  present.  11  were  ol  tins  Inrin. 
This  has  heen  eonlirnied  hv  Netter.  Kanthaek.  and  others.  M.  nm-itis  was 
jissoeiate.l  with  eiidoeanlilis  in  ■.':.  of  the  -.M)',!  eases,  and  m  i:.  tiu'ie  was  also 

iiiieiiiMonia.  •       p  1    .       „ 

'n„,  iitVeetinii  i.iav  eoinplieate  erysipelas.  septieaMina  (from  vvhatexer 
cans..)  and  jULMperal  fever  and  -onorrluea.  Mali;inaut  end.uarditis  is  very 
rare  in  tnhereulosis.  tviihoid  lever,  and  diphtheria. 

It  ha<  I.eeii  stated  hv  manv  writers  that  endoearditis  occurs  m  a.LUio. 
Will,  the  unusual  facilities  for' the  study  of  this  disease  which  1  have  had 
in  the  past  nine  vears  1  liav.'  not  yet  met  with  an  instance.  I  miuestion- 
,,1,1  V.  in  the  majoritv  of  these  ea^es.  the  intermittent  l-vrexia,  which  has 
)„,,:„  ,,..arde.l  a>  characteristic  of  the  a-ue.  has  depei.de.l  upon  the  endn- 
cardilis'.  ill  dvsenterv  cases  have  heen  descrihed.  In  small-pox  an.  scarlet 
fever,  with  wliich  simi.le  endocanlilis  is  not  infre^iueiitly  eoniplicated,  the 
niali-iiaiit  f.triii  is  extremely  rare. 

Morbid  Anatomy  of  Simple  and  Malignant  Endocarditis.-> ;//////*'  e,i,h- 
rnnlilis  i>  characlerized  hv  the  presence  .,n  the  valves  or  on  the  lininj,^  niem- 
b,,,ne  of  the  chamhers  of  minute  ve-etations.  ran-in-  Irom  1  to  4  mm. 
i„  .liaiueter,  with  an  irreKular  aud  fissure.l  surface,  -ivin-  to  them  a  warty 
or  vernH(,se  ai,|,earance.  Often  thes..  little  caulillowei-like  excrescences  are 
„tached  hv  verv  mirrow  vedicles.  They  are  more  common  on  H'^' 1^'^^  ^"^^ 
of  the  heart  than  the  ri-lit,  and  oceur  on  the  mitral  va  ves  more  (,ften  han 
,„,  ^1,,  ,..„i,.  The  veoetations  are  usually  ahove  the  hne  ot  ^'l-"';;'  ''';;' 
v.,lve-=  It  i<  rare  to  see  any  swellin^r  or  macroscopic  evidence  of  infiltration 
,;,.  ,,„\,,„iocardium  in  the'nei-hhorhood  of  even  the  smallest  of  the  granu- 
lations, and  redness,  indicative  of  distention  of  the  vessels,  is  uncommon, 
oven  when  thev  occur  upon  valves  already  the  seat  of  sderotic  changes,  in 
which  capillary  vessels  extend  to  the  ed.es  With  time  the  v^'J^^hU-ns  may 
increase  ',n-eatly  in  size,  but  in  what  may  be  called  simple  endocaiditi.  the 
size  rareiv  exceeds  that  mentioned  above.  ,    .     .,         ,,     n     inn.l 

The  Earliest  veoetations  consist  of  elements  derived  trom  the  blood,  and 
are  composed  of  blood  platelets,  leucocytes,  and  tibrin  iii  varying  propor- 
tions. At  a  later  stage  they  appear  as  small  outgrow  hs  of  coiinect.v  ti>M  e 
The  transition  of  one  form  into  the  other  can  often  be  f'  f;;-!;  , '  ^^^ 
proee-  consists  of  a  ],roliferation  of  the  emlothelial  .rlls  and  the  celU  o 
he  subendothelial  laver  which  gradually  invade  the  fresh  vegetation,  and 
nltimatelv  entirelv  re'.place  it.  The  blood-eells  and  hbrin  undergo  disinte- 
gration and  uraduallv  they  are  removed..  The  whole  process  has  reeeu  d 
the  name  of  "  organization."  Kven  when  the  vegetation  has  been  en  irely 
conv^^IIed  into  g,;nulations  or  connective  tissue  it  is  often  found  at  autopsy 
to  be  capped  with  a  thin  layer  of  llbrin  and  leucocytes. 


EXnoPARDITIS. 


701 


ilily  hvMh  the 
■  older  writers, 
liicli  my  (iiil- 
11'  disease  eamc 
>i'  in  T)!  of  the 
in  |iiH'Uiiioiiiii 
my  1<»I)  ai.tol>- 
(■  ot'  tins  form. 
Mr  iiiii;j:itis  wari 
p  thcic  was  also 

from  wliatcvtT 
H-aiditis  is  very 

nccurs  in  a.L'iie. 
lifh  I  iiavi'  bad 
3.  UiitiiH'stion- 
,'.\ia.  wiiicii  has 
upon  tlio  endo- 
-|)ox  and  scarlet 
■omiilitated,  the 

, — Simple  cmh- 
tlie  lining  mem- 
)m  1  to  1  mm. 
to  tliem  a  warty 
excrescences  are 
on  the  left  side 
more  often  than 
of  closure  of  tl'.o 
CO  of  in  tilt  rat  ion 
\st  of  the  ;rranu- 
5,  is  uncommon, 
rotic  changes,  in 
vegetations  may 
endocarditis  the 

111  the  hlood.  and 
varying  propor- 

?onneetive  tissno. 

J  followed.  The 
and  the  cells  of 

1  vegetation,  and 
undergo  disinte- 

cess  has  received 

has  been  entirely 

found  at  autopsy 


Micro-organisms  are  generally,  even  if  nni  invarialily,  found  associated 
uilh  tiu'  vcgctatinns.  'I'licy  tend  to  lie  (ntanglcd  in  the  gianular  and 
fibrillatcil  lilirin  or  in  tlie  oliK'r  mic-i  to  cap  tiie  apices. 

In  both  man  and  animals  tlu're  is  a  foini  of  ilinniir  vrijfhiHrv  nnhi- 
ciirdilis  in  wiiicli.  uitliout  mucli  or  any  lii»  of  >idi>tance.  the  valves  and 
cbonlie  tcndinea'  are  covered  witli  large,  iirm  outgroutlis.  In  .-cvcral  cases 
(d'  tills  kind  the  clinical  history  has  been  characterized  liy  a  proti'actcil  fever 
of  a  marke(l  remittent  or  even  intermittent  tyjie. 

SiihsciiHinl  Clnnnics. — (1)  The  vegetation.-  may  become  organized  and 
the  valve  restored  to  a  normal  state  (!').  (".')  The  process  may  extend,  and  a 
.'^imple  may  become  an  ulcerative  endocarditis.  (:!)  The  vegetations  may  be 
broken  oil'  and  carried  in  tb(>  circulation  to  distant  parts.  (  i)  'l"he  vegeta- 
tions beconu'  organized  and  disap])i'ar,  but  they  initiate  a  nutiitive  change 
in  the  valve  ti-siu'  which  ultimately  leads  to  xlerosi-,  thickening,  and  de- 
formity. 'I'he  danger  in  any  ca<e  of  simple  endocarditis  is  not  immediate, 
but  remote,  and  consists  in  this  |ierversion  of  the  normal  processes  (d'  nutri- 
tion wliicli  results  in  sclerosis  of  the  valves. 

A  grailual  transition  from  the  simjilc  to  a  more  severe'  all'ection,  to  which 
the  nanu'  ukiVhjikiuI  oi'  iihi'mlirc  ('iiiliiciinlilis  has  been  given,  nuiy  lie  traced. 
I'ractically  every  case  of  ulcerative  endocarditis  is  attemlc(l  by  vegetations. 
In  this  form  the  loss  of  suiistance  in  the  valve  is  more  pi'oiiounceil,  the  dep- 
osition— thntmlius  formation — from  the  blooil  is  more  extensive,  and  the 
micro-oi'gani>ms  are  lU'csent  in  gi'cater  ninnbci-  and  often  show  inci'ea~ed 
virulence.  I'Icei'ative  endocarditis  is  often  fnund  in  conueition  with  heart 
valves  already  the  seat  (d'  chronic  prolib'rativc-  and  sclerotic  changes. 

In  malignant  endocarditis  there  is  distinct  hiss  of  suiistance  in  the  heart 
valve.  This  loss  may  be  su|ieriicial  and  limited  to  the  endoeai'dium.  or, 
what  is  more  conunon,  it  involves  deej)er  striu'tures,  and  not  very  infre- 
(juently  leads  to  j)erforation  of  a  valve,  a  septum,  or  even  of  the  heart  itself. 

I']ion  micioseopieal  cxann'nation  the  all'ecled  valve  shows  neci'osis,  with 
more  or  less  loss  of  suiistance;  the  necrotic  ti-sue  is  devoid  of  ])re<erved 
nuclei  and  i)resents  a  coagulated  ajipearanco.  I'pon  it  a  mixture  of  blood 
])latelets,  filirin — granular  or  filirillated — and  leucocytes  eiu-losing  masses 
of  nnero-organisms  are  met  with.  The  subjacent  tissue  ofteji  shows  scle- 
rotic thickening  and  always  infdtration  with  exuded  granulation  tissue-cells. 

I'(irl-<  afjcrh'd. — 'Phe  following  figures,  taken  from  my  (inlstonian  h'c- 
tures  at  the  lioyal  College  of  I'hysicians.  give  an  approximate  estimate  of 
the  frecpiency  with  which  in  'iti'.)  ca-;es  dilVerent  pai'ts  of  the  heart  were 
atVected  in  malignant  endocarditis:  .\ortic  and  mitral  valves  together,  in 
-11;  aortic  valves  alone,  in  '^'-l;  mitral  valves  alone,  in  TT;  tricuspid  in  ID; 
the  ])ulmonary  valves  in  l.");  and  the  heart  walls  in  ;!:!.  In  !•  instances  the 
right  heart  alone  was  involved,  in  most  cases  the  auriculo-ventricular  valves. 

]\Iural  endocarditis  is  seen  most  often  at  tlie  upjier  part  id!  the  se])tum 
of  the  left  ventricle.  Next  in  order  is  the  endocarditis  of  the  left  auricle 
on  the  postero-external  wall.  The  vegetations  may  extend.  a<  in  a  recent 
case  in  my  wards,  along  the  intima  of  the  pulmonary  artery  into  the  hilum 
of  the  lung.  The  ulcerative  changes  may  lead  to  perforation  of  a  valve  seg- 
ment, erosion  of  the  chorda-  tendinea',  jjcrf oration  of  the  septum,  or  even 


«■* 


-jO-i  KISKASFS  OF  TIIH  CIIU.'L'LATOUY  SYSTEM. 

(.f  til.'  h.art  itself.  A  iomiiihm.  ivsiill  of  llu'  iihrnM.i.m  i<  tli.'  i.r.Mliictiuii  ..f 
v;il\  uliir  im.uiiM.i.  Ill  tlirir  luurtlis  of  tlii'  cases  tlif  allVH.'.l  valves  prcseiil 
„1,|  ..Inniie  (lian-cs.  'Vhv  i-nn'css  may  fxt.'i.d  tu  the  aorta,  i-nxlm  iii^r,  as 
in  niie  of  inv  ea-es.  extensive  cn.lartcritis  witli  imiltil.ii'  aeute  aiieunMu>. 

\<sn,ialnl  I,rsl„iis.—T\\i>  assneiated  i.atli.-lc.KMcal  cliaiij.a'!i  aiv  i-arlly 
ti„,.e  of  the  piiinaiv  .liM.ise  to  whieli  til.'  eixhuanlitis  is  seeoiuhiry  ami 
,,nllv  thoM'  .lu.'  to  einhoiism.  Jii  llu'  emh.eanlitis  of  septie  i.roir>ses  theiv 
i.  the  loeiil  lesion— an  aeiit.'  necrosis,  a  suppurative  woiiiul,  or  puerperal  dis- 
ease In  iiiaiiv  eases  the  h'sioiis  a.e  those  of  pneumonia,  rheumatism,  or 
„tl„.r  fehrile  pVoeess.s.  The  ehau-es  due  to  emholism  constitute  the  most 
strikin-  features.  |,iit  it  is  remarkahle  tliat  in  some  iiistanees,  even  with 
.ndocanlitis  of  a  markedly  uleerative  character,  there  may  he  no  trace  oL 
cmholic  processes. 

'I'he  infarcts  mav  he  few  in  numher— only  one  or  two.  perhaps,  in  tUe 
sphrn  or  kidncv— (ir  thev  may  exist  in  hundreds  throughout  the  vari.uis 
jmrts  (d'  the  l.oilv.  Thev  may  present  the  ordinary  appearance  of  red  or 
white  infarcts  of' a  >uiM.ura1ive  character.  They  are  most  eoiumon  in  the 
spleen  and  kidncvs.  thou-h  thev  may  lie  numerous  in  the  hram.  and  in 
many  cases  are  verv  ahun.lant  in  the  intestines.  In  ri-ht-sided  endocar- 
ditis there  mav  he 'infarcts  in  the  luu^s.  In  many  of  the  cases  there  are 
innumcrahle  ndliarv  ahscesses.  Acute  supi.urative  meningitis  was  met 
with  in  :.  of  -v';!  of  the  .Montreal  cases,  and  in  over  10  per  cent  of  the  -.'(H) 
cases   analyzed    in    th"   literature.     Acute   suppurative   parotitis   also   may 

occur.  .  1  •     ii      t 

r„uln-h,huni  —)^o  di>tinctioii  in  the  niicro-or^Minisms  louiid  in  tiie  tuo 
forms  of  endo'earditis  can  he  mad...  In  hotli  the  pyogenic  cocci-strepto- 
coeei,  stai.hvloeoeei.  pneumococci,  and  gonoeoeci— are  the  most  frequent 
Imcteria  luei  xvith.  More  rarely,  .•specially  in  the  simple  vegetative  endo- 
carditis, the  bacilli  of  tnherculo>is.  typln.id  fever,  and  anthra.K  have  been 
encountered  The  br  illus  coli  communis  has  also  been  found,  and  Ihuvard 
]n«  described  a  case  .d'  malignant  eiidoearditis  due  to  an  attenuated  form 
,d-  the  dii.htheria  bacillus.  Flexner  *  has  aiudy/.ed  ;!  I  cases  of  acute  endo- 
car.litis  associated  with  chronic  renal  and  canliae  disease,  and  lonnd  the 
,nieroc.-eus  lanceolatus  and  the  streptococcus  pyogenes  present  each  twelve 
times,  the  staphvlococcus  three  times.  Other  bacteria  enc.mntered  were 
bacillus  pvoevaiieus,  eoli.  and  iniluenxa>.  and  the  gonococcus. 

Sympto'ms.— Neither  the  clinical  c<nirse  imr  the  physual  signs  c.t 
,h„pU'  nulnan-'Ulls  are  in  anv  respect  characteristic.  The  great  majority 
of  the  cases  are  latent  and  there  is  no  indication  whatever  ol  cardiac  mis- 
chief. Kxperience  has  taught  ns  that  endocarditis  is  frequently  found  p<.st 
mortem  in  i.ers.ms  in  whom  it  was  n-d  suspected  during  lite.  1  here  aro 
pertain  features,  however,  hv  which  its  presence  is  indicated  with  a  degree 
of  imdiabilitv.  The  i.atieiit.  as  a  rule,  does  not  complain  of  any  paiu  or 
cardiac  distrc'ss.  In  a  case  (d'  acute  rheumatism,  for  example,  the  symptoms 
to  excite  siispici.m  would  be  increased  rajudity  of  the  heart's  action,  per- 
haps slight  irremdaritv.  and  an  increase  in  the  fever  with.uit  aggravation 


Journal  of  Experimental  Mcaicine,  1890,  i,  p.  559. 


ENDOCAKDITIH. 


703 


iroiluc'tion  ot 
iilvos  prL'st'iit 
irmliiciiij:,  as 
iiiu'iiri>ius. 
s  ail'  iMilly 
■idiidaiT  ami 

•()l'('>Sl'Sj  lliiio 

juorpi^ral  tlis- 
riiiiialisin,  nr 
iUl'  the  must 
'^*,  evrii  with 
L'  no  trace  nL' 

iliaiit",  in  the 
t  the  various 
ice  oi  red  or 
imnon  in  tlie 
brain,  ami  in 
ided  emlocar- 
iises  tiiere  are 
it  is  was  met 
nt  of  the  •,'1111 
itis   also   may 

ul  in  the  two 
oeei — strepto- 
luost  fretjuent 
lietative  endo- 
rax  have  been 
I,  and  Howard 
tennated  form 
)[  aeiite  endo- 
ind  found  tlie 
nt  I'aeh  twelve 
(luntered   were 

>'sical  si<;:ns  of 
trreat  majority 
)f  cardiae  niis- 
itly  found  post 
fe.  There  are 
with  a  degree 
of  any  pain  or 
,  the  symiitoms 
t"s  action,  per- 
lut  atrtrravation 


(if  the  joint  troulile.  ilnws  of  tiny  vegetations  on  liie  mitral  i<v  on  the  aortie 
htgments  M'cm  a  trilling  matter  to  excite  fever,  ami  it  is  ilillicidt  in  tin- 
endocarditis  (d'  fchrile  jprocesses  to  say  definitily  in  every  in.-taiiee  that  an 
increase  in  the  fever  depends  upon  the  endocanlial  coniplicalion.  I>iit  a 
ctuily  of  the  ncurriiig  en(locarditi> — which  is  ni  the  warty  variety,  con- 
sisting of  minute  lieatls  on  old  .-clerotie  valves — shows  that  this  procc.-s  may 
he  a>so(  iiitcd,  for  days  or  week^  at  a  time,  with  slight  fever  ranging  from 
1(1(1  to  Krj.i, '.  I'alpitalion  may  he  a  marked  featiiie  and  i>  a  symptnm  uy^n 
which  certain  authors  lay  great  .-tre.-s. 

The  iliiKjiKisi.t  of  the  condition  rests  upon  phy.-ical  signs  which  are 
notoriously  uncertain.  Tlie  presence  of  a  miiiiiiur  at  mu'  or  other  nf  tlie 
cardiac  areas  in  a  case  of  fever  is  (d'tcii  regarded  as  indicative  of  the  exist- 
once  of  endocarditis.  This  extremely  common  iiiistak<'  has  arisen  from  the 
fact  that  the  hriiil  dc  snii/llv  or  hellows  murmur  is  common  to  endocarditis 
and  a  numher  of  other  eoiiditicms  which  have  nothing  to  do  with  it.  .\t 
first  there  may  he  only  a  slight  roughening  of  the  [\:A  sound,  which  may 
gradually  develop  into  a  distinct  murmur.  Taken  aloiu',  it  is,  howi'ver,  a 
very  uncertain  ami  taiiacioiis  sign. 

It  is  dillicult  to  give  a  satisfactory  clinical  |)icture  id'  „nili'jn(Uil  nuhi- 
cardilis  hecaiise  the  modes  of  onset  are  so  varied  and  the  symptoms  so 
diverse.  Arising  in  the  course  (d'  some  other  disease,  there  may  he  simjily 
an  intensillcation  of  the  fever  or  a  change  in  its  character.  In  a  majority 
of  the  cases  there  are  present  certain  general  features,  such  as  irregular 
l)yrexia,  sweating,  delirium,  and  gradual  failure  of  strength. 

l-lmholic  iMdccsscs  may  give  special  characteis,  such  as  delirium,  coma 
or  iiaralysis  from  invidvement  of  the  hrain  or  its  memhrancs,  pain  in  the 
side  and  local  peritonitis  from  infarction  of  the  spleen,  hloody  urine  from 
implication  (if  the  kidneys,  impaired  vision  from  retinal  luemorrhage,  and 
suppuration,  and  even  gangrene,  in  various  parts  from  the  dislrihulion  of 
the  emboli. 

Two  special  types  of  the  disease  have  Iteen  recognized — the  septic  or 
pyainie  and  the  typhoid.  Other  cases  clo.sely  resemble  true  intermittent 
fever.  In  some  the  cardiac  symptoms  are  most  prominent,  while  in  others 
again  the  main  symptoms  may  be  those  of  an  acute  I'll'ection  of  the  cerebro- 
spinal system. 

The  srplii'  liipc  is  met  with  usually  in  connection  with  an  external 
wound,  the  imerjieral  jiroeess,  or  an  acute  necrosis.  There  are  rigors,  sweats, 
irregular  fevers,  and  all  of  the  signs  of  septic  infection.  The  heart  .symp- 
toms may  be  completely  masked  liy  the  general  condition,  and  attention 
calU'd  to  them  only  on  the  occurrence  of  embolism.  In  a  most  remarkable 
snb-group  of  this  type  the  disease  may  simulate  a  <piotidian  or  a  tertian 
ague.  The  symptoms  may  develoj)  in  jicrsons  with  chronic  heart-disease 
^  withont  any  external  lesions.  These  oases  may  be  much  prolonged — for 
three  or  four  months,  or  even  longer,  as  in  one  of  Piristowe's.  The  ex- 
istence in  some  of  these  instances  of  a  [U'cvious  genuine  malaria  ha.s  boon 
a  very  ])u//ling  eircumstanee. 

The  hipltnul  tjipp  is  by  far  the  most  common  and  is  cliaracterized  by 
an  irregidar  temperature,  early  prostration,  delirium,  somnolence,  and  coma, 
44 


ro-t 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


Tolaxod  Innvols,  swoatin>^  nvI.uI,  mny  l.e  of  a  most  <  rcnc  ..ng  clmiacte 
K.chial  and  .^l.er  rashes,  and  occasionally  parotifs.    The  heart  synipto    , 
,y  ho  cniplotclv  overlooks,  and  in  some  instances  the  most  caieiul 


ni! 


oxaniination  has  tailed  to  discover  a  nuirnuir. 

Under  the  conliac  f/roup,  as  suggested  l.y  Brannvell,  may  he  consid- 
ered those  cases  in  uhich  patients  uith  chronic  valve  disc.ise  are  a  tacked 
tith  marked  fever  and  evidence  of  recent  endocarditis.  Many  such  ca.c. 
present  svniptoms  of  the  pya^nic  and  typhoid  character  and  may  run  a 
nost  acute  bourse.  In  others  the  course  is  chronic,  lasting  f'>Y^'^"'?.,^; 
months  I  have  reported  two  cases  of  this  chronic  vegetative  eiidocaiditis, 
;;;,;  intermittent  fiver,  one  of  more  than  a  year's  duration.  The  autopsies 
showed  extensive  vegetative  and  ulcerative  disease  ot  the  mitral  vahe.. 

Thei^nre  cases  in  which  it  is  often  diiUcult  to  decide  whether  malig- 
mnt  endocarditis  is  i.resent  or  not.  Thus,  a  patient  with  aortic  valve  dis- 
Te  is  umii  treatment  for  fa  '  ig  compensation  and  hegins  to  have  irregu- 
lar fever  with  restlessness  and  cardiac  distress;  embolic  phenomena  may 
aevelop-sudden  hemiplegia,  pain  in  the  region  of  the  s,.leen,  or  bloody 

ne,  or  perhaps  peripheral  embolism.  There  may  he  a  low  dohrium  and 
Ihe  case  may  run  I  tolerably  acute  course;  but  in  other  instances  the  fe^er 

subsides  and  recovery  occurs.  ,,       i-   •    i     v^^^n 

In  what  may  be  termed  the  cerrhral  :jrnup  of  cases  the  clinical  picture 
xnay  simulate  a  meningitis,  either  basilar  or  cerebro-spinal.     There  may 
ricute  delirium  or,  a^in  three  of  the  Montreal  cases,    he  l-<>-t  may  be 
hrou-ht  into  the  hospital  unconscious.    Ileineman  reports  an  inst  nee,  mi 
autopsy,  in  which  the  clinical  picture  was  that  of  an  acute  cerebro-spmal 

"'"tvSin  -p.H.ial  svmptoms  m:,v  be  mentioned.     The  fever  is  not  always 

of  !  r^i  ttei      vpe;  bit  may  be  high  and  continuums.     Tetechial  rashes 

o'V    r^uumon  and  render^he  similarity  very  strong  to  certain  c^ises^o 

vpluS  and  cerebro-spinal  fever.      In  one  case  the  disease  was  thought 

o  1      lu^m  r  hagic  sniall-pox.     Erythematous  rashes  are  not  uncommon 

Th    swit  n.  may  be  nioi  profuse,  even  exceeding  t'u.twh-l;  occurs    n 

nlvthils  anf  a.n.  .     Piarrho'a  is  not  necessarily  associated  with  embolic 

iet,^  in  the' intestines.     Jaundice  has  been  observed  and  cases  are  on 

record  which  were  mistaken  for  acute  yellow  atrophy. 

The  heart  svmptoms  mav  be  entirely  latent  and  are  not  found  unle..  a 

VT       !.  ,  he  nride      fVcii  on  examination  there  may  be  no  murmur 

^:^  "d^n  e     li^oclnh;;  by  careful  observers,  in  which  the  exann.a- 

l!;w"the  heart  has  been  negative.    Cases  with  chronic  valve  disease  u.u- 

allv  present  no  dilliculty  m  diagnosis.  „.w„,.o 

•  The  course  of  ihe  disease  is  varied,  depending  largely  upon  the  na      o 

of  the    n-imary  trouble.    Except  in  ti.e  disease  grafted  ^M--l---^ - 

liti.  the  course  is  rarelv  extended  beyond  five  or  six  yek..     As  alreu  j 

;^ntloned,  there  are  instances  in  which  tlm  disease  ^^V^^^^^^;^ 

The  most  rapidlv  fatal  case  on  record  is  described  bj  Ebeith,  th.   duiatnn 

^'  DiagSs^:^'--  --  the  detection  of  the  disease  is  verydini- 
cul-3;^rs   with  marked  embolic  symptoms,  it  is  easy.    From  simple 


ENDOCARDITIS. 


r()5 


ig  character, 
ii't  symptoniri 
luorit  ciirei'ul 

y  be  consiil- 
are  attacked 
ly  such  ca!-es 
1  may  ruu  a 
for  weeks  or 
ciiiloearditis, 
Ihe  autopsies 
ral  valves, 
hcther  inalig- 
I'tic  valve  dis- 
)  have  irregu- 
niomena  may 
en,  or  bloody 
delirium  and 
nces  the  fever 

linieal  ])icture 
.  Tiiere  may 
latient  may  l)e 
instance,  with 
cerehro-spinal 

■  is  )iot  always 
jtechial  rashes 
ertain  cases  of 
i  was  thought 
ot  uncommon, 
hich  occurs  in 
with  embolic 
1  cases  are  on 

fiumd  unless  a 
be  no  murmur 
•h  the  examina- 
ive  disease  usu- 

pon  the  nature 
.  chronic  valvu- 
cs.  As  already 
gcd  for  months, 
h,  the  duration 

ise  is  very  difTi- 
•.    From  simple 


endocarditis  it  is  readily  distinguished,  though  confusion  occasionally 
occurs  in  tlic  transitional  stage,  when  a  sini|)le  is  developing  into  a  malig- 
nant form.  The  conslitntioiial  symptoms  are  of  a  graver  type,  the  fever 
is  higher,  rigors  are  common,  and  septic  and  tyjihoid  symptoms  develoi). 
Perhaps  a  majority  of  the  cases  not  associated  with  [uierperal  processes  or 
bone-disease  are  confounded  with  ty[ihoid  fever.  A  tlilferenlial  diagnosis 
may  even  be  impossible,  particularly  when  we  consider  that  in  typhoid 
fever  infarctions  and  parotitis  may  occur.  The  diarrluea  and  abdominal 
tenderness  may  also  be  present,  wliicli  with  the  stnjior  and  progressive 
asthenia  make  a  picture  not  to  be  distinguished  from  tliis  disease.  Points 
which  may  guide  us  are:  The  more  abrupt  onset  in  endocarditis,  the  ab- 
sence of  any  regularity  of  the  pyrexia  in  tlie  early  stage  of  the  disease,  and 
the  cardiac  ])ain.  Oppression  and  shortness  of  breath  may  be  early  .symp- 
toms in  malignant  endocarditis.  Pigors,  too,  are  not  uncommon.  There 
is  a  marked  leucocytosis  in  infective  endocarditis.  Pctween  pyicmia  and 
malignant  endocarditis  tliere  are  i»ractica]ly  no  diU'erential  features,  for 
the  disease  really  constitutes  an  (iiicriiil  pi/iciiiia  (Wilks).  Jn  the  acute  cases 
resembling  malignant  fevers,  tiie  diagnosis  is  usually  made  of  tyi)hus, 
typhoid,  cerebro-spinal  fever,  or  even  of  luemorrliagic  sinall-|)ox.  The  in- 
termittent i)yrcxia,  occurring  for  weeks  or  montlis,  has  led  in  some  ca.^es 
to  the  diagnosis  of  malaria,  but  this  disease  could  now  be  positively  excluded 
by  the  blood  examination. 

The  cases  usually  terminate  fatall .-.  The  instaiu'cs  of  recovery  are  those 
more  sul)acute  forms,  the  .<o-called  recurring  endocarditis  developing  on 
old  sclerotic  valves  in  cases  of  cliro  lie  heart-disease. 

Treatment. — We  know  no  measures  by  wliich  in  rheumatism,  chorea, 
or  the  eru])tive  fevers  the  onset  of  endocarditis  can  be  jircvented.  As  it  is 
l)robable  that  many  cases  develo]),  jiarticularly  in  children,  in  mild  forms 
of  these  diseases,  it  is  well  to  guard  the  jiatients  against  taking  cold  and 
insist  upon  rest  and  quiet,  and  to  l)ear  in  mind  that  of  all  comjilications 
an  acute  endocarditis,  though  in  its  immediate  effects  harmless,  is  \m-- 
]iai)s  the  most  serious.  This  statement  is  enforced  by  the  oi)servations  of 
Sibson  that  on  a  system  of  al)solute  rest  the  proiiortion  of  cases  of  rlieu- 
matism  attacked  liy  endocarditis  was  less  than  of  those  who  were  not  so 
treated. 

It  is  doubtful  whether  the  salicylates  in  rheumatism  have  an  intluence 
in  reducing  the  liability  to  endocarditis.  When  the  endocarditis  is  jn-escnt 
we  know  no  remedies  whicli  will  definitely  inliiience  the  valvular  lesions. 
If  there  is  much  vascular  excitement  aconite  may  be  given  and  an  ice-bag 
jilaced  over  the  heart. 

The  salicylates  are  strongly  advised  by  some  writers  and  the  su]|)ho- 
carliolates  have  licen  recommended  by  Sansoni.  In  the  severer  cases  of 
malignant  endocarditis  the  treatment  "is  jiractically  that  of  septiciemia. 

CrtT^oxTc  ExDorAitTUTrs. 

This  condition,  wliich  is  a  sclerosis  of  the  valve,  may  be  primary,  Imt  is 
oftener  secondary  to  aeut        docarditis,  particularly  the  rheumatic  form. 


J> 


706  DISEASES  OF  THE  CTKCULATORY  SYSTEM. 

Tt  is  c?«oiitially  a  slow,  insidious  pvocoss  wliicli  leads  to  deformity  of  the 
valve  se-Mueiit  and  is  the  foundation  of  chronic  valvular  disease. 

Certain  poisons  appear  capaljle  of  initiiting  the  change,  such  as  alco- 
hol svpliilis,  and  gout,  though  we  are  at  present  ignorant  of  the  way  in 
whieli  tlu'y  act.  A  very  important  factor,  particularly  m  the  case  ot  the 
aortic  valve-,  is  the  strain  of  prolonged  and  heavy  muscular  exertion.  In 
no  otlier  wav  can  he  explained  the  occurrence  of  so  many  cases  of  sclerosis 
of  the  aortic  valves  in  young  and  middle-aged  men  whose  occupations  neces- 
sitate the  overuse  of  the  muscles.  ,  .  ,    „ 

Morbid    Anatomy.— Vegetations  in  the  form  in  which  they  occur 
in  acute  endocarditis  are  not  present.     In  the  early  stage,  which  we  have 
frequent  opjiortunities  of  seeing,  the  edge  of  the  valve  is  a  little  thickened 
and  perhai)s  presents  a  few  small  nodular  i.rominences,  which  m  some 
cases  mav  represent  the  healed  vegetations  of  the  acute  process.     In  tlie 
aortic  valves  the  tissue  ahout  the  corpora  Arantii  is  first  all'ected,  producing 
a  <VM\t  thickening  with  an  increase  in  the  size  of  the  nodules.    The  suh- 
^lan^e  of  tiie  valve  may  lose  its  translucency,  and  the  only  change  noticeable 
l.e  a  grayish  opacity  and  a  slight  loss  of  its  delicate  tenuity.    In  the  aunculo- 
ventricular  valves  these  early  changes  are  seen  just  within  the  margin 
and  here  it  is  not  uncommon  to  find  swellings  of  a  grayish-red,  somewhat 
infiltrated  appearance,  almost  identical  with  the  similar  structures  on  the 
intinia  of  the  aorta  in  arterio-sderosis.    Kven  early  there  may  V)e  seen  yellow 
or  oi^aciue-white  subintimal  fattily  degenerated  areas.     As  the  sclerotic 
chancres  increase,  the  fibrous  tissue  contracts  and  produces  thickening  and 
deformitv  of  the  segment,  the  edges  of  which  become  round,  curled    and 
incaiwble  of  that  delicate  apposition  necessary  for  perfect  closure.    A  sig- 
moid valve,  for  instance,  may  be  narrowed  one  fourth  or  even  one  third 
across  its  face,  the  most  extreme  grade  of  insufliciency  being  induced  with- 
out any  special  deformity  and  without  any  definite  narrowing  of  the  arterial 
orifice     In  the  auriculo-ventricular  segments  a  simple  process  of  thicken- 
ing and  curling  of  the  edges  of  the  valves,  inducing  a  failure  to  close  with- 
out forming  any  obstruction  to  the  normal  course  of  the  blood-flow,  is  less 
common.     Still,  we  meet  with  instances  at  the  mitral  orifice,  particularly 
in  chil.lren.  in  which  the  e.lges  of  the  valves  arc  curled  and  thickened, 
.0  that  there  is  extreme  insufliciency  without  any  material  narrowing  of  the 
orifice      More  fremicntlv,  as  the  disease  advances,  the  chorda>  tendmciu 
iH-come  thi.'kencd,  first  at  the  valvular  ends  and  then  along  their  course 
Tlie  ed-es  of  the  valves  at  their  angles  are  g-odually  drawn  together  and 
tiiere  is^i  definite  narrowing  of  the  orifice,  leading  in  the  aorta  to  more 
or  le«s  stenosis  and  in  tlu'  left  auriculo-ventricular  orifice-the  two  sites 
n.ost  frequently  involvcd-to  constriction.     Finally,  in  the  sclerotic  and 
necrotic  tissues  lime  salts  are  de,.<.sited  and   may  even  reach  the  deeper 
structures  of  the  fibrous  rings,  so  that  the  entire  valve  becomes  a  dense  cal- 
careous mass  with  scarcelv  a  remnant  of  normal  tissue.     The  chordic  ten- 
dinciv  mav  graduallv  become  shortened,  greatly  thickened,  and  in  extreme 
cases  the"p'M^illi»'v  """'«'l^^^  ^'''^  i"M'li"itcd  directly  upon  the  sclerotic  and 
deformed  valve.    The  apices  of  the  papillary  muscles  usually  show  marked 
filiroid  change. 


L. 


CnilOXIC  VALVL'LAIl  DISPLVSE. 


ru7 


rmity  of  the 
e. 

nu'h  as  aloo- 
1'  the  way  in 
e  case  of  the 
exertion,  in 
js  of  sclerosiri 
,)ations  ucces- 

■h  they  occnr 
liieh  we  liavc 
Ltle  thickened 
hich   in  some 
)eess.     In  th.e 
ed,  producing 
es.     The  snh- 
nge  noticeable 
1  the  auriculo- 
n  the  margin 
red,  j-(jme\vhat 
ictures  on  the 
he  seen  yellow 
,   the   sclerotic 
hickening  and 
d,  cnrled,  and 
iosure.    A  sig- 
>vcn  one  third 
induced  with- 
of  the  arterial 
ess  of  thicken- 
;  to  close  witli- 
)od-flow,  is  less 
:'e,  ]wrticularly 
and  thickened, 
irrowing  of  the 
ordic  tendineie 
ig  their  course, 
n  together  and 
'  aorta  to  more 
— the  two  sites 
,e  sclerotic  and 
ach  the  deeper 
lies  a  dense  cal- 
'he  cliorda^  ten- 
and  in  extreme 
ic  sclerotic  and 
ly  show  marked 


In  all  stages  of  tlie  process  the  vegetations  of  simple  endocarditis  may 
he  present,  and  upon  sclerotic  valves  we  iind  tlie  severer,  idcerative  form  of 
the  disease. 

Chronic  inura]  endocarditis  jirodiiccs  cieatrieial-like  patches  of  a  gray- 
ish-white aiipearance  wliich  are  sometimes  seen  on  the  inusriilar  trabecuia; 
of  the  ventricle  or  in  the  auricles.  It  often  occurs  in  association  witli  myo- 
carditis. 

The  fretpiency  with  wliich  chronic  endocarditis  is  met  witli  may  he 
gatliered  from  the  i'o]h)wiiig  ligures:  hi  tlie  statistics,  ainouiitiiig  to  from 
l:i,l)UU  to  11,U0()  atitojjsies,  rejiortcd  from  Dresden,  Wiirzburg,  and  Prague 
the  percentage  ranged  from  four  to  nine.  The  relative  frequency  of  involve- 
ment of  the  various  valves  is  thus  given  in  the  collected  statistics  of  Parrot: 
The  mitral  orifice  was  involved  in  (i>M,  the  aortic  in  oSO,  the  tricuspid  in 
4(i,  and  the  pulmonary  in  11.  This  gives  5T  instances  in  the  right  to  1,001 
ill  the  left  heart. 

The  endocarditis  of  tlie  fietus  is  usually  of  the  .sclerotic  form  and  in- 
volves the  valves  of  the  right  more  frcipicntly  than  those  of  the  left  sitle. 


11.    CHRONIC  VALVULAR    DISEASE. 

1.   Gkxek.vl  InTUODL'CTION'. 

The  incidence  of  valvular  lesions  may  lie  gathered  from  the  following 
figures  com])iled  by  (iillespie  from  the  records  of  the  l?oyal  Indrniary,  Edin- 
burgh: Of  •■^,3(i8  cases  with  cardiac  lesions,  valvular  disease  occurred  in  80.8 
per  cent;  endocarditis  and  ]iericarditis  in  5.3;  myocardial  lesions  in  11.9 
per  cent;  (ifi.'^  ])er  cent  of  the  ca.«es  were  in  males. 

Effects  of  Valve  Lesions. — The  general  inlluence  on  the  work  of  the 
heart  may  be  briefly  stated  as  follows:  The  sclerosis  induces  iusulFiciency 
or  stenosis,  which  may  exist  separately  or  in  comliination.  The  narrowing 
retards  in  a  measure  the  normal  outflow  and  the  insullieiency  jiermits  the 
blood  current  to  take  an  abnormal  course.  In  Ijotli  instances  the  effect  is 
dilatation  of  a  chamber.  The  result  in  the  former  ca.*e  is  an  increase  in 
the  dilliculty  which  the  chamber  has  in  exiielling  its  C(mtents  through  the 
narrow  orifice;  in  the  other,  the  overfilling  of  a  chanilier  by  blood  flowing 
into  it  from  an  improper  source,  as,  for  instance,  in  mitral  in.suf!iciency, 
when  the  left  auricle  receives  blood  both  from  the  pulmonary  veins  and 
from  the  left  ventricle. 

The  cardiac  mechanism  is  fully  pre])ared  to  meet  ordinary  grades  of 
dilatation  which  constantly  occur  during  sudden  exerfion.  A  man,  for  in- 
stance, at  the  end  of  a  hundred-yard  race  has  his  right  chambers  greatly 
dilated  and  his  reserve  cardiac  power  worked  to  its  full  capacity.  The  slow 
])rogress  of  the  sclerotic  changes  brings  about  a  gradual,  not  an  abrupt,  in- 
suiTiciency,  and  the  moderate  dilatation  which  follows  is  at  first  overcome 
by  the  exercise  of  the  ordinary  reserve  strength  of  the  heart  muscle.  Grad- 
ually a  new  factor  is  introduced.  The  reserve  power  which  is  capable  of 
meeting  sudden  emergencies  in  such  a  remarkable  manner  is  unable  to  cope 


T^ 


i! 


Y08  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

loiK'  witli  a  pormam.nt  and  prrliaps  incroasinj.-  .lilalati-.n.    More  work  lias 
to  1)0  clone  and,  in  acronlanco  with  .IHlnitc  pl.ysiolo.i.al  laws,  more  power 
i«  .riven  by  increase  of  the  nH.s.-tes.    The  heart  hyi-ertropues  an-     he  efTee 
of  the  valve  lesion  he.'on.es,  as  we  say.  mmpensated.     The  equ.hbnmn  ol 
the  circulation  is  in  tliis  way  maintained. 

^'ae  nature  of  the  process  with  whic'li  we  have  to  deal  is  graphically 
illustrated  in  the  accompanying  diaf:rams,  which  we  owe  to  Martins,  ot 
l{o«tock  The  perpendicular  lines  in  the  fi-ures  represent  the  jtovver  ol 
w.n'k  of  the  heart.  While  the  muscle  in  the  healthy  luv,rt  (Diajiiam  1)  has 
at  its  disposal  the  maximal  force,  a  c,  it  carries  on  its  w<.rk  under  ordinary 
circumstances  (when  the  body  is  at  r-.'st)  with  the  foire  .  h  1  he  t<.rce  h  c 
is  reserve  force,  hy  means  of  which  the  heart  accommodates  itsc't  to  greater 

'''' nTciw  there  he  a  gross  valvular  lesion,  the  force  rcciuired  to  do  the  ordi- 
narv  work  of  the  heart  (at  rest)  hecuues  very  much  increased  ^Diagram  11). 
Rut  in  spite  of  this  cnorm..us  call  for  f-.ree,  insuir.ciency  of  tl:.  hoar  muscle 
does  not  necessarily  result,  for  the  working  force  required  is  still  withm  the 


Reserve-force-      . 
AccomiTiodation-  S 
capacity 


Reserve-force- 
Accommoiiation-  ^ 
capacity 


•^b 


bt 


V  Power  of  work 
(body  at  rest) 


V  Power  of  work 
(body  at  rest) 


Total  power  of  heart 
\  less  than  amount  needed 
'   when  the  body  is  at  rest. 
Insufficiency  otthe  heart 


1.  Normal  heart 


II.  Heart  in  valvular  disease 
stage  of  cornpcnsation 

Chart  XVI. 


III.  Heart  in  uncompensated 
valvular  disease 


limits  of  the  maximal  power  of  the  heart,  a,  h„  being  less  than  a,c,.  The 
muscle  accommodates  itself  to  the  new  conditions  by  making  its  reserve 
force  mobile  (experiment  of  Eosenbach).  If  nothing  further  occurred, 
however,  this  condition  could  not  l)e  permanently  maintained,  for  tliero 
would  be  left  over  for  emergencies  only  the  small  reserve  force,  h,  //.  hven 
when  at  rest  the  heart  would  be  using  continuously  almost  its  entire  maxi- 
mal force.  Any  slight  exertion  retpiiring  more  extra  force  than  that  repre- 
sented by  the  small  value  h,  y  (say  the  elfort  required  on  walking  or  on 


it 

11 


CnilONK'   VALVULAR   DISEASE. 


70S) 


ro  work  has 
more  power 
1(1  the  efToct 
jilibriiiiii  of 

praphieally 
^lartii's,  of 
lie  ])o\vev  of 
ijliain  1)  lias 
(icr  ordinary 
riu'  force  h  e 
■U'  to  greater 

(1,)  the  onli- 
Diagram  II). 

I  eart  rnnselo 

II  witliiu  the 


Total  power  of  heart 
ss  than  amount  needed 
vhenthe  body  is  attest, 
isufficienc^y  ofthe  heart 


going  upstairs^  would  bring  tiie  heart  to  the  limit  of  its  working  power, 
and  pali)itati(  ■  md  djspntea  would  apjiciir.  Sinli  a  condition  does  nut 
last  long.  The  working  power  of  the  heart  gradually  increases.  3Iore  and 
more  exertion  can  lie  home  without  causing  dyspntea,  tor  the  licurl  lii/itcr- 
trophics.  Finally,  a  new,  more  or  K'ss  pernMinent  condition  is  attained,  in 
that  the  hypertrophied  heart  possesses  the  maximal  force,  ti,  c.  Owing  to 
the  increase  in  volume  of  the  lieart  iiniscle,  the  total  force  of  the  heart  is 
greater  (ibsohilcli/  than  that  of  the  normal  heart  by  the  amount  //,  c.  It  is, 
however,  rcliilircli/  less  eilicient,  for  its  reserve  force  is  much  less  than  that 
of  the  healthy  heart.  Its  capacity  for  accommodating  itself  to  unusual  calls 
ujion  it  is  accordingly  permanently  diminished. 

Turning  now  to  the  disturbances  of  compensation,  it  is  to  be  distinctly 
borne  in  mind  that  any  heart,  normal  or  diseased,  can  become  insuilicient 
whenever  a  call  U))on  it  exceeds  its  uiaximal  working  capacity.  The  liability 
to  such  disturbance  will  depend,  above  all,  upon  the  accomuKtdation  limits 
of  the  heart — the  less  the  width  of  the  latter,  the  easier  will  it  lie  to  go 
beyond  the  heart's  cnicieney.  A  coni]iarison  (d'  Diagrams  1  and  II  will  im- 
mediately make  it  clear  that  the  heart  in  valvular  disease  will  much  earlier 
become  insuilicient  than  the  heart  of  a  healthy  individual.  If  the  heart 
mnscle  is  compelled  to  do  maxinuil  or  nearly  maximal  work  for  a  long  time, 
it  becomes  exhausted.  It  is  obvions  that  the  heart  in  valvular  disease  has 
on  aceonni  of  its  small  amount  of  reserve  force  to  do  maximal  or  nearly 
maximal  Mork  far  more  fretpiently  than  does  the  normal  lieart.  The  power 
of  the  heart  may  become  decreased  to  the  amount  necessary  simply  to  carry 
on  the  work  of  the  heart  when  the  body  is  at  rest,  or  it  may  cease  to  be 
snlhcient  even  for  this.  The  reserve  force  gained  throngh  the  compensa- 
tory process  may  be  entirely  lost  (Diagram  III).  If  the  loss  be  only  tem- 
porary, the  exhausted  heart  muscle  qnickly  recovering,  the  condition  is 
s]ioken  of  as  a  "disturbance  of  com])ensation."  The  term  "loss  of  com- 
j)ensation  "  is  reserved  for  the  condition  in  which  the  disturbance  is  con- 
tinuous. 

2.    AOKTIC    IxCOMrETEXCY. 


1  uncompensated 
ar  disease 


an  rtifi.  The 
ng  its  reserve 
tlier  occnrrcd, 
ued,  for  there 
re,  ?>,  //.  Kven 
ts  entire  maxi- 
lan  that  repre- 
M-alking  or  on 


Inc(mipetency  of  the  aortic  valves  arises  either  from  inability  of  the 
valve  segments  to  close  an  abnormally  large  orifice  or  more  commonly  from 
disease  of  the  segments  themselves.  This  best-defined  and  most  easily 
recognized  of  valvidar  lesions  Avas  flr,st  carefully  stndicd  by  (.'orrigan,  whoso 
name  it  sometimes  bears. 

Etiology  and  Morbid  Anatomy. — It  is  more  frequetit  in  males 
than  in  females,  alTecting  chiefly  able-bodied,  vigorous  men  at  the  middle 
period  of  life.  The  ratio  which  it  bears  to  other  valve  diseases  has  been 
varion.sly  given  from  30  to  50  per  cent. 

Among  the  important  factors  in  ])rodncing  this  condition  are:  («)  Con- 
genital malformation,  particularly  fusion  of  two  segments — most  com- 
monly those  behind  which  the  coroiutry  arteries  are  given  off.  It  is  prob- 
able that  an  aortic  orifice  may  be  competent  with  this  bicuspid  state  of  tho 
valves,  but  a  great  danger  is  the  liability  of  these  malformed  segments  to 
sclerotic  endocarditis.     Of  17  cases  which  I  have  reported  all  presented 


^ 


ria* 


710 


DISHASKS  OP  THE  CIRCULATORY  SYSTEM. 


I, 


lit 

■3 


9-B 

i 


1^ 


,-ck'n.tic  olianfrcs,  and  tlio  ninjovity  ol'  tlinn  liiul,  duiiii^^  lif(\  tlio  clinirnl 
IVatiiivs  of  clironic  hcart-discasi-. 

ih)  Acute  (Midocaiditis.  Tliis  d.u>s  not  produce  aortic  incoinpeteiicy 
unless  tlie  i.rocoss  passes  on  to  ulceration  and  destruction,  under  wliicli 
circumstances  it  is  often  found,  and  may  cause  a  rapidly  fatal  issue.  Sim- 
ple nidocanlitis  associated  with  the  specilie  fevers  is  not  nearly  so  coni- 
m,.n  on  the  aortic  as  on  the  mitral  se-ments;  so  also  with  rheunr.tism, 
which  tilays  a  less  important  role  lu'ie  than  in  mitral  valve  disease. 

(r)  r.yfar  the  most  fiv.pieiit  cause  of  insulliciency  is  a  slow,  'progressive 
sclerosis  of  the  segments,  resulting  in  a  curling  of  the  edges,  which  lessc'iis 
the  workin-'  surface  of  the  valve.     This  may,  of  curse,  follow  acute  (Mido- 
carditi.s  bu't  it  is  so  often  met  with  in  strong,  ahle-hodied  men  among  the 
workin<'  classes,  without  any  history  of  rheumatism  or  special  fehrih;  dis- 
eases w'^ith  which   endocarditis   is   commonly   associated,   that   other   con- 
ditions must  he  sought  for  to  explain  its  fre.iueiicy.     Of  these,  un<iuestion- 
ahlv  strain  is  the  most  important— not  a  sudden,   lorcd.le  strain,  but   a 
persistent  increase  of  the  normal  tension  to  which  the  segments  are  sul),iect 
durin"  the  diastole  of  the  ventricle.     Of  circumstances  increasing  this  ten- 
sion  iieavv  and  excessive  use  of  the  muscles  is  perhaps  the  most  important. 
So  often  is  this  form  of  heart-disease  found  in  persons  devoted  to  ath h'tics 
that  it  is  sometimes  called  the  "  athlete's  heart."     Al.-ohol  is  a  second  im- 
portant factor,  and  is  stated  to  raise  considerahly  the  tension  in  the  aortic 
svstem.    A  eondunation  of  these  two  causes  is  extremely  common.    A    lurd 
element  in  inducing  chronic  sclerotic  changes  in  these  valves  is  syi-liilis. 
Cases  are  rarely  seen  in  which  other  factr)rs  must  not  be  taken  into  account, 
but  the  association  is  too  fre.|ueiit  to  be  accidental.     That  syphilis  is  capa- 
ble of  inducin-^  arterial  sclerc.sis  is,  I  think,  acknowledged,  although  the 
way  in  which  it  does  so  is  not  yet  clear.    It  is  interesting  to  note  with  what 
frcquenev  this  form  of  valve  dis-ase  occurs  in  soldiers.    I  was  struck  with 
this  fact' in  the  riiiladelpbia  Hospital,  to  which  so  many  veterans  (d  the 
civil  war  are  admitted.     1  was  in  the  habit  of  enforcing  upon  my  students 
the  etiological  lesson  bv  a   reference  to  Bacchus  and  Vulcan,  at   whose 
shrines  a  majority  of  the  cases  of  aortic  insuiTicieiicy  have  worshipiicd.  and 
not  a  few  at  those  of  Mars  and  Venus. 

The  condition  of  the  valves  is  such  as  lias  already  be(Mi  dcscnl.ed  in 
chronic  endocarditis.  It  may  be  noted,  however,  bow  slight  a  grade  of 
curlin-'-  mav  ])roduce  serious  incompetency.  Associated  with  the  valve  dis- 
ease is,  in  a  majoritv  of  the  cases,  a  more  or  less  advanced  arterio-sclerosis 
of  the  arch  of  the  aorta,  one  serious  ellect  of  which  may  be  a  narrowing 
of  the  orifices  of  the  coronarv  arteries.  The  sclerotic  changes  are  often 
combined  with  atheroma,  cither  in  the  fatty  or  calcareous  stage.  This  may 
exist  at  the  attached  mar-in  of  the  valves  without  inducing  insufTiciency. 
In  other  instances  insutricieiicv  mav  result  from  a  calcified  spike  projecting 
from  the  aortic  attachment  into  tl'ie  body  of  the  valve,  and  so  preventing 
its  proper  closure.  ^Some  writers  (refer)  have  laid  great  stress  upon  the 
extension  of  the  endarteritis  to  the  valve,  and  would  s(  parate  the  instances 
of  this  kind  from  those  of  simple  valvular  endocarditis.  I  must  say  that 
I  have  not  been  able  to  recognize  clinical  differences  between  these  two  cou- 


i' 

i 


CHRONIC   VALVULAR  DISEASE. 


TU 


tlio  flinirnl 

lu'oiiiiu'toncy 
iinilcr  wliicli 

i.-suc.  Sim- 
:iii_v  so  (•(iiu- 

rlK'Uiii'.tisin, 

:,  j)rngrcs>ivo 
ivliicli  lessens 
-  acute  (Mido- 
n  among  the 
il  fe1)i'ile  ilis- 
t  other  onii- 
,  lUKHiest ion- 
strain,  hut  a 
ts  lire  sulijcit 
sinj;  tliis  teii- 
).-t  important. 
(1  to  athletics 

a  second  im- 

in  tlie  aortic 
lion.  A  thinl 
cs  is  syjiliilis. 

into  account, 
]ihilis  is  eapa- 

althon<rh  the 
ote  witii  whnt 
IS  struck  witli 
eterans  of  the 
n  my  students 
can,  at  whose 
jrshippcd,  and 

II  described  in 
ht  a  firade  of 

tlte  valve  dis- 
irterio-sch'rosis 
w  a  narrowing 
nges  are  often 
igc.  Tliis  may 
ir  insutricieucy. 
pike  i)rojecting 

so  preventing 
tress  upon  the 
e  the  instances 

must  say  that 

these  two  con- 


ditions, though  nnatomically  we  may  sei)arate  the  cases  into  two  gro\ips— 
the  endo(  nrditic  and  the  arterio-sclerotic. 

((/)  Ami.  lastly,  insutliciency  may  be  indiucd  hy  rujiture  of  a  segment 
— a  very  raie  event  in  healthy  valves,  liut  not  uncouunon  in  di>ease.  eitlu  r 
from  excessive  strain  during  heavy  lifting  oi'  from  the  ordinary  ciKhuterial 
strain  in  a  vahe  ei'odcd  ;ind  weakened  hy  uh-cralivi'  cnihicarditis. 

I'cliilirc  iiixii/licii'iirii  of  the  sigmoid  valvt'S,  due  to  dilatalioii  of  the 
aortic  ring,  is  a  rare  condition.  It  is  said  to  occur  in  extensive  arterial 
sclerosis  of  the  ascending  ]i(Ulion  of  the  arch  with  great  dilatation  ju-t 
ahove  the  valves.  Jn  such  ca>es  the  valve  ^eguu'nts  are  usually  involved 
with  the  arterial  coals,  in  aneurism  ju.-t  ahove  the  aortic  ring,  relative  in- 
suilicieiicy  of  the  \i\\vv  may  he  present. 

It  would  ajipear  from  the  careful  measurements  of  I'cncke  that  the 
aortic  orilice.  which  at  hirth  is  'H)  mm.,  inci'cases  gradually  with  the  growth 
of  the  heart  until  at  om'-and-twenty  it  i>  ahout  (!()  mm.  At  this  it  remains 
until  the  age  of  forty,  beyond  which  date  there  is  a  gradual  increase  in  the 
size  u]i  to  the  age  of  eighty,  when  it  may  reach  from  tIS  to  TO  nun.  There 
is  thus  at  the  veiT  period  of  life  in  which  s(derosis  of  the  valve  is  most 
common  a  ]ihy>iolo;^i(al  teiidemy  toward  the  production  of  a  state  of  rela- 
tive insutliciency. 

The  insulVicicncy  may  he  comhined  with  various  grades  of  nai'rowiiig, 
but  the  mnjority  of  the  cases  of  aortic  insuiheiency  ])resent  no  signs  of 
stem)sis.  (»n  the  other  hand,  cases  of  aortic  stenosis  almost  without  ex- 
ception are  associated  with  some  grade,  ]H)wever  slight,  of  regurgitation. 

The  direct  eil'ect  of  aortic  insulliciency  is  the  regurgitation  of  blood 
from  the  artery  into  the  ventricle,  causing  an  overdi.>teution  of  the  cavity 
and  a  reduction  of  the  lilood  colinnn;  that  is,  a  relative  ana'Uiia  in  the  ar- 
terial tree.  As  an  immediate  etl'ect  of  the  double  blood-llow  iiUo  the  left 
ventricle  dilatation  (jf  the  chamber  occurs,  and  linally  hypei'trojihy.  Jn 
this  way  the  valve  defect  is  comi)cnsated  and  as  with  each  ventricular  sys- 
tole a  larger  amount  of  blood  is  pro])elled  into  the  aiterial  system,  the  re- 
gurgitation of  a  certain  amount  during  diastole  does  not,  for  a  time  at  least, 
seriously  impair  the  nutrition  uf  the  i)erii)hcral  ])arts.  In  this  valve  h'si(tn 
dilatation  ami  hypertroidiy  reach  their  most  extreme  limit.  The  heaviest 
hearts  on  record  ai'c  described  in  connection  with  this  all'ection.  'J'lie  so- 
called  bovine  heart,  ror  burin  inn,  may  weigh  '■)')  or  10  ounces,  or  even,  as 
in  a  case  of  ])ulles"s,  48  ounces.  'J'he  dilatation  is  usually  extreme,  and  is 
in  marked  contra>t  to  the  condition  of  the  chamber  in  cases  of  ])ure  aortic 
sleno-is.  The  jiapillary  nuisclcs  may  be  greatly  flattened.  The  mitral 
valves  are  usually  not  seriously  all'ected, though  the  edges  may  ])rescnt  slight 
sclerosis,  and  there  is  often  relative  incom])t'tency,  owing  to  distention  of 
the  I  litral  ring.  JHlatation  and  hypertrophy  of  the  left  auricle  are  com- 
mon, and  secomhiry  enlargement  (d'  the  right  heart  occnrs  in  all  cases  of 
long  standing.  'J'he  myocardium  usually  ])rcsents  changes,  fibroid  or  fatty; 
more  commonly  the  former  in  association  with  disea-e  of  the  coronary  ar- 
teries. The  arch  of  the  aorta  may  present  extensive  arterio-sclerosis  and 
dilatation.  In  the  endocarditic  cases,  particularly  those  following  rheu- 
matism, the  intima  is  perfectly  smooth,  and  the  arch  with  its  main  branches 


I 


rtaA 


•IT' 


^12  DISEASES  OP   THE  ClUCrLATORY  SYSTEM. 

his  cdiidititiii  innv  lie  fduiiil  \n<A  indrtciii  cvi' 
Ik'1'11  Iho  iiin.-t  ;iKinut.ri>tic  si^'iis  of  ciiliirjioiiiciit  oi  tho 


I'  iiot  (lilatia.     This  condition  may  Ik.  f.uiiHl  \n<A  niortrui  .■v^n  wlicn  (luring 

1:  lil'c  lluTc  liavc   ..w.  w.v .  •Ill 

i  arch  an.l  vi  dihitation  ..f  the  iiuiuniinato  and  ngl.t  caivtid.     I  have  even 


kiHuvn  the.  ccnditinn  o[  aneurism  t..  l-c  dia-ncsc..!  whrn  post  n.urU.m  no 
trac-e  of  dilatation  or  s(l..rosis  was  Inund,  only  an  cxtrcnu.  grade  ol  msulh- 
cicn.v  with  cnornious  dilatation  and  hypertrophy.  The.  coronary  arteries 
•uf  u'^uallv  involved  in  tho  sclerosis,  and  their  ordiees  may  he  much  nar- 
n.wcd  \lthou-h  those  vessels  have  hec.n  shewn  hy  Martin  and  S..dfiWRk 
to  he  iilled  durin-  the  ventrieular  systole,  the  eireulatu.n  in  the.a  must  ho 
cn.harrasM..l  in  aortie  inc-ompetemy.  They  must  miss  the  elleet  ot  ho 
l,i„od-pn.ssmv  in  the  sinuses  of  Val-alva  -lurin-  the  elastic  rcvoil  of  the 
arteric.^  whicli  surelv  aids  in  keeping  tlie  eorc.nary  vessels  lull,  i  lie  ar- 
teries of  the  l)odv  usuallv  present  more  or  less  sclerosis  consequent  upon  the 
strain  which  thc'y  undergo  .luring  the  f..rcihle  ventricular  sy>t..le. 

Symptoms.'— The  condition  is  often  discovered  acculentaily  in  per- 
s„i,>  who  have  not  presented  any  features  of  cardiac  disease. 

Headache,  dizziness,  flashes  of  light,  and  a  feeling  of  faintness  on  ris- 
ing duicklv  are  among  the  earliest  symptoms.  I'ali.itatuai  and  carduie 
di"tre<s  on'sli'dit  exertion  are  comnuai.  Long  before  any  signs  of  failing 
compensation  ].ain  may  become  a  marked  and  troublesome  feature.  It  is 
cxtrcmelv  variable  in  its  manifestations.  It  may  he  of  a  dull,  aching  char- 
acter confined  to  the  i.necordia.  More  frciuently,  however,  it  is  sharp 
and  radiating,  and  is  transmitted  up  the  neck  and  down  the  arms,  particu- 
lirlv  tlic  left  Attacks  of  true  angina  i.ectoris  arc  more  frciuent  m  this 
1  thai,  in  any  other  valvular  disease.    Anannia  is  also  common,  much  more  so 

I  than  in  aortic  stenosis  or  in  mitral  alfections. 

I  More  serious  svmptoins,  as  compensation  fails,  are  slinrtncss  ot  l.rcatti 

i  and  cedc.ma  of  tbe  fec.f.    Tl.e  attacks  of  dysim.ea  are  liable  to  come  on  at 

ui.dit    and   the   i.atient   has  to  slc.ep  with   the  head  high   or  even   in   a 
i  chair       Cyanosis    is   rare.      It   is    most   commonly    due    to    complicating 

i  valve   disease,   or   it   is   stated   that   it   may   result   from   bulging   of   tho 

\  sfi.tuin  ventriculorum  and  encroachment  upon  the  right  ventricle.     Of  rc- 

::  spiratory  svmjitoms  cough  mav  develop,  due  to  the  congestion  of  the  lungs 

i  or  cedema.'    IhemojUvsis  is  less  freeiuent  than  in  mitral  disease.     I  have 

i  reported  a  ca<e  in  wldch  it  was  profuse  ami  believed  to  be  due  to  tubercu- 

I  losis  of  the  lungs,  inasmuch  as  the  patient  was  admitted  in  a  state  of  ema- 

<  ciation   and   i)rofound   exhaustion,     (ieneral   dropsy   is   not   common,   but 

;i  cvdcma  of  the  feet  mav  occur  earlv  and  is  sometimes  due  to  the  anaMuia.  at 

;i  others  to  the  venous  stasis,  at  times  to  both.     Unless  there  is  coexisting 

i  disease  of  the  mitral  valve,  it  is  rare  in  aortic  incom])etcncy  for  the  patient 

^^  to  die  with  general  anasarca.     Sudden  death  is  frcpient;  more  so  in  tins 

i  than  in  other  valvular  diseases.     As  compensation  fails  the  patient  takes 

jl  to  bod  and  slight  irreunilar  fever,  associated  usually  with  a  recurring  endo- 

i  carditis,  is  not  uncommon  toward  the  close.     Embolic  symi)tonis  are  not 

'V  infreciuent— pain  in  the  splenic  region  with  enlargement  of  the  organ, 

hiomaturia,  and  in  some  cases  paralysis.     Distressing  dreams  and  disturbed 
ii  sleep  are  more  common  in  this  than  in  other  forms  of  valvular  disease. 

!|  Here  mav  appropriately  be  mentioned  the  connection  between  mental 


vlicn  (luring 
uciit  u£  the 
I  have  even 

iiiiirtciu  no 
U'  (li  iut^ulU- 
lary  ai'turits 
L'  nuK'l.  nar- 
1(1  S('(lfi;\viek 
uMi  must  1)0 

llVct  uC  tho 
ifCdil  (if  tho 
ill.  Tlio  ar- 
jiit  upon  tlio 
-tulc. 
tally  in  per- 

tnoss  on  ris;- 
and  cardiao 
ns  of  failing 
■atuve.  It  is 
atliiug  cliar- 
,  it  is  sharp 
rms,  particu- 
juont  in  this 
luicli  nioro  so 

CSS  of  Lrcath 

0  conic  on  at 
)r  even  in  a 

complicating 
Iging  of  the 
riclo.     Of  rc- 

1  of  the  lungs 
ease.  I  have 
le  t(^  tulicrcu- 

stato  of  enia- 
connnon,  but 
lie  auiiMuia.  at 

is  coexisting 
or  the  jtatient 
ore  so  in  this 

patient  takes 
cnrring  cndo- 
itoms  are  not 
of  the  organ, 
and  disturbed 
ir  disease. 


tweeu  mental 


CIIROlNnc  VALVUIi.Ml  DISEASE. 


■i;{ 


pvmptiuns  and  cardiac  disease,  as  tliey  are  oftcnest  seen  with  this  lesion.  An 
admiralile  acrount  of  the  relations  Itclween  insanity  and  disease  of  the  heart 
is  to  he  found  in  Mickle's  (iidstonian  lectures  for  l.sSS.  in  geneial  med- 
ical practice  we  .-cldom  lind  marked  menial  syiH)itoms.  e\(cpt  toward  the 
close  of  the  disease,  when  there  may  hi'  delirium,  hallncinalions,  ami  mor- 
bid hnpnlscs.  It  is  to  he  remeinliered  that  in  many  luait  cax's  this  ter- 
minal delirium  is  uneniic.  The  irritaliility  and  pcevishiie.-s  sometimes 
found  in  ]>ersons  the  subject  of  organic  heart-disease  caniKit.  I  think,  he 
associated  with  it  in  any  si»ecial  manner.  We  do  meet  insanity,  breaking 
out  in  [)atients  with  aortic  and  mitral  disease,  in  the  stage  of  compensation, 
which  appears  to  l)e  related  definitely  to  the  cardiac  lesion.  It  is  important 
to  hear  this  in  ndnd.  for  eases  occasionally  dis|)Iay  suicidal  tendencies.  1 
have  twice  bad  patients  throw  themselves  from  a  window  of  the  ward. 

Physical  Signs. — Insiirction  shows  a  wide  and  forcible  area  of  cardiac 
impulse  with  the  apex  beat  in  the  sixth  or  seventh  interspace,  and  perhajis 
as  far  out  as  the  anterior  axillary  line.  In  young  sid)jects  the  pra'cordia 
may  bulge.  On  jmliiation  a  thrill,  diastolic  in  time,  is  occasionally  felt, 
l)ut  is  not  common.  The  impulse  is  usually  strong  and  heaving,  unless 
in  conditions  of  extreme  dilatation,  when  it  is  wavy  and  indelinite.  Occa- 
sionally two  or  three  interspaces  betwcHMi  the  nipjde  line  and  sternum  will 
be  depressed  with  the  systole  as  a  result  of  atmos])lieric  pressure,  rciriii'sidn 
shows  a  greater  increase  in  the  area  of  heart  dulness  than  is  found  in  any 
other  valvular  lesion.     It  extends  chieily  downward  and  to  the  left. 

On  (nisriiUalinn  there  is  beard  a  murmur  during  diastole  in  the  second 
right  interspace,  which  is  jtropagated  with  intensity  toward  the  eusiform 
cartilage,  or  down  the  left  margin  of  the  sternum  toward  the  apex.  In 
the  niajcmty  of  cases  it  is  a  soft,  long-drawn  hniit.  and  is  of  all  cardiac 
niurmurs  the  most  trustworthy.  It  occurs  during  the  time  of,  and  is  pro- 
duced l)y,  the  reflux  of  blood  fronr  the  aorta  into  the  ventricle.  In  a  large 
})roportion  of  the  cases  there  is  also  a  systolic  murmur  heard  at  the  aortic 
region,  usually  shorter,  often  rougher  in  (piality,  and  which  may  lie  propa- 
gated npwani  into  the  neck.  A  common  mistake  is  to  regard  this  as 
indicating  stenosis,  whereas  in  the  great  majority  of  instances  of  aortic 
insufficiency  there  is  no  material  narrowing,  and  the  murmur  is  produced 
bv  roushening  of  the  segments  or  of  the  intima  of  the  arch.  'I'lie  scc<md 
S(jund  Ts  usually  obliterated,  but  when  the  valves  are  only  slightly  curled  or 
if  one  cus])  only  is  involved  both  the  murmur  and  the  valvular  sound  may 
be  distinctly  heard.  At  the  apex  murmurs  are  also  heard,  either  transmitted 
from  the  aortic  orifice  or  jn'oduccd  at  the  mitral.  In  the  majority  of  cases 
with  aortic  incompetencv  of  high  grade,  the  mitral  orifice  is  dilated,  and 
there  is  relative  insufficiency  of  the  valves.  It  can  fretjuently  be  deter- 
mined that  the  systolic  murmur  at  the  apex  differs  in  (jiiality  from  that  at 
the  base.  A  second  murmur  at  the  apex,  probably  produced  at  the  mitral 
orifice,  is  not  uncommon.  Attention  was  called  to  this  by  the  late  .\.ustin 
Flint,  and  the  murmur  usually  goes  by  his  name.  It  has  a  distinctly  rum- 
bling ([ualitv,  is  limited  in  area,  and  is  sometimes,  though  not  always,  ex- 
actly pn^systolic  in  time.  The  explanation  of  its  occurrence,  as  given  by 
Flint,  is  that  in  the  extreme  dilatation  of  the  ventricle  the  mitral  segments 


m^ 


1 


u. 


Yi.^  DISKASES  OF  TIIK  CIUCULATOUY  SYSTEM. 

iimuoi  duriiij;  dinstolo  be  f<.rctHl  l)iid<  n-iiinst  tlu>  wall,  nn.l  Ihcnforo.  rc- 
luaininj,'  in  llio  I.Io.rI  eiinvnt,  tlu'V  l-rcihu'C  ii  >^uvi  of  ivlativo  iiarn,win,u% 
1,11(1  iii^oiisniuciuc  a  vibratory  iminiuir  not  unlike  in  (jnabty  tlic  [.rcsys- 
tolic  niunniir  nf  mitral  stenosis?.  r.n.adlK'ni,  on  tbo  other  band,  siij.-fsts 
tliat  the  rc'Mir-itant  current  from  tlio  aorta  iin|)injrinj.'  upon  tiio  anterior  or 
a,.'rlie  llai.'of  "the  mitral  uiay  .set  it  into  vilirati(.n  and  thus  produee  the 
munnur  This  ajicx  diastolie  murniur  of  aortie  iusullieieney  oeonr  in  a 
...HMderabi.  proportion  oi'  all  eaxs.  It  is  variable,  and  may  disappear  as 
the  dilatation  of  the  veiilriele  diminishes.  Their  is  never  the  h.ud  systolic 
shoek  whieh  follows  the  murmur  of  mitral  stenosis. 

The  I'xaminaliou  of  the  arteries  in  aortic  insunieieiicy  is  of  great  value. 
Visible  pulsition  is  more  coinnionlv  seen  in  the  peripheral  vessels  m  this 
than  in  anv  other  condition.     The  carotids  may  be  seen  to  throb  forcibly, 
the  tempcmds  to  dilate,  and  the  brachials  and  ra.lial-  t..  exi-aud  with  each 
heart-beat.    With  the  ophthalnioscoi.e  the  retinal  arteries  are  seen  to  pu  - 
sate      Not  onlv  is  the  ].ulsation  evident,  hut  the  characteri>tic  jerkm--  qual- 
itv  is  api)arent.     In  the  thmat  the  tlirobhinj.^  carotids  may  lead  to  the 
dia-nosi.  of  aueuriHU.     in  many  cases  the  pulsation  can  be  seen  in  the  su- 
,,ra"lernal   nouh,  and   i.rominent,  fnreibly-throbbinj,'  vessels  beneath  the 
ri.dit  steruo-mastoid   nniscle.     The  abdominal  aorta   may   lift   the  epigas- 
trhim  with  each  svslole.     To  be  mentioned  with  this  is  the  capillary  pulse, 
met  verv  ofti'ii  in  aortie  iusullieieney,  and  best  seen  in  the  linger-uails  or  by 
drawiujr  a  line  upon  the  forehead,  when  the  margin  (.f  hyi.era'inia  on  either 
Mde  alt'ruaiclv  l)lushes  and  j.ales.     In  extreme  grades  the  face  or  the  hand 
may  blush  visiblv  at  each  systole.     It  is  met  with  also  in  profoumi  amvnna, 
occasionallv  in  neurasthenia,  and  in  health  in  conditions  of  great  relaxa- 
tion of  the  peripheral  arteries,   ridsallou  may  also  be  pirsent  in  the  periph- 
eral  veins.      On   ].alpation   the   cbaracteristie   water-hammer   or   Corrigan 
pulse  is  felt.     In  the  majority  of  instances  the  pulse  wave  strikes  the  finger 
forcibly  with  a  (piick  jerking  imjudse,  and  immediately  recedes  or  collapses. 
The  characters  of  this  are  sometimes  best  appreciated  by  grasping  the  arm 
above  the  wrist  and  holding  it  up.     :Moreover.  the  ]nilse  of  aortic  regurgita- 
tion is  usually  retarded  or  delayed— i.  e.,  there  is  an  appreciable  interval 
between  the  beat  of  the  heart  and  the  pulsation  in  the  radial  artery,  winch 
varies  according  to  the  extent  of  the  incompetence.     On  auscultation  a 
double  muimui^mav  be  heard  in  the  carotids  and  subclavians  when  it  is 
present  at  the  aortic  orifice.     Occasionally  in  the  carotid  the  second  sound 
is  distinctlv  audible  when  absent  at  the  aortic  cartilage.     Indeed,  accord- 
m<r  to  r.roadbent,  it  is  at  the  carotid  that  we  must  listen  f(n'  the  second 
aortic  sound,  for  when  heard  it  indicates  that  the  regurgitation  is  small  in 
anunint,  and  is  conse<iucntly  a  very  favorable  prognostic  element.     In  the 
femoral  artery  a  double  nuirnuir  also  may  be  heard  sometimes,  as  pointed 
out  by  Duroziez. 

Aortic  insufliciency  may  for  years  be  fully  compensated.  Persons  do 
not  necessarily  suffer  anv  inconvenience,  and  the  condition  is  often  found 
aceidentaViv.  "  So  long  as  the  hypertrophy  just  equalizes  the  valvular  de- 
fect there  may  bo  no  sym])toms  and  the  individual  may  even  take  moder- 
ately heavy  exercise  without  experiencing  sensations  of  distress  about  the 


fllRONir   VALVULAR  DISEASE. 


'i; 


ilu'i'cforo.  ro- 
f  iiiiiTuwiiiir, 
\-  till'  [in'sys- 

111(1,    SllJiJifsIS 

10  anU'rinr  or 
produce  tlio 

■  oc'cnir  in  a 
(lisappoar  a-< 
lo'.ul  siy^tolic 

f  jircal  valuo. 
i's<e'ls  in  tliis 
irob  fiircibly, 
nd  witli  each 
'  seen  to  iiul- 
jerlxin^'  qiial- 

■  lead  to  llio 
■en  in  the  su- 

heneatii  the 
't  tlie  eiiigas- 
ijiilhiry  pulse, 
ter-iiails  or  hy 
■luia  on  either 
e  or  the  hand 
ound  ana'iuia, 

j^^reat  relaxa- 
in  the  periph- 
'  or  Corrigan 
ikes  the  iinjier 
■s  or  coUapses. 
sping  the  arm 
rtic  regurgita- 
'ialile  interval 

artery,  whieli 
auscultation  a 
ins  when  it  is 
!  second  sound 
ndeed,  aceord- 
fiu'  the  second 
ion  is  small  in 
iiient.  In  tlie 
[les,  as  pointed 

1.  Persons  do 
is  often  found 
le  valvular  de- 
m  take  moder- 
trcss  about  the 


lieart.  The  cases  whidi  last  tiie  longest  are  tlioso  in  which  the  insuiricieiicy 
follows  eiidocai'ditis  and  is  not  a  jiart  ol'  a  general  artcrio-sclerosis.  The 
age  of  the  patient  too.  at  tlie  time  the  lesion  is  ai<iuire(l.  is  a  most  important 
consideration,  as  in  youth  the  heart  is  niMch  more  prone  to  take  on  com- 
]iensatoiy  changes,  ('oexisteiil  loioiis  of  the  mitral  valves  tend  early  to  di- 
tiirl)  the  compeiisatioii.  It  has  scarcely  been  sullicieiitly  recognizt'd  by  the 
jirol'ession  at  large  that  pure  aortic  insutlleiciicy  is  consistent  with  years  of 
average  health  and  with  a  tolerably  active  life.  1  know  several  [ihysicians 
with  aortic  insulliciency  who  have  been  able  to  carry  on  for  yiars  large  and 
somewhat  onerous  jiractices.  One  of  them  since  the  estahlishnient  of  iii- 
sutlicieiU'V  has  [lassed  successfully  through  two  attacks  of  acute  rheuma- 
tism, in  a  large  hospital  practice,  scarcely  a  month  passes  without  the  dis- 
covery of  a  case  of  aortic  insuiliciency  in  connection  with  some  other  af- 
fection. 

Willi  the  onset  of  mvocanlial  changes,  with  increasing  degeneration  of 
the  arteries,  ]iarticularly  with  a  ]irogressive  sclerosis  of  the  arch  and  in- 
volvement of  the  orilices  of  the  coronary  arteries,  the  compensation  liecoiiies 
disturbed.  In  advanced  cases  the  changes  about  the  aorlic  ring  may  be 
associated  with  alterations  in  the  cardiac  nerves  and  ganglia,  and  so  intro- 
duce an  important  factor. 

3.  Aortic  Stknosis, 

Narrowing  or  stricture  of  the  aortic  orifice  is  not  nearly  so  ccunmon  as 
insulliciency.  The  two  conditions,  as  already  stated,  may  occur  together, 
however,  aiid  jiroliably  in  almost  every  case  of  stenosis  there  is  some  leakage. 

Etiology  and  Morbid  Anatomy.— In  the  milder  grades  there  is 
adhesion  between  the  segments,  which  are  so  still'eiied  that  during  systole 
they  cannot  be  pressed  back  against  the  aortic  wall.  The  process  of  cohe- 
sion between  the  segments  may  go  on  without  great  thickening,  and  pro- 
duce a  condition  in  which  the  oriiice  is  guarded  by  a  comparatively  thin 
membrane,  on  the  aortic  face  of  which  may  be  seen  the  primitive  raphes 
separating  the  sinuses  of  Valsalva.  In  some  instances  this  membrane  is 
so  thin  and  presents  so  few  traces  of  atlieromatous  or  sclerotic  changes  that 
the  condition  looks  as  if  it  had  originated  during  fietal  life.  ^More  com- 
monly the  valve  segments  are  thickened  and  rigid,  and  have  a  cartilaginous 
hardness.  In  advanced  cases  they  may  be  represented  by  still',  calcilieil 
masses  obstructing  the  orifice,  through  which  a  circular  or  slit-like  passage 
can  be  seen.  The  older  the  patient  the  more  likely  it  is  that  the  valves 
will  be  rigid  and  calcified. 

We  may  speak  of  a  relative  stenosis  of  the  aortic  orifice  when  with  nor- 
mal vahW  and  ring  the  aorta  immediately  bey(md  is  greatly  dilated.  A 
stenosis  due  to  involvement  of  the  aortic  ring  in  sclerotic  and  calcareous 
changes  without  lesion  of  the  valves  is  referred  to  liy  some  authors.  I  have 
never  met  with  an  instance  of  this  kind.  A  subvalvular  stenosis,  the  result 
of  endocarditis  in  the  mitro-sigmoidean  sinus,  usually  occurs  as  tlie  result  of 
fcetal  endocarditis.  In  comparison  with  aortic  insulliciency,  stenosis  is  a 
rare  disease.     It  is  usually  met  with  at  a  more  advanced  period  of  life  than 


no 


DISKASIW  OF  TllK  flUCrLATOKY  SVSTKM. 


ii.siillicicncv,  niul  the  iii..st  typical  cuscs  of  it  an-  fmmd  associated  with 
cxtcii-ivi'  calcanM.iis  tiiaiips  in  tlu'  arterial  system  in  old  nun. 

Wlieii  "raduallv  i.n.diurd  aii<l  wIhh  tli.Mv  is  not  imi.li  iiisiinicioncy 
(lu.  ,lilatati"nii  of  till'  left  veiitri.lc  may  l.e  sli-l.t,  tlioi.-ii  I  tiiink  that  in 
all  cases  it  does  oeeiir.  Tlie  walls  of  tiie  ventrieles  h.'eome  hyperlrophied 
and  wo  «ee  in  this  condition  the  most  tyjucal  in>^tances  of  what  i.s  called 
concentric  iivi.crtroi.l'v.  in  ^vl>i<•l^  ^^'ll'""<  '""*'''  ''"  "">''  '■'•l'>''P'"'7't  "f 
the  cavitv.  tiie  walls  are  -reatlv  tliiekeiicd.  in  contradistinction  to  the  so- 
rdid eccentric  hviu'itrophv.  in  which.  VMth  tiie  increase  in  the  thickness 
„r  the  walls,  th.'  ciian.hcr  itself  is  jrrcatly  dilate.l.  'I'here  may  he  no  chancres 
in  the  other  cardiac  cavities  if  cmni.ensatiim  is  well  inaintaiiied;  hut  with 
its  failure  come  dilatation,  impeded  auricular  dischai-e.  pulmonary  cm- 
cc<tioii.  and  in.reaM.l  work  for  the  ri-lit  heart.  The  arterial  cliaii-es  are. 
as  a  rule,  not  so  marked  as  in  aortic  insulliciency,  for  the  walls  have  not 
lo  withstand  the  impulse  of  a  jrrcatly  increased  Idood-wave  with  each  sys- 
tole On  the  c.mtrarv.  the  amount  of  Mood  prui^Hi'd  throii-h  the  narrow 
orifice  may  ho  smaller  than  normal,  tl.ou-li  when  compensation  is  tully 
c-taldishcd  the  pulse-wave  mav  he  of  medium  v(diinie. 

Symptoms.— Physical  Signs.— I nsinrlim  may  fail  to  reveal  any  area 
of  cardiac  imi.ulso.  Particularly  is  this  the  case  in  (dd  men  with  rifiid 
chest  walls  and  lar<ro  emi)hvscmatous  Innjrs.  rndcr  these  circiim>taneo3 
there  mav  ho  a  hij-h  grade  of  hypertmidiy  without  any  visihle  impulse. 
Even  when  the  ai-ex  heat  is  visihle.  it  may  he,  as  Traulie  pointed  out.  iechle 
and  indefinite.  In  many  cases  the  apex  i^  seen  displaceil  downward  and 
outward,  and  the  impulse  looks  stroii},'  and  forcihlc. 

J'alpnlwu  reveals  in  many  cases  a  thrill  at  the  hase  of  the  heart  of 
maximum  force  in  the  aortic  re<.!:ion.  AVith  no  other  condition  do  wo  meet 
with  thrills  of  ;.n-eater  inti^nsity.  The  apex  heat  may  not  he  palpahlo  under 
the  conditions  aliove  mentioned,  or  there  may  he  a  slow,  heavinir,  forcihlc 

impulse.  ,  . 

rcnussiiin  never  <;ivcs  the  same  wide  area  of  dulness  as  in  aortic  iii- 
snfTicicncy.  The  extent  of  it  depends  lar-cly  on  the  state  id'  the  lungs, 
whether  emiihysematous  or  not. 

Au>tciiIl(ilinii.—\  systolic  murmur  of  maximum  intensity  at  the  aortic 
cartHage,  and  proiiapated  into  the  great  vessels,  is  present  in  aortic  stenosis, 
hnt  is\v  no  means  italhognomonic.  One  of  the  last  lessons  learned  hy 
the  student  of  physical  diagnosis  is  to  recognize  the  fact  that  this  systolic 
murmur  is  onlv  iii  comparatively  rare  cases  produced  hy  decided  narrowing 
of  the  aortic  orifice.  Ihnighening  of  the  valves,  or  the  intiina  of  the  aorta, 
and  iKvmic  states  are  much  more  frequent  causes.  In  aortic  stenosis  the 
miirnuir  often  has  a  much  harsher  quality,  is  louder,  and  is  more  fretiuently 
musical  than  in  the  conditions  just  mentioned.  When  compensation  fads 
and  the  ventricle  is  dilated  and  feehle.  the  murmur  may  he  soft  and  distant. 
The  second  sound  is  rarelv  heard  at  the  aortic  cartilage,  owing  to  the  thick- 
ening and  stitfnoss  of  the  valve.  A  diastolic  murmur  is  not  uncommon, 
hut  In  many  cases  it  cannot  he  heard.  Occasionally,  as  noted  hy  ^^  .  IT. 
Dickinson,  there  is  a  musical  nuiruuir  of  greatest  intensity  in  the  region  of 
the  apex,  due  prohahlv  to  a  slight  regurgitation  at  high  pressure  through 


iL 


(IC 


iati'd  with 


insutluipnoy 
liiiik  that  ill 
vpt  rlrdphii'il. 
hat  is  ralkd 
hir^M'iiu'iit  of 

111  to  thi'  !*0- 
Ihi'  tiiiriuicss 
)('  no  chancres 
I'd;  but  with 
Imonary  c-on- 

cliaiigcs  are, 
alls  have  not 

ith  each  svs;- 
li  thi'  narrow 
itioii  is  fully 

'vcal  any  area 
•n  witli  rijrid 
iir<'uni>tan(i's 
<il)lo  impulse. 
I'd  out.  IVililc 
uwnward  and 

the  heart  of 
111  do  wc  nit'i't 
mlpalilo  under 
iviuL 


foreil 


)ie 


;  in  aortic  iii- 
uf  the  lungs, 

■  at  the  aortic 
iiortic  stenosis, 
ns  learned  hy 
it  this  systolic 
ded  narrowin<:f 
a  of  the  aorta, 
ic  stenosis  the 
lore  frequently 
lu'iisation  fails 
ift  and  distant. 
If  to  the  thiek- 
ot  nneonimon, 
)ted  hy  W.  11. 
1  the  region  of 
cssurc  throush 


CMUONIC   VAI,VIL.\U    DISHASi:. 


717 


lh(>  niilral  vaho.  The  pnl-e  in  pure  aortic  >lcnosis  is  small,  Usually  of 
^'iiod  ten-ion.  wdl  su-taiind.  reuMilar.  and  |ierhaps  -louir  than  nnniial. 

The  condition  may  lie  latnit  for  an  inildiiiilc  period,  as  Ion;.'  as  the 
hvpertrophy  is  maiiitaiiie(|.  Marly  symptoms  are  tlio,-.c  due  to  defe(tiv(3 
ll|(lod-^upply  til  the  hrain,  diz/tiness,  ami  fainting.  I'alpilalioii.  jiain  aiioiit 
the  heart,  and  an;;inal  symptoms  are  not  so  marked  a<  in  in>uiri(  ieiicy. 
With  (legem  ration  of  the  lu'art-mnscle  and  dilatation  relative  insuHlcieiicy 
of  the  mitral  valve  is  estahlisheil.  and  the  patient  may  present  all  the  fi'U- 
lures  of  engorgement  in  the  lesser  and  .s\steiiiic  circulations,  with  dys|)mea, 
cough,  rusty  expectoration,  and  the  signs  of  anasarca  in  tlu'  lower  part  of 
the  Inidy.  .Many  of  the  cases  in  old  people,  without  presenting  any  dropsy, 
have  symptom.-  pointing  rather  to  general  arterial  disease.  ('heyiie-Stokc.s 
lireathing  is  not  uncommon  with  or  without  signs  of  ura'iiiia. 

Diagnosis.  —  With  an  exticmely  rough  or  musical  miirmur  of  maxi- 
mum intensity  at  the  aortic  region  and  signs  of  hypertrophy  of  the  left 
ventricle,  a  thrill,  and  e-pccially  a  hard,  slow  pulse  of  moderate  volume  and 
fairly  good  tension,  which  in  sphygmographic  tracing  gives  a  curve  of  slow 
rise,  a  iuoad  well-sustained  summit  and  slow  decline,  a  diagnosis  of  aortic 
stenosis  can  he  made  with  some  degree  of  ]irohaliility,  jiartieiilarly  if  the 
siihjcet  is  an  old  man.  Mistakes  are  common,  Imwever.  and  a  roiiglu'iied 
or  calcilied  valve  segment,  or.  in  some  instances,  a  very  roughened  and 
prominent  calcilied  |ilate  in  the  aorta,  and  hypt'rtro|)hy  associated  with 
renal  disease,  may  |iro(luce  similar  symptoms. 

].ct  me  re])cat  that  a  mnnniir  of  maxiniiim  intensify  at  the  aortic  car- 
tilage is  of  no  importance  in  itself  as  a  diagnostic  sign  of  stenosis.  Ifough- 
ening  of  the  valve,  sclerosis  of  the  intima  of  the  arch,  and  anieniia  are  con- 
ditions more  freipieiitly  as.sociated  with  a  systolic  muriniir  in  this  region. 
Seldom  is  there  ditliculty  in  distinguishing  the  murmur  due  to  amemia, 
.since  it  is  rarely  .so  inten.<e  and  is  not  associated  with  thrill  or  with  marked 
hypertrophy  of  the  left  ventricle.  In  aortic  insulliciem'y  a  systolic  mur- 
mur is  usually  in'esent,  hut  has  neither  the  intensity  nor  the  miisi<a!  (jual- 
ity.  nor  is  it  accompanied  with  a  thrill.  Willi  roughening  and  dilatation 
of  the  ascending  aorta  the  nuirmnr  may  he  very  harsh  or  musical;  l)iit  the 
cxistince  of  a  second  sound,  accentuated  and  ringing  in  (quality,  is  usually 
sullicieut  to  dill'erentiate  this  condition. 

■1.  ]\Irn{.\L  Ixco.ni'KTKNX'Y. 

Etiology. — Insufhcieney  of  tlie  mitral  valve  results  from:  (") 
Changes  in  the  segments  wherehy  they  are  contracted  and  shortened,  usu- 
ally comhined  with  changes  in  the  chonhv  teiidinea^  or  with  more  or  le-s 
narrowing  of  the  orifice.  (/*)  As  a  result  of  changes  in  the  muscular  walls 
of  the  ventricle,  either  dilatation,  so  that  the  valve  segments  fail  to  close 
an  enlarged  orifice,  or  changes  in  the  niuscuhir  substance,  so  that  the  seg- 
ments are  im])erfeetly  coapted  during  the  systole — muscular  incompetency. 
The  common  lesions  producing  insnilicieiicy  result  from  endocarditis,  which 
causes  a  gradual  thickening  at  the  edges  of  the  valves,  contraction  of  the 
chorda}  tcndineiv.  and  nnion  of  the  edges  of  the  segments,  so  that  in  a 


II 


1 1. 

if 
'I 


-IS  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

niaiority  of  tlie  instances  there  is  not  only  insnnieieney,  Imt  some  grade  of 
narrowing  as  well.  Except  in  chiklron,  we  rarely  see  the  nutral  leallels 
curled  and  i.uckered  without  narrowing  of  the  orifice.  Calcareous  plates 
■it  the  base  of  the  valve  niav  prevent  perfect  closure  of  one  of  the  segments. 
In  lon<T-standing  cases  the  entire  mitral  structures  arc  converted  into  a  firni 
ealearc^.us  ring."  From  this  valvular  insulliciency  the  other  condition  .if 
muscular  incompctencv  must  he  carefully  distinguished.  It  is  met  with 
in  all  conditions  of  extreme  dilatation  of  the  left  ventricle,  and  also  in 
weakening  of  the  nniseles  in  prolonged  fevers  and  in  anaemia. 

Morbid  Anatomy.— The  effects  of  incompetency  of  the  mitral  seg- 
ment upon  the  heart  and  circulation  are  as  follows:  («)  The  imperfect 
closure  allows  a  certain  amount  of  hlood  to  regurgitate  from  the  ventricle 
into  the  auricle,  so  that  at  the  end  of  auricular  diastole  this  cluunher  con- 
tain^ not  only  the  hlood  which  it  lias  received  from  the  lungs,  hut  also  that 
which  has  regurgitated  from  the  left  ventricle.  This  necessitates  dilata- 
tion, and,  as  increased  ^\ork  is  thrown  upon  it  in  expelling  the  augmented 
contents,  hviiertrophy  as  well.  <.,,!• 

(b)  With  each  svstole  of  the  left  auricle  a  larger  volume  ot  blood  is 
forced  into  the  left  Ventricle,  which  also  dilates  and  suhsequeiitly  becomes 

hvi)ertrophied.  •.   .    i  •   * 

'  {(■)  During  the  diastole  of  the  left  auricle,  as  blood  is  regurgitated  into 
it  from  the  left  ventricle,  the  pulmonary  veins  are  less  readily  emptied. 
In  conseciuence  the  right  ventricle  expels  its  contents  less  freely,  and  m 
turn  becomes  dilated  and  hypertrophied. 

((/)  Finahy,  the  right  auricle  also  is  involved,  its  chamber  is  enlargetl, 
and  its  walls  are  increased  in  thickness. 

(e)  The  effect  upon  the  pulmonary  vessels  is  to  produce  dilatation  botli 
of  the  arteries  and  veins— often  in  long-standing  cases,  atheromatous 
changes;  the  capillaries  are  distended,  and  ultimately  the  condition  ot 
brown  induration  is  produced.  Perfect  compensation  may  be  cfTected, 
chiefly  through  the  hvpertrophy  of  both  ventricles,  and  the  effect  upon 
the  peripheral  circulation  may  not  be  manifested  for  years,  as  a  normal 
volume  of  blood  is  discharged  from  the  left  heart  at  each  systole.  The 
time  comes,  however,  Avhen,  owing  either  to  increase  in  the  grade  of  the 
incompctencv  or  to  failure  of  the  compensation,  the  left  ventricle  is  unable 
to  send  out  it^-  normal  volume  into  the  aorta.  Then  there  is  overfilling  of 
the  left  aurice.  engorgement  in  the  lesser  circulation,  embarrassed  action 
of  the  ridit  heart,  and  congestion  in  the  systemic  veins.  For  years  this 
somewhat  congested  condition  mav  be  limited  to  the  lesser  circulation,  but 
finally  the  right  auricle  becomes  dilated,  the  tricuspid  valves  incompetent, 
and  the  systemic  veins  are  engorged.  This  gradually  leads  to  the  condi- 
tion of  cyanotic  induration  in  the  viscera  and,  when  extreme,  to  dropsical 

effusion.  e    ^  -t-    ^        i 

Muscular  incompe*^encv,  dm.  to  impaired  nutrition  of  tlie  mitral  ami 
pa])illary  muscles,  is  raielv  followed  by  such  perfect  compensation.  There 
may  be'in  acute  destruction  of  the  aortic  segments  an  acute  ddatation  of 
the  left  ventricle  with  relative  incompetency  of  the  mitral  segments,  great 
dilatation  of  the  left  auricle,  and  intense  engorgement  of  the  lungs,  under 


^ktas^i^^i^ 


lino  grade  of 
lit  Till  lealk'is 
u'C'oiis  plati'S 
he  segments. 
(1  inlo  a  Ili'in 
condition  oC 
is  mot  with 
and  also  in 

0  mitral  sog- 
ho  imporfoot 
tho  vontriolo 
iluunhor  oon- 
but  also  that 
iitatos  dilata- 
10  augniontod 

0  of  blood  is 
.'iitly  bocomos 

irgitatcd  into 
(lily  emptied. 
!reely,  and  in 

'r  is  enlarged, 

ilatation  both 

atheromatous 

condition  of 

\-  be   effected, 

10  effect  npon 

,  as  a  normal 

systole.     Tho 

'  grade  of  the 

riole  is  unable 

?  overfilling  of 

irrassed  action 

For  years  this 

irculation,  but 

s  incompetent, 

to  the  condi- 

10,  to  dropsical 

ho  mitral  and 
sation.  There 
:e  dilatation  of 
;ogii;onts,  great 
10  lungs,  under 


CIIROXIU   VALVULAR,  DlSEASK. 


719 


which  cironmstanecs  profuse  lia'morrhagc  may  result.  In  these  oases  Huto 
is  little  chance  i\)r  the  ostablishment  of  compensation,  in  cases  of  hvpcr- 
tropliy  and  dilatation  of  the  heart,  witiioiit  Valvular  lesions,  hut  associalod 
with  heavy  work  and  alcohol,  the  insullicieiicy  of  the  mitral  valve  inay  hi; 
c.xti'cino  and  load  to  groat  pulmonary  congestion,  engorgoiuont  of  tho  svs- 
triiiic  veins,  and  a  condition  of  cardiac  drojisy,  which  cannot  bo  distiii- 
guishcil  liy  any  feature  from  that  of  mitral  incompetency  duo  to  lesion  of 
the  valve  itself.  In  chronio  iSright's  disease  tho  hypertrophy  of  the  left 
ventricle  may  gradually  fail,  loading,  in  the  later  stages,  to  relative  in- 
sullicieiuy  of  the  mitral  valve,  and  the  production  of  a  condition  of  pul- 
monary and  systemic  congestion,  similar  to  that  induced  by  the  most  ex- 
treme grade  of  lesion  of  the  valve  itsoli'.  Adherent  iioi'icardium,  espeoially 
in  children,  may  lead  to  like  results. 

Symptoms. — During  tho  develo]unont  of  the  lesion,  unless  the  in- 
competency comes  on  acutely  in  consequence  of  rupture  of  the  valve  seg- 
ment or  of  ulceration,  the  comiionsatory  changes  go  hand  in  hand  with  tho 
defect,  and  there  are  no  subjective  symi)tonis.  Ho,  also,  in  the  stage  of 
perfect  compensation,  there  may  bo  the  most  extreme  grade  of  mitral 
insuincioncy  with  enormous  hypertrophy  of  the  heart,  yet  tli(>  patient  may 
not  be  aware  of  tho  o.xisteiico  of  heart  trouble,  and  may  siilfor  no  incoa- 
venicnce  oxce]it  ]iorhaps  a  lillK'  shortness  of  breath  on  exertion  or  on  going 
upstairs.  It  is  only  when  from  any  cause  the  compensation  has  not  boon 
perfectly  effected,  or,  having  been  so,  is  broken  abruptly  or  gradually,  that 
the  patients  begin  to  bo  troubled.  The  symptoms  may  ho  divided  into  two 
groups: 

(a)  The  miiun-  manifestations  while  compensation  is  still  good.  Pa- 
tients with  extreme  incompetency  often  have  a  congested  ai)|)oarance  of 
the  face,  tho  lips  and  ears  have  a  bluish  tint,  and  the  venules  on  the  cheeks 
may  be  enlarged,  which  in  many  cases  is  very  suggestive.  In  long-standing 
cases,  partinilarly  in  children,  tho  fingers  may  be  clubbed,  and  there  is 
shortness  of  breath  on  exertion.  This  is  one  of  the  most  constant  features 
in  mitral  insnfTicioncy,  and  may  exist  for  years,  even  when  the  compensa- 
tion is  perfect.  Owing  to  the  somewhat  congested  condition  of  the  lungs 
those  patients  have  a  tendency  to  attacks  of  bronchitis  or  haMno[)tysis. 
There  may  also  be  ))alpitation  of  the  heart.  As  a  rule,  however,  in  well- 
balanced  lesions  in  adults,  this  ]ioriod  of  full  compensation  or  latent  stage 
is  not  associated  with  symptoms  which  call  the  attention  to  an  affection 
of  the  heart,  and  with  care  the  patient  may  roach  old  age  in  comparative 
comfort  without  being  compelled  to  curtail  seriously  his  pleasures  or  his 
work. 

(h)  Sooner  or  later  conies  a  period  of  disturbed  or  broken  compensa- 
liim,  in  which  tho  most  intense  symptoms  are  those  of  venous  engorgement. 
There  are  jialjiitation,  weak,  irregular  action  of  the  heart,  and  signs  of 
dilatation.  I)ys])na'a  is  an  especial  feature,  and  there  may  be  cough.  A 
distressing  symptom  is  the  cardiac  "sleep-start."  in  which,  just  as  the  pa- 
tient falls  asleep,  he  wakes  gasping  and  fooling  ;■  if  the  heart  was  stopping. 
'li.ore  is  usually  a  slight  cyanosis,  and  even  jaundiced  tint  to  the  skin. 
The  most  marked  symptoms,  however,  are  tlioso  of  venous  stasis.  The 
45 


1 


!i 


^^^j  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

overnUin.^  of  the  puLnonary  vessels  a.rounts  in  part  for  the  dycrncoa 
1^  e  r^ugh,  oiten  .'ith  l.loody  or  watery  oxpeetorat.on,  a.J  tlu;  a  veo  a, 
,,   t heliinn  ^onUunhvj  brown  piLnnent-grains  is  abundant.     Dropsieal  elln- 

n  ™H;.ets  .n,  beginnu.g  u.  the  leet  an.l  extending  to  the  bo  y  and 
)L  «<.ron/saos.  The  livrr  is  enlarged,  an.l  there  are  signs  ot  poital  n- 
^  tion'astric  irritation,  an.l  ealarrh  of  the  stomaeh  a.d  .nb^tines.  Hie 
t,'  u  :  u  ually  seanty  and  all,nn>inons,  and  n.nta.ns  tul)e-easts  ami  some- 
:Z  M^d-e-^puselel  With  ju.lieions  treatment  tl-o  eoi.n-s,a..m  ma 
1,0  rest..red  and  all  the  serions  syn.ptoms  may  pass  a.a>.       ■"^"  '^  ^^  ^^ 

>ve  reenrrin-  attacks  of  this  kind,  and  dic  .d  a  general  drop>> .  o,  ih  u 
l!: "Irc'I^s^urdilatation  of  the  heart,  and  d.a.h  tn.m  asystole.     Sudden 

nh^iKi^-/^:^^;'^"" -!■•  children  ti.e  pr.eordia  n.ay  bnlge  ami 
there  may  be  a  large  area  of  visible  pnlsat.on.  ^J  lie  apex  beat  »  to  the  t 
o  the  nipple,  in  some  cases  m  the  sixth  interspace,  u,  the  antenor  ax  1  y 
line  There  may  be  a  wavy  in.pnlse  in  the  cervical  veins  which  are  olten 
full,  particularly  when  the  patient  is  recumbent 

ralnnlion.-A  thrill  is  rare;  wIumi  ].resent  it  i.  felt  at  the  apix.  in 
in  a  liiiiled  area.  The  force  of  iiie  impulse  may  depend  large  y  upon  1  e 
ta'e  in  which  the  case  is  examined.  In  full  compensation  it  is  -re 
and  heaving;  when  the  compensation  is  disturbed  usually  wavy  and  lee  le. 
Vv.«.,sioH.-Tlie  dulness  is  increased,  particularly  lu  a  lateral  direction. 
There  is  no  disease  of  .ne  valves  which  pruduces,  in  h.ng-standing  ease-, 
a  nore  extensive  transverse  area  of  heart  dulness.  It  does  no  extei.l  . 
;,HH.h  upward  along  the  left  margin  of  the  sternum  as  beyond  the  light 
niariiin  and  to  the  left  of  the  nipple  line. 

AusrullaHon.-Ai  the  apex  there  >s  a  systolic  murmur  winch  wholly 
or  partly  obliterates  the  iir.«t  s<,und.     It  is  loudest  here,  7;'  '•-  ^    '''^^Vj^f; 
sometimes  musi<.al   character,   particularly   toward   the   latte     1    >  •        i^^ 
„n,rmur  is  transmitted  to  the  axilla  and  may  be  heard  at    he  ''^nd.   n     o 
instances  over  the  entire  chest.     There  are  eases  in  which,  as  pom  ed  out 
V  >!aunvn,  the  murmur  is  heard  best  along  the  left  border  of    he  sternuim 
Usually  in  dia..tole  at  the  apex  the  loudly  transmitted  second  s.mnd  may 
be  heard.    Occasionally  there  is  also  a  soft,  sometimes  a  rough  or  rumldnig 
esystolie  murmur.     As  a  rule,  in  cases  of  extreme  mitral   iiisu   u.em.y 
roni  valvular  lesion  with  great  hypertrophy  "V-^'\ -"^"tr;  '"  i  ,-  1 
heard  onlv  a  loud  blowing  murmur  during  systole.     A  murniiu  of  initial 
n  ufficiency  mav  vary  a  great  deal  according  to  the  position  oi  tLo  pa  .en 
It  mav  be  present  in  the  recumbent  and  abs.mt  111  the  erect  postuie 
cases  of  dilatation,  particularly  wlu.,  dropsy  is  present,  there  may  be  lie 
nt   the  ensiform  cartilage  and  in  the  l.iwer  sternal   region  a  soft  s.>.to   c 
„n,rn,ur  due  to  tricuspid  regurgitation.     .\n  iniportant  sign  oun^^^ 
tion  is  the  accentuated  pulmonary  second  s.mnd.       his  is  lujii     to  the       t 
of  the  Btcrnnm  in  the  second  interspace,  or  .iver  the  third  l.'ft  costal  ca, 

''^'"tIic  pulse  in  mitral  insufbcaency,  during  th..  pericid  of  ^"^  --F;;-- 
tion,  mav  bo  full  and  regular,  ..ften  of  low  tension.     T  sual  y  ^^^         -  fi'> 
onset  of  the  symptoms  the  pulse  b..conies  irivgular.  a  feature  ^^hlch  tl.cn 


ic  (ly-pnof^n. 
the  iilvcnlar 
opskiil  ell!u- 
10  body  and 
'  portal  cini- 
stines.  The 
ts  and  sonic- 
nwitio'i  may 
iciits  iisiiaily 
is\ ;  or  there 
)lc.      Sudden 

ay  l)ul^'e  and 
is  to  the  left 
crior  axillary 
ieh  are  often 

e  apex,  often 
fi'ly  upon  the 
it  is  foreil)le 
vy  anil  feet)le. 
.>ral  direction, 
anding  cases, 
not  extend  so 
Hid  the  right 

which  wholly 
las  a  hlowing, 
■r  ])art.     Tlie 
hack,  in  some 
is  ])oiiited  ont 
f  the  stermim. 
nd  sound  may 
h  or  rumlding 
1   insutlicieiicy 
I'ieles,  there  is 
•mur  of  mitral 
of  the  ]Kitieiit. 
't  posture.     In 
'  nuiy  he  heard 
a  soft  systolic 
n  on  ansculta- 
■ard  to  the  left 
left  costal  car- 
full  conipensa- 
y  with  the  first 
Lire  which  then 


CUUONIC   VALVULAR  DLSEASE. 


11 


dominalis  the  case  througliout.  There  may  he  no  two  heats  of  equal  force 
or  vdhiiiic.  Often  after  the  disa]i})earairce  of  the  ,<ymj)l(ims  of  lailiire  of 
compensation  the  irregularity  of  the  i)ulse  jtersists. 

The  three  important  physical  signs  then  of  mitral  regurgitation  arc  : 
(fl)  Systolic  murmur  of  maximum  intensity  at  tiie  a})ex,  whicli  is  jirojia- 
gated  to  tlie  axilla  and  heard  at  the  angle  of  liie  scajjiila;  (/*)  accentuation 
of  the  ]tulmoiiary  second  sound;  (r)  evidence  of  eulaigcmcnt  of  the  heart, 
particularly  the  increase  in  the  transverse  diameter,  due  to  hyperlrophv 
of  hoth  right  and  left  ventricles. 

Diagnosis. — Tliere  is  rarely  any  difliciilty  in  the  diaguosi.^  of  mitral 
insullicieiicy.  The  physical  signs  just  referred  to  are  quite  clu;racl(,'ristic 
and  ilisiinctive.  'I'wo  ]ioints  are  to  he  borne  in  mind.  First,  a  murninr. 
systolic  in  character,  and  of  maxinuim  inti'iisity  at  the  apex,  and  projia- 
gated  even  to  the  axilla,  does  not  necessarily  indicate  incompetency  of  the 
mitral  valve.  There  is  heard  in  this  iv^'um  a  large  groiij)  of  what  are 
termed  accideiUal  murmurs,  the  jirccise  nature  of  whicli  is  still  donhtful. 
They  are  pmhahly  formed,  however,  in  the  ventricle,  and  are  not  associated 
with  hypertrophy,  or  accentuation  of  i)ulmonary  second  sound. 

Second,  it  is  not  always  ])ossihle  to  say  whether  the  insulliciency  is  due 
to  lesion  of  the  valve  segineiU  or  to  dilatation  of  the  mitral  ring  and  rela- 
tive incoin[>etency.  Jlere  neither  the  character  of  the  murmur,  the  propa- 
gation, the  accentuation  of  the  pulmonary  second  sound,  nor  the  hyper- 
trophy assists  in  the  diil'erentiation.  The  history  is  sometimes  of  greater 
value  i"  this  matter  than  the  physical  examination.  The  cases  most  likely 
to  lead  ,o  error  are  those  of  the  so-called  idiopathic  dilatation  and  hyper- 
trophy of  the  heart  (in  whicli  the  systolic  murmur  may  he  of  the  greatest 
intensity),  and  the  instances  of  arterio-sclerosis  with  dilated  heart.  Halfonr 
and  others,  however,  maintain  that  organic  disease  of  the  mitral  leallets 
suiVicicnt  to  ])rodiice  incoin]ieteiicy  is  always  accompanied  with  a  certain 
degree  of  narrowing  of  th.e  orilice,  so  that  the  only  uneipiivocal  [U'oof  of  the 
actual  disease  of  the  mitral  valve  is  the  presence  of  a  pre.-ystolic  murmur. 

0.    ^llTliAL    StKXOSIS. 

Etiology. — Xarrowing  of  the  mitral  orifice  is  usually  the  result  of 
valvular  endocarditis  occurring  in  the  earlier  years  of  life;  very  rarely  it 
is  congenital.  It  is  very  much  more  common  in  w(unen  than  in  men — in 
fi3  of  SO  cases  noted  l)y  Duckworth,  while  in  4,7!tl  autopsies  at  Ony's  IIos- 
])ital  during  ten  years  there  were  IDG  cases,  of  which  107  were  females  and 
89  males  (Samways).  This  is  not  easy  to  exjdain,  but  there  are  at  least  two 
factors  to  be  considered.  IJheumatism  prevails  more  in  girls  than  in  boys 
and,  as  is  well  known,  endocarditis  of  the  mitral  valve  is  more  common 
in  rheumatism.  Chorea,  also,  as  suggested  by  Barlow,  has  an  important 
influence,  occurring  more  frequently  in  girls  and  lieing  often  associated 
with  endocarditis.  Of  I-IO  cases  of  chorea  which  I  examined  at  a  period 
more  than  two  years  subse(]uent  to  the  attack,  t'i  had  signs  of  organic 
heart-disease,  among  which  were  "i-l  instances  with  the  physical  signs  of 
mitral  stenosis.    Amemia  and  chlorosis,  which  are  prevalent  in  girls,  have 


-.,.)  DISEASES  OP  THE  CIRCULATORY   SYSTEM. 

been  rc-'anlHl  as  possil.le  factors.  In  a  surpri^ini:  minilxT  ol'  cases  no  rccog- 
,u/ablc%tiological  factor  can  l.e  discovered.  This  lias  been  regarded  by 
some  writers  as  favoring  the  view  that  many  cases  arc  of  congenital  ongni; 
but  it  is  not  iinprohahle  that  with  any  of  the  febrile  alTections  of  childhood 
endocarditis  inav  be  associated.  Whooping-cough,  too,  with  its  terrible 
.train  on  the  heart-valves,  may  be  accountable  for  certain  cases.  Lou- 
.renital  affections  of  the  mitral  v.^b.'C  are  notoriously  rare.  \\  lule  met  wilh 
at  all  ages,  stenosis  is  certainly  more  frciuent  in  young  persons 

Morbid   Anatomy.-lu  a  maj..iity  of  instances  with  the  stenosis 
then'  i^  some  incompetencv;  indeed,  Balfour  maintains  that  we  never  hnd 
mitral  stenosis  without  some  degree  of  regurgitation.     The  narrowing  re- 
sult <  from  thickening  and  contraction  of  the  tissues  of  the  ring,  oL  the  valve 
«ecnnent-.  and  of  tlie  chorda;  tendinea".     The  condition  varies  a  good  deal 
a«'ordin.r  t„  the  amount  of  atheromatous  change.     In  many  cases  the  cur- 
fiin<  are'-o  w-ld..!  tuuether  and  the  whole  valvular  region  so  thickened  that 
the  orilice  is  redmrd'lo  a  mere  chink— t'orrigan-s  button-hole  contraction. 
In  other  cases  the  curtains  are  not  much  thickened,  but  narrowing  has 
re-ulted  fnun  -radual  adhesion  at  the  edges,  and  thickening  of  the  chorda- 
lendiiHW,  so  tiiat  from  tiie  auricle  it  looks  cone-like— the  so-called  funnel- 
shaped  variety  of  stenosis.    The  instances  in  which  the  valve  segments  are 
very  sli<ditly 'deformed,  but  in  which  the  orilice  is  considerably  narrowed, 
are  regarded  by  some  as  possibly  of  congenital  origin.     Occasionally  the 
curtains  are  in  great  part  free  from  disease,  luit  the  narrowing  results  from 
lar<^c  calcareous  masses,  which  project  into  them  from  the  ring.     11>C'  "> 
voUvment  of  the  chorda,-  tendinea-  is  usually  extreme,  and  the  pai.iUary 
muscles  mav  be  inserted  directly  upon  the  valve.     In  moderate  grades  oi 
I  constriction"  the  orilice  will  admit   the  tip  of  the  inde.K-finger;  in  more 

I  extreme  forms,  the  tip  of  the  little  finger;  and  occasionally  one  meets  with 

I  i,  specimen  in  which  the  orifice  seems  almost  obliterated,  as  in  a  case  which 

i  (.,,ine  under  my  notice,  which  only  admitted  a   medium-sized  J]owman"s 

4'  iirobe.                                                                                                                          . 

I'  The  heart   in  mitral  stenosis  is  not  greatly  enlarged,  rarely  weiglung 

I-  niore  than   14  or  15  ounces.     Occasionally,  in  an  elderly  iierson,  it  may 

I  Pocm  only  sliuhtlv,  if  at  all,  enlarged,  and  again  there  are  instances  m  which 

I  the  weight  n'lay  roach  as  much  as  20  ounces.    The  left  ventricle  is  usually 

|,  small,  and  may  look  very  small  in  comparison  with  the  right  ventricle, 

I  which  forms  the  greater  portion  of  the  ajiex.     In  cases  in  which  with  the 

;;!•  narrowing  there  is  very  considerable  incompetency  the  left  ventricle  may 
be  moderately  dilated  and  hypertro]ihied. 

These  changes  gradually  induced  are  associated  with  secondary  altera- 

,,..  tions  of  great  ini])ortancc  in  the  heart.    The  left  auricle  discharges  its  blood 

ij  with  greater  difficulty  and  in  consequence  dilates,  and  its  wa'ls  reach  three 

li  or  four  times  their  normal  thickness.    Although  the  auricle  is  by  structure 

If  unfitted  to  compensate  an  extreme  lesion,  the  probability  is  that  for  some 

'i  time  durina  the  gradual  production  of  stenosis,  the  increasing  muscular 

,'  ].ower  of  the  walls  is  sufficient  to  counterbalance  the  defect.     Samv.ays 

!•;  f<iund  in  3(?  cases  of  well-marked  stenosis  the  auricle  hypcrtrophied  in  2fi. 

i-  dilatation  coexistim^  in  It.    Eventually  the  tension  is  increased  in  the  pul- 


ill' 


ix'ganled  by 
iiilal  origin; 
)i'  chiklhuuil 

its  torriljlo 
3ases.  Coii- 
Lle  met  with 
s. 

tl.o  sterosiis 
0  iiL'VLT  fiiul 
lUTowing  re- 

ot  the  valve 

a  guild  deal 
asc's  the  cur- 
ickened  that 

contraction, 
irrowing  has 
1'  the  chordie 
ailed  fiinnel- 
f^egnicnts  are 
ily  narrowed, 
asionally  the 

results  from 
ng.  The  in- 
the  papillary 
ate  grades  ol' 
ger;  in  more 
le  meets  with 

a  case  wliieh 
L'd  Bowman's 

•ely  -weighing 
_>rson,  it  may 
nces  in  which 
icle  is  usually 
'x\\t  ventricle, 
hich  with  tlie 
ventricle  may 

3ndary  altera- 
irges  its  blood 
Is  reach  three 
s  by  structure 
that  for  some 
>ing  muscular 
■ct.  Samvi-ays 
rophicd  in  2Ct, 
ed  in  the  pul- 


CIIIIOXIC   VALVULAR   DISKASK. 


?2:] 


monary  circulation,  owing  to  imi)cded  outtlow  from  the  veins.  To  over- 
come this  tlu'  right  ventrick'  undergoes  dilatation  and  hypertropiiy,  and 
ui)on  this  chamber  falls  the  woik  ot  eipializing  tlic  circulation,  lielativo 
incompetency  of  the  tricuspid  and  congolion  of  liic  .'-y>temic  vuiiis  at  la<t 
sui)ervene. 

It  is  not  uiu'onimon  at  the  examinalion  to  find  white  thrombi  in  the 
a])pendi.\  of  the  lelt  auricle.  Occasionally  a  huge  part  of  the  auricle  id 
occuiiied  by  an  ante-mortem  thrombus.  Still  more  rarely  the  rciuarkablo 
ball  thrombus  is  found,  in  uliich  a  globular  concretion,  varying  in  si/^e  from 
a  walnut  to  a  small  egg,  lies  free  in  the  auricle,  two  examples  of  which  have 
come  under  my  observation. 

Symptoms.— Physical  Signs.— fnsprclii,ii.—\n  children  the  lower 
.sternum  aiul  the  iifth  and  sixth  left  costal  cartilages  are  oflen  i)rominent, 
owing  to  hypertrojihy  of  the  right  ventricle.  The  apex  ])eat  may  be  ill- 
defined.  I'siially,  it  is  not  dislocated  far  beyond  the  nii»i)le  line,  "and  the 
chief  impulse  is  over  the  lower  sternum  and  adjacent  costal  cartilages. 
Often  in  thin-chested  persons  there  is  pul.sition  in  the  third  and  fourth 
left  interspaces  clo,<e  to  the  sternum.  When  coin])ensation  fails,  the  pne- 
cordial  imimlse  is  much  feebler,  and  in  the  veins  of  the  neck  there  may  ho 
marked  systolic  regurgitation. 

I'dlpalinn  reveals  in  a  majority  of  the  cases  a  characteristic,  well-defined 
fremitus  or  thrill,  which  is  best  b'lt.  as  a  rule,  in  the  fourth  or  fifth  inter- 
space within  the  ni])ple  line.  It  is  of  a  rough,  grating  fpiality,  often  pecid- 
iarly  linuted  in  area,  most  marked  during  expiration,  and  can  be  felt  to 
ternnnate  in  a  sharp,  sudden  shock,  synchronous  with  the  impulse.  This 
nuist  characteristic  of  physical  signs  is  ])athognomonic  of  mirrowing  of  the 
nntral  orifice,  and  is  perhaps  the  only  instance  in  which  the  diagnosis  of 
a  valvular  lesion  can  be  made  by  palpation  alone.  The  cardiac  inii)ulse  is 
felt  most  forcibly  in  the  lower  sternum  and  in  the  fourth  and  fifth  left  in- 
ters])aces.  The  im])nIso  is  felt  very  high  in  the  third  and  fourth  interspaces, 
or  in  rare  cases  even  in  the  second,  and  it  has  been  thought  that  in  the 
latter  interspace  the  im]iulse  is  due  to  ])uIsation  of  the  auricle.  It  is  always 
the  im])ulse  of  the  conns  arteriosus  of  the  right  ventricle;  even  in  the  most 
extreme  grades  of  mitral  sleiu)sis,  there  is  never  such  tilting  forward  of  the 
auricle  or  its  ajipendix  as  would  emible  it  to  produce  an  ini})ression  on  the 
cliest  wall. 

rrrnissinn  gives  an  iiu'rease  in  the  cardiac  dulness  to  the  right  of  the 
sternum  and  along  the  left  margin;  not  usually  a  great  increase  beyond 
the  ni])ple  line,  except  in  extreme  cases,  when  the  transver-e  dulness'may 
reach  from  5  cm.  beyond  the  right  nuirgin  of  the  sternum  to  10  em.  beyond 
the  nipjde  line. 

AufiruHatinn. — Tn  the  mitral  area,  usually  to  the  inner  side  of  the  apex 
beat  and  often  in  a  very  limited  region,  is  heard  a  rough,  vibratory  or  purr- 
ing murmur,  wiiich  terminates  abruiitly  in  the  first  sound.  P.y  combining 
]ialpation  and  auscultation  the  purring  murnnir  is  found  to  i)e  synchro- 
nous with  the  thrill  and  the  loud  shock  with  the  iirst  souml.  This  is  the 
]iresystolic  murmur,  about  the  time  and  mode  of  production  of  which  so 
much  discussion  has  occurred.     I  hold  with  those  who  retrard  it  as  occur- 


724 


DISKASHS  OF  THE  ClUCULATOllY   SYSTEM. 

,in.  durin-  the  auricular  sy.tolo.     In  wlialovcr  way  pr-Mlu,...!    it  remains 
It,  !^nost  ,listi>u.tive;uul  ei>arueteri.tic  of  nuK.nurs  an.l  Us  invseneo 

,otv  elv  iiuUeative  ..f  narruwin.  ..f  the  luitral  oriiiee     Tin-  ...U.  exeep- 
,r  0  U  L  .tate,.,e„t  i.  ti>e  Flint  muvnmr  alrea.ly  referred  t,.  m  aort.e 
nr.v      Onee    in  a  ease  of  enormous  enlargement  of  the  spleen, 
;;•  ;::  ;:^:^  n  .du:h  ti::  ileart  ...  ,.eatly  pushed  up,  1  hea.l  a  ..esystolic 
,    UM>    rou.h  quality,  and  th.  nutral  valv..  were  found  post  mea. 
,         .  ,„„1     The  presvstoUe  murmur  n>ay  oeeupy  the  entire  permd  of  t.-.e 
.a  he  nuddle  or  only  the  latter  half,  eorrespondmg  to  the  aur.eu- 

•  ;    ;.le     The  diirerence  may  sometimes  be  noted  bet^^^en    he  hrs    and 
:    ond  portions  of  the  nu.rmur,  when  it  oeeup.es  the  ent.re  tune     Oft 
t  KTo  i^  a  peeuliar  rund.ling  or  eehoing  quality,  whieh  in  sonu   instances 
'      .;  li  died  and  may  he  Imard  only  over  a  single  bell-spaee  of    lie  s  e  ho- 
copc     A  systolic  murmnr  may  be  heard  at  the  apex  or  along   he  1  it  st  u    1 
iuXr  often  of  extreme  softness  and  audible  only  when    he  breath  is  lul  b 
Si      imes  the  systolic  murmur  is  loud  and  distinct  and  is  transnntted  to 
^  e  Sa     The  second  sound  in  the  second  left  interspace  is  b.udly  ac.HM.tu- 
'  .r'!metimes  reduplicated.     U  may  be  transnntted  far  to  the  Mt  am 
be  heard  with  great  clearness  beyond  the  ape.x.     In  nncunpbcated  fa>c. 
mm  stenosis  there  are  usually  no  murn.urs  audible  at  the  aort,e  regum, 
vl  ich  s,.ot  the  second  sound  is  less  intense  than  at  the  pulmonary  aiea 
1  loJer  sternum  and  to  the  right  a  tricuspid  murmur  is  sometime 

1    a      in  advanced  cases.     Other  points  to  be  noted  are  the  fo'— - 
unlisually  sharp,  clear  first  s<mud  which  folio.,  the  F-^-*'; ;-;;  ™  '',; 
the  cause  of  which  is  by  no  means  easy  to  explain.     It  can  .au  1>   b    . 
valvular  sound  produced  chielly  at  the  mitral  orifice,  since  i    may  be  h  a  d 
,       .reat  intensity  in  cases  in  which  the  valves  are  rigid  and  calcihed 
a':  I'Jen  sug.e'ted  by  W.  S.  Fenwick  and  Overend  that   it  is  a  loud 
.'.„ap"'  of  the  tricuspid  "valves  caused  by  the  powerful  contraction  oi  the 
crreat  V  hypertrophied  right  ventricle.     J'.roadhent  s  explanation  is  a.  fol- 
io"   '' Owing  ti  the  narrowing  of  the  mitral  orifice  there  .s  not    ime 
Ihe  diastolic  interval  for  a  sullicient  amount  of  bloo     to  ^  -;;;*;';,  * 
ventricle  to  completely  fill  it.     At  the  commenceuumf  o    s>>t  Ic   <  ^'^'^  <^' 
the  veutri.ular  onitv  is  not  fully  distended  with  blood,  so  that  the  m  ij- 
cular  walls  at  the  iirst  monuMit  of  their  contraction  meet  with  no  lesi.t- 
•  then  closing  down  rapidly,  they  are  suddenly  brought  up  and  mad 
n  ;     s  thev  en^^mnter  the  contained  blood.     This  sudden  tension   an 
abhreviated  Vvstole  may  thus  account   for  the  short  firs     ->">;1-  > 

valvular  sound  may  be  audible  at  a  distance,  as  one  sits  at  the  bedside  of 

^^''The^e'phvsicarsisns,  it  is  to  be  borne  in  mind,  are  characteristic  only 
of  the  sta-'e  in  which  compensation  is  maintained.     Finally  there  comes  a 
period  in\vhich.  with  rupture  of  compensation,  tbe  presystolic  murm 
disappears  and  there  is  beard  in  the  apex  region  a  sharp  i^^'^^""'    ;     J 
sometimes  a  gallop  rhythm.     The  marked  svstobc  slmck  may  he  p  e.n 
after  the  disappearance  of  the  thrill  and  the  characteristic  mm-mu  .    b  ulc 
ivcatment.  with  gradual  recovery  of  compensation,  probably  ^^    \  y;^*^' 
in.r  vioor  of  contraction  of  the  right  ventricle  and  left  auricle,  the  pre- 


CHRONIC   VALVULAR    DL-iKASH. 


725 


it  remains 
ts  pn'soufo 

sole  t'Xfop- 
0  ill  aorlio 
the  t^iilecn, 
L  pre.-*y^l(ilie 
ost  nu'itein 
eriod  ol'  t'u' 

the  auricu- 
he  liivt  aiitl 
inie.  Oi'ten 
lie  instances 
t'  the  stetho- 

■  left  sternal 
eatli  i:^  luld. 
iiisinitted  to 
(lly  aeeeiitu- 
tlie  left  ami 
licaled  cases 
Kirtie  rejJiion, 
luoTuiry  area, 
is  sometimes 
lowing':  The 
die  imirmur, 
searcely  he  a 
iiiiy  he  lieard 
iiid  ealeilied. 

it  is  a  loud 
action  of  the 
ion  is  as  fol- 
j  not  time  in 

iiitd  the  left 
lie,  therefore, 
liat  the  mus- 
itli  no  resist- 
up  and  made 
\  tension  and 
=onnd."  Tlie 
he  hedside  of 

acterislic  only 
there  crimes  a 
;tolic  murmur 
first  sound,  or 
iiiv  he  iivesent 
ivmur.    Under 

■  \vit!i  increas- 
riele,  the  pre- 


systolic ninrmur  reappears.  In  cases  seen  al  Ihis  stage  of  tlio  dis(>ase  the 
nature  of  the  valve  lesion  may  he  entirely  overlooked. 

Stenosis  of  tiie  mitral  valve  may  for  years  he  elliciently  (fompcnsated 
hy  the  hypertrophy  of  tlie  rij^ht  ventricle.  Many  j)ersoiis  with  tlie  char- 
acteristic jiliysical  siyns  of  tiiis  lesion  jircsent  no  symj)toms.  Tliey  may 
for  years  iierlia[)s  he  short  of  hreath  on  going  upstairs,  hut  arc  ahle  to  pass 
through  tlie  ordinary  duties  of  life  without  discomfort.  The  pulse  is 
smaller  in  v(dume  tlian  normal,  hut  may  ho  ])crfectly  regular.  A  special 
danger  of  this  stage  is  tiie  recurring  endocarditis.  Vegetations  may  he 
whipped  olf  into  the  circulation  and,  hlocking  a  cerehral  vessel,  may  cause 
hemiplegia  or  aphasia,  or  hotli.  Tiiis,  unfortunately,  is  not  an  uneonunon 
sequenee  in  women.  Patients  with  mitral  stenosis  may  survive  this  acci- 
dent for  an  indefinite  ]ieriod.  A  woman,  ahove  seventy  years  of  age,  died 
in  one  of  my  wards  at  the  JMiihuU-ljihia  ilospihil,  who  had  lieen  in  the 
aimsiiouse,  hemiplegic,  for  more  tlian  thirty  years.  Tlu'  heart  presented 
an  extreme  grade  of  mitral  stenosis  wliich  had  prohahly  exislc.'il  at  the  time 
of  the  ]ieini])lcgic  attack. 

rressiire  of  tiie  enlarged  auricle  on  the  left  riH'urrent  laryngeal  n(>rve, 
causing  jiaralysis  of  the  Aoca!  cord  on  the  corresponding  side,  has  heen 
de.<crihed  hy  Ortner  and  hy  Jlerrick.  [  have  met  with  two  instances.  It 
is  a  ])oint  to  he  home  in  mind,  as  the  diagnosis  of  aneurism  of  tlie  arch  of 
the  aorta  may  he  made. 

Failure  of  compensation  ])rings  in  its  train  the  gioup  of  symptoms 
which  have  heen  discussed  \inder  mitral  insiilhciency.  J^rielly  enumerated 
they  are:  Rapid  and  irregular  action  of  the  heart,  sh.ortness  of  hrciath, 
cough,  signs  of  pulmonary  engorgement,  and  very  frecpiently  luemoptysis. 
Attacks  of  this  kind  may  recur  for  years.  Bronchitis  or  a  fehrilo  attack 
may  cause  shortness  of  hreath  or  sligiit  lilueness.  Indanimalory  all'eclions 
of  the  lungs  or  ])leura  seriously  disturh  the  right  heart,  and  these  patients 
stand  ]ineiimonia  very  hadly.  ]\Iany,  ))crhaps  a  majority  of  cases  of  mitral 
stt'iiosis,  do  not  have  dropsy.  The  liver  may  he  greatly  enlarged,  and  in 
the  late  stages  ascites  is  not  uncommon,  particularly  in  children.  General 
anasarca  is  most  frequently  met  with  in  those  cases  in  which  there  is  sec- 
ondary narrowing  of  the  tricuspid  orifice  (Broadhent). 

f!.  Tmcx'sriD  Yai.vi':  Disk.vsid. 

{")  Trictispid  Regurgitation. — Occasionally  this  results  from  acute  or 
chronic  endocarditis  with  puckering;  more  commonly  the  condition  is  one 
of  relative  insulTiciency,  and  is  secondary  to  lesions  of  the  valves  on  the  left 
side,  particularly  of  the  mitral.  It  is  met  with  also  in  all  conditions  of  the 
lungs  which  cause  ohstruction  to  the  circulation,  such  as  cirrhosis  and 
emphysema,  particularly  in  comhination  with  chronic  hronchitis.  The 
symptoms  are  those  of  ohstruction  in  the  lesser  circulation  with  venous 
congestion  in  the  systemic  veins,  such  as  has  already  heen  descrihed  in  con- 
nection with  mitral  insufTiciency.     The  signs  of  this  condition  arc: 

(1)  Systolie  regurgitation  of  the  hlood  into  the  right  auricle  and  the 
transmission  of  the  puNc-wave  into  the  veins  of  the  neck.     If  the  regurgi- 


720 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


t-,li(.ii  is  slight  or  the  contraetiDii  of  the  vo.itrido  is  fool.lo  there  may  l)e 
no  ve.K.us  throbbing,  b..t  in  oilier  eases  there  is  marked  systnlie  pulsation 
iu  the  eervieal  veins.  Tliat  in  the  right  jugular  is  more  foreible  than  that 
in  the  left  11  may  lie  seen  both  in  the  internal  an.l  the  external  win, 
nartieularly  in  the  latter.  .Marked  pulsation  in  these  veins  oeeurs  only 
when  the  valves  guarding  them  beeome  ineompetent.  blight^  oseillatiun. 
are  bv  no  means  uncommon,  even  when  the  valves  are  intaet.  the  dis- 
tenli.m  is  sometimes  enormous,  particularly  iu  the  act  oi  eoughmg,  when 
the  rhdit  jugular  at  the  root  of  tlie  neek  may  stand  out,  lormmg 
an  e.xmu.r;iin.u-y  prominent  ovoi.l  mass.  Occasionally  the  regurgitan 
pulse-wave  may  be  widely  transmitted  and  he  seen  m  the  st.l.clavian  an.l 
axillarv  veins,  and  even  in  the  subcutaneous  veins  over  the  shoul.lcr, 
or,  as"in  a  ease  recently  under  observation,  in  the  superficial  mammary 

'"'l{e.'urgitant  pulsation  through  the  tricuspid  orifice  may  be  transmitted 
to  the"inferior  cava,  and  so  to  the  hepatic  veins,  causing  a  systolic  disten- 
tion of  the  liver.  This  is  hest  appreciated  hy  bimanual  palimfion,  i.lacing 
one  hand  over  the  fifth  and  sixth  costal  cartilages  and  the  other  m  the 
lateral  region  of  the  liver  in  the  mid-axillary  line.  The  rhythmical  ex- 
pansile pulsation  may  be  readily  distinguished,  as  a  rule,  from  the  systolic 
depression  of  the  liver  due  to  communicated  pulsation  from  the  left  ven- 

"^C>)  The  second  imixirtant  sign  of  tricuspid  regurgitation  is  the  occur- 
rence of  a  systolic  murmur  of  maximum  intensity  in  the  lower  sternum. 
It  is  usually  a  soft,  low  murmur,  often  to  lie  distinguished  from  a  coexist- 
m^r  mitral  murmur  hy  dilferences  in  (luality  and  pitch,  and  may  he  heard 
to'the  right  as  far  as  "the  axilla.     Sometimes  it  is  very  limited  m  its  distri- 

htition.  .         ...  .,   ,. 

To<rether  these  two  signs  positively  indicate  tricuspid  regurgitation. 
In  add'^ition,  the  percussion  usually  shows  increase  in  the  area  of  dulness 
to  the  ri"ht  of  the  sternum,  and  the  impulse  in  the  lower  sternal  region  is 
forcihle  "  In  the  great  majority  of  cases  the  symptoms  are  those  of  the 
associated  lesions.  In  cirrhosis  of  the  lung  and  in  chronic  emiihysema  the 
failure  of  compensation  of  the  right  ventricle  with  insufTiciencyol  the  tri- 
cuspid not  infrequently  leads  either  to  acute  asystole  or  to  gradual  failure 

with  cardiac  dropsy.  ,       •,, 

{h)  Tricuspid  Stenosis.— This  interesting  condition  may  be  eitiier  con- 
genital or  acquired.  The  congenital  eases  are  not  uncommon,  «inl  ^^ 
associated  usually  with  other  valvular  defects  which  cause  early  death.  The 
acquired  form  is  not  very  infrequent.  Bedford  Fenwick  collected  4fi  oh- 
«ervations,  of  which  41  were  in  women.  Leudet  *  has  analyzed  117  cases 
Of  101  of  these  in  which  the  ages  were  mentioned,  80  were  in  women  and 
21  in  men.  A  great  majority  of  the  cases-  were  in  adults,  only  8  heing 
hetween  the  ages  of  ten  and  "twenty.  Its  rarity  as  an  isolated  condition 
nun-  he  gathered  from  the  fact  tliat  of  114  autopsies,  in  11  only  was  the 
h-ion  c.mfined  to  this  valve.    In  21  the  tricuspid,  mitral,  and  aortic  seg- 


*  Paris  Thesis,  1888. 


I' 


r 


ore  may  lie 
ic  pulsiilioii 
c  than  that 
tcrniil  vein, 
occurs  only 

oscilliitioiiii 
.  Tlu'  dis- 
jliin<r,  when 
it,    lovniinjj; 

regurgitant 
icluvian  and 
ic  shoiddcr, 
.1  nianiniary 

tran^niittod 
itolic  di^tcn- 
ion,  placing 
jtlicr  in  till! 
y-thmical  cx- 

tho  syr^tolic 
ho  Ici't  Yon- 

is  tlie  oocur- 
vor  sternum, 
im  a  cooxist- 
lay  1)0  hoard 
in  its  distri- 

cgurgitation. 
.'a  of  dulno:^s 
•nal  regiim  is 
those  of  the 
i])hysonia  the 
cy  of  the  tri- 
•adnal  failure 

)o  either  con- 
non,  and  are 
V  death.  The 
looted  4G  ob- 
5od  117  cases, 
n  women  and 

only  8  being 
ted  condition 

only  was  tlie 
nd  aortic  seg- 


CIIKONIC   VALVULAU   DISKASK. 


i2i 


monts  wore  involved,  and  in  TS  the  tricuspid  and  mitral.     J'ractically  liio 
coiidition  is  almost  always  secondary  to  le,-inns  of  tlio  left  heart. 

The  jiliysical  .signs  are  soinetinu's  cliaraoteristic.  For  instance,  a  pre- 
systolic thrill  has  been  noted  by  several  observers.  Tiie  percussion  shows 
(iulness  to  lie  increased,  particularly  to  the  right  of  the  sternum.  On  aiis- 
cultatidii  a  ])ro.syst()lie  murmur  has  been  di'termined  in  certain  caso.<,  and 
is  iieard  best  at  the  root  of  the  eiisiform  cartilage,  or  a  little  to  the  right 
of  it.  t)f  general  symptoms,  cyanosis  of  the  face  and  lips  is  very  common, 
and  in  the  late  stages,  wnon  dropsy  supervi'iios,  it  is  apt  to  be  intense.  'I'lie 
lesion  is  interesting  chielly  because  it  forms  one  of  the  most  serious  ooiii- 
plicatioiii  of  mitral  stenosis. 

7.  Pn.MONAiiY  A'ai.vi:  Disuasi;. 

Mitrmurs  in  the  region  of  the  ])ulmonary  valves  are  extremely  common; 
lesions  of  the  valves  are  exceedingly  rare.  Ualfonr  has  well  called  the  pul- 
monic ar(>a  the  region  of  romance.  A  systolic  mnrnnir  is  heard  here  under 
many  conditions — (1)  very  often  in  health,  in  thin-chested  persons,  jiar- 
tionlarly  in  children,  during  expiration  and  in  the  recumbent  posture;  ('i) 
wlien  the  heart  is  acting  rapidly,  as  in  fever  and  after  exertion;  (I?)  it  is  a 
favorite  situation  of  the  car(lio-res])iratory  murmur;  (I)  in  auiemic  slates; 
and  (5)  as  mentioned  prcvionsly,  the  systolic  murmur  of  mitral  insufficiency 
may  be  transmitted  along  the  loft  sternal  margin.  Actual  lesions  of  the 
valves  of  the  ])ulmonary  artery  arc  I'aro. 

(a)  SloiDsin  is  almost  invariably  a  congenital  anomaly.  It  constitutes 
one  of  the  most  important  of  the  congenital  cardiac  aifoctions.  The  valve 
segments  are  nsnally  united,  leaving  a  small,  narrow  orifice.  In  the  adult 
cases  occasionally  occur.  In  Case  OOS  of  my  ])ost-mortem  records  there 
was  extreme  stenosis  in  a  girl  of  eighteen,  owing  to  groat  thickening  and 
adhesion  of  the  segments,  and  there  were  also  numerous  vegetations.  The 
orifice  was  only  2  mm.  in  diameter.  The  congenital  lesion  is  commonly  asso- 
ciated with  patency  of  the  ductus  r>otalii  and  imperfection  of  the  ventricu- 
lar septum.    There  may  also  bo  tricuspid  stenosis. 

The  physical  signs  are  extremely  uncertain.  There  may  bo  a  systolic 
murmur  with  a  thrill  heard  best  to  the  left  of  the  sternum  in  the  second 
intercostal  P])aco.  This  murmur  may  be  very  like  a  murmur  of  aortic 
stenosis,  but  is  not  transmitted  in'o  tlie  vessels.  Xaturally  the  pulmonary 
second  sound  is  weak  or  obliterated,  or  may  bo  replaced  by  a  diastolic  mur- 
mur.   Usually  there  is  hypertrophy  of  the  right  heart. 

(h)  Pithnnnarij  Insnfjkiennj. — This  rare  affection  is  occasionally  duo  to 
congenital  malformation,  particularly  fusion  of  two  of  the  segments.  It  is 
sometimes  present,  as  Bramwell  has  shown,  in  cases  of  malignant  endocar- 
ditis.   Barie  has  collected  58  cases. 

The  physical  signs  are  those  of  regurgitation  into  the  right  ventricle, 
but,  as  a  rule,  it  is  difficult  to  difTerentiate  the  murmur  from  that  of  aortic 
insufficiency,  though  the  maximum  intensity  may  be  in  the  pulmonary 
area.  Tlie  absence  of  the  vascular  features  of  aortic  insufficiency  is  sug- 
gestive.   Both  Gibson  and  Graham  Steoll  have  called  attention  to  the  pos- 


-•^rr 


^oi  DISEASES  OF  THE  rmcri.ATORY  SYSTEM. 

'.  I  puliuoiuiry  aitery." 

8,  CoMniNi-.n  V.\iA-ti,An  Lksu»ns. 


( 

\ 


\ 


!, 


(I 


liii;. 


mi 
ill' 


!   1  'n.;  :iiaj:no.i.  rests  u,on  the  ehanu-ter  o    tl.o  n.ur.nurs  and  the  state 

'f  I  of  the  ehan.hers  as  regards  hypertrophy  and  ddatat.un 

'M  ProKnosis  in  Valvular  Disease. -l  lu-  qnest....    s  entm      one 

J  x-iugiiuoio  *"  ,  .     .    ,,,,,  ...Mined  the  imtient 


InlV,,'  n„  i,uo,„-,.,m.nc,,  ..ml  cv«„  .ill.  11..'  .....st  -"™f  f"™«  '"  "'"' 


Slier  no   ineonMnn-iiv^v,  ....>■   -• -,,„i,  ,^i 

k.<inn  tin.  function  of  the  heart  n.ay  he  little,  ,1  at  all,  d.sti  rl.ed 

r        itioners  who  are  not  adepts  in  auscultation  and  ieel  "-^''l;   ^^    ; 
nvito  the  value  of  the  varhu.s  heart  murmurs  should  rememher  that  the 
i  u  nnent  of  the  conditions  nuty  he  feathered  from  inspeet.on  and  ijal- 
I  ;;!.i;     WHh  an  apex  heat  in  the  uorn>al  situation  and  regular  tn  rhytluu 

he  auscultatory  ,.henomena  may  he  practically  disregaiHled. 

r  Si    Andre  V  Clark  states,  a  mnrn.ur  per  se  is  of  little  or  uo  monumt 
d  in  (Mc^mil,  the  prognosis  in  any  given  case.     There  is  a  large  group 

i  o"        ients  who  presint  no  other  syn^.tonis  than  a  systol.c  nmrmnr  h  aid 

f  o  r  L  hody  o/thc  heart,  or  over  the  apex,  in  whom  the  leit  ventnde  . 

V  mi  1  vpertrciphied,  the  heart  rhythm  is  normal,  and  who  n,ay  not  have 

I  ;:d  rh!::mat!sm.    'indeed,  the  condition  is  --l-^'^b'  <  ---;^^  o^  - 

:V:  durin-  CNan.ination  for  life  insurance.     I  know  cases  of  this  k  ml  whicH 

:5; ;  h!;;.e  pev^'ted  unchanged  for  more  than  fifteen  years.     Among  the  condi- 

i|!  tiniie  inlluencinc;  prognosis  are:  .         , 

m  (.       "  .-Childrcm  under  ten  are  had  suhiects.     Compensation  is  wdl 

I  elTe  t  *d  La  thev  are  free  from  many  of  the  inllucuces  which  d,si.ir^i  eom- 

M  ^n'  t  oiHu  adidts.     The  coronary  arteries  are  healthy    ->f  ""^n  ion  of 

^lll  el    art-muscle  cau  he  readily  maintained.    Yet,  ,n  spde  of  this,    ho  out- 

t  ook    n  cardiac  lesions  developing  in  very  young  children  is  usually  had. 

Ifi^  One    ^^  is  that  the  valve  lesion  itself  is  apt  to  he  -l-Uy  P-ogr^sive, 

|l  and  the  limit  of  cardiac  reserve  fo.ce  is  in  such  cases  early  reached      1    en. 

k  eems  to  he  proportionately  a  greater  degree  of  hypei'trophy  '"^     f  :^  ^• 

i  Among  othcJr  cLses  of  the  risks  of  this  period  are  to  he  "-"^;^-;^.  ";*;  J 

J-  flcient^ood  in  the  poorer  classes,  the  recurrence  of  rheumat  e  att^acks,  am 

'  f^n  i   ^0    of  pericardial  adhesions.    The  outlook   n  a  child  who  c^n  he 

cnrefu  Iv  "upervi  ed  and  prc'vented  from  damaging  himselfhy  overexert  on 
"  tSail^b    ter  than    n  one  who  is  constantly  overtasking  his  musclec. 


CIIUONIC   VALVULAR   DISKASK. 


r2i> 


of  pressure 
iiuU'i'  thi'se 
iure  in  tlio 


'iits  miiy  1"' 
iiiitnil  iiinl 
.ortic  iusiil'- 
itiiil  iiu'cini- 
ciKisis  witli 
(111  is  luii'tic 
Uiickcniiif,' 
111111)11. 
lul  the  state 

I'litin'ly  one 
puticnt  iiiiiy 
'ins  ot  vaho 

■a. 

iialilc  to  osti- 
lior  that  tlic 
JDii  and  i>al- 
ir  ill  rliytiuu 

r  no  momont 
large  grouj) 
\irnuir  heard 
t  ventricle  is 
lay  not  have 
overed,  often 
;  kind  -which 
ig  the  condi- 

sation  is  well 
disturb  eoni- 
.  nutrition  of 
this,  the  out- 
:  usually  had. 
y  ])rogressive, 
ichod.  There 
nd  dilatation, 
itioned  insuf- 
H  attacks,  and 
d  who  can  he 
If  overexertion 
2  his  muscles. 


The  valviihir  lesions  which  (Icvelop  at,  or  Mili^eniieiit  lo.  ihe  period  of 
pul)erty  are  more  likely  to  he  peniiaiieiilly  and  ellieieiilly  compensated. 
SuchU'ii  death  I'roiii  hi'art-disea.se  is  very  rare  in  children. 

(Ii)  >V,r. — Women  hear  valve  h'sions,  as  a  rule,  hctter  tliaii  men,  owing 
partly  to  the  fact  that  they  Uve  quieter  lives,  jiartly  to  the  less  common 
involvement  of  the  coronary  arteries,  and  to  the  greater  frei|iiency  of  mitral 
lesions.  Pregnancy  and  parturition  arc  distiuhing  i'actfU's,  hut  are,  I  think, 
less  serious  than  soiiu'  writers  wcuild  have  us  helievc. 

((■)  \'(ilfe  alJcclctl. — The  relative  prognosis  of  the  dilVeicnt  valve  le>ions 
is  very  ditlicult  to  estimate.  Kaeh  case  must,  therefore,  he  judged  on  its 
own  merits.  Aortic  insiiHieiency  is  uii(Hies1i(uialily  the  most  serious;  yet 
for  years  it  may  he  perfectly  compensated.  Kavoraiile  eireiimslaiiees  in 
anv  case  are  the  moderate  grade  of  hy|iertropliy  and  dilatation,  the  altscnce 
of  all  sym|itoms  of  cardiac  distress,  and  tlii'  ahsence  of  extensive  arterio- 
sclerosis and  of  angina.  The  ])rogiiosis  rests  in  reality  with  the  condition 
of  the  coronary  arteries.  Kliciimatii'  lesions  of  the  valves,  inducing  insuf- 
liciency,  are  less  apt  to  he  associated  with  endarteritis  at  the  root  of  the 
aiu'ta;  and  in  such  cases  the  coronary  arteries  may  escape  for  years.  1 
know  a  physician,  now  ahoiit  hu'ty-thrce  years  of  age,  who,  when  sixteen, 
had  his  iirst  attack  of  rheumatism,  which  involved  Ihe  aortic  segments. 
lie  has  had  two  suhsei|uent  attacks  of  rheumatism,  hut  with  care  has  hecn 
ahlc  to  live  a  conifortalile  and  fairly  active  life.  On  the  other  hand,  when 
the  aortic  insullicicncy  is  only  a  part  of  an  extensive  arterio-sclerosis  at  the 
root  of  the  aorta,  the  coronary  arteries  are  almost  invariahly  involved,  and 
the  outlook  in  such  cases  is  much  more  serimis.  Sudden  death  is  not  un- 
coninKUi,  either  from  acute  dilatation  during  som(>  exertion,  or,  more  fre- 
(picntlv,  from  hloeking  of  one  of  the  hranches  of  the  coronary  arteries. 
The  liability  of  this  form  to  be  associated  with  angina  pectiu'is  also  adds 
to  its  severitv.  Aortic  stenosis  is  a  c(uii])aralivcly  rare  U'sioii,  most  coin- 
nionly  met  with  in  midille-agcd  or  elderly  men,  and  is.  as  a  rule,  well  com- 
pensated. In  r>roadl)ent's  scries  of  cases,  in  which  autopsy  showed  definite 
aortic  narrowing,  forty  years  was  the  average  age  at  death,  and  the  oldest 
was  but  (ifty-thrce. 

In  mitral  lesions  the  outlook  on  the  whole  i-  miich  more  favorable  than 
ill  aortic  insullicicncy.  Mitral  insullicicncy,  when  well  compensated,  car- 
ries with  it  a  hctter  prognosis  than  mitral  stenosis.  Practically  it  is  the  only 
valvular  disease  we  meet  with  in  jiatients  over  threescore  years.  It  must 
he  borne  in  mind  that  the  cases  which  last  the  longest  are  those  in  which 
the  valve  orifice  is  more  or  less  narrowed,  as  well  as  incompetent.  There 
is,  in  realitv.  no  valve  lesion  so  poorly  compensated  and  ,so  rajiidly  fatal 
as  that  in  which  the  mitral  segments  are  gradually  curled  and  ])iickcred 
until  thcv  form  a  nan-ow  strip  around  a  wide  mitral  ring — a  condition  spe- 
cially seen  in  children.  There  are  many  cases  of  mitral  insuHiciency  in 
which  the  defect  is  thoroughly  balanced  for  thirty  or  even  forty  v'cars, 
without  distress  or  inconvenience.  l''.ven  with  great  hypertrophy  and  the 
a\)vx  beat  almost  in  the  mid-axillary  line,  there  may  be  little  or  no  distress, 
and  the  com])ensation  may  be  most  cfTective.  Woukmi  may  iiass  safely 
through  ivjieated  pregnancies,  though  here  they  arc  liable  to  accidents  asso- 


f 

i' 

8 

! 


^t 


.  ,1 


'J 


DISEASES  OF  THE  C'lUClLATOUY  SYS'n:M. 

,i,„,,l  ,,i,h  tlK-  S..VC..V  stn.in.     1  l-av.  l>.ul  um\vv  my  cut  for  ninny  year. 

if     ■    -Iv  l>aa  a  .vll-.ua,k...l  nutral  nu.nuur.     Sho  lir.t  canu.  umU-r  m 

'  ,  t  ■     0  ami  a  lou'.!  svstulic,.  n.ur.nur.     Sho  has  had  no  canhac  ch.urha  ur 

H-  tho.,,d.  .h.-has  livHl  a  v.ry  ac^tive  lif.,  has  b...n  unusually  v  ,o  - 

uus!  has  hurnodovon  chikhvu,  an.l  has  i-as^.l  through  tlure  suhs.4u.nt  at- 

tai'Us  of  rlR'UUiatisiu.  1  „c  1,.  ,:  I'lvni-ililr 

In  niitral  stenosis  tliu  pn.-nosis  is  usually  iv-anlnl  as  U»  lax.iai,!.. 
AIv     w  ■ricnc.e  has  led  nu-.  however,  to  ,,laee  this  los.ou  almost  on  a 

1    c     1  mrt    ularly  in  .on.en.  with  tlu-  n.itral  insuiruu.ney      It  .s     ouu, 
.  o    ";  in  persons  in  perlVet   heahh,  who  have  ha.l  -""-  l-  P;      j, 
„„:  H,M,s  (,r  heart-failure,  a.ul  who  have  lived  lahonous  lives,      lie    i^u 
,!  ven,^oo,  hv  I'.roadhent  indieate  that  the  .late  of  death  n.  nntra    ste     s^ 
ts  eo  iparatiu.lv  advanced.     Of  r.:5  cases  ahstra.ted  Iron,  tlu"  post-moiten 
m   d     o     St.-.Mary-s  Hospital,  thirty-three  was  the  a,a>  lor  males,  and 
h  r  tov.n  or  thirty-eight  for  females.     These  women.    .)o,  pass  throu, 

t.:d  pre,iian..ies  wiTh  safety.     There  are  of  eourse  those  too  eonnn 
Lddents!  ti;;  result  <.f  eerehral  .inholiMU.  whieh  are  more  likely  to  oeeu. 
in  this  than  in  other  forms.  .  ,.  •     • 

'    rd     nd  fast  lines  eannot  he  drawn  in  the  question  ol  prognosis  m 

valv  ihr  di<ea<e.     Kverv  ease  must  he  judged  separately,  and  all  the  c  r- 

nnstiuicc^carefullv  baiamed.     There  is  no  ,,uestion  which  requires  grca  er 

experience  and  mo:'e  mature  judgnieut,  and  even  the  most  experienced  are 

sometimes  at  fault.  ;,,.4;f,.  „  fivm- 

The  following  brief  summary  of  the  conditions  wh  eh  iu>Uh   a  i,no,- 
able  prognosis  caubodies  the   large  and   varied   clinical   expericm-e  ot   b.r 

\   dr. w  Clark:  G<.od  general  health:  just  habits  of  hvmg:  no  excep  lonnl 

1  to  rheumatic  !,r  catarrhal  alTections;  origin  of    he  valvular  lesion 

dependentlv  of  degeneration;  existence  of  the  valvular  lesion  withon 

3>  for  over  tlirJ^  years;  sound  ventricles,  of  moderate  Ireqiiency  and 
;  eneml  ron.laritv  of  action;  sound  arteries,  with  a  normal  amount  of  blood 
tn^  tension  in  the  .nailer  vessels;  free  course  of  blood  through  the  cer- 
vical veins;  and.  lastly,  freedom  from  ].nlmonary,  hepatic,  and  renal  con- 

^''■'Treatment  of  Valvular  Lesions.-F.^r  this  purpose  the  valvular 
lesion  mav  be  divided  into  the  j.eriod  of  progressive  development,  with  es- 
tablishment and  maintenance  of  hypertrophy,  and  the  period  of  disturbed 

"''""y^ntaffeof  Compensation.-Medicinal  treatment  at  this  period  is  not 
nec(-4rv  and  is  often  hurtful.  A  very  common  error  is  to  administer 
cardiac  drucs.  such  as  digitalis,  011  the  discovery  of  a  murmur  or  of  hyper- 
tr.u.hv  If  the  lesi.m  lias  been  found  accidentally,  it  may  be  best  not  to 
tell  tlie  patient,  but  rather  an  intimate  friend.  Often  it  is  necessary,  how- 
ever to  be  perfectlv  frank  in  order  that  the  patient  may  take  certam  pre- 
ventive measures.  ITe  should  lead  a  qui(>t.  regulated,  orderly  life,  free  from 
excitement  and  worrv.  and  the  risk  of  sudden  death  makes  it  imperative 
tint  the  patient  sufferiui:  from  aortic  disease  should  be  specially  warned 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


wklo 


7//    /  ^^  /M 

v/>^    '  /  '£y  #3  ^^    A- 


•^ 


1.0 


I.I 


1.25 


•  56 

■  ■M 


mil 


It    140 


-    6" 


IM 

22, 
2.0 

1.8 


1.4    111  1.6 


Photographic 

Sciences 

Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  canadien  de  microreproductions  historiques 


L\ 


m 


■^v 


n IRONIC    VALVULAR  DISEASE. 


731 


a.^ainst  ovoroxortion  nn.l  luirry.     An  ordinary  ^vlu.lo.olno  diot  .n  iiKulrnito 
.nuu.tifu.^^  should  he  tMkcn,  tnl>ncen  sIh.uM  l.c  iuterclietL.d,  and  stimu  antf? 
not  allowed.     Exorcise  should  ho  ro-uh,tod  ontiroly  by  the  loolinjjs  ot  tho 
nationt.    So  Ion-  as  no  oardia<>  distress  or  imlpitation  i'.dlows.  niodorate  ex- 
orcise will  nrovp  vorv  henolieial.     The  skin  should  ho  kept  aetive  hy  a  dady 
hath      Jlot  Imths  siu.uld  he  avoided  and  the  Turkish  hath  should  lie  inter- 
dicted     In  the  case  of  full-hloodcd.  somewhat  cor]ndent   individuals,  an 
occasional  saline  pur-e  should  he  taken.     Tationts  with  valvular  lesions 
shonld  not  jio  into  vorv  hi-h  altitudes.     The  act  of  coition  has  seruuis  risks 
particularly  in  aortic 'insullicioncy.     Knowin-  that  the  causes  which  most 
surely  and  p..werfully  disturb  the  compen>ation  are  overexertion,  mental 
Morrv,  and  malnntrition,  the  physician  should  -ivo  snilahle  .n<tnu:tions  in 
eicl/ca-o      As  it  is  always  better  to  have  the  co-operation  of  an  intelligent 
patient    he  sluuild,  as  a 'rule,  bo  told  of  tho  condition,  hut  m  this  matter 
the  iihysician  must  he  -nided  ])y  circumstances,  and  there  are  cases  in 
which  reticence  i?  the  wiser  policy.  ^■  ,      ,.i 

(h)  Stage  of  Broken  Compensation.— The  break  may  he  immediate  and 
final,  as  when  sudden  death  results  from  acute  dilatation  (U'  from  hocking 
of  a  branch  of  the  corouarv  artery,  or  it  may  bo  gradual.  Anmng  the  first 
indications  are  shortness  oi'  breath  .u.  exertion  or  attacks  of  noctnrual  dysp- 
nn.a  These  are  often  associato.l  with  impaired  nutritmn,  particularly 
with  ana^mia,  and  a  course  of  ircui  or  change  of  air  may  sutlice  to  relieve  tho 

syniiitoms.  ,  ,     ^  i         •„ 

'  IiTC-ndarity  of  the  action  of  the  heart  cannot  always  l)o  termed  an  in- 
dication of  failing  compensation,  particularly  in  instances  of  mitral  disease. 
It  has  .rreater  si-nificanco  in  aortic  lesions.  Serious  failure  of  comi.ensa- 
tion  is  hidi..,ted  hv  signs  ..f  dilatation  of  the  heart,  marked  cyanosis,  the 
-allop  rhythm,  or'various  forms  of  arrhythmia,  with  or  without  tho  ex- 
fstenco  of  dropsy.     Under  these  circumstances  the  following  measures  are 

to  ho  carried  out:  ,  , 

n)  /.Vs7 —Disturbed  compensation  may  be  com|.letely  rotoied  in  ic.t 
uf  the  hodv.  l-.oth  in  Montreal  and  in  I'hilad.^phia  it  was  a  favorite  dem- 
onstration'in  ,n'a.tical  therapeutics  to  slmw  the  b.^iign  intluence  of  com- 
pete rest  and  -piiet  on  the  cardiac  dilatation.  In  many  oases  with  .edc-ma 
of  the  ankles,  moderate  dilatation  of  the  heart,  and  irregularity  ot  the  pulse, 
the  re<t  in  b.-.l.  a  few  dos.-s  of  the  compound  tincture  of  cardamoms,  and  a 
silinepurge  suflice.  within  a  week  or  ten  days,  to  restore  the  com,K>nsation. 
One  p  tie^it,  in  Ward  11  of  tho  Montreal  General  Hospital,  ^ylth  aortic 
ii'sulliciency  recoyered  from  four  successive  attacks  of  tailing  compensation 
with  these  measures  alone. 

(•')  Tho  relief  of  the  embarrassed  circulation. 

,;  1'>I  Vcnrsrcl in,,. -In  cases  of  dilatation,  fnuu  whate^;e^  cause,  whether 
i„  mi  rai  or  aortic  lesions  or  distention  of  the  right  yentricle  ,n  emphysema 
; ;.,n  siens  of  ven.ms  engorgement  are  marked  and  when  there  is  orthopm  i 
^vith  cyanosis,  tho  abstraction  of  from  20  to  30  ounces  of  blood  is  indi- 
cated '  This  is  tho  occasion  in  which  timely  yenesection  may  save  the 
„;tient'slife.  It  is  a  condition  in  which  1  have  had  most  satisfactory  re- 
lult<  fruni  blood-letting.     It  is  done  much  better  early  than  late.     I  have 


i:i. 


ill 


'1! 


y 


J 


DISEASES   OP  THE  CIllCULATORY   SYSTEM. 


.,n  sev..r:.l  orca^ions  n.^zrott...!  its  i.osi,,nnoment    imrtK.ular!y   m  instance 
„.•  acute  (lih.tati.Hi  ami  lyano.is  in  (■...uurli.ni  with  cmplivsrina. 

,7;,  Drplrdon  H,rou„h  ll,r  //..vk-This  >.  partKularly  v:;lu:.l>le;       ' 
,1,.,,     V  i:  nirlnt      (»t  tin.  varinus  lun-rs  tl>c  saluus  a.v  to  l.o  i-nl.  m-l. 

W  •  ,1   J,;  .vacuafon.     Tl>e  con>iK,und  Jala,  vnw.U.  'j^  ;;;';-   ;;;;;;:; 

tlu'  I'ortal  system  rapidly  ami  ctlR-K-ntly.  ,-.    l./;„„      Of  those 

bv  1     mo  t  Lportant  is  digitalis,  which  was  introduced  n.t.,  prac  u. 

V    ^tlc  iu^     ThJ  indication  for  its  use  is  dilatatu.n;  t  u.  -"'--■;';; 
k>n  i      VerR.ctlv  halanced  con.pensatory  hypertro,.hy,  such  as  we  sen 
urn  IS  a  pu  ^,,„u,t.nsation,   no   matter   what    the 

r  l^s  0   'n         0  t;i:;ii.l  for  its  uie.     It  acts  up<m  the  hearty  sW 
i  'ml    t  the;anu'  tin>e  increasino-  Uk-  force  of  the  contrao  ions      It 
rt^  pcd   ileral  arteries,  raisin,  their  tension,  .>  that  -teady  and  e., 
n    of  blood  is  n.aintained  in  tlie  capillaries,  wluc.h,  after  all,   ^  the  p    n  c 
I  Hi  ol.ieet  of  the  circulation.     The  henelicial  eiCcts  arc  ^^^    --"  - 

;  w.:       nutnU  disease  with  sn.all,  irregular  pulse  and  carduic  drop^> .     It. 
Xc^    ir        less  striking  in  the  dilatation  of  the  left  ventricle    .n  the 
U^l       upensati.m  of  aortic  insulliciency  or  of  arteno-selen.s.s.     On  theo- 
. e,     a     r  un.ls  it  has  been  uri^ed  that  its  use  is  not  so  advantapeons  .n 

r;i:  in:;n;;.!eney.  since  it  prol.>n,s  the  ^^^^^^^^u'  tl':^^ 
tention.  This  need  not  be  c.onsulere.l  and  dip.tal.>  ..  .)n>t  a>  ^  '  ^^^;: 
n  this  ns  in  anv  other  c-mditicm  associated  with  pro.uressne  dilatation. 
Ir.  do  0  \  re  often  rcnpiived.  It  may  be  pnven  as  the  tincture  or  the  m- 
^Son  1  '" 'or  cardiac  dropsy,  from  whatever  cause,  15  minims  ..I  he 
^^  u-G  or  half  an  cunur  of  the  infusion  may  be  given  every  hrcv  Imu, 
f  .  vn  d  V  after  which  the  dose  mav  be  reduced.  Some  preler  the  tinc^- 
te  0  llt^il^h  f^^oK  it  i.  a  mattc^r  of  indiiVerence  ,i  the  drug  is  good. 
^'Z^;  a  patient  taking  digitalis  should  be  ca..fully  ostnnated  .n.h 
d  A    a  rule    when  its  action  is  beneiicial,  there  :s  w.tlun  twenty-  cur 

our.  an  ncrease  in  the  anunu.t;  often  the  flow  is  very  groat  1  nc  e  U 
u^^i^v^^ncea  is  relieved,  the  dropsy  gradually  disappears,  the  pulso  e- 
comos^lrmer,  fuller  in  volume,  and  sometimes,  if  it  has  boon  very  mtci- 

""^^.t^Sf Lietimes  follow  digitalis.  There  is  no  such  thing  a^a 
,,,  ^lativo  action  of  the  drug  manifested  by  sudden  ^X^M;  --  ^'-e 
clVects  arc  «oon  in  the  production  of  nausea  and  vomiting.  1  le  pnl>c  he 
m  h"^h  "id  snlall.  and  there  may  be  two  beats  of  the  heart  ^j  one 
0  10  nul^e  which,  as  pointed  out  by  Broadbont,  is  found  partirula.l>  m 
t^  of  m^r        onosis\vlien  they  are  under  the  iniluonce  of  tins  drug. 


*For  ihuslnuivo  cases  from  my  wards  sec  paper  by  II.  A.  Latlour,  Medical  News, 
July.  1891. 


II  instiinco? 

iiiil»le  wluMi 
,'  jiirlVrrcil, 
to  all  hinir 
K[)S()in  siilts 
(Hii  tliroe  to 

iU-lun  lloSl':-, 
•n  ilu'  pulse 
Lhrv  deplt-'te 

.—Of  those, 

lltd    ])ViH'ti('0 

iiitra-imlica- 
wc  sec  in  all 
■r   what    the 
heart,  slow- 
ms.     It  acts 
and  e(iuahle 
is  the  jtrinie 
host  seen  in 
dropsy.     Its 
triele.  in  the 
IS.     On  tl'.eo- 
antageous  in 
)  tvreater  dis- 
is  serviceahle 
;e  dilatation; 
ive  or  the  in- 
nininis  oi'  the 
\-  three  lunirs 
eiVr  the  tine- 
drug  is  good. 
stinuited  caeh 
II  twenty-four 
t.     Under  its 
tlie  pulse  he- 
Lii  very  intcr- 

h  thing  as  a 
|itoins.  Toxic 
The  i)nlsc  he- 
e  heart  to  one 
particularly  in 
of  this  drug. 


ir,  Modiful  Nows, 


CIIHONIC   VALVULAR   DISKASE. 


733 


The  urine  is  reduced  in  amount.  These  syni])tonis  suhside  on  the  with- 
drawal of  the  digitalis,  and  are  rarely  serious.  There  are  patients  who  take 
di-italis  uninterruptedlv  for  years,  and  leel  pal|Mtatiou  and  distress  it  the 
drn<'  is  ouiilted.  In  mitral  disease,  even  when  it  (hu's  good  it  does  not  al- 
wm^  steady  the  pulse.  There  are  many  eases  in  which  the  irregularity  is 
not  alVectell  hv  the  digitalis.  ^Vhen  the  coinpeii-ati.m  has  lieen  rc-08tah- 
li.hed  the  drug  may  lie  (.niitted.  When  there  is  dyspn(ea  on  exertion  and 
eanliac  di^tres's.  from  5  to  It)  miuims  three  times  a  .lay  may  he  advan- 
ta"-eou-ly  given  for  prolonged  periods,  hut  the  clVeets  should  he  carefully 
watched'  ""in  cardiac  dropsy  digitalis  should  he  used  at  the  (nitset  with  a 
free  haiul  Small  doses  should  n..t  he  given,  hut  frum  the  first  half-unice 
,h,scs  of  the  infusion  every  three  hours,  or  from  i:.  to  V'O  minims  of  the 
tincture.     There  are  no  suhstitiitcs  for  digitalis. 

Of  other  remedies  strophanthus  alone  is  of  service.  Giyen  in  doses  ot 
from  5  to  S  minims  of  the  tincture,  it  acts  like  <ligitalis.  It  certainly  will 
sometimes  steady  the  intermittent  heart  of  mitral  valve  disease  when  digi- 
talis fails  to  do  so,  hut  it  is  not  to  he  compared  with  this  drug  Alien  dropsy 
is  i)resent.  Convallaria,  citrate  of  calfcine.  and  <nlniiiy.  irntnhs  and  spai- 
tcine  are  warmly  recommended  as  Mihstitutes  for  digitalis,  hut  their  lule- 
riority  is  so  maiiifest  that  their  use  is  rarely  indicated. 

There  are  two  valuahle  adjuncts  in  the  treatment  of  valvular  disease— 
in.n  and  strychnia.  When  aiiaMuia  is  a  marked  featun'  iron  should  he 
.riven  in  full"  doses.  In  some  instances  of  failing  com|)ensation  iron  is  the 
only  medicine  needed  to  restore  the  halance.  Arsenic  is  occasionally  an 
exc'cllcnt  suhstiliite.  and  one  or  other  of  them  should  he  adniinisteivd  in 
all  instances  of  heart-trouhle  when  pallor  is  present.  Strychnia  is  a  heart 
tonic  of  very  ureat  value.  It  may  he  given  alone  or  in  c(nnl.iuation  willi  the 
dio-italis  in'l'or  'l  drop  (l(Hes  of  the  I-i)er-<rnt  s(dutioii.  .Mcolu.lic  stimu- 
lants ill  moderati.m  are  occa>ioually  useful,  especially  in  tiding  over  a  i)ennd 
of  acute  cardiac  weakness. 

Treatment  of  Special  Symptoms.  (</)  7>re/,.s//.— Ihe  increased 
arterial  tension  and  activity  of  the  capillary  circulation  under  the  iniluence 
of  diuitalis  hastens  the  interstitial  lymph  How  and  favors  resorption  of  the 
lluid.'"  The  hydragogue  cathartics,  hy  raj. idly  depleting  the  hlood,  jmniioto. 
too,  the  ahsorption  id'  the  lliiid  from  the  lymph  spaces  and  the  lymph  sacs. 
These  two  measures  usually  sulliee  to  rid  the  patient  of  the  drojisy.  In 
some  cases,  however,  it  can'iiot  he  relieved,  and  then  Sonthey's  tuhes  may 
i)e  used  or  the  legs  ])nncturcd..  If  done  with  ca -e.  after  a  thorough  wa-^li- 
int,'  of  the  parts,  and  if  antiseptic  iirecantions  i.re  taken,  scarification  is  a 
very  serviceahle  measure,  and  should  he  resorted  to  more  fre(|uently  than  it 
Canton  tlauncl  handages  may  he  ai)iilicd  on  the  (edematous  legs. 
{h)  ])iispiiira.—'V\w  imticnts'are  usually  nnahle  to  lie  down.  A  com- 
fortalile  hed-rest  should  therefore  he  in-ovided— if  jiossihlc,  one  with  lateral 
l,r.M«'it'*">'^-  ^"  tl>'>^  i"  ^li~''l'i".ir  tlie  head  can  he  suiiported  as  it  falls  over. 
The  shortness  of  hreatli  is  associated  with  dilatation,  chronic  lironchitis, 
or  hydrothorax.  The  chest  should  he  carefully  examined  in  all  these  cases, 
as  hydrothorax  of  one  side  or  of  hoth  is  a  common  cause  of  shortness  of 
breath.     There  are  cases  of  mitral  regurgitation  with  recurring  hydrothora.K 


IS. 


'A 


m^i 


DISEASES  OF  THE  CHlCrLATORY  SYSTEM. 


MS  tlic  o\v  (li(i]»si(al  ^^ymptoni,  wliii'li  is  rclit'vod,  week  by  week  or  month 
hv  111(11  li.  liv  tii|ii>iiiii. "  Tor  tlu'  mKluriuil  ilysiuuua.  partifularly  when  (■(•lu- 
liiiicd  wilh  'irstlcssiK'ss,  morphia  is  iiivalualile  and  may  be  given  witiiont 
liesilation.  The  vahie  of  the  eahnin.ix  inthienee  of  opium  in  all  (■ouditions 
of  eardiae  iiisiillieienev  is  not  enonuii  reeognized.  Tl  Te  are  instanecs  of 
cardiae  dv.«l»n(ea  nn  .<soeiated  witii  dropsy,  particularly  in  mitral  valve  dis- 
ease, in  wiiich  nifogivcerin  is  of  great  service,  if  given  in  the  1-por-eent 
solution  in  increasing  doses.  It  is  especially  serviceable  in  the  cases  in 
which  the  ])ulse  tension  is  high. 

((■)  PaliniitlwH  (111(1  CiiriVuir  n!shr.<s.—Jn  instances  of  great  hypertrophy 
and  in  tiie  throbbinir  wliich  i^  so  distressing  in  some  eases  of  aortic  in- 
sutliciencv,  aconite  is  of  sernce  in  doses  of  from  I  to  3  minims  every  two 
or  three  hours.  An  ice-l)ag  over  the  heart  or  Letter's  coil  is  also  of  service 
in  allaying  the  rapid  action  and  the  tlirobi)ing.  Imu-  the  pains,  which  arc 
often  .so  marked  in  aortic  lesions,  iodide  of  potas-^ium  in  10-grain  doses, 
three  times  a  dav,  or  the  nitroglycerin  may  be  trii'd.  Small  blisters  are 
sometimes  advant'agecnis.  It  must  be  rememliered  that  an  important  cause 
of  palpitation  and  cardiac  distress  is  flatulent  disi:enti(m  of  the  stomach 
or  colon,  against  wiiich  suit  ilile  measures  must  be  directed. 

(tl)  (uislrir  !>!iiiiiih>iiis.—T\\e  cases  of  cardiac  insnllicienev  which  do 
badly  and  fail  to  respond  ti:  digitalis  arc  most  often  those  in  wliicli  nausea 
andvoiiiitiug  are  prominen  features.  The  liver  is  often  greatly  enlarged 
in  these  cases;  there  is  moie  or  les-  stasis  in  the  hepatic  vessels,  and  but 
little  can  be  expected  of  drugs  until  the  venous  engorgement  is  relieved. 
]f  the  vomiting  iiersists,  it  is  best  to  stop  tiie  food  and  give  small  hits  of 
ice,  small  (luaiititics  of  milk  and  lime  water,  and  en'ervescuig  drinks,  such 
as  Apollinaris  water  and  champagne.  Creasoie,  hydrocyanic  acid,  and  the 
oxalate  of  cerium  are  sometimes  useful;  Vmt.  as  a  rule,  the  condition  is  ob- 
stinate and  always  serious. 

(c)  Cduijh  and  Ifd'iivipli/si.^. — The  former  is  almost  a  necessary  concomi- 
tant of  cardiac  insufliciency,  owing  to  engorgonient  of  the  pulmonary  ves- 
sels and  more  or  less  bronchitis.  It  is  allayed  by  measures  directed  rather 
to  the  heart  than  to  the  lungs.  ITa-moptysis  in  chronic  valvular  disease 
is  sometimes  a  salutary  symiitom.  An  army  surgeon,  who  was  iiivali(h'd 
during  the  late  civil  war  on  account  of  hivmoptysis,  supposed  to  he  due 
to  tuberculosis,  has  since  that  time  had.  in  association  with  mitral  insulTi- 
ciencv  ami  enlarged  heart,  many  attacks  of  luemoptysis.  He  assures  me 
that  his  condition  is  invariabl;;  better  after  the  attack.  It  is  rarely  fatal, 
cxcejit  in  some  cases  of  acute  dilatation,  and  seldom  calls  for  special  treat- 
ment. 

if)  Sice ii]rxsu(\^s.— One  of  the  most  distnssing  features  of  valvular  le- 
sions, oven  in  the  stage  of  couipeusatiou,  is  di>turbcd  ,*lrep.  Patients  may 
wake  suddenly  with  throbbing  of  the  heart,  often  in  an  attack  of  night- 
mare. Subsequently,  when  the  compensation  has  failed,  it  is  also  a  wcu-ry- 
inir  symptcnn.  The  sleep  is  broken,  restless,  and  fre(|uently  disturbed  by 
frisrbi  ful  dreams.  Sometimes  f  dose  fif  the  spirits  of  chloroform  or  of  other, 
with  half  a  drachm  of  s])irits  of  camphor,  given  in  a  little  hot  wliiskv,  will 
give  a  quiet  night.     The  compnuiul  spirits  of  ether,  llofl'inan's  anodyne, 


ir  month 
lu'ii  com- 

witlioiit 
onditioiH 
taiK'Os  of 
k'iilvo  di.s- 
-per-CL'iit 

casL':<  in 

|)crtro|)hy 
iioi'tic  in- 
L'vcrv  two 
ol'  scrvico 
ivhifh  lire 
lin  (losi's, 
istcrs  arc 
ant  cause 
'  stoiiuuli 

wliicli  do 
eh  nausea 
•  enlarji'iHl 
;  and  but 
^  relieved, 
all  bits  of 
inks,  such 
1,  and  the 
lion  is  ob- 

■  conconii- 
onarv  ves- 
ted rather 
lar  disease 
invalided 
to  be  due 
ral  insiiiVi- 
issnres  me 
irely  fatal, 
jcial  treat- 

alvidar  le- 
tients  may 
;  of  niiiht- 
:o  a  wori'y- 
sturbed  by 
)r  of  otlier, 
liisky,  will 
s  anodvnc. 


nYPKRTROPlTY   AND   DILATATION. 


735 


tlion,i,di  very  unjileasant  to  take,  is  freciucntly  a  great  boon  in  llie  inler- 
mcdiate  jieriod  when  ccin|iensation  has  partially  failed  and  the  [latients 
snifer  from  restless  and  sieepless  nights.  Paraldehyde  and  aiiiylene  hydrate 
are  sometimes  serviceabl--.  I'rethan,  Hnlphonal,  and  ehloralatnido  are  rarely 
ellicacious,  and  it  is  best,  alter  a  few  trials,  parlieidarly  if  the  paraldehyde 
docs  not  answer,  to  resort  to  morphia.     It  may  be  given  in  eond)inatioii  with 

atropine. 

(7)  //(■*((//  Siiiiiphinis.—V^hh  ruptured  compensation  and  lowering  oi 
the  ten.-ion  in  the  aorta,  the  urinary  secretion  is  greatly  diniinish<'d,  and 
the  amount  mav  sink  to  .■")  or  (1  ounces  in  the  day.  Digitalis,  and  strophan- 
tlms  wbni  elllcient,  usually  increase  the  How.  A  brisk  purge  may  be  fol- 
h)wed  l)y  augmented  secretion.  The  cond)ination  in  pill  form  of  digitalis, 
s((nill,  and  the  black  oxide  of  mercury,  will  sometimes  prove  ell'ective  when 
the  inl'usion  or  tincture  of  digitalis  alone  has  failed.  Calomel  acts  well  in 
some  cas(s,  given  in  ;i-grain  doses  every  six  hours  for  three  or  four  days. 

The  (//('/  in  chronic  valve-diseases  is  often  very  dinienlt  to  regulate. 
With  the  dilatation  and  venous  engorgement  come  nausea  and  often  a  great 
distaste  for  food.  The  amount  of  li(iuid  should  be  restricted,  and  niilk, 
beef-juice,  or  egg  albumen  given  every  three  hours.  When  the  serious 
symp'tonis  have  passed,  eggs,  scrajied  meat,  tish,  and  fowl  may  he  allowed. 
Starchy  foods,  ami  all  articles  likely  to  cause  llatulency,  should  be  for- 
bidden.    Stinndanls  are  usually  necessary,  eitlier  whisky  or  brandy. 


III.     HYPERTROPHY    AND    DILATATION. 

Ilvpertroi)hy  is  an  enlargement  of  the  heart  due  to  an  increased  thick- 
ness, total  or  partial,  in  the  muscular  walls.  Dilatation  is  an  increase  in 
size  of  one  or  more  of  the  chambers,  with  or  without  thickening  of  the  walls. 
The  conditions  usually  coexist,  and  ecndd  be  more  correctly  described  to- 
gether under  the  term  enlargement  of  the  heart.  Simple  hyportrophy,  in 
which  the  cavities  remain  of  a  normal  size  and  the  walls  are  increased, 
occurs,  but  simple  dilatation,  in  which  the  cavities  arc  increased  and  the 
walls  remain  of  a  normal  diameter,  ])robably  does  not,  as  it  is  always  asso- 
ciated with  thinning  or  with  thickening  of  the  coats.  Commonly  we  have 
the  forms  of  simple  bypertroi)hy,  hypertrophy  wiMi  dilatation,  and  dilatation 
with  thinning  of  the  coats. 

ITYiMniTKOViiY  OF  Tin:  ITi;.\t?t. 

There  are  two  forms— the  simple  hypertrophy,  in  which  the  cavity  or 
cavities  are  of  normal  size;  and  hypertro])hy  with  dilatation  (eccentric 
hypertroi)hy),  in  which  the  cavities  are  enlarged  and  die  walls  increased  in 
thickness.  "The  condition  formerly  spoken  of  as  concentric  hypertrophy, 
in  which  there  is  diminution  in  the  size  of  the  cavity  with  thickening  of 
the  walls,  is,  as  a  rule,  a  post-mortem  change. 

The  enlargement  may  affect  the  entire  organ,  one  side,  or  only  one 
chamher.  Naturally,  as  "the  left  ventricle  does  the  chief  work  in  forcing 
46 


I 

■I 


I 


n 

1; 


d^ 


Y3g  DISEASES  OK  THE  CIliCLLATOllY  SYSTEM. 

,,,,  ,,l,..l   ,hnu„h   tl.e  systcni..  art.ri.s  the  <.han,,.  is   n.ost    f.v.inontly 

'""miology.-nviH.rt>n,hv  of  tlu.  lu.vl  follow-  tl>..  l.nv  K.-nin^  ,nus- 

'f;nowed  hy  i.u.,vas...l  siz._i.  o.,  hy,>H-.,o,.hy.    ^yV^^^V^  ^       !  J 
ventricle   alone,   or   uith   general   enlargenK'nt    ol   tl.e   hca.t,   ..         u,u 

"'"rondiu<ms  alTeetin.  the  heart  itself:  (1)  Di^^ase  of  the  a-^rtie  valve; 
(,)  '  •  rll  l^nthLieney?  (.)  perieanlial  adhesions:  (!)  ^<  -;;;;;  >;'^-;f- 
r.    .li.turbeu  innervation,  with  overactn.n.  as  in  ».xoi.hthaln.u    g  itri    m 

;:^-:^;rr::^^sr;:'iitr=;ru;',;;;':: > 

f.nrf-iiii   tnvie  substances,  wnun,  ^l^   1111^,111   •>•,-,-'  .  in, 

u^        ^     larv  circulation,  render  greater  action  necessary  to  --1      h- 

'■""(;)'i;:sion.  of  H.  nmral  valve,  either  incon,.tence  or  ^^^^^^^^^^ 

act  bv  increasing  the  resistance  m  the  puhnonary  ves>el>.      -)  1  """•*'     j^ 

^io  s     bliteration  of  anv  nun.ber  of  bloo.l-vesse  s  w.tun  the  1"»S^  ^  •  1 

,      en       n  emphysen.a  or  cirrhosis,  is  folh.wed  by  hypertrophy  of  to 

^M  ^ntncle.  \'I)  Valvular  lesions  on  the  rigl.  ^'^  l^-'l-^ ^, ^    ^ 

Innertrophv   in   the  adult,  not  infrequently  m  the  fatus.     (1)   Unon  e 

vah'llr  dlLse  of  the  l.-ft  heart  and  pericardial  adbesu>ns  are  sooner  or 

later  associated  with  hypertrophy  of  the  right  ventricle      _ 

Tn  the  auricles  sinude  hvpertrophv  is  never  seen:  it  is  always  dilata- 
tion with;         ophy.  '  In  tiii  left  .uuicle  the  condition  develops  m  lesions 
tTh    n^t  I  0   ficc.  particularly  stenosis.    The  right  auricle  hy,,ertrophic^ 
wh  n  ?iere  is  greatly  increased  blood-pressuro  in  the  lesser  cnx-ulatimi^ 
whother  due  to^ritral  stenosis  or  pulmonary  lesions,     ^arrow,ng  of  the 

''''^i^lZ^PvC^Z::i  an  average.si.ed  man  weigl.  aboi. 
.  o^^(^n,es^  that  of  a  woman,  about  H  ounces  (.50  grammes  • 
Tn  CISC  of  general  hypertrophy  the  heart  may  veigh  from  10  to  .0  oum  c. 
mSTts  above  25  ou'uces  are"  rare.     So  far  as  I  know,  the  heaviest  heart 
Tn  ml    is  one  of  53  ounces,  described  by   P.everly  ^'^--^^'^^ 

ns  rcnorted  one  weighing  48  ounces.    The  measurement  of  the  thickues. 

?y  ^!n      is  next  to  vvebdiing.  the  ])est  means  of  determining  the  hyi)er- 
tr.^;     In  :;;;S- aal^^ioirthe  walls,  though  actually  thickened,  may 


■'Jl 


llYPEllTHorJIY   AND   DILATATION. 


r3< 


liiontly 


iiil:  mus- 
sel I  V.nlk 

llic  l.'ll 

lirniij:lit 

ic  valvo; 
(icnnlilis; 
j,()itri'.  in 
)t'  ccrtiUii 
itioiis  the 

1}  ilUTl'llSC 

ailluTcnt 
luiui'trii'iil 

)-s('li'i'(>si?. 
ill  tt'iisidii 
thionce  of 
■ctinji  till' 
semi  tin' 

';  (:5)  \n-o- 

i(l-pivssuro 
stenosis, 
following 

isis,  which 
I'nlmoniU'y 
nngs,  such 
.hy  of  the 
iially  cause 
1)  Chronic 
>  sooner  or 

i-ays  (lilata- 
)s  in  lesions 
•])ortroi)hies 
circulation, 
ving  of  the 

i-eighs  aliout 
1)  o-ranunes). 
^  20  ounces, 
'avicst  heart 
?on.  Dulles 
he  thickness 
cr  the  hvper- 
ckencd,  may 


look  thin.  When  riijur  iinirlis  is  jircscnt,  tlie  cavity  utay  he  small  ami  the 
wails  may  ajipear  ^'reatly  tiiiikeiied  The  mca-iirements  should  not  lie 
made  iinlil  tiie  liiart  has  been  soaki'd  in  water  and  lli()rouj;hly  ri'la\e(h  In 
tile  left  ventricle  a  thickness  of  ten  lines,  or  from  Vd  to  t.':>  mm.,  indicates 
hy[)ertroiihy.  The  rif,dit  ventricle  is  thinner  than  the  left,  and  has  an 
averajre  diameter  of  from  d  to  T  mm.  In  hy|iertro|iliy  it  may  meai-ure  from 
i;j  to  "^'0  mm.  Tiie  left  auricle  has  a  normal  tiiickness  of  ai)ont  3  mm., 
whieii  may  lie  doiihled  in  hy[)ertro|ihy.  'i'lie  wall  of  the  ri^lit  auricle  is 
thinner  than  that  of  the  left,  rarely  exceeding  '^  mm.  in  diameter.  The 
apiiemlices  of  tiie  auricles  often  pre-ent  markid  increa.-e  in  thickness  and 
the  iiuisculi  pectinati  are  greatly  developed. 

The  shape  of  the  heart  is  altered  in  hypertrojihy;  with  great  enlarge- 
ment of  the  ventricles,  the  apex  is  broadened,  and  the  eonica!  sha]ie  is  lost. 
In  the  enormous  enlargement  of  aortic  insulliciency  this  rotnndity  uf  the 
ai)ex  is  very  marked.  When  the  right  ventricle  is  chieily  alfected  it  occu- 
l)ies  the  largest  share  of  the  apex.  In  mitral  stenosis  tlie  contrast  is  very 
striking  hetweeii  the  large,  hroad  right  ventricle,  reaching  to  the  ai>ex,  and 
the  small  left  chamlier. 

The  hypertrophied  muscle  has  a  deep  red  color,  is  firm,  and  is  cut  with 
increasing  resistance.  Tlie  right  ventricle,  as  K'okitansky  noted,  may  have 
a  peculiar  hard,  leathery  consistence,  in  simple  Jiypertrophy  of  the  left 
ventricle  the  pajiillary  muscles  and  the  coluniiia'  carnea'  may  lie  I'lilarged, 
hut  the  former  are  often  much  tlattened  in  dilated  hypertrophy.  The 
muscular  trahecuhe  are  more  developed,  as  a  rule,  in  the  right  ventricle 
than  in  the  left. 

The  increase  in  size  of  the  heart  is  prohalily  due  to  a  dellnite  numerical 
increase,  resulting  from  development  of  new  fibres. 

Symptoms. — llypertroiihy  is  a  conservative  jirocess,  secondary  to 
some  valvular  or  arterial  lesion,  and  is  not  neees,<arily  accomiianied  hy 
.sym]»toms.  So  adniiral)le  is  the  adjusting  jiower  of  tlie  heart  that,  for 
example,  an  advancing  stenosis  of  aortic  or  mitral  oriiice  may  for  years  he 
jHM'fectly  e(pialized  by  a  ])rogi'essive  hypertrophy,  and  the  subject  of  the 
all'ection  be  happily  uiuonscioiis  of  the  existence  of  heart  trouble.  Ilyper- 
tro]ihy  is  in  almost  all  eases  an  unmixed  good:  the  symptoms  which  arise 
are  usually  to  lie  attributed  to  its  failure,  or,  as  we  say,  to  (li>tur!)ance  of 
com])eiisation. 

Among  the  most  common  symptoms  are  unpleasant  feelings  aliout  the 
heart — a  sense  of  fulness  and  discomfort,  rarely  amounting  to  pain.  This 
may  ho  very  noticealile  when  the  jiatient  is  rccumlxMit  on  the  left  side. 
Actual  pain  is  rare,  except  in  the  irritalile  heart  from  tobacco  or  in  neur- 
asthenics, ralpitatioii  may  not  occur,  nor  do  jiatients  always  have  sensa- 
tions from  the  violent  shocks  of  a  greatly  hyiiertrophied  organ.  There 
are  instances  in  which  very  uneasy  feelings  arise  from  a  moderately  exag- 
gerated pulsation.  The  general  condition  has  much  to  do  with  this.  In 
health  we  are  not  conscious  of  the  heart's  ])ulsations,  hut  one  of  the  first 
indications  of  exhaustion  from  excesses  or  overstudy  is  the  consciousness 
of  the  heart's  action,  not  necessarily  with  palpitation.  Headaches,  flush- 
ings of  the  face,  noises  in  the  ears,  and  Hashes  of  light  may  he  present. 


•  >i 


51 


738 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


arteriosclerosis.    1';";-  ";  y,/;^^    ^'tUo  h  i^hlennl  i;io.Ml-p.vsM,re  (ex- 

,„,,s.ea  by  the  word  slra.n)  in  the  "^^^.^^^^jf         ',„,.,,,.,  to  i.-viz.,  the 
;„„,   ,  „i,V.  ineh>st,c  stale  nl   ^l-^    ;;^  ^J   .,    ,,,    .,,i,,lu.ral  uhstruetio. 

,,,,  ,,vpH.ro,hy  'Muins  the  >utem.    s  a  ^M^  -^^^^^ 

,.,,,.,,,,.,1  .nuseular  exert .nn  ;>'7  -^^,  I],    ,   ,,,,tieuhuly  those  of  the 

Another  dan^H.r  .s  rup  uro  ol  \^  ;"';;. ^,^^.,   \,;,\,  ,.,„„,,elnl  ki.lnevs 

i-;^;:t:v;=rx>i  ;;f  .;..«..^ > ■ ^- ^'- 

,a„«Hl  by  the  forcible  action  of  tl>^  he.jr  ,„,,H.onlia,  yn-o- 

Physical  ^\gns.-lnspccum  n,a>  sh.  u       .1.    .  ^^^,^,^^^.  ^^.„,. 

,..,i  J  u>  eluhiren  --l^-^-^"-;;^^^;^;     ;, ,  ^  .^^  invariably  associated 

,„t  pericardial  adhesuM^,  ^^"^^f  J'^  T.      e       o  ^^^^'''^^^  '^"'^  '^''  "''' 
,,ith  this  condition.     '  l.e  '"^'''''^^^^''l;',"^;  ;,'•„,  t-u-  in>pnlse  is  forcible 
visible  in.pnlse  is  nn-eh  increase        On  M  '  ^,^^^.  ^^     ,,,.i  ,,,,  the 

and  hoavin.,  and  with  each  ^^f '^^ j''  J^  '  ,/  n>pulse  is  one  ot  the  best 
heart  n,ay  be  visibly  ra,sed.  ^.;;1;;  ;  ^'^^  [j^n^pertronhy  the  forcible 
sinis  of  sinM'lo  hypertropliy.    ^\  '  h  lai^c  '1"^^*-       >  ^,^^,,,  j,,      i,,  can 

hnpnlse  i.  often  nun-e  sndden  and  aljmp  •    „;^,  ^  tic  valves   (lowers). 

so,netin.es  bo  felt,  due  perhaps  to  --'-'^  f^^  '  Ih  ntorspaci  from  1 
The  beat  :n.y  bo  felt;  m  '}^' ^^^'^^Z'' "^^Z^  aislo..ation  of  the  apex 
,.,  ,  hK.l,es  ontside  iho  "'Pl^^-  J^^  j'X  Mt  ventriele.  In  n.oderato 
^^  '';;?^r  ::U^:e:inXr  Ibi  ht-!  disease,  the  i,n,.lse  n>ay  be  >n 

s;:^;;tw:s,:;; .  the  -n.- ;;;--,:;;,;^:r  ;;;!j:;.rnai  une  .ay 

Percussio,,  reveals  increased  ^l"l"''^^-;\'";'  ,  "  '  .'  -,  t,ansverselv  may 
ho,in  at  the  third  rib  or  in  the  sec.nd  ;;;^  ;  ^  -"  ^  ^  ^  ,,,  ^nd  an 
extend  from  half  an  inch  to  2  ^^^']^^^^^J''W  dnll  area  is 
eqnal  distance  beyond  the  middle  line  ^^  ^^^  ^  ^^^i,,  ,„i,„,al  hypor- 
n,'ore  ovoid  than  in  healtli.  ^^hen  care  n  ^^-^^^\^^^^^  f,,,„,  ,  to  8 
trophy  of  aortic  valve  disease  "-^f '^^ ^  ,.^,^\  tr  nsverse  dulncss  of  4 
inehes  in  transverse  extent.    Tn  modeiato  .ia.l(. 

inches  is  not  nncommon.  ^^^,^^^,,   ._  ,^,,,.  p,,,ont 

On  au^rvllatwn  the  sound>  ^^^'"l  ^  '  ;"  '  ,,i„„.,„i  and  dull.  When 
no  special  changes,  but  the  fust  sound  ';;^^:"/;;  ^  'f,^,  Eeduplication 
therl  is  dilatation  as  well  it  may  be  v  <^-^^' ^^^^  .,,!„,_the 
i,  common  in  the  hypertrophy  of  icna    cl  .  e,^o.  ^^  ^^^^ 

apexbeat.    Tl-.-^f  ^^;;^ ':;;^,rt:s:  t^  sounds,  of  conrse,  are 

s:;.:^:^S^^^"^;^-7t:;^=^     .m  nse 


-L 


llYPHUTUorilY   AND  DILATATION. 


7;'.i» 


ho  loft 
lion  of 
'  rosults 
lire  (I'X- 
arteritis 
&/..,  tho 
tnictio.i 
Iut^mU). 

,<o  of  tho 
kidneys 
iniijoi'ity 
I-  vossol:?, 
.>  may  bo 

•dia,  V"'"" 
I'ur  wilh- 
vssooiatvd 
,Q  aroa  of 
s  foroililo 

ovor  the 
f  tlio  he^t 
ic  I'oroiblo 
iinilr^o  oan 

((lowers). 
CO  from  1 
'  tlio  apex 

moderate 
may  bo  in 

il  line  may 
ersely  may 
lie  and  an 
lull  aroa  is 
)ssal  liypcT- 
rom  7  to  8 
hilne?s  of  -i 

may  pre?ent 
lull.  When 
LMliiyilication 
•  clink— the 
rigbt  of  the 
finji'  in  cliar- 
f  conrso,  are 

IP,  tlie  pnli=e 
be  increased 


in  rai)iditv.  but  is  ol'lcii  normal.  In  .cc  iitiir  jiypcrtroj.hy  the  piil.^o  is  lull. 
I. Ill  >ollcr.  and  nsiiiiily  iikhv  rapiil.  nnr  ol'  the  carlic-i  ^i-iis  of  lailuro  and 
dilatation  is  irn -iilanty  and  intcrniittcnic  ol'  the  lailso. 

lly|M'iiroiihy  oT  \\u'' riijlil  milrirlr  in  the  adull  very  rarely  follows  valvu- 
hir  di'-rax'  on  ilic  right  side,  i)nt  rosnlts  from  increased   ivsislance  in  the 
piiliiionarv  ciivnliition.  as  in  cirrhosis  of  the  Inng  and  cnii.hy.-eina,  or  in 
flcno.-is  (if   the   mitral   orifice.      With    perfect    c(Hniien>ation,   whicli    fully 
maintain>  the  e(piililniiini  of  the  circulation,  there  arc  no  syin|itoms.     Kxtra 
exertion,  as  the  a.~ccnt  of  stairs  or  iMinning.  may  causi'  shortness  of  hrcath. 
l)iit  in  many  ways  hypertrophy  of  the  right  ventricle  is  the  most  enduring 
and   salutary    form  "in   the   whole   cycle   of  cardiac  alVeetions.      For   long 
periods  of  years  the  elVect>  of  mili'al  stenosis  may  he  countcrhalanccd,  aiul 
oidy  sudden  death  liv  accident  or  an  acute  disease  rcvi-al  the  cxistemc  of 
an  "unsii.-pectcd   l.-iim.      In   tiie  hypcrtrojihy  secondary  to  emphysema  (ir 
cirrhosis  of  the  lungs,  there  may  be  sciiMition^  of  distress  in  tlie  e.irdiac 
regi<ni,  with  eoiigii  and  shortness  of  lireath;  hut  as  long  as  the  dilatation 
is'^moderate  the  symptoms  are  not   marked.     With   great   dilatation  and 
triciisiiid  leakage  come  venous  engorgement,  u'dema.  and  imluionary  trou- 
bles.    'I'he  inercasi'd  pres>iirc  in  the  lesser  circtilation  leads  to  sclerosis  of 
the  piil'iomiry  arteries  ami   the  constant  engorgement   of  tho  capillaries 
leads   ultimately  to  a   de]iosition   of  ])igment   and   increase   in    the   lihrons 
elements  in   the  lung — the  iirown   induration.      Ivxtrcme   i.ulmonary  con- 
gestion and  apoplexy  are  more  often  associateil  with  dilatation.     Ihemo])- 
tysis  mav  result  from  rupture  of  vessels  during  sudden  exertion. 

riu/siail  ,s'/v»N.— I'-ulging  of  the  lower  jiart  of  the  >ternnm  and  left 
cartilages  occurs.  The  ajiox  beat  is  forced  to  tho  left.  Imt  is  not  so  (d'teii 
displaml  downward.  'I'he  most  marked  imimlse  may  be  in  the  angh-  be- 
tween tho  onsiform  cartilage  ami  the  seventh  rib  or  beneath  the  cartilago.s 
of  the  sixth  and  seventh  ribs.  The  luilsation  is  rather  dilVuse,  not  punc- 
tate, particularly  if  there  is  much  dilatation.  I'l  thin-walled  chests  there 
may  be  pulsati(m  in  the  third  ami  fourth  right  intersi>aces.  The  cardiac 
dulness  is  increased  transversely  and  toward  the  right;  it  may  extend  an 
inch  or  more  lievond  tho  border  of  tho  stenntm.  On  auscultation  the  first 
connd  at  the  lower  part  of  the  sternum  is  louder  and  fuller  than  normal, 
but  The  dilVcrences  are  not  very  marked  unless  there  is  mitch  dilatatiim, 
when  the  sound  is  eloarer  and' shari.or.  Accentuation  and  reduplication 
of  the  second  sound  are  heard  in  the  pulmonary  artery  on  account  of  tho 
increased  tension.  The  pulse  at  tlic  wrist  is  usually  small.  Pulsation 
occurs  in  the  juu-ulnrs  when  there  is  tricuspid  inccimitetenco. 

Tlyportro]div  of  the  aurlrlcs  always  .icctirs  witli  dilatation.  Tt  is  more 
common  in  tho  left  chamber,  wliicli  hyiKutrophios  in  nntral  stenosis  and 
incomiiotoncv.  and  naturally  assists  in  restoring  tin-  l)a]ance  of  tho  circu- 
lation. There  arc  no  distinctive  i.hysical  signs,  and  we  usually  can  infer 
its  presence  onlv  bv  tho  existence  of  mitral  stenosis  nnd  a  presystolic  mur- 
mur. Tncreased  dulness  may  be  determined  to  tlie  h'ft  of  the  sternum,  and 
there  may  be  a  lu-osvsfolic  wave  in  tbe  second  left  interspace. 

ITypcrtropliv  and  dilatation  of  the  right  auricle  are  met  with  (associ- 
ated with  a  similar  condition  in  the  right  ventricle  and  incompetency  of 


l«» 


DISKASES  OF  TllH  CIUCULATCKY  SYSTEM. 

•  1  ; .  ,>f  ill,,  lim"  rlivoiiic  lironihitiH,  and 
U.  trK...,i.l)  in  -M-lO---  -■;^-'-  ':/-,„  U.  .n.t.r  dcvelo,- 
„,^„l  .lisniK..     m  7'''M;'>  -  >  ,     '  ;„.,  i,^  ,„„,,„,i  ,...Hinati  is  very 

nu.nt  an.l  l.v,..rtn.rl,v  '^      ;  ,  1  .  v.r  tl:.  nnl.nur  wall  nl'  th.  sinns 

to  a  gn.at.r  .xU.-t   than  .n  '"•"^'';.,  ',,,„.,'    ,„,,vslulie.  in  rl.ythn,. 
,„ra  :.n.l  fourth  in,...,...    I     -       '  1  '  .U  ;„„.•  ..1,1.,..  ..f 

.i,n,s  of  vcncns  cnjior^iriiK'nt,  jn-nlai    lau 
ailalali.Mi  of  thi"  ri-ht  lu.art.  aUlin-uishr.l  an-. 

(1)  N-nu,u.  ,al,.i,a„nn,  'Y''-,       '         !    .  j.^     '  ,,„,„.,..n,;.nt  ..f  U.o 
Has  not  tin.  lu.avm,  '-i;;;  ^      f    ^    !  j;^.L,ion!  a^  in  th.  sn.k.rV  lu;art, 

r  •  .;;;;;i:u^:::r.;/  t^JiLni.;  an.,  m  ...^.hahni..  ..it,. .....  n . 

,,„,,,..>u..>  -'^;;;-^;'::;;  'L         ;   ;  i:;-;„>ont  of  »....  ln.u-t   fn.n 
sion,  anc-unsm,  "'^"''"^*'"''',^'  ',„,,:„,,    ,f  the  clu.t.     NVitl«  tlu>  oxct- 

Lo  of  ..n.inary  .arc.  l.ow.vo^    ...  ;^^    ;;/;;; ^„i;u,     ^Vi,.>  tin-  left 

„ro  two  ••1M''-V\''''''''7''"  f  Ml  i'  r  rHu-sis.  a  lar,o  .urfa.  of  t.>e 
luns  contra......  fn.u  p.cnr  sy,  l'''^'  '     '  ^  ;      ^.^,  ,„  ,,  f, „, -,,,0,  an.l  may  at 

Heart  i.."MH-.l;  ^•>;'  I'"'-*"'"  ""^^J"  •  ^ "i  ai  „  t.u.r..  is  .lisl..cation 
first  si.ht  sn,,..st  X^^''-;  '^,;i.^  ,  '  ^  !  ^I^nary  ..r  pM-ritio  aisoaso 
uiiwar.!  an.l  t<.  tlu>  l.'it.     1  1h  ^•^'■;'"''.     ,'.„,,■  ,,  ..ii,  .i,nu.,,  to  nrovent 

.nistrtos.     A  l'-""""\'/"  .  „,   „,i,|,    i|l.,u.v,.|o|«.,l    luii?»;   lioi-o, 

.■„„s..  .,f  l,.v|,..rtr.,l,liy  «-,n  nil"!.!  '■""*"'•  1,  ™,„l,v-.'„«i  n,»«ta  i,„Kl.Tatc 

an.l  inorcnsin-  imv)>i™ont  of  tlio  vaho  ,ta-.>-(lnrin-  which 

(h)  The  period  ..f  full  eomiuMisation— the  l.it.nl   .ta  .  r^ 

any  symptoms  that  he  has  a  valvular  lesion. 


IlYI'EUTllorilY   AND   DILATATION. 


(41 


tif,  and 
li'vc'Uni- 
is  very 
lie  simirt 
;  in  the 
vliythiii, 
rncfS   tit' 


foroilile, 
it  of  tlio 
rV  lu'iu't, 
l)Ut  it  is 

)t'  I'uuscs, 
dial  cltii- 
'11  rt   i'nnn 
tlie  vKvr- 
i'.    Thove 
1  tlie  left 
IPC  of  the 
1(1  may  at 
lisldcation 
AC  iliseaso 
o  prevent 
tliout  any 
ii(r<;   liore, 
il   positittn 
ly  obvious 
(isis.    The 
s  moderate 
ien  dimin- 
diagnosis; 

hy  may  l)e 

ure  of  the 
ring  a  sud- 
r'oiiies  fully 
)\v  from  an 
tions  of  the 
ips  etep  hy 
progressive 

iring  which 
This  period 
le  aware  by 


(r)  Tlie  period  of  briki'ii  eoiiipensiilioii,  which  may  ei)nie  on  suddenly 
during  very  severe  exertion.  Death  may  result  from  aeiite  dilatation;  l)Ut 
more'^eomi'imnly  it  tal<es  place  .-h.wly  and  results  from  degeneration  and 
weakening  td'  the  hcarl-nui.-cle. 

'I'he  hreaking  or  niplure  of  cardiac  compensation  may  he  indueed  hy 
numy  causes,  among  which  the  most  important  are:  (1)  Failure  of  the 
general  nutrition.  In  many  instances  of  heart-disease,  exposure,  poor  food, 
and  aleolud  eomhine  to  bring  about  disturbance  of  a  well-balanced  heart 
lesion.  Acute  illnesses,  particularly  t'le  levers,  may  induce  general  debility 
and  with  it  weakening  of  the  heart-muscle,  f.')  Disturliance  of  the  hieal 
nutrition  (tf  the  heart,  owing  to  gradual  sclerosis  of  the  coronary  arteries, 
is  a  comnuui  cause.  (:5)  Very  severe  muscular  exertion,  whicli  may  disturi) 
a  compensation,  perfect  for  years,  and  induce  death  in  a  few  days  (Traube)- 
(1)  .Mental  emotions.  Severe  grief  or  fright  may  bring  on  failure  of  com- 
pensation. 

The  progiK.sis  is  largely,  as  already  stated,  a  matter  of  maintained  com- 
pensation. Once  cstablislu'd,  the  hypertrophy  rarely,  if  ever,  disap|tears, 
inasmuch  as  the  cause  usually  persists.  Occasionally,  perhaps,  the  hyper- 
trophy associated  with  iieiiiotic  palpitation  from  tobacco,  or  other  causes, 
or  the  hypertrophy  following  muscular  oveiexertion,  may  disappear. 

l)||,.\r\Tl()N    Ol"   Tin:    IIl'.AllT. 

Two  varieties  are  recognized,  dilatation  with  tliiela'ning  and  dilatation 
with  thiniung.  The  former  is  the  more  couim  m,  and  corresponds  to  tin- 
dilated  or  eccentric  liy])ertrop]iy. 

Etiology.— Two  important  causes  combine  to  jjrodiice  dilatation-- 
increased  pressure  within  the  cavities  and  impaired  resistance,  due  to  weak- 
ening (d'  the  muscular  wall— wiiicli  may  act  singly,  but  are  often  couiliiued. 
A  weakened  wall  may  yield  to  a  normal  distending  force,  or  a  normal  wall 
may  vield  under  a  heigliteiied  blood-pressure. 

"(i)  lieiLditened  eiidocardiac  pressure  results  either  from  an  increased 
(plant  ity  of  hUnd  to  be  moved  or  an  obstacle  to  be  overcome,  and  is  the 
more  fre(iueiit  cause.  It  does  not  necessarily  bring  about  dilatation;  simple 
hypertrophy  may  follow,  as  in  the  early  jteriod  of  a(;rtic  stenosis,  and  in  the 
liypertroiih'v  of  the  left  ventricle  in  {'.right's  disease. 

A  majority  of  the  important  causes  of  increased  eiidocardiac  ])ressure 
have  already  been  discussed  under  hypertrophy.  One  or  two  may  be  con- 
sidered more  in  detail. 

The  size  of  the  cardiac  chambers  varies  in  health.  "With  slow  actum 
of  the  heart  the  dilatatitm  is  complete  and  fuller  than  it  is  with  rapid 
action,  riiysiologicaliv,  the  limits  of  dilatation  are  reached  when  the 
chamber  does  not  empty  itself  during  the  systole.  This  may  occur  as  an 
acute,  transient  condition  in  severe  exertion— during,  for  example,  the 
ascent  of  a  mountain.  There  may  be  great  dilatation  of  the  right  heart, 
as  shown  by  the  increased  epigastric  pulsation,  and  even  increase  in  the 
cardiac  dnlness.  The  safety-valve  action  of  the  tricus])id  valves  may  here 
come  into  ]dav,  relieving  the  lungs  by  permitting  regurgitation  into  tlie 


^ 


o 


,^,  DISEASES  OF  THE  ORCULATORV  SYSTEM. 

•  „i    luit  if  il  liiis  l)L'on  cxtvcmo, 
,,nclo.     With  rest  the  condiUou  ^^X^t^l^^^^r  slo.ly,  c,  ind.0,1. 
the  heart,  nmy  .ulVor  a  ntnun  tvo     .    uh  .    ^  ^    ^^^^^^  ^^^^^,^_  ^^^_^^.^^,^ 
Uu.  individual  ,nay  nov.r  he  «       'V    >  ^  „^^„^,i   j,  i,,.,iy  a  gradual 

,1^^.     „,,,,  of  trai.nnji,  the  go  t^,^^  ;\  '  l  i^  ..larly  of  tlie  ri.^ht  dunnh.rs. 

A  de.H'ee  of  exertion  can  he  salelj  '"•^"';  '  ,  ^     ^  gradual  process 

;^;;ite  inipossdde  under  ^^  ^ --:::;;^r  he  -r^^^  s^engtl^ened  its 
of  Ihat  we  may  call  phy^'eal  ^^  ^^l^^^"'^'  ^^  „,.  u^^iological  work,  hhi- 
reserve  force-widened  ^77;-^^,,     ^l^  t!ie\.M>ahilities  of  the  heart, 

durance  in  1-''-^-^ -"^t^  "  1^  "  ''-^  ^'^  -"'^'""'^"^  ^"'''""■^  '^ 
and  its  essence  consists  in  l)(jn„ 

overstep  the  limits  of  dilatation.  ^^^,  ^,^^,  ^,,^^^,,„.,,^  ;„  ^1,, 

We  have  no  positive  knowkHlge        tu   n.it  ^^^_  ._^  ^^^^  ^^.^^_^^.^^^^  ^^^  .,^. 

heart  wliich  occur  in  this  V^-^^l,^  The  large  lieart  of  atliletos  may  ho 
,reased  muscular  »»V''''  Sr  mii  h,rt  no  man  heconies  a  great 
a,„  to  the  prolonged  use  of  ^^'^'^  n  -^  .^.  ^^^^^  ^^  ^^^,.^,  i,,,,t. 

runner  or  oarsman  wlio  has  not  nalu  all.>       «  race-liorse, 

both  famous  (or  cmlur»,K>iM",ll.cim-C  ^^^   ^^^^^^^^   ._^  ,,^,,„.|. 

K,c„rivc  dil..t»t,....  'l"nng  ►-."';",,      „„  |,is  l.Mrt  t.v  .xln. 

^"■'""•,  '^  ■'"";■  '";S ;."  r. ,  tniai.'  l-i » ■' ""» --"  -it 

work  during  the  ascent  o    a  11^0  .^^  ^^^^  epigastrium.     He 

nain  ahout  the  heart  and  a  «^'"^  '  ^  ,  ..  .^  ,  ,,ut  tlie  symptoms 
Leathes  rapidly  for  some  tn^e^ ;«  H  ;^,  ^  ^  ^^exercise  is  h.Howed 
pass  off  after  a  night  s  qu  ei.    A    a    cm  t  y^  ^^^^^^.  ^,^^^^^^  „^^ 

bv  another  attack,  or,  UHleel   ;^     •  ^<; '  ,,^,  ,„;,uuh1  for  severe  cxei- 

while  he  is  at  rest.    For  nionth>  ^'  ^^^    >    j,^  ,„„,,  ^^y  he  has  over- 

tion,  or  he  may  he  permanen  ly    -  J  ^    ^^     ;,  ..     Exactly  ^vhat  has  taken 
.trained  liis  heart  and  l)ecome         o     1       ^  '^  J  .^  ,„,t.  and  with 

1,,,  i„  tliese  hearts  we  canuo    ^>'    f  ^^^  .   ,^^„  „„intaining  the  circula- 
it  the  power  of  meeting  tlie  ^-;^:!^^X^^^.  ,^  i,t,,ani  includes  cases 

sis  of  the  heart.  „  f  ^.„|,.^.  lesions.     In  aortic 

Examples  of  dilatation  ';^^^^     ^^^^^'Zu.^  diastole  from  the  uii- 

i,K.ompctency  hh.od  enters  tl-  Ic  t       ;^'  ,,,,   ;,,,titv  of  hlood  at  the 

cn.arded  aorta  and  from  the  l^'f*'^'';.    ';''.,    ^,,t  erne  de.rec  of  pressure, 
U.ruiinationof  diastole  si  ;j«.ts    he.. dl,.mc.^^  ^^^       ,^^  .^  ^^.^^^^^^^ 

„ndcr  which  they  !"7^t'^''^\V;^  ;,,,,, 'hv  of  tliis  condition. 

and  present  the  typical  eccentr.c  ^n  -^"^^  ^,^^^^  ,!,,;,,„  i,to  the 

Tn  mitral  ^-^-^^^^^y^^f,^^'Z{^"Zn.  which  it  came,  and  then 
aorta  is  forced  into  and  ^\'1^\^%^1;;;;";;;  ^^  is  returned  from  the  auri- 
i„  the  diastole  of  the  Yutricle  "-^  ''^^  J  I;,,;,  the  left  auricle  is  the 
cle,  and  with  increased  force. _    ^^  \;,^'^,i„i,,  ,,,d  dilates  as  well   as 

.eat  of  greatly  -"f  f  \*^""?"  '^    ."^;  '  eno  n  o--     I^'^'^^'^^'"'^  '^  '''' 
hvportrophies;  the  distention,  too,  m,n    he 


1 


IIYPERTUOPIIY   AND   DILATATIUN. 


•  43 


cxtvcmo, 
,  iiuU't'il. 
ion.  In 
I  gradnal 
havnlu'i's. 
eh  wolllil 

il  process 
hcnLHl  its 
Ilk.  l''n- 
[ho  hoart, 
iidoncy  In 

res  in  tho 
[on  of  in- 
p?  nmy  hp 
I's  a  giH'Ut 
irjii'  heart, 
race-liorse, 

irts. 

in  licart- 
t  for  extra 
seized  with 
riuni.  11^' 
^  symiitonis 

is  followed 
ay  come  on 
severe  exer- 
le  has  over- 
it  has  taken 
st,  and  with 
the  cirenla- 
iclndes  eases 
,  due  to  rnp- 
diirin.u'  lo^iS" 
1  and  paraly- 

s.  In  aortic 
I'roni  the  nn- 

l)lood  at  the 
0  of  yiressure, 

in  thickness, 

n. 

iven  into  the 
me.  and  then 
ntiii  the  anri- 
anriele  is  tlie 
tos  as  well  as 
itation  of  the 


ri'^ht  ventricle  is  ])roduced  hy  a  nuiuhcr  of  conditions,  whicli  were  con- 
sidered under  hyjiertrophy.  All  circuiii>ianees,  such  as  mitral  stenosis, 
emphysema,  etc.."  wliieii  permanently  incri^ase  the  teiisiiui  of  tlie  hlood  in 
the  pulmonary  vessels,  cause  its  dilatation. 

(•*)  Impaired  nutrition  of  the  lirarl-walls  may  lead  to  a  diminution  of 
the  resistinji'  power  so  that  dilatation  readily  (tccurs. 

'I'he  loss  of  tone  due  to  iiareiichymatous  de^^cneration  or  myocarditis 
in  fevers  may  lead  to  a  fatal  condition  of  acute  dilatation.  It  is  a  recoj;- 
nized  cause  of  deatli  in  scarlatinal  dmiisy  ((ioodharl).  ami  may  occui'  in 
rheumatic  fever,  typhus,  typhoid,  erysipelas,  etc.  The  changes  in  the 
heart-muscle  which  ac'comi>any  acute  eiidocardiiis  or  pericarditis  nuiy  lead 
to  dilatation,  especially  in  the  latter  disease,  in  amemia,  leuka'mia,  and 
chlorosis  the  dilatation  may  l)e  consideralilc.  In  sclerosis  of  the  walls,  the 
yielding  is  always  where  this  ])rocess  is  most  advam-cd,  as  at  tiie  left  apex. 
I'nder  any  of  these  circumstances  the  walls  may  yield  with  normal  Ijlood- 

pressuro. 

Pericardial  adliesions  are  a  cause  of  dilatation,  ami  we  generally  find 
in  cases  with  extensive  and  firm  union  cousidei'alile  hy|)ertroi>liy  and  dihi- 
tation.  There  is  usually  here  some  impairment  as  well  of  the  superlicial 
lavers  of  muscle. 

Morbid  Anatomy.— 'i'he  comliti(m  usually  exists  with  hyi>erfro]ihy 
in  two  or  more  ciuimhers.  it  is  more  common  on  the  right  than  on  the 
left  side.  'I'he  most  extreme  dilatation  is  in  cases  of  aortic  incompetency, 
in  wliich  all  the  cavities  may  lie  enormously  distended.  In  mitral  stenosis 
the  left  auricle  is  often  trciiicd  in  capacity,  ami  the  right  chandlers  also  are 
very  capacious.  The  auricles  may  contain  from  IS  to  30  ounces  of  hlood. 
In  chronic  lesions  of  the  lungs  the  right  chaml)ers  are  chielly  involve<l. 
In  great  distention  of  one  ventricle  the  septum  may  h\dge  toward  the  other 
side.  The  auricnlo-ventricular  rings  are  often  dilated,  and  Iherc  may  he 
an  increase  in  the  circumference  of  11  (H-  even  2  inches.  Thus,  the  tricus- 
pid orifice,  the  circumference  of  which  is  ahout  IJ  inches,  may  freely  admit 
a  graduated  heart-cone  of  ahove  H  inches;  and  tlie  mitral  orifice,  which 
normally  is  al)out  ^  inches,  may  admit  the  cone  to  .'i^  inches  or  even 
mnro.  (ircat  dilatation  is  always  accompanied  hy  relative  inconii)etency 
of  the  valves,  so  timt  free  regurgitation  into  tlie  auricles  is  permitted. 
The  orifices  of  the  vena>  cava>  and  of  the  ]mlmonary  veins  may  he  greatly 

dilated. 

The  endocardium  is  often  opa(pie.  jiarticularly  that  of  tlie  auricles. 
The  muscle  snlistance  varies  according  to  the  in'es(-nce  or  ahsenco  of  de- 
sionerations.  'i'he  microscope  may  show  marked  fatty  or  parenchymatous 
change,  hut  in  some  instances  no  sjiecial  alteration  may  l)e  noticeahlc. 
Tlierc  is  much  truth  in  Xiemeycr's  assertion  "that  it  is  not  possihlo  hy 
means  of  the  microscope  to  recognize  all  the  alterations  of  the  muscular 
fdirilla^  which  diminish  the  functional  power  of  tlie  heart."  Of  the  changes 
in  the  ganglia  of  the  heart  we  know  very  little.  As  centres  of  control 
they  prohahly  have  more  to  do  with  cardiac  atony  and  hreakdown  than  we 
generally  admit.  Degeneration  of  tliem  has  l}een  noted  by  Putjakin,  Ott, 
and  others. 


J 


^^ 


,jj  DISEASES  OF  THE  CMiCn.^TOKV  SYSTEM. 

tl,e  canliiic  walls,  chnuni^ho.  he  ^'^"V  /  ',''  „,„,,„^,,ji^„  j,  niaintained 
f.,.o  the  reverse  of  hyperln.phy.  So  ^;  «  ^^  ;i""!^;^"i  „  jt  i^  roaehed 
the  enlarge.nent  of  a  eav.ty  nu.y  be  ^^•^'J^^^,^^  ,„,,i  .u  the 
when  the  hypertroj-lual  .alls  .n  tl'  ^>^t  ^^  ^  the     hamber  is 

Srtl;  the  a.:r  as  ...1  as  the  au-J^l.  ^jnat.-^^-.  ^j^^also 
hypertrophy  as  a  direet  elled  "^  '  /^  ^^  /  ,,  ",,e  hypertrophy 
anu.unt  of  bhuul  to  be  juove.l  1'^'^  /^^^  ^;,  *  \,'  ,tv  it<eli'  -onipletely, 
weakens  an.l  the  ventriele  durn.,  ^^ 'l^^  ;^  ^'  ^  "^^  e  a  d  the  dibtath^a 
a  .till  lar-HT  a.aount  is  m  .t  a  the  end  f  ^  ^;^™'  ^^.^^t,  tUe  blood 
U,.o,Hes  ^.vater.  The  an>ou.d  ren.ann ng  ^  ^^^^^^^.f  ^^  ,,^,  ,,,ieulo- 
Ironi  entering  freely  from  tl'o  ^un  e  e  "  "  ^^l  ,.^.^;  ^^„a  impeded 
ventricular   valves   follows,   w.th   '^'^''^  '   ,,;^!^,j^"  "  ^^^^  Jf  the 

,,l„„a.,lnw   in  the  P"1"h>'>'''T;-^''"%.1^'''*    ;''   ,;^'\;;iVLls\he  venous 
right  heart  nu>y  oomp.nsate  for  a  ^-.o      u     .  un  tl  ^^  ^  ,,^ 

The   nln/siral  sinus  ot  dilatatu.n  aie  thoK    ot  ^\'\^;''  ^,^ 

„,„,  ■„,  ,r„„t  ot  .1.0  l„.»vt.  ana  J ;';  ;-;.;;|-,  ,'''       '        !.ilroartiln«c,  a,„l 

the  second  interspace.     J  ho  a  ea  ot  ^'"1"^;*^;^  ;""';„  ,  '         i,,av,ration  mav 

r:;:v^°i:tr  ^,^^h"  s«:'.".:;f  C:; r... 

,„„,riL;i  .00,,..  A,  „H.  .f ;««-; ;-™;- lir:::;::^  ,s  le  ti 

Reduplication  is  not  common,  but  oeca.ionall>  ailleitnct.        y 


HYPERTROPHY   AND   DILATATION. 


745 


knct^s  of 
is  llu-rc- 
lintiiinod 

roac'lK'd 
■1  all  the 
amber  is 
leit  vou- 
aiul  also 
increased 
[xMlrophy 
)iupletely, 
dilatation 
the  blood 

auriinilo- 

inipeded 
hy  oi  the 
he  veiiuvis 
oration  of 
talion  and 
I  en  failure 
nis — weak, 
us  circula- 

d   enlarged 
iver  a  wide 
t  be  found. 
-a  valuable 
th  a  quiek, 
rt  is  chielly 
ss  extensive 
.dt;  but  the 
rtilage,  and 
,»aees  to  the 
a  ])ulsation 
he  sternum, 
n  eharaeter. 
;pace  is  ever 
e  sometimes 
etly  systolic, 
he  auricular 
beat  against 
emphy^^ema- 
Inration  may 
IS  of  increase 

laraeter,  and 

gets  weaker. 

lay  be  heard 


in  the  first  sound  over  the  rigiit  and  left  iu'art-^.  The  siuinds  are  freiiucntly 
()l)scured  liy  murmurs,  which  are  produced  liy  incompetency  ()f  the  valves 
due  to  the"^  great  dilatation,  or  are  associatcil  with  the  chronic  valve  dis- 
ease on  wliich  the  condition  depends.  The  ai.rtic  second  sound  is  replaced 
by  a  murmur  in  aortic  regurgitation.  The  piilinonary  souik!  is  accentuated 
in  mitral  regurgitation  and  pulmonary  congestion,  iuit  witii  exirciiic  dilata- 
tion it  may  lie  much  weakened.  Tiie  heart's  action  is  irregular  and  inter- 
mittent, and  the  pulse  is  small,  weak,  and  (piick. 

On  auscultation  both  tlie  sounds  may  lie  free  from  munnur.  There 
is  the  condition  known  as  eml)ryocardia  or  fietal  hcart-rhythiu,  in  which 
the  iirst  and  second  sounds  are  very  alike,  and  the  long  pause  is  siiortened. 
In  other  instances  there  is  the  typical  and  characteristic  gallop  rhythm, 
rarely  found  apart  from  conditicnis  of  dilatation.  With  the  various  valvu- 
lar lesions  the  corresponding  murmurs  may  be  heard.  Miirniurs,  however, 
which  I'.ave  l)een  pre.-^ent  may  disappear,  as  in  the  case  of  mitral  stenosis. 
In  other  instaiu'cs  a  loud  systolic  iiiiinmir  may  lie  heard  at  the  apex,  and 
when  the  case  first  comes  under  observation  it  ir -v  be  iniiiossible  to  say 
vhether  this  is  due  to  organic  mitral  lesion.  T.  murmur  may  be  con- 
fined to  the  apex  region,  or  proiiagated  well  to  the  back.  It  is  extremely 
common  in  tiie  dilatation  which  follows  the  hypertrophy  of  the  left  ventri- 
cle in  arterio-sclerosis.  I'nder  treatment,  with  tiie  gradual  disappearanee 
of  the  dilatation,  a  murmur  of  this  kind,  even  though  most  intense,  may 
completely  disapjiear,  showing  that  it  has  lieen  due  to  a  relative  insulliciency, 
not  to  a  valvular  lesion.  All  varieties  of  arrhytlimia  may  occur  in  dilata- 
tion of  the  heart.     Tiie  i.ulse,  as  a  rule,  is  small,  weak,  (piick,  and  often 

Dilation  and  Hypertrophy  due  to  Overexertion  and  Alcohol.— There 

is  a  group  of  cases  of  dilatation  and  hyiiertropliy  dependent  upon  pro- 
longed overexertion,  which  rarelv  conies  under  observation  until  comjien- 
«ation  has  failed,  and  which  then  may  lie  very  ditlicult  to  distinguish  from 
the  similar  conditions  produced  by  valvular  disease.  The  patients  arc 
able-bodied  men  at  the  middle  jieriod  of  life,  and  complain  first  of  pal- 
pitation or  irregularity  of  the  action  of  the  heart  and  shortness  of  breath; 
Hib-equcntly  the  usmil  svmi.toms  of  cardiac  insuflieiency  develop.  On  in- 
quiring into  the  history  of  these  patients  none  of  the  usual  etiological 
factors  causing  valve-disease  are  present,  but  they  have  always  been  en- 
<M<rcd  in  laborious  occui)ations  and  have  usually  been  in  the  habit  of  taking 
stimulants  freelv.  This  is  the  affection  wliich  has  been  specially  studied 
by  :McLean,  OliiTord  Albntt,  Seitz,  and  others,  and  in  its  earlier  condition 
by  Da  Costa,  in  what  he  termed  the  irritable  heart.  It  is  met  with  very 
frequently  in  soldiers.  These  cases  may  return  to  hospital  three  or  four 
times  with  cardiac  insufTiciency,  sometimes  with  .«light  anasarca,  luemop- 
tv«i*  and  signs  of  pulmonarv  engorgi'ment.  The  c(mdition  is  by  no  means 
infrequent  P.ollingcr  has  called  attentimi  to  the  common  occurrence  of 
dilatation  and  hvpertrophv  in  beer-drinkers,  particularly  in  the  workers 
in  the  (ierman  breweries,  who  drink  20  or  more  litres  in  the  day.  Strum- 
pell  at  his  Erlangen  clinic,  told  mo  that  this  condition  was  very  common 
in  the  dravmen  and  workers  in  the  breweries  of  that  town,  very  few  of 


1^ 


I  i 


^■ik 


740  DISEASES  OF  TllK  riUCULATORY  SYSTEM. 

,vlH.m  pa-^.  tlu-  fovlv-ilfth  year  without   in.li.afu.ns  of  I'MH'Hroi.l.y  and 
ti  .     of  the  lu.art.     On  im.t-nuutc-n,  ..xauunat.on  tho  valv..  n,a^   he 
,  ,     .       ,■    orta  <n,ooth,  an.l  extensive  arterio-^el.Tos.s  or  renal  .1,.- 

''"     '  ''t   e  t  weid.    rron>  IS  to  •>:,  ounees;  the  ehan.hers  are 

;;;:::        The        d      ;rhas  Ceen  n.e,  with  ai.o  in  ...l.naK  -'lll-'^  J;- 
i  In      he  heart  of  the  eelehrate.l  greyh-unul  Master  MeCrath  w.^lu  I 

0^  omiees!  just   threetohl  in  exeess  oi  the  normal   pro.orfon  ot  hea.t- 

^-li;o;;t;;cS^;lon._An.l.  las.,y.  there  are  other  eases  in  whieh  dila 

--hlt^r^:-;^;;;^^^^^^^^^^ 

hi  cases  the  eon<lition  seen>s  to  have  eonie  on  spontaneous!  .     In  s 

a'a  ;^e  ei  ,nav  heeon>e  dnonic.     Delaheld  has  reported  an  .ntere.fn, 

^"■^^L;;;;^ -'n>f3n,ent  oC  hypertropm-  and  dilatation  has  ,.1- 
reaJflSr^n  i>1--ed  un.ler  the  section  on  valvular  lesions.  I  wouW 
reach    nctu  i""  ^     j,         f  dilatation,  as  mdieated  In 

::  CXZ     :^  ."d^'pncelrlnd^^        Hvidi.y.  venesection  is  in  n.any 
S       t        .    V  nu^us  bv  whieh  the  life  of  th-  patient  may  hc'  saved,  ami 
;'  m    '  t  o  n,ees  of  hlood  should  he  ahsf.eted  witlu>ut  ^^^^y.^^^^ 

u    tlv    tinudants.  su.h  as  annn.nda  and  dij:      h^.  may  he  adnnn  steied 
i         H.V  eeslories  only  to  the  hleedin,  ,n   .he  erit.ea    eoudmon  of 

^^t       natation,  which  is  so  fre-inently  met  with  .n  card.ae  les.ons. 


IV.    AFFECTIONS   OF   THE    MYOCARDIUM. 

1  Lesions  due  to  Disease  Of  the  Coronary  Arteries.-.\  knowledge  of  the 
,l,,„.e     pmluced  in  tl..  mvo<.ardiun>  by  disease  of  the  coronary  vessel. 
I  V    ''a  klv  to  the  understanding  of  many  problems  in  cardiac  pa  hology. 
5^h    tn-m  na   branches  of  the  coronary  vessels  are  end-artenes;    hat  is     he 
,       ..,ti,m  between  neighboring  branches  is  throno-h  capillaries  onh. 
riir        *    1^  M:;  Uh-^vn  thaf  the  vessels  <;f  Tl-obesius    which  opn 
;„m  the  ventricles  and  auricles  into  a  system  of  fine  branches  anc    tl    s 
n   nicate  with  the  cardiac  capillaries  and  coronary  veins,  "^^5'  1^^  ^j^" 
fc  -din,  the  mvocardium  sutruiently  to  keep  it  ahve  even  when    he 
c      narv  arteries  are  cHrluded.     The  blocking  of  one  o    these  vessels  1     a 
h  us  or  an  embolus  leads  nsually  to  a  condition  wlnc^b  is  known  a  - 

;.«..-■<■  necrosis,  or  white  infarct.     When  tins  does  not  occui    1 
Jn  mav  be  sou.bt  in  (1)  the  existence  of  abnormal  «>>«^t-----  ^^  ^ 

V  t  leir  pn-ence  take  the  c.ronary  system  out  of  the  group  of  end-artenes, 

0     '\  the  vi     rions  flow  through  the  vessels  of  Thebesius  and    he  coronary 

■ci  :?    1^1    c .mdition  is  most  c^on.monly  seen  in  the  left  ventricle  an.   m  the 

sptnm.  in  the  territory  of  distributi.ni  of  the  anterior  coronary  artei  v .    The 


*  The  American  Journal  of  Pliy#icjl«gy.  vol.  i,  180S. 


AFFECTIONS  OF  TUB  MYOCARDIUM. 


Wi 


iliy  and 

may  \n) 

.'iial  ilis- 

lu'i'f!  art' 

OUJilltoll 

wi'iifhiMl 
)f  heart- 


icli  tlila- 
iiistaiucs 
1,  Ijut  iu 
In  soino 
inil  fzrcat 
u|H'rvcno 
ilcir.slin^- 

1  lias  al- 
I  would 
iratod  by 
;  in  many 
avod.  and 
,'.  Suhso- 
lini^lcri'd, 
iditiou  of 
ins. 


iIlM'  of  tlu' 
iry  vi'ssi'ls 
jiatholo^y. 
hat  is,  the 
avies  only, 
ihich  ojien 
s  and  thus 
may  be  ca- 
n  when  the 
:csscls  hy  a 
uiown  as — 
t  oecnr  the 
OSes,  whieh 
'ud-arteries; 
ho  coronary 
e  and  in  the 
irtery.    The 


atrt..'t.d  area   luis  a   vUowish-white  eolor,  sometimes  a  turl)ul    parhoded 
a.uoet,  at  other  tin.es'a  ^^ayi^h-r.d  tint.     It  may  he  somewhat  w-e-lj^e-shaped, 
more  often  it  is  irre-nlar  in  contour  and  pn-jeets  ahove  the  snrlaee      Miero- 
sn.pic-ally  the  ehanoes  are  very  ohara.t.riMie.     The  nueloi  either  .lisappear 
tn.m  the  muscde  libres  or  they  nndei-o  fia-mrntation.     Leiu..eytes  wander 
in  from  the  surrounding  tis,.:ue.  and  these  may  sullVr  dis.ntegratioii.     At  a 
ViWv  .ta>'e  a  new  growth  of  llhrons  tissue  is  found  in  the  peni-hery  ol  tlie  m- 
iarct  wluH.  ultimalelv  may  entirely  ivpla.r  tin-  .h'ad  lilurs.    The  iihres  pre- 
,.nt  a  homogeneous/hyaline  api-earaiu-e.     In  some  inslamrs  iheiv  is  .om- 
pk.l,.  tiansformati(m,and  even  to  tlu-  naked  ,.y.  a  linn  white  patrh  ol  hyahiu' 
;i,„,,,u.ration  may  appear  in  the  centre  of  the  area.     Sud.l.'ii  death  not  m- 
frniucntlv  follows  the  Mocking  of  one  of  the  branches  of  the  coronary  ar- 
tcrv  and'the  production  of  this  anaMiiic  necrosis.     //(  nmtico-lnial  rasr,  U 
i.  a  puiul  of  priiHuni  uni>nytanrc  to  n-ntcmb,;-  Unit  litis  is  one  of  the  amunua 
causes  of  smhlni  dmth.     This  condition  should  be  carefully  sought  tor,  in- 
asmuch as   it    mav   be  the  sole  lesion,  excei-t   a  general,  sometimes   shght 
arterio-sclerosis.    "iluptinv   of   the   heart   may   be  associated   with   aiuemie 

necrosis.  ,, 

{h)  The  second   important   elVect   of  con.nary-artcry  disease   upon   tlit 
mvocardium  is  seen  in  the  production  of  librons  mrranhiis.     '1  his  may 
re'^ult  from  the  -radual  transformation  of  areas  of  anaMuic  necrosis.     More 
commonlv  it  is  caused  1,'v  the  narrowing  ..f  a  coronary  branch  in  a  process 
of  obliterative  endarteritis.    Where  the  process  is  gradual  cvidemvs  ol  gran- 
ulath.n  tissue  are  often  wanting,  and  any  distinction  between  tlu,'  iiecrutic 
nuKcle  fibres  and  the  new  scar  tissue  is  diilieult  to  cstal)lish.     J.  I..  Mac- 
Calhim  has  shown  that  the  muscle  libres  undergo  a  change  the  reverse  ot 
that  of  their  normal  development  and  lose  their  libril  bundles  preliminary 
to  their  c.mplete  replacement  by  connective  tissue.     The  sclerosis  is  mos 
freunentlv  seen  at  the  ape.x  of  the  left  ventri.le  and  in  the  sep  un.,  but  it 
may  occur  in  any  ,>orti<m.    In  the  septum  an.l  walls  then-  are  olten  streaks 
and  patches  which  are  only  seen  in  carefully  made  systematic  sections. 
Ilypertrophv  of  the  heart  is  commonly  associated  with  this  degeneration. 
It'is  the  invariable  precursor  of  aneurism  of  the  heart.  n     ,      • 

Comidete  obliteration  of  one  cor.mary  artery,  il  produced  suddenly,  is 
usually  fatal.     When  induced  slowly,  either  by  arterio-sclerosis  at  the  ori- 
fi'ee  of  the  arterv  at  the  root  of  the  aorta  (U-  by  an  obliterating  endarter.  is 
•i.  the  course  of  the  vessel,  the  circulation  may  be  earned  on  through  the 
other  ye«el.     Sudden  death  is  not  uncommon,  owing  to  thrombosis  ot  a 
vUel  which  has  become  narrowed  by  sclen.sis.     In  the  most  extremo  grade 
one  coronary  arterv  may  be  entirely  blocked,  with  the  production  of  ex- 
tensive fibroid  disease,  and  a  main  branch  of  the  other  also  may  be  occluded. 
A  lar.a^  powerfully  built  imbecile,  aged  thirtytlve,  at  the  hhvyn  Ins  itu- 
tion    I'ennsviv'una:  who  had  for  years  enjoyed  doing  the  heavy  work  al)out 
the  place    died  suddenly,  without  any  preliminary  symptoms,      the  heart, 
which  is  in  mv  collection,  weighed  over  ^0  cuinces;  the  anterior  coronary 
artery  was   i.ractically  occluded  by  obliterating   endarteritis,   and   of   the 
TjostcM-ior  artery  one  main  branch  was  blocked.  ,  .  ,, 

(r)  Septic  'lnfarcts.--[n  pyaMuia  the  smaller  branches  of  the  coronarv 


> 


r 


^lU 


74S  DISEASES  01.'  THE  CIKll-I-ATcmV  SYSTEM. 

„,,.,,i,.  „„v  1,..  i,i..,.k..i  will.  .'i.ii".ii  -I"'-'!  i--i>"  '■«' '"  "''"•'"':■"'  "''■;:|.',!;;; 

;:,r:;\i;;;r:-;':rlu/i,';;o\r;,.i.iH..i^  '-- 

mmismm. 

;  •.,.(;,  fl,o  intiTstithil  ti^siK'.     Coumilnmn  lias  doscnluHl  tlii> 

C     rm  <c.narat.a  at  th.  crnu.nt  line     'i.  So.n.u.ntat.nn.     1  ho  Inu-tme 
^       >        ao      s    ho  iihro  itsolf,  and  ,.orha,.s  at  tho  lovol  ot  t h o  nuoUn. 
i:^.:      linal  division  is  unusual.     Although  tho  oond.t:on  ^l-'  ;^1-;  j  ^  ; 
;    mno  in<tanoos  during  tho  doalh  agony,  a.  m  ca.os  of  snddon  death  1  - j 
ll  n  ^     n  othovs  it  wmdd  soon,  f,  lu.vo  .linioal  and  patholog.oal  s.gn.fi- 
^an  0     1  ^^  f  n,"<l  --'-tod  uith  othor  losions.  llhrous  W-ard.t.s  .n  arc- 
tfon   an  Ifattv  dogonoration.    J.  V.  ^laoCalhnn  dist.ngu.shos  a  snnplo  i  om 
:""  ■      vo  fvag.nontati..n.     Tho  first  takos  plaoo  in  tho  normal  hl.n. 
t   i  .1     1  mvovor   shows  irrogular  oxtonsious  and  oontraotu.ns.     'J  ho  sooond 
:  :  ^1    d  ;im;     on  in  tllL  iihro.     lloarts  tho  soat  of  niarkod  fragn>onta- 
Illm  aitlaxroasily  torn,  tho  .nusolo  lihros  widoly  soparatod,  and  olton  palo 

""•^4  Schymatous  Degeneration.-This  is  usually  n.;t  with  in  fovors, 
or  in  ^mnootion  with  ondooarditis  or  porioarditis  and  '"^'oc^'^  ^f^,^  " 
toxio-itions  .ronorallv.  It  is  charaotorizod  l,y  a  i.alo,  turhid  stato  of  tho  cai- 
d  "n  "  .:  Inch  is  gonoral,  not  looalixod.  Turhidity  and  s-.ltnoss  =>ro  ^>o 
s^ci  foat  .ros.  It  is  tho  softonod  hoart  of  Laonnoc  and  l.orus  htokos 
'^,k  o  an  instanco  in  whioh  "so  groat  was  tho  softo.ung  of  tho  organ 
whon  tho  hoart  was  graspod  hy  tho  groat  vossols  anu  hold  wUh  ti,o  apov 
pointing  upward,  it  foil  down  ovor  tho  hand,  covonng  U  hko  a  cap  of  a 

^"^l";:io:;:;;iw'  H-ro  is  a  dogonoratlon  of  tho  nu.olo  ilhros,  whioh  a,. 

infdtratod  to  a  various  oxtont  with  granules  whioh  ros>st  the  ac  ion  of  other 

a  0  dissolved  in  acotio  aoid.     Souiotinios  this  granular  c  ,ango  m    he 

0  "  oxtren,o.  and  no  traoo  of  tho  stria^  .an  bo  dotooted      It  is  probaW 

,,  HToc-t  of  a  toxio  agent,  and  is  seen  in  its  n.ost  ox.,u,s,to  form    n    ho 

lumbar  nn.selos  in  cases  of  toxic  hannogloWm^tho  hor.o.     It  i.  met 

*  Ilcktoen,  American  Journal  of  the  ^ledical  Sciences,  1^97. 


AFFKCTIOXS  OF  THE   MYoCAUDlUM. 


74'J 


ir  Pt'i)tic 
zo  I'ri'in 
lit  wlirll 
11,  I'liriu- 

1  1111(1  in 
Ik'ii  aiiil 
.  (lilntnl, 
lUTUtiiin. 
iTiiso  ami 
ilanl  this 
iu4nitiii,iX 
iro  I'oiiml 
10  studies 
)t'  lilirous 

crilii'il  liy 
(lillVrcnt 
le  inusclo 
L"  fracture 
'  inulcus. 
k'ss  arises 
ileath  liy 
•ill  si<inifi- 
tis,  int'aro- 
injile  from 
•null  iibre, 
'he  seeond 
"r.ifrnK'iita- 
ofteii  pale 

in  fevers, 
)iis  and  in- 
of  the  ear- 
less are  the 
is.     Stokes 

the  orpm 
th  tiie  ajK'X 
a  cap  of  a 

,  which  are 
on  of  ether, 
in.iie  in  the 
is  ])ro1)al)ly 
'orni  in  the 
It  is  met 


with  in  cases  of  typhniik  typhus.  sniall-]inv,  niid  other  infectious  diseases, 
particularly  wlu'iithe  ci.m>c  is  prntracted.  'i'licre  is  no  dellnite  relation 
between  it  and  the  lii-h  temperature. 

5.  Fatty  Heart.— I'nder  this  term  are  enihraccd  fatty  de^'iicratinii  and 

fatty  overjirowth. 

(rt)  Falhi  (h'linirniU'in  is  a  very  common  condition,  and  mild  j:iade-  are 
met  with  in  many  disea.-es.     It  is"  found  in  the  failin,!,'  nutrition  of  did  age, 
of  wasting  diseases,  and  (d'  cacheetic  state-:  in  proldiigcd  infectious  fevers, 
in  which  it  may  follow  or  accompany  ihe  parenchymatous  change;  associ- 
ated with  acuteaiid  chronic  aiuvmias.    t'eitain  pois(Uis,  such  as  phosphorus, 
])roduce  an  intense  fatty  degeneration.     Local  caiwes:   Pericarditis  is  usu- 
ally associated   with   fatty  or  parenchymatous  changes   in   the  superilcial 
layers  of  the  myocardium.     Disease  of  the  c(a'onary  arti  ries  is  a  coiiinion 
and  imjiortant  cause,  and  it  is  associated  with  fat  cniholism.     Lastly,  in 
the  hvpeilrophied  ventricular  wall  in  chronic  heart-disease  fatly  eliangv  is 
hy  no  means  infre.picnt.     This  degeneratiim  may  be  limited  to  the  heart  or 
it  may  he  more  or  less  general  in  the  soli<l  viscera.     The  diaphragm  may 
also  ije  involved,  even  when  the  other  muscles  show  no  siiecial  changes. 
There  appears  to  lie  a  spec  ial  pnmetiess  to  fatty  degeneration  in  the  heart- 
muscle,  which  may  perhaps  he  connected  with  its  incessant  activity.     So 
great  is  its  need  of  an  ahuiidant  oxygen  sujiply  that  it  feels  at  onee  any  de- 
tieiency.  and  is  in  coiise(pience  the  ilist  muscle  to  show  nutritional  changes. 
Anatomicallv  the  comlitioii  may  be  Incnl  or  general.    The  left  ventricle 
is  most  frecpientlv  alVected.     If  the  j.rocess  is  advanced  and  general,  the 
heart  looks  larg(>  and  is  flabbv  and  relaxed.     It  has  a  light  yellowish-brown 
tint,  or.  as  it  is  called,  a  faded-leaf  color.     Its  consistence  is  reduced  and 
the  substance  tears  easily.     In  the  left  ventricle  the  papillary  columns  and 
the  muscle  beneath  the  endocardium  show  a  streaked  or  patchy  ajiiiearance. 
]ilicroseopicallv,  the  iil)res  are  seen  to  be  occupied  by  minute  globules  dis- 
tributed in  rows  along  the  line  of  the  ])rimitive  fibres  (\V(dch).     In  ad- 
vanced grades  the  fibres  seem  completely  occupied  by  the  minute  globules. 
(/))  Falhi  Onrfjr()irlh.—'Vh\<  i<  usually  a  simple  excess  of  the  normal 
siilipericardial  fat,' to  which  the  term  cm-  (uliposum  was  given  by  the  older 
writers.     In  iironouneed  instances  the  fat  inliltrates  between  the  muscular 
iHibstance  and.  separating  the  strands,  may  reach  even  to  the  endocardium. 
In  corpulent  i)ersons  there  is  always  muck  itericardial  fat.     It  forms  ])art 
of  the  -xeneral  oliesitv.  and  occasionally  leads  to  dangerous  or  even  fatal 
impairnient  of  the  co'ntractile  ].ower  of  the  heart.     Of  Vi'i  cases  analyzed 
by  Forcbheimer  there  were  SS  males  and   34  females.     Over  SO  per  cent 
oecnrred  between  the  fortitnh  and  seventieth  years. 

The  entire  heart  mav  be  enveloped  in  a  thick  sheeting  of  b't  tbiough 
which  not  a  trace  of  muscle  substance  can  be  seen.  On  section,  the  fat 
infiltrates  the  muscle,  separating  the  fibres,  and  in  extreme  cases— particu- 
larly in  the  richt  ventricle— reaches  the  endocardium.  In  some  places  there 
may  be  even'  comidete  substitution  of  fat  for  the  muscle  substance.  In 
rare  instances  the  fat  mav  be  in  the  pai.illary  muscles.  The  heart  is  usually 
much  relaxed  and  the  chambers  are  dilated.  :\ncroscopically  the  muscle 
fibres  mav  show,  in  additi.m  to  tke  atrophy,  marked  fatty  degeneration. 


'>• 


^ 


m^ 


I 

i 

\ 


,,„  WSEASES  OP  THE  CIRCULATOKY  SYSTEM. 

'    0.  Other  Degenerations  of  the  ^'•^'^i::;,X"n  .^'^••!'"^- 

v„l„r  K-.i.i..s  ....'I  ...  <!"■  «'...l^'  l.""t.     "'         '",.,„,!,  i„,,,,,s,,l.     'n..^ 

„„„,w  is ..  .i...'t  .■■■.I-'..-""": ""-'  ';'■,;:      ,: ;  r,.i.idiv  .1,.,...  ,1,.' 

!;;;x,'"^^t  ;;:.:r:;;;:;;;r  i^;^;';::!;:.;  *......., .... ...... ...-.- 

fra-ile  than  in  hoalthy  musde  occasmnallv  wrii.     It  ocrurs 

;„£;;:;•  :;;;;!,S'::ru;::  "..r:^'^  i..  - -•--- 

lilj''^'**'  ,         *•„,,(•  7nnl-(.r  i>;  soiiictiincs  iiu'l  with  in  \n-o- 

,„„S'^^:r '^.:'r;::r  :l;i'f  nf :  - .«■  '■---• 

,u,atlu.stri,ua.r  very  faint  or  ont.rolyah^.n  .,,,^,,,iiinn,  and  the 

^,,  CaLueous  ;K'^;;"-;  ^      y  ,  ^  :  ,  n  their  a  pearanee  as  iigu.d 
muscle  llbres  may  be  n  liltiat    I  ail  >  i 
„Hl  .Inscribed  by  Coj-t^n  h>s  '^i?^.'";^^' ^^^.^^^e  are  notoriously  un- 

,„,,ain.  A  n.an  w  th  ''^^^'" .  .^^™  *  j,;^.,,.,  ,„„,ph,ined  of  cardiac  d.s- 
denly,  while  doinji  heavy  work,  ^\l  bout  ''''''-  V.  ,,^  irre-ndar  aetiou 
tress  •    On  the  <.ther  baud,  a  patient  may  1'  '-^^^"^'^^fj;  :      V  and  the 

Ind  signs  of  dilatation;  he  may  l--';-  'j^^f  ^.^  f  ^  u    ^d  i^iul  fatty 
..neral  symptoms  believed  '^^^^l^^^^'^^^,:'^,  the  mvoeardium. 
heart,  and  the  post  '-'>•  ^^  ^ '''  ,,^' ;' ,";^   "  ;:,es  eharac:terized   by   a 
Cardio-selerosiB  or      ;':-\J,;,^/  Exertion  an.l  oeeasional  at- 
fceble,  irregular,  slow   P'^  *  '    I  ,V  in   nnuv    but  not   in   all  cases, 

tacks  of  angina.  Irregularity  is  pr  .e  n  ; »  ;  ^  y^,-^^^,^,  the 
The  pulse  may  be  very  slow,  even  M  '[^^J^^^^'^^-,,  i„sullieieney. 
ca- come  under  ''J'^^'^II^Y!,  \  '^^  U--'  aggravated  and, 
The  arrhythmia,  ^vllleh  '"■'>  /''  \. '  ;^  i^,  ,3^,t\dso  persist  after  the  ear- 
according  to  IJiegel,  may  not  or,l>  picecck,  out  i 
diac  insufficiency  has  passed  away.  aimculties.  Extreme 
rattv  degeneration  of  the  heart  V^^^^^^^^^^^^^^^]^^^  ,    .,iar 

the  fatty  degeiierati.m,  but  of  dd.itat,.m  .he  ^  ^  -^l^  ^^  ^i^,  i,,,,t- 
arcus  senilis  is  of  no  moment  m  the  ^lagn  m  of  ^;^^  "  ,^^^^^^i,^„  ,,,„,,, 
sounds  may  be  weak  and  the  ^^^^['^  ;''':^  .  J^'^^^^'Z^^  and  a  sys- 
t,    re  is  often  tl;e  P^l^P  ^^.^^n   s  .^^^  ,,  ,,Vly 

tolic  niurinur  at  Mie  apex.     ^""""'  ,  .^,r.     There  is  some- 

foature  in  many  eves,  and  '^"^"^  .^''^j^^.^^^^.^Mtv  heart  there  arc 
times  a  tendency  to  syncope   and  ,n  lotl    fio    id  a^^^^^       y  ^.^^ 

attacks  in  which  the  patient  feels  cold  ai  d  '      •--.;  <^  „.^,„^ 

t.  .10  or  150.  or  even,  as  in  one  ca^e  -l'^^' ^  -^^-  *^  ;^  ^  J^^^^  ^^^^^j.^ 
wake  from  sleep  in  the  early  morning  uith  an  attack 


AFFECTION'S  OF  TIIK  MYOCAUDIUM. 


'rniihij. — 
onic  val- 
)!•  of  the 
ud.  Tlic 
iboul  tlu' 
L'lns  nnnv 

It  occurs 
lot  in  the 

th  in  jtro- 
ausluccnt, 

,   and   the 
as  ligured 

■un\Ay  \\n- 
(Uail  >u(l- 
artliae  ilis- 
uhir  action 
la,  and  the 
1  and  fatty 
cardivnn. 
rized   by   a 
n\sional  at- 
;i  all  cases, 
iinately  the 
iisutlicicney. 
avated  and, 
tor  the  car- 

s.  Extreme 
foil,  regular 
fat  does  not 

The  truth 

IS,  so  long  as 

irregularity, 

symptoms  of 

,.     The  fatty 

The  heart- 
ation  occurs, 
ic,  and  a  sys- 
1  is  an  early 
lere  is  some- 
.'art  there  arc 
10  pulse  sinks 
L'  patient  may 
severe  cardiac 


asthma.  These  "sjiells"'  may  he  associated  with  nausea  and  may  alter- 
nate with  others  in  which  there  are  anginal  symptoms.  These  are  tiie 
cases,  too,  in  which  for  weeks  there  may  he  mental  symptoms.  The  i)a- 
tient  has  delusions  and  may  even  become  maniacal.  Toward  the  dose, 
the  type  of  breatiiing  known  as  L'iioyne-Stokes  may  occur.  It  was  descrilteil 
in  the  foHowing  tonus  liy  .lolni  Cheyne,  s[ieakiiig  of  a  case  of  fatty  heart 
(Dulilin  Hospital  JJoports.  vol.  ii.  p.  -.'vM,  1818):  "For  several  days  his 
breatiiing  was  irregular;  it  would  entirely  cease  for  a  cpiarter  of  a  minute, 
then  it  would  become  pcrce])tii)k'.  tlmugli  very  low,  then  by  degrees  it  be- 
caiuo  heaving  and  (piick,  and  then  it  would  gradually  cease  again:  this 
revolution  ill  the  state  of  bis  breatiiing  lasted  aiioiit  a  minute,  during  which 
tiiere  were  about  thirty  acts  of  respiralioii."  It  is  seen  niucii  more  fre- 
quently in  arterio-sclerosis  and  ura'Uiic  stati's  than  in  fatly  iieait. 

Fatty  ovi'rgrowth  of  the  heart  is  a  coiulilion  ci'rtain  to  exist  in  very 
obese  jiorsons.  Jt  jiroduces  no  symptoms  until  liie  muscular  lilire  is  so 
weakened  that  dilatation  occurs.  Those  patients  may  for  years  present  a 
feeble  but  regular  pulse;  the  heart-sounds  are  weak  and  muilled,  and  a 
murmur  may  be  heard  at  the  apex.  Attacks  of  cardiac  asthma  are  not 
nncoiumon,  and  the  jiaticnt  may  sulfer  from  broncl'.itis.  Dizziness  and 
pseudo-aiioplectic  seizures  may  occur.  Siiddi'ii  death  may  result  from  syn- 
cope or  from  rupture  of  the  heart.  'J'he  physical  examination  is  often  dilli- 
cult  because  of  the  great  increase  in  the  fat,  and  it  may  be  iinin)ssible  to 
define  the  area  of  dulness. 

For  practical  purposes  we  may  group  the  cases  of  myocardial  disease 
as  follows: 

(1)  Those  in  which  sudden  death  occurs  with  or  without  previous  indi- 
cations of  heart-trouble.  Sclerosis  of  the  coronary  arteries  exists — in  some 
instances  with  recent  thrombus  and  white  infarcts;  in  otiiors,  extensive 
fibroid  disease;  in  others  again,  fatty  degeneration.  .Many  patients  never 
comiilain  of  cardiac  distress,  but,  as  in  tlie  i^ase  of  Chalmers,  the  colebrato<l 
Scottish  divine,  enjoy  unusual  vigor  of  mind  and  liody. 

(2)  Cases  in  which  there  are  cardiac  arrhythmia,  shortness  of  breath  on 
exertion,  attacks  of  cardiac  asthma,  soniolimos  anginal  attacks,  collapse 
syiuptoms  with  sweats  and  extremely  slow  pulse,  and  occai^ionally  marked 
iiiental  symptoms.  These  are  the  cases  in  wiiich  the  condition  may  be 
strongly  suspected  and,  in  some  instances,  diagnosed.  It  is  rarely  possible 
to  make  a  distinction  between  the  fifty  and  fibroid  heart. 

{;{)  Cases  in  which  there  are  (  ;rdiac  insuHiciency  and  syiuiitoms  of  dila- 
tation of  the  heart.  Drojisy  is  often  present,  and  with  a  loud  niuriuur  at 
the  apex  it  may  bo  ditlicnlt,  unless  the  case  has  been  seen  from  the  outset, 
to  determine  whether  or  not  a  valvular  lesion  is  present. 

Pl'Ognosis.— The  outlook  in  affections  of  the  myocardium  is  extreme- 
ly grave,  ralients  recover,  liowever,  in  a  surjirising  way  from  the  most 
serious  attacks,  particularly  those  of  the  second  group. 

Treatment. — :\Iany  cases  never  come  under  treatment;  the  first  are 
the  fii.al  symptoms. 

Cases  with  signs  of  well-marked  cardiac  insufficiency,  as  manifested  by 
dyspniea,  weak,  irregular,  rapid  heart,  and  anlcma,  may  be  treated  on  the 
47 


!  1 


I 


J 


1,ISKASKS  OF  TUK  CimTLATORV  SYSTEM. 


j;:'t,^;:"l:;t:r™:.:V'S:\;:;::"S:;;v:.^;:::::;:^ 

ia  ol'tcn  v(  vv  bom'fu'ial.  ,.  ,,         ,,,,^,,s  in  winch  tlun' 

"  tu  I    .uoro  diili.nlt  is  Uu.  "--;^-:;         I^^J      r,  vory  slow  puLe.  and 

",...,,.  or  angina.    »-lf 'f  !;;.   '.^     jl.'^'.i  ailata.iou.     Digitalis,  un.  .r 
.        I   ^^^,^,  ^,,^,^,,.^  ,„,i  tlurc  an  '  ;    j^.,,,,,,,,  .vhcn  tlu>  puis,  .s  inl.  - 

t  »,L  cirnuMslauces,  is  not  'f '^'''''^  ,   j^*    ^  lu.l  -li.t.  and  tlu-  us.  of  tlie 
unt      I'o.npU'lo  rost  in  bod,  '^/••»-^''!'"  ,  ';"  '    ,  ,ti,nulanls  avo  indic^ated. 
;:Lie  s,,i.L  of  auu.u>.m   r^''^^^    ,  t  "f    nxidy  u.orphia  is  invaUw 
For  tho  nsllrssnoss  and  '>'^^''^':^  '!^,;;   ''^;.„,,in  ..f  strv.luua  n.ay  In-  j-Mven 
...    rron.  an  eightieth  to  a  ->^»  J'       '  ,;   ^     !  ,1,,  pulse  is  hard  an.l  tirn. 
m-ee  thues  a  day.     H,  -;-'?;t     •  d      .  'd.  i.^'^i.-in,  with  I  nuuuu  ot 
„it,,„.lv,rrin  n.ay  be  eautiou>l>  •^^;  ,,,,•,,,,,,,,,,!  gradually. 

'      H^r-cent  solution  Ihn.   unes  '^^  >:  -;,^„^  ^^is  due  to  iaUy  over- 

In  certain  case,  of  weak  l'-"'  ' J'  ''  , '  1  ,,,.  Schott  are  advantageous, 

growth,  the  V^^--jr'TtVC  --^^  of- heart-weakness  due  to  m-- 
Thev  are  invaluable  nu'thod.  i'Y'^»;\  ,  ,,,iv,,,ive  Ix.dily  exen.se.  1  lu 
u!:  .eranee   in  eating   and   ^nnku.g   and  ^^  ,^  ,„,  ,,„n,nt  of 

er  el  pkn  consists  of  »'"•*-  I'^^vum      in-  the  fat  in  these  ,n.t.ents 
,   id.     This  is  an  in.portan    iaeto,  ^^^^^^^    ^,^^^.,^.^  „ilows  daily  about 
'so  slightly  ineroasos  the  dens,  y  ebb  ^^.^^^  ^^^^  ^^^,.  j_ 

'-''trZ^^^^-  - '-' ''''' '  ''"^ "''''  '""^' '  ^'''"'^'  '''^" 

gether.     Bread,  3  ounces.  ^^^^^^^,,,^  ,,f  ,,„,t  beof    voal. 

^      Y,,„_'rhi'ee  to  4  ounces  o    soup,   .  ^^^_^^^,^,  ^f  ,,,,,..,,1 

„,„:i:^  poultry,  sabnl  or  a  light  v^g^tabl     a  b     ^  _^      ^^  j,^^,,,  ,, 

C  7a;inaious  V^^^<^^^ .' }^^ ;:;Z: ^[^    ^  light  wi..e  n.ay  be  taken. 
--;:l-r^•r.r:^:;t'^..^vitha.n.uehwater.     As  an 

indulgence  an  ounce  ..t  ^^'^^^-  ^„,.,,   ,,  ,„„ce  of  bread,  pe-^baps  a  small 

-'^r^::!!:.  buportant   element  oj  all  is  gv^;;^;^  -^'-^  '^^ 

l,vcl.  but   up  hills  of  v^v-;;;  ;^^  -       j,^  ,,,;,  ,.ay  tbe  heart  is  systen.at- 
,,„,ked  oiV  a.ul  is  gradually  IcngbuKd. 

ieally  exercised  and  strengthened.  ^^  ^  ,,,,i,ination  of  l;^tbs  wdh 

n,  .'Jr/,.//   ^'•'■"'""•",;r'''    ,,     ,'   ,  ten.perat.ire  of  from  S-ML.    1  •• 
exereises  at  Xaubei...      'Ibo  w  te.  1m>  a  U     ^  ^^^^^^^  ^^  ^^^^    ,    ^^ 

and  ^s  very  ric^hly  charged  ^^dl^^  0  -^  .        .^^^^.^^^  j,,!,,,,,!  hy  the 

elain.ed  by  Scbott  to  c«"\^./'''  "/^,f  "  ,,,h,  and  a  stin.ulation  of  tbe 
---^  '^"'^  '''^:'^':;^i^:^  'L  tl.  bath,  m  .uitaUo  ca^s,  W.U 
sensory  nerves,     incit  1.,  i      1 


AFFECTION'S  OF  TllF  MYOCAKDllM. 


753 


ailnr  iVi^- 
ctcil.  iiU'l 

lich  tlifiv 
|iul>f,  ami 
iiimls  may 
ilis,  uuiKt 
.e  iri  inl'i'i'- 
use  of  tlu' 

indu'ati'tl. 

is  inviilu- 
ly  l)f  Jlivi-'U 
li  iuul  linn, 
I  in'miiu  ut 

I'atty  nver- 
viiiita>ii'i>u>. 
;  (lui-  to  in- 
.ni>o.     Tlu. 
.  iiimmnt  of 
,,s,.  jnitii'iitr;. 
i  daily  aliout 
e  solid  food, 
ivkish  bath), 

,vhieli  should 

;  ouiK'i'f-  alto- 

ist  beef,  veal, 
inipo  of  broad 
^'o  liiiui^l'^  iit 
may  bo  taken. 
A-ator.     As  an 

erbaV'S  a  small 
or  5  ounces  of 

^0,  not  on  tlie 
■d  oaeb  day  is 
art  is  systemat- 

of  batbs  with 

om  s-r-!i.r  v.. 

3{  the  batb  are 
indneed  by  the 
nidation  of  tbe 
itablc  cases,  will 


nltor  the  ]iositioii  of  the  ajiex  beat,  and  tbal  it  lessens  the  area  of  eardiao 
(hdness;  this  means  tliat  it  diminishes  tiie  ddalation  of  tlie  heart.  Artilleial 
baths  are  n.-ed,  eonsistinj;  of  fmly  jiallons  of  water,  with  various  strengths 
«\'  sodium  chloride  and  eah  ium  eldoride.  'Die  exercises,  resistance  <;yin- 
nasties.  cunsist  in  slow  movenients  executed  by  the  |ialieid  and  resisted 
by  the  o]ierr.lor.  Any  one  wishing;  to  carry  out  in  private  the  Si  hott  treat- 
nient  .-iiouhl  consult  the  work  of  i'.e.-ley  'i'horne.  Camac's  articles  (.1.  H. 
II.  Ibdietin,  vol.  viii,  and  dour,  id'  the  Am.  Med.  Assoc,  bS!»r,  ii)  give  a 
brief  account  of  our  cxiierience  witli  it. 

,\\iMitisM  or   riii:  IIcaui'. 

((()  Aneurism  of  a  valve  results  from  acute  endocarditis,  which  |iro- 
duces  suficiiing  oi'  erosion  anil  may  lead  eitlu'r  to  |ierfoi'atioii  of  the  seg- 
ment or  to  gradual  dilatation  of  a  limited  area  under  the  intliience  of  th« 
hli.oil-|iiessure.  'i'he  aneurisms  arc  usually  spheroidal  and  project  from 
the  ventricular  face  of  a  sigmoid  valve.  'I'hcy  are  much  Ie>s  common  on 
the  nutral  segments.  They  frcijuently  rupture  and  iirodiice  extensive  de- 
struction and  incompetiiiiy  of  the  valves. 

(h)  Aneurism  of  the  walls  results  fiom  the  weakening  induced  hy 
cliroinc  myocarditis,  or  occasionally  it  follows  acute  mural  endocarditis, 
which  more  commonly,  however,  leads  to  perfoi'atimi.  It  has  followed  a 
stai)-wounil,  a  gumma  of  the  veidricle,  and.  according  to  some  authors,  peri- 
cardial adhesions.  'JMie  left  ventricle  near  the  ajiex  is  usually  the  seat,  tills 
being  the  situation  in  which  fibrous  degeneration  is  most  conunon.  Fifty- 
nine  of  the  (!0  cases  collected  hy  Legg  were  situated  here.  In  the 
early  stages  the  anterior  wall  of  the  ventrici",  lu'ar  the  septum,  sometimes 
even  the  septum  itself,  is  slightly  dilated,  the  endoeardium  opaipie,  and 
the  muscular  tissue  sclerotic.  Jn  a  more  advanced  stage  the  dilatation  is 
pronounced  and  layi'rs  of  tlirond)!  oecujiy  the  sac.  I'ltimately  a  large 
rounded  tumor  may  project  from  the  ventricle  and  may  attain  a  size  equal 
to  that  of  tlu'  heart.  Occasionally  the  aneurism  is  sacculated  and  eoin- 
nntnicati's  with  the  vi'utricle  through  a  very  small  orilice.  The  sac  may  be 
double,  as  in  the  cases  of  daneway  and  Sailer.  In  the  museum  of  (iuy's 
Ili)si)ital  there  is  a  specinu'ii  showing  the  wall  of  the  ventricle  covered  with 
aneurismal  bulgings.     Kuplure  oeeurred  in  T  of  the  HO  cases  collected  by 

Legg. 

The  si/nijiloDis  produced  by  aneurism  of  the  lieart  ar.  ■ndefliiile.  Occa- 
sionally there  is  marUed  bulging  in  the  apex  n'gion  and  the  tumor  may  per- 
forate the  chest  wall.  In  nutral  stenosis  the  right  ventricle  may  bulge  and 
])roduce  a  vi.-ible  pulsating  tumor  belmv  the  left  costal  l)order,  which  I  have 
known  to  be  nnstaken  for  cardiac  aneiirism.  ^\\\vn  the  sac  is  large  and 
])roduees  pressure  upon  the  heart  itself,  there  may  he  a  marked  disi)roportioii 
between  the  strong  cardiac  impidse  and  the  feeble  pidsatioa  in  the  periph- 
eral arteries. 

Itri'Tfiii;  ()!•  Tin:  IThakt. 

This  rare  event  is  usually  associated  with  fatiy  infdtration  or  degenera- 
tion of  the  heart-muscles.     In  some  instances,  acute  softening  in  conso- 


y 


*ii 


^5^  DISKASKS  OF  THK  (-IUCULATOIIY  SYSTKM. 

.       1    r         f  .,  l.ruuh  (.f  Ihc  coronavv  artery,  suppurativo  !ny»>- 
,„,,i,is.  nr  a  .nuMinamus  ,ruwtli  has  Inrt,  llu     auK.     i  ^^^^ 

lltcHl  l.v  (^uun.  latty  A.^^nvvMum  was  m.tnl  in   ...      l^^o 
luUu-nts\vrro  over  sixty  yrars  Ml  a^:.  ,     ,,    ,„„   •„  f,„„„l  most   fr.'- 

.l>-..tlv  in  tlu.  Urt  vontmU.  on  ^''V'''^-'''  ;;;;'"!,,  j    J'      /bo  no  ,ro- 
'Mk>  airi.lont  usually  take.  J.^ur  •''''•'''^,,  "  /     '  •    ,        /  ,„,.  ,all  an-iaio 

;-;r=:::t.:;;:n;y....n.t...^ 

snlVoeation.  and  lilV  nu.y  l-c  l'';"'''"^''    /'  ,;;,,,,  ,rt.,.  , ho  onsot  of 
ease,  wlm-h  1  cxanunc.l,  tho  ,mtH.nt  wa  1.      up  ..  s  .  ._^  ^^^  .^^^ 

the  svn.plon.s.  an.l  live.l  for  llurtirn  luuu,.     A  ca>L 
the  I'latient  livid  for  fk-ven  ilays. 

Xl-W    (lUOWniS    AM)    I'AUASITKS. 

„  „„,.  „.|,i,.h  i„v..iv,,i  '1'^-;; -;:„'■  ",,,;,,,,  „„.,!■  «..■ ■■. 

,„,  ;,„,,,.,,,„s  ,.mli"li  I"    I."  l;"l"""         ■  ;    ,    'i    ,„„„„,,|,|,.  ,„„«■»  ..( 

,,,„rt  w»s  ,r...ly  .■.;l.r,.;.l,  ...,„..  to     -  ,„„„  ,„,,  ,„,„„„,„, 

'"■'■",';  •*    .  l.nvo  l,.vn  (liseusscd  under  tlu>  approi.riate  section.  Imt  it 

,„„:",;;:  ;;:;:;;;;,:.;;7,;.,v';:;  >-.,  ,.„.  ..f^n. ,,»,.,.. »....  t,..  «....„o- 

,.,.eeus  cysts  oe-nir  oceasionally  in  the  heart. 

WolNDS   AND   FOBKTGN    BODTES. 

,       1      <•  .1      iw.orf  Mvo  usnnllv  fatal.  althou<.di  there  are  many  in- 
■      Wounds  of  the  heait  -^  ^  "^        >  "     ,   „  ;  ^,^^,,  i,,,„  f,„„a  en- 

■  .tanoos  in  which  reeovery  ^'^^^^'^^  ^''\;  \^;'l\^^^  ^^  ,,„,,Uot  wounds, 
.vsted  inside  the  vc^tneU.  A  -j;  /  ^  i^.^l^^^t^a  sharp-pointed 
however,  are  uecessanl\   tat..!      '  i'"*""  ;    j.^ ^      Toahody 

lias  n.imrl.-.l  a  <a«.  m  iiliicli  a  l>iii  »  .         |,,^ 

,1,0  <'«"i"\ ««■"■';,;;,  ;™'™,V"^'';;".ii,,™  ««oi,o„on,  „,ui  ti,o 

;;::;rorS';„'«"tnTo;;S0e  C  .l.  rig„l  vo„.Hc,o.     «  ...  ,ra,pod 


NKUUOSES  OV  TIIK  IIKAKT. 


i,>,> 


L-  inyo- 

lOS  col- 

.,f  tlio 

.st   fre- 

MO    jH'O- 

aiiil  ilii' 
's  cast'-*, 
lisli  ami 
Imitrcal 
onset  of 
II  wliich 


y  caiipor 
or  imil- 
('  (liscaso 
vciitriili' 
alvL-  and 
('  luinuT- 
anic  the 
masses  of 
j)enetrate 
V  niedias- 

lai'ts.  and 
casionally 

on,  Imt  it 
lie  oeliino- 


niany  in- 
found  on- 
i)t  wonnds, 
U'p-pointed 
.     Poahody 
le  loft  ven- 
in  into  the 
d  a  case,  at 
while  on  a 
od,  and  the 
was  grasped 


und  nn  attempt  made  to  r.'inove  it.  lint  it  \u\*  withdrawn  into  the  heart 
and,  it  is  said,  caused  tlie  patient  no  I'nrliier  troiil.lc.  Hysterical  -.'iris  some- 
times swallow  pins  ami  ncedh's,  whi.  h.  pa>Mn;.'  tlimn-ii  the  .esoitha-ius  and 
Htoinacli,  are  found  in  various  paits  of  the  hody.  A  remarUalile  ease  is 
reported  i)V  Allen  J.  Smilii  of  a  -irl  Iruni  wiioni  several  duzeu  needles  and 
pins  were"  removed,  eliielly  from  suiicutancous  ahseesses.  Several  years 
later  she  ilevdoped  sympt""!^  "f  chronic  heart-disease.  At  the  post  mor- 
tem needh's  wt  re  fouml  in  tlie  tissues  of  the  adiii'rcut  pericardium,  an. I  lie- 
tween  thirty  ami  forty  were  emlicdded  in  the  thickened  pleural  meml)rane3 
of  the  left   side. 

J'uneture  of  the  hear,  uas  heeii  recomiueiidid  as  a  therapeutic  procedure 
to  stiinuhite  it  to  action,  •■■■  in  chloroform  narcosis,  and  experimental  evi- 
dence has  hecn  hrought  forward  hy  W.  A.  Watson  in  favor  of  the  operation. 
lie  advises  alistraction  of  i)Iood  ill  coml»ination  with  the  puiutun — car- 
dioeeiitcsis.  Tlic  proceeding'  is  not  without  risk,  ihciuorrha^ic  may  take 
place  from  tiie  imiicture.  tliouj:h  it  is  not  often  extensive.  Sloane  lias  re- 
cently ur;:-cd  its  u.se  in  all  ca-^es  of  asphyxia  and  in  sutl'ocation  Ity  drowning 
and  from  coal-gas.  'i'he  successful  case  which  he  reports  illustrates  foreihly 
its  stimulating  action. 

V.    NEUROSES   OF   THE    HEART. 

I'ai.imtatiox. 

In  health  we  are  unconscious  of  the  action  of  tiu-  heart.  Tn  some  people 
one  of  tlie  iirst  indications  of  debility  or  overwork  is  the  conseiousness  of 
the  cardiac  pulsations,  which  may,  however,  he  jicrfcctly  regular  and  or- 
derly. 'I'his  is  not  paliiitation.  The  term  is  proi)erly  limited  to  irregular 
or  forcible  action  of  the  heart  peree[)tihle  to  the  individual. 

Etiology.— The  expression  "  perce])til)le  to  the  individual"  covers 
the  essential  element  in  palpitation  of  the  heart.  The  most  extreme  dis- 
turbance of  rhvthm,  a  condition  even  of  what  is  termed  clrllniuii  mnhs, 
mav  be  unattended  with  subjective  sensations  of  distress,  and  tiiere  may 
be  no  consciousness  of  disturbed  action.  On  the  otlier  hand,  there  are 
cases  in  which  complaint  is  made  of  tlie  most  distressing  palpitatu.n  and 
sensations  of  throbbing,  in  wliich  the  physical  examination  reveals  a  regu- 
larly acting  heart,  the  sensations  being  entirely  subjective.  We  meet  with 
this"  symptom  in  a  large  group  of  cases  in  which  there  is  increased  excita- 
bility'of  the  nervous  svstcm.  rali)itation  may  be  a  marked  feature  at  the 
time  of  pubertv,  at  the  climacteric,  and  occasioiuilly  during  menstruation. 
It  is  a  very  common  svmptom  in  hysteria  aTul  neurasthenia,  particularly  in 
the  form  of  the  latter'which  is  associated  with  dysjiepsia.  Kmotions,  such 
•as  fright,  arc  commim  causes  of  palpitaticm.  It  may  occur  as  a  sequence  of 
the  acute  fevers.     Females  are  more  liable  to  the  afl'ection  than  males. 

In  a  second  group  the  palpitation  results  from  the  neiion  upon  the 
heart  of  certain  substances,  such  as  tobacco,  colTeo,  tea,  and  alcohol.  And, 
lastly,  ])a!pitation  mav  be  associated  with  organic  disease  of  the  heart, 
either  of  the  myocardium  or  of  the  yalvcs.     As  a  rule,  however,  it  is  a 


J 


•i.'. 


..^  DISEASES  OF  THE  CIHCULATORY  SYSTEM. 

cuustilules  the  ^^^^^ ^^''^'l^ly'^l^^^-,^  wa.  .0  commcn  among 
Tho  irritable  lioart  doscri bod  \^^^'^^',^^^^,,^  ,f  Has  kiud.  Th. 
the  young  soldier.  :>-;;;.  ^^.rth;^^  Irl^ueney  of  the  pulse  on  ^x- 
c-hief  synu-lonis  wore  F'  »'^f  ^""  ?  ,  .  ^^-^^  and  dvsi.ua'a.  The  laetors  at 
crtion/a  variable  anuu.nt  '^ ^^^^^^^^  y,;,  L  gonial  exeitenu^nt, 
.vork  in  producing  th>s  ^^^^^^^^  I,,,  the  drill,  and  diarrhoea. 

)^.r ;;;;;;:;  ;:r  :;;^r:;r ;.:  civu  u.  a.ong  ,0.. ....  ..d  u  h.. 

aiiJ,  t^re.. light  ll^^teru^  .^    he  h.u^-J^-  ^,^^  ,^^,^^^  ,^^     ,^. 
sometimes  call  "goneness.       In  noi  .  .c  ^^^^_  ^^^  .  ^^^  ^j^^ 

lontlj,  its  V^f^^^;j;^:\^l^^    :.b  forcibly,  and  there  is  a  sense 
action  is  much  increased,  the   ''i^"*-;  .        ^^^^j,  j,  ^ot  at  all  quick- 

oi  great  distress.  In  some  '"«t'^"'^''^^^'''^,;"-;;iu;  i^  ,vomen,  in  whom  the 
e„il.  The  most  striking  cases  are  m  "''"  '^  J  ^^^  ,„  ,i.,u,ut  action 
nere  entrance  of  a  person  into  the  "'<-  "^^/Xie  Th  pulse  may  bo 
of  the  heart  and  throbbing  « ^^^  1^^^^^  '^^/^'^  Mu  o  flushing  of\he 
rapidly  increased  until  it  roaches  1^>«  «  /^  ;  ^^^^^^  ^herc  nuiy  be  the 
.4  may  api^ar  at  the  same^  nno-     A    a  su  h    U      ^^^^  ^^^  ^^^,^^^.^^^ 

passage  of  a  largo  ciuant.ty  l'*^^  ;  .^  ^^^  ,,,,^  ,,iieved  l)y  exertion, 
particularly  in  young  men,  ;^'^^'^;\'\\7; /^^^^  „,,,,  ,fter  walking  cpiickly 
A  patient  with  extreme  ;;-|;  ^^^^^^  h  he  j-ulse  perfectly  regular. 
100  yards  or  running  up.tauN  K-tm"  i„.,,.rular  action  of  the  heart  in 
This  is  not  infrequently  seen,  too,  in  the  uu^ular 

mitral  valve  disease.  p  .i  „  iw.nrf  U  n<5uallv  ne"-ativo.    The  sounds, 

The  physical  examination  of  the  ^^^'^ ^"^^^.^^.^  dear,  ringing, 

the  shock  of  which  may  be  v^vv  palpa  •  ^^  •     J^   't      second  sound  at  the 

and  niotallic,  but  nj.  ^^^J^'^Z:^^  ^    -metimos  be  heard 

-is:-7^:i:r:i^^;  -n:;:>;i;  i^^    extremdy  diaicmt  to 

remove  the  conditions  underlying  the  palpitation. 


Arkhythmia. 


,„  „„„,„i.ion ,.™.  ,v,„.„  „„c ;;;--;;';;;  t';;;,;;rT,!  ™,rr:i.'a 

(1)  The  paradoxical  pulse  of  Ivussmaul,  m  uhich  tiie 


NEUROSES  OF  THE  IlEAllT. 


iOt 


>ase — m 
iiy  exi^t 

0  which 

1  among 
(1.  The 
e  oi\  -^x- 
ictors  at 
■ileinont, 
liarrhtca. 
\  it  k'atls 

dyspeptic 
:  patients 
)oats  vio- 
.ty  of  the 
is  a  sense 
all  ipiiek- 
,vliom  the 
L-nt  aetii»n 
<e  may  he 
ng  oi  the 
lay  he  the 
alpitation, 
,•  exertion, 
ng  (luiekly 
ly  rognlar. 
le  heart  in 

'he  sonnds, 
ir,  ringing, 
lund  at  the 
SI  1)6  heard 
d  action  in 
ont.  lasting 
[n  some  in- 
difficult  to 


[ire  dropped. 
Yolnnie  and 
lia  is  a  term 
rhythm, 
in i zed: 
ts  during  in- 


spiration are  more  frcpient  but  less  full  than  during  expiration      This  is 

n     m  weak  heart,  ni  chronic  pericarditis,  and  when  lihrous     an.ls  eu- 

.   de  the  root  of  the  aorta;  but  it  may  also  occur  normally  from  th    u  lu- 

Z.oi  the  respirations  upon  the  heart.    It  is  somet.mcs  to  he  ielt  .n  sleci-mg 

'''''Jrinterniittence,  in  which  there  is  simply  an  intennissio.i  or  dropping 
of  a  cardiac  beat.  The  term  dc/icu-nrcl.  inore  -"-'^ly  "M;;; '^^^  ^'^  ^ 
in^tanccs  in  which  the  absence  of  the  heart-sound  pnnes  that  the  sy  to  c 
i<  reallv  onnttcd.  The  systole  may  be  so  weak  as  not  to  produce  a  pul.a- 
th.n  and  vet  at  the  same  time  a  fcchle  iirst  sound  may  be  heard. 

(4  The  alternate  heart-heat,  in  which  strong  and  weak  con  racfos 
alternate  regularly  and  ^vhich  is  expressed  in  the  peripheral  artene.  hy 
alternate  full  and  feeble  pulse-beats. 

(4)  The  bigeminal  and  trigeminal  pulsations  occur  when  two  or  three 
beats  follow  each  other  in  rapid  succession,  each  group  being  separat  d 
irl  the  following  by  a  longer  interval.  This  ,s  not  very  .----  non  . 
Litral  disease  and  as  an  elTcct  of  digitalis.  In  f lie  l.genuna  pub-^  he 
fh-.t  beat  of  the  pair  is  usually  the  stronger.  Indeed,  in  lie  condition 
Inln  as  ca  bLcminism  the  second  systole  is  so  feeble  that  the  pulse 
!rc  dcH^s  tt  readi  the  .peripheral  arteries  and  the  two  systoles  are  repre- 
contpd  bv  only  a  single  pulse-beat  at  the  wrist.  ,  .      i        i 

^     ^  I.cl^ium  conlis,  in  which  these  various  factors  are  combined  and 

eonini;  condition  in\vhich  the  long  pause  is  ^1^^^^^^^;^^  ^^:^ 

t.r«  of  the  sounds  are  "almost  comidetely  identical       lie  rcscml  Ian  t 

U      fetal   heart-beat  is  ver-y   striking.     In   the   later  stages   ol     ev    s 

!;;,a  in  extreme  dilatation  this  form  of  heart  rhythm  is  very  fre.,..e«tly 

'"'(!)  Gallop  rbvthni,  in  which  the  sounds  resemUe  the  footfall  of  a  horse 
at  canter,  us  lalh-  results  from  the  reduplication  of  the  sounds  m  a  rapidly 
Tot    "  h;.irt      It  is  expressed  by  the  words  "  rat-ta-tat.  '     Sometimes  it 
f    r      the  li^t  s  und  was'split;  more  commonly  it    s  tlu-  second 
";    t  Uuently  heard  in  the  failing  heart  of  ^^^^^^f^^^^^;^;^^. 
arterio-sclerosis.     Its  mode  of  origin  has  heen  much  '^'f''^  ;-'^-  ■': ,     .J^^ 
doubtful  whether  a  satisfactory  explanation  has  yet  '-^^^^^^^^^^^Z 
Steell  states,  its  presence  indicates  muscle  weakness.    It  is  intcustm    amon 
disturbance;  of  rhythm  as  the  only  one  which  we  can  see  and  feel  as  well 

"'  ^^li:  causes  of  these  various  disturbances  of  rhythm  are  thus  classified 

""l^^Tl  central-cerebral-causes,  either  organic  disease,  as 
in  1  a4orrhage,  or  concussion;  more  commonly  psychical  mi  uences 

n  IJellex^  iUuences,  such  as  produce  the  cardiac  irregularity  m  dNS- 
pepsia  and  diseases  of  the  liver,  lungs,  and  kidneys. 
^  ^.^)  Toxic  influences.    Tobacco,  coffee,  and  tea  arc  common  causes  of 


♦Transactions  of  tho  Association  of  American  Physicians,  vul.  iii. 


A 


ii' 


!■'; 


,jS  DISEASES  OF  TUE  CIRCl'LATOItT  SYSTEM. 

„lhvlhn,i..     V»,.i,„.  .bugs,  .,„.l,  ..  .!i..i.»li^,  1.^'"^"'--'.  »'"1  -""»'• 

',n".;;:I":  ii,  ,1.,.  .,.„■.  luor,  (.,)  ■..  .w  0.^1.0  ,..^,«.  j».;y. 

:;;;:;;:;;i':*;;;;:t: ;;;»;  i.:!;;J:w  ,.n,™i.  ...■  ^«.  >:..-  --"^  -- 

■  .    1  ,.;(i,  <i.li.r(i>.i^  of  till'  fonmarv  iii'toriff*.  , 

■■"i;;;  .;,':,:;.',■ .. .,.,. •.  -  «■ -j  \tr-,,.  ;:£ 

""    hI  t  \^r:o    ^^     n-Ono  or  two  otliov  instances  Lay.  oojne  un^er 
almost  iilt)  joais  ol  lu,.  iiu.  ,,it,,oi,t  arterial  or  cardiac  disease,  m 

,ny  notice  of  persons  m  j;oo.l  •'''•>•*'.'' \\\'*\'';^,i,,      t,,,  bi.,,Hinal  and 

rhythm  is  rarely  found  apart  from  dilatation. 

EaIMD    llKAltT— TaCHVCAUDIA. 

The  rapid  action   may  he   perfec^lly  natural.     There  ^^^  ^-^^^^ 
,  1  l„>.,rt  •ictiun  is  at  1»H»  or  even  more  per  minute.     It  ma> 

^Hilv  11'  ,1!:.  l!; '.rl  «n.i-"'-     '■»-  "-  "•"  ""»■"■'"■"  '"  ""  """"" 
'"'"tL.t,.  »n.  ....o.  „Rni..  in  "hid,  111.  < .lilim,  c.n  lunlly  l..'  K'n^l  » 

:^;L^:;,;L:'T';*:l::^r;■:;;;;:;;TX,ri^:^^r^ 

5;:;;;*  ;;;;,,; ih.mght  to  l.e  due  to  renex  irritation  from  ovarian  o,   uteiiuc 
9on  Ir  ?W  ■„..!  tluT,.  »-,.rc  mch  M\«ff  «l  <li-l"''"'  »'"'  '""■"^""■-'-  '.'■'' 


iM«i 


NEUROSES  OP  TUE  HEART. 


aconite, 

Fatty, 
oi'  this 
s  in  tlio 
loy  may 
changes 
cjroneni- 
lly  as>^o- 

Simplo 
lanc'C'lli)!' 
al  vigor, 
|)ulse  I'ov 
lie  uniler 
isoa^L',  in 
linal  and 
in  otlxT 
iHSOciatcd 
■tal  heart 


ulividualr^ 
,  It  may 
;  bnt  thi' 
M'ciso,  and 
ion.  Tlio 
s,  ov  oven 
I'reiso,  tlie 
the  nicno- 

«  tornu'd  a 

niogastrics 

or  clot  in 

•iatod  witli 

in  woinon 

or  uterine 

.'d  l>y  spells 
,  the  \n\he 
ndition  has 
(inile  short 
a  Infirmary 
1  would  rise 
nsiness  that 
o  buljjeetivo 


distnrhanee,  and  in  another  ease  the  patient  wa>  ahle  to  walk  ahout  during 
the  imruNvsn.  and  had  no  dyspn.ea.     One  ot  the  most  remarkahle  eases  is 
reiH.rted  hv  11.  C.  Wood.     xV  physieian  in  his  ei-hty-seventh  year  had  had 
attaeks  at  intervals  sinee  his  Uiirty-.^eventh  year.    The  onset  was  ahnipt  and 
the  i)ul>e  u(Uild  rapidlv  rise  to  -.MiO  a  minute.     For  more  than  twenty  years 
the  takim>-  of  iee-wate^'  or  strong  colleo  would  arrest  the  attaeks.     l.ouveret 
has  analvzed  a  nuiuher  of  eases  of  this  essential  or  idiopathic  iorni;  lie 
finds  that  a  permanent  cure  is  rare,  and  that  the  patients  suller  lor  ten 
or  more  years.     Four  instances  terminated  fatally  from  heart-iailure.    .Mar- 
tin^ look'<  upon  it  as  a  svmpt(mi  oi  an  acute  dilatation  of  the  heart,  appear- 
in-  paroxvsmallv.    Wood  suggests  that  these  cardiac  paro.xysms  are  cause.l 
bv"  discharging 'lesions   atVecting   the    centres   of   the    accelerator   nerves. 
Franc^-ois  Framk  has  shown  that  the  acceleration  of  the  heart  s  action  is 
due  to  the  sh..rteiiing  of  the  diastole,  and  during  the  systole  so  little  blood 
is  expelled  from  tl-     '-eart  that  the  average  amount  m  the  miiuite  is  not 
increased.     .More     ;     the  accelerators  appear  to  have  no  iroi-hu-  relation 
to  the  heart,  and  .     .nutation  of  them  is  not  accompanied  either  by  in- 
creased arterial  pressure  or  by  augmentation  of  the  work  done  hy  the  heart. 

Slow  ITkaut— Br.vciiyc.vudi.v  {Unuhjcardui). 

Slow  actiim  of  the  heart  is  sometimes  normal  and  may  be  a  family  pecul- 
iarity.   Napoleon  is  stated  to  have  had  a  pul..e  of  only  10  per  minute. 

in  •my  c'ase  of  slow  pulse  it  is  important  first  to  make  sure  that  tlio 
inimber  of  heart  and  arterial  beats  corresi..md.  In  many  instances  this  is 
not  the  case,  and  with  a  radial  j.ulse  at  -lU  the  cardiac  inilsations  may  bo 
80  half  Mie  beats  not  reaching  the  wrist.  The  heart  contractions,  not  tlio 
pulse  wave,  should  be  taken  into  acc.n.nt.  A  most  exhaustive  study  ot 
this  condilion  has  been  made  by  Uiegel,  whose  division  is  here  lollowed: 

(fl)  I'hysiological  brachvcardia.  In  the  jtuerperal  state  the  pnlsc  may 
l)eat  from  44  to  (10  i^er  minute,  or  may  even  be  as  low  as  :5 4.  It  is  seen  in 
premature  labor  as  well  as  at  term.  The  ..xplanation  of  its  o.^ciirrence  at 
this  period  is  not  clear.  Slowness  of  the  i-ulse  is  associated  with  hunger. 
Bra(4ivcar.lia  depending  on  individual  peculiarity  is  extremely  rare 

ih)  Tatlndogical  bra<4ivcardia,  which  is  met  with  under  the  to  lowing 

conditions:  (1)    In   convalescence   from  acute   fevers.     This   is   extremely 

common,  particularly  after  ].neunionia,  ty]ihoid  fever,  a.ute  rheumatism, 

and  diphtheria.     It  is  most  fre(iuently  seen  in  young  p.'isons  and  in  cases 

^vhi<4i  have  run  a  normal  course.     Tranbe's  explanation  that  it  is  «l»o  to 

exhaustion   is  probably  the  correct  one.     (•.')  In  diseases  ot   the  digestive 

«v.teni    sn(4,  as  (bronie  dyspepsia,  ulcer  or  cancer  of  the  stomach,  and 

ianndiee      The  larizest  number  of  Eiegel's  cases  were  of  this  group.     (.?) 

Tn  diseases  of  the  respiratory  system.     Here  it  is  by  n..  means  so  common, 

but  is  seen  not  infrecpiently  in  emphysema.     (I)  In  diseases  oi     he  <.ircii- 

latorv  system.     Kxcludim:  all  cases  of  irregularity  of  the  heart,  brachy- 

eardia  ii  not  c<nnn.on  in  diseases  of  the  valves.     It  is  most  frequently  seen 

in  fattv  and  fibroid  changes  in  the  heart,  but  is  not  constant  m  them.     {-. 

In  diseases  of  the  nrinary  organs.    It  occurs  occasionally  in  nephritis  and 


A 


m^ 


i: 


,1 


n 


-7(50  DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

,„av  1.0  n  foaturo  of  unv.nia.    (i>)  rnm.  11,.  n.^lion  ..r  toxi.  a^vnts.    It  oc^u,^ 
/unnnia,   puis-ninj,^  by   Ica.l,  aU...hol,  an.l   lulluws  the-   u>.  ..t  tobacco, 
"ir  0    and   lli.i.alis      (T)    In   constitutional   disonlo,   sucl,   as   an.cnu 
Lisis.  an.l  dial...tcs.     (S)  In  disease,  oi  the  nervous  svste.n.     Apu,.le 
'il,n.v    the  cerchral  tumors,  atVections  of  the  medulla,  and  .li.eaK^  a  ul 
■i'.^'  the  cervical  cord  UK.y  bo  associated  with  very  slow   ,.uls..     In 
1  paresis,  .nania,  and  n.elancholia  it  is  not  infrc.iuent      ,!•)  it  oc..u^ 
:;.c;;;onldlv  m  alVections  of  the  skin  and  sexual  organs,  and  >n  suns-roke. 
,.r  in  prolonged  exhaustion  from  any  cause. 

The  Stokes-Adams  ^Syndrome.-.s7.«'  Pnl.'  u.lh  S^inrop.l  -l '."'•-- 
Hubert  Adau.s  and  Stokes  desc.ribed  a  rcM.arkablc  condit.on  u,  winch  tl 
pulse  was  permanently  slow  in  association  with  attack,  ol  .yncope.     Ihc 
patients  ar   nsuallv  advanced  in  years  and  show  an  extreme  grade  ..   arteiio- 
1  k'rosis     The  pulse-rate  mav  be  30  or  -.'(.  t..  the  nunute,  or,  as  >n  Prenfce  s 
;.ase   as  l..w  as  1"^,  or  even  10  or  5.     The  cerebral  symi.t(uns  are  very  re- 
markable, and  Stokes  suggested   for  them  the  nan>e  ^^^  ^  ^^^ ^;^'^;:: 
.nmnlexv      Attacks  of  vertigo,  which  nuiy  recur  several  time,  m    he  da\, 
.       !  :  of  svncopc,  in  wliich  the  patient  is  insensible  for  lour  or  hve  min- 
i   Is      r^iilepti  orni  attacks,  as  in  Ogle's  cases,  are  the  most  pronounced 
;  e{,ni   s  iniloms.    llucliard  regards  the  condition  as  the  resu  .  ot  change, 
n  the  piieumogastric  centres  due  to  disease  of  ^  -  artenes  ol    he  nu    u    t^ 
(See  Lecture  JV  in  inv  monograph  on  Angina  Pectoris  and  Allied  StaUs 
^Treatment  of  Palpitation  and  Arrhythmia  -An  uni.ortant 
element  in  many  cases  is  to  get  the  patienfs  mind  quieted,  and  he  can  be 
assured  that  there  is  no  actual  danger.    The  mental  elenicnt  is  oitentune. 
very  strong.     In  palpitation,  before  using  medicines,  it  is  well  t..  try  tiic 
eifect  of  hvgieiiic  measures.     As  a  rule,  moderate  exercise  may  be    aken 
with  advantage.     Pegnlar  hours  should  be  kept,  and  at  least   ten  hours 
out  of  the  twentv-fonr  should  be  spent  in  the  recumbent  posture.     A  tepid 
bath  mav  be  taken  in  the  morning,  or,  if  the  patient  is  weakly  and  iutv- 
ou<   in  the  evening,  followed  by  a  thorough  rubbing.     Hot  baths  and  the 
Turkish  bath  should  be  avoide.l.     The  dietetic  management  is  most  mi- 
iMirtant      it  is  best  to  prohibit  absolutely  alcohol,  tea,  and  coilee.      Hie 
did  should  be  light  and  the  patient  should  avoid  taking  large  ineals.    Arti- 
cles of  food  known  to  cause  flatulency  should  not  be  used.     It  a  smoker, 
the   patient   should   give   up  tobacco.     Sexual  excitement    ,s   particularly 
pernicious,  and  the  patient  should  be  warned  specially  on  this  point,    lor 
the  distressing  attacks  of  palj.itation  which  occur  with  neurasthenia,  par- 
ticularlv  in  women,  a  rigid  Weir  Mitchell  course  is  the  most  sat.slac tory. 
It  is  in'these  cases  that  w«  find  the  most  distressing  throbbing  m  the  abdo- 
men   which  is  a,.t  to  come  on  after  meals,  and  is  very  much  aggravated 
by  llatulencv.    The  cases  of  paliiitation  dne  to  excesses  or  to  errors  in  diet 
and  dyspepsia  are  readily  remedied  by  hygienic  measures. 

A  coul-se  of  iron  is  often  useful.  Strychnia  is  particularly  valuable, 
and  is  perhaps  best  administered  as  the  tincture  of  ""'^-'''.'''^^l,  f^,^^^ 
doses.  Very  little  good  is  obtained  from  the  smaller  (piantities.  It  should 
be  civen  freely,  20  minims  three  times  a  day. 

If  there  is  great  rapidity  of  action,  aconite  may  be  tried  or  veratrum 


t  occurs 
tobacco, 
iiiicmia, 
pu|ik'.\y, 
iscs  anil 
Iso.  Ill 
t  occurs?! 
lusti'oko, 

tiad-s.— 
liich  the 
)e.  The 
f  artcrio- 
•rciitice's 

very  rc- 
'  jiR'udo- 

the  day, 
five  iiiin- 
)nouncc(l 
1'  chan^a's 

medulla. 
il  States.) 
injiortant 
lie  can  be 
il'tentinicri 
()  try  the 

lie  taken 

ten  hours 

A  tei)id 

and  nerv- 

is  and  the 

most  im- 
IVee.  The 
als.    Arti- 

a  smoker, 
articularly 
loint.  For 
u'nia,  pir- 
itisl'actory. 
I  the  abdo- 
ajxpravated 
'ors  in  diet 

y  valuable, 

ca  in  lar^'e 

It  slionld 

)r  veratrum 


NEUKOSKS  OB^  THE   HEART. 


701 


viridc  Tliero  arc  cases  associated  with  sUrplessmss  and  restlessness  whuh 
luv  .rreativ  benelited  by  bromide  ol'  p.itassiu.u.  Di-ilalis  is  v.Ty  rari'ly 
indi('^ated,"but  in  obstinate  cases  it  may  be  tried  with  the  nu\  v.aiuea. 

(•a<es  ol'  heart  hnrry  are  often  extremely  olisliiiatc,  as  may  be  judged 
from  the  case  of  the  idivsieian  reported  by  Jl.  C  W.-d,  in  whom  the  con- 
dition persisted  in  spit." -f  all  measures  b.r  iifty  years.  The  brnmidcs  are 
sometimes  useful;  the  ^^'iieral  condition  of  neurasthenia  should  be  treated, 
and  duriu-  the  pan.xvsm  an  iee-ba-  may  be  placed  up-ui  the  heart,  or 
Inciter's  coil,  throuuh  which  ice-water  may  be  passed.  Klivtncity,  m  t he 
form  of  tralvanism,  is  sometimes  servicablc,  aiul  for  its  mental  ellect  the 
Franklinie  current.  For  the  condition  of  slow  pulse  but  little  can  be  done. 
A  great  majority  of  the  cases  are  not  dangerous. 

Anoixa  I'kctoui.-^. 

Stenocardia,  or  the  breast-pan-,  described  by  Ilcbenlcn,  is  imt  an  inde- 
pendent alfcction,  but  a  svmptom  associated  with  a  number  of  morbid 
conditions  of  the  heart  and  vessels,  more  particularly  with  s.lcrosis  ol 
the  root  of  the  aorta  and  changes  in  the  coronary  artm.-.  True  angina, 
which  is  a  rare  disease,  is  characterized  by  paro.xysms  m  agoni/.ing  paiii 
in  the  region  of  the  heart,  extending  into  the  arms  and  neck.  \n  violent 
attacks  there  is  a  sensation  of  im])en(liiig  death. 

Etiology.— It  is  a  disease  of  adult  life  and  occurs  almo,>^t  exclusively 
in  men.  In  lluchard's  statistics  of  •.>;5r  cases  only  4"^  were  in  women  In  my 
.cries  of  40  cases  there  was  onlv  one  woman.  It  may  occur  through  several 
crenerations,  as  in  the  Arnold  family,  (buit,  diabetes,  and  syphilis  are  im- 
portant factors.  A  number  of  c'ases  of  angina  peiloris  have  l.dlowed  milu- 
cnza  Attacks  are  not  infrciuent  in  certain  forms  of  heart-disease,  par- 
ticularlv  aortic  insuiliciencv  and  adherent  pericardium.  It  is  much  less 
common  in  disease  of  the  mitral  valve.  Almost  without  cxcrptiun  the  su b- 
iccts  of  true  angina  have  arterio-sc-lerosis,  cither  general  or  localize.  ,  at  the 
ro..t  of  the  aorta,  with  changes  in  the  coronary  arteries  an.!  in  the  myo- 

""  Phenomena  of  the  Attack.-The  exciting  cans.'  is  in  a  maj.uity  of  all 
cases  well  dclined.  In  only  rare  instances  d.)  the  iiatieiits  have  attacks 
when  <piict.  They  come  on  during  excrti.)n  most  fre.pi.'iitly,  as  m  walking 
n.)  hill  or  something  entailing  sudden  muscular  elfort;  .)ccasionally  even  the 
elTort  of  dressing  or  of  stooping  to  lace  the  shoes  may  bring  .)n  a  paroxysm. 
]^[ental  emotion  is  a  second  very  potent  cause.  John  Hunter  appreciated 
this  when  he  said  that  "  his  life  was  in  the  hands  of  any  rascal  who  chose 
to  annoy  and  tease  him."  In  his  case  a  fatal  attack  occurred  during  a  fit 
of  an-w  A  third,  ami  in  many  instances  the  most  important,  lactor  is 
flatulent  distenti..n  of  the  stoma.h.  Another  common  exciting  cause  is 
cold;  even  the  chill  of  getting  out  of  bed  in  the  morning  ..r  on  bathing 
may  bring  on  a  paroxysm.  ,.      ,,         .•     i.  •       •     i 

"Usually  during  exertion  or  intense  mental  emotion  the  patient  is  seized 
with  "an  acnmizing  pain  in  the  region  of  the  heart  and  a  sense  of  constric- 
tion   as  if  the  heart  had  been  seized  in  a  vice.    The  pams  radiate  np  the 


-^ 


•rr 
t 

1 


!1 


i 


.•-,5 


7C2  DISEASES  OF  THE  CIRCULATORY  SYSTEM, 

in  syncoiR'.     Hif  coii.n  i<>n       i  tension,  however,  is 

,„„.„,,„.  ,„.y  1..  >;;";"■■  »■;;'     f ;,.,  '  ,  Z^.  u  e..r™,o  »>■..,■•,.,■. 

iisuallv  increased,  l)ut  it   is  suipu.in   , 

1,.,.-  sii^l.tly  the  eharaeter  of  the  pulse  nwn    i;-^;;^;,!;^'^  urine. 

*"'r'\;;ii: ;;:;;:  ;n;  i  "  r"'un.-o.  ,1,.  ,;,m.„x,,„  i,  „«.  .(«- 

;;;:;«;, '1  ;i'« '..  -■-«o,,,  .1.1,  ,-n,g.-e.ivc.  .„.,  hK.,,,.-,,,..  ...ak,,... 

--  ;S:lJ:;r\::;■;2:7:.;;:'--""*--- 
^:::;;;i:.  :';„,':;:",  .;;-■ -i^-.i.  -.1  ..!.>"■  "->-'  --''  "■"' '« "'»■">■'  ""■°"- 

nanied  liv  i>ain  in  certain  cervical  areas.  ,   •       <■  ♦,,,,  ,,.,r,1i.ip 

'    Theories  of  Angina  Pectori8.-(l)That  it  - ;}-^^^r^;:;;' ^^^X^ 
norve<      In  the  true  f.n'in  tlie  ajronizin-  eranip-hke  ehaiacter  ot  t  .     p.   n 
Suddenness  of  the  onset,  and  the  associated   featun-.  -  unh  c>  an> 
n,.urihne  aiVection.     The   pain,  liowever,   is  undouhtedly   in   t  a   carcliac 
X  r  nd    adiates  to  adjacent  nerves.    It  is  interesting  to  note,  in  eo i- 
£  ni  "'th  the  ahuost  constant  sclerosis  of  the  coronary  arteries  in  a  - 
^  ,n     h  t  Thonia  has  found  marked  sclerosis  of  the  temporal  artery  in 
S:;a^el^  Dana  has  met  with  local  thickening  of  the  -tories  in  s..n^ 
^is  of  nenral,ia.    (2)  Ileherden  helieves  that  it  -^^J}^:^^;^^  ^^^  ^'^  . 
ele   itself.      CVamp   of  e^tanin.^ 

a.:;^^!^  ci;U;:t;U  a^'lleute  dilatatmn  -Ha^;/--  ^ 
ioritv  of  eases,  with  alTeetion  of  the  coronary  -^'^^^^/?V^;       ^ !    ^ 
ported  this  view,  held  tliat  the  ajronizin?  pam  resulted  fiom  ^^^^  '-''' 
retching  and  tension  of  the  nerves  in  the  muscular  suhstanee.    A  mod. 


^•^m 


NF,r ROSES  OP  THE  HEART. 


:o3 


rs  or  in 
lu  ashy- 

surl'aco. 

r  wliit'h, 

l)()intL'il 

U lldlol' 

luniiK'iit 
cty,  and 
lass  away 
ilik",  tlio 
wovcr,  is 

severity, 
le  attaelv 
■ar  urine, 
be  liadly 
i  hini^^elt 
lot  infre- 
the  bron- 
s  short  of 
mt  warn- 
i  tlie  lirst 
ird  group 

llunler'ri 
ig  attacks 

weakness 

s  of  ^rac- 
(1)  in  dis- 
pain  is  re- 
in angina 
sixtli,  and 
lys  accom- 

:ho  cardiac 
f  the  jiain, 
unlike  any 
lie  cardiac 
ite,  in  coii- 
■ries  in  an- 
1  artery  in 
ies  in  some 
f  the  heart- 

1  letter  ox- 
of  the  ven- 

iii  the  ina- 
e,  who  sup- 
[i  the  great 
?.    A  modi- 


fled  form  of  this  view  is  that  there  is  a  spa.m  of  the  coronary  arteries  with 
..-real  increase  of  the  inlraeariliae  pressure.  ,i  ,.  ,i,,. 

"        1    The  theorv  nf  Allan  lU.rns,  revived  by  I'nta.n  and  nther>.  that  the 
eon  1    i<'     <   .ne  of  transient  ischaniia  of  the  heart-n.usele  .n  euuse^iucnco 
n^    or  spa.m,  of  the  coronary  arteries.     The  eu.uUt.nn   known  a> 
nt      ,     tn.t   cl  udic^tiou  illustrates  what   n>ay  take  place.      In   man  (.uid 
l"  horse),  in  conse.p.enco  of  thrombosis  ot   the  al.lmnnial   ao    a 
,.s  transient  i.araplegia  ami  spasm  may  follow  exert  urn.     1  he  eoUateial 
e  ;  ui.d      :        Ph'  wlie,:the  limbs  are  at  rest,  is  insullieient  alter  the  urns- 
^  ^         ac-  ivel     use.1,  and  a  state  of  relative  isc.h.cmm  .s  induced  w„l,  los. 
dp  we     whh^i  disappears  in  a  short  tin.e.     This  ;  .nternuttent  ela>u     .  - 
ion-  thc.rv  has  be'./i  api-lied  to  explain  the  angina  paroxysm.     A  hea  t 
e  c<.n    arv  arteries  of  which  arc  sekrotic  or  calcilied,  is  in  a.,  ana  oguu, 
t.env  extra  exertion  is  likc.ly  to  be  fullowcd  by  a  relative  iseluenua 
^;i  :,       1       n        an  lU.rns-s  work  on  The  Heart  (i^n.)  the  theory  is  dis- 
nllXI  lengih,  but  he  does  not  think  that  spasm  is  a  necessary  accom- 

iiiniinellt  of  the  iscliaMUia.  .    ,  ,       ,• 

'  al  cases  of  angina  the  coronary  arteries  are  alm-.t  •;vana^|ly  a^- 

oased  cither  in  their  main  <livisions.  or  there  >s  .•luomc  ^■;';'"''»;       »"    ^ 
Je,    narrowin.^  of  the  oriiices  at  the  root  of  the  aorta.     Kxpennientall 
^   . t        of    lu.  eoronarv  arteries  produces  slowing  of  the  hearts  action 

ih';:i;;'i:,i::\;!:i.:;rjxt;';r:.;^ 

■*^     o  ,       .  (•  ,];,(,.,,«  •ind  imea-iucss.  and  laiiiaiiou  oi. 

.li,bt  pnecon  nil  pain,  a  sense  *''^  ^>       .;  ;^         ,^^,        ^j  ,,,  ,,,,,ion,  an 

h  creased   tension   and   signs  of  general   ''•■t^''-'"'--!''''''^';- J'\;'  V'    J/ 
tacks. 


■•T^ 


:g4 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


.»J 


If 

ft 


i 


rSKI'DO-ANOINV. 

At  every  age,  even  six  years. 

;Most  coiniiiou  in  women.  At- 
tacks siiontanetius. 

(H'ten  peritnlieal  and  nocturnal. 

Associated  witli  nervous  symp- 
toms. . 

Vaso-niotor  form  common,  l  am 
less  severe;  sensation  ol'  di.-tention. 

Tain  lasts  one  or  two  hours.  Agi- 
tation and  activity. 

Neuralgia  oi'  nerves  and  cardio- 

ple.xus. 

jS'ever  fatal. 
xVntineuralgic  medication. 


TKUi:   .\N(iINA. 

Most  con\mon  liclwccn  the  ages 
of  forty  ami  litly  years. 

Most  connnon  in  men.  Attacks 
brought  on  by  e.xertiou. 

Attacks  rarely  periodical  or  noc- 
turnal. 

y,o{  associated  with  other  symp- 
toms. 

Vaso-motor  form  rare.  Agoniz- 
ing pain  and  sensation  oi  compres- 
s^ion  by  a  vice. 

Tain  of  short  duration.  Atti- 
tude: silence,  immobility. 

Lesions  :    sclerosis    of    coronary 

artery. 

Prognosis  grave,  often  fatal. 
Arterial  medication. 

A  form  which  Nothnagel  has  described  as  ra.:-,nnlnr  -'^^;;  ^  ^^  ^l^;^] 
nu..nt      The  <vnn.toms  set  in  with  coldness  and  numlmess  in  the  c'xtumi 
?:::"*foll!,!;;.d-b;' great  pnccomial  pain  and  feelings  ot   la.ntness.     bomc 

^^^iw;^;:;::;::;:^.;^!!::^.^--  due  to  the  abuse  or  tc.  co.e.  and 

.  1  ,;  o     'PI  ere  -ire  three  .n-oups  of  eases  of  so-called  tol,acco  heart:  1mi.  , 
t        tal  e       .       o    siiu^ers!sccn  parti..ularly  in  y.mng  lads,  in  which 
e    "m It  ins  are  palpitation,   irregularity,  and   rapid  action;    secondly, 
.^vt-  a  sharp,    hooting  character,  which  may  ho  very  severe;  and, 

;.  1  -       tacks  of     ich  severity  that  they  deserve  the  name  of  angn,  . 
I     c     I'd  r  marks  that  thcv  are  usually  of  the  vaso-m<.tor    ype,  accoin- 
S     it         lling  of  the  extremities,  feeble  pulse,  and  a  tendency  to  syrv 
^  T  i    .  itlu.r  di.tin.niishes  between  functional  tohacco  angina,  due, 

;;:'     in        o^!!:!;!;;.  ;.-traction  of  the  corona,,  arteries,  and  an  organic 
o,:;.;.o  a;ginJ  due  to  a  nicotine  artcrio-sclerosis  of  tj- -^  ^^^^,^   ^, 
PrOffnosis.-('ardiac   pain   withont   evidence   of   aiterio-sckroM>   or 
vaUv-di™   is  not  of  much  moment.     True  angina  is  almost  invariably 
.i  ted  with  marked  cardio-vascular  Icsi.ms.  in  which  the  P-gn^s    . 
"hv  v«   <n-ave.     With   iudicioiis  treatment   the   attacks,   however,   may  he 
o  '  def    red,  and  a  few  instances  recover  comph^iely      The  prognosis    s 
hir  llv  moo  serious  with  aortic  insiilTiciency  and  advanced  arterio-scle- 
^^i!^     ^1     nts  who  have  had  well-marked  attacks  ma;,-    ive    or  "-"^y  F^    ' 
In    miK-h  depends  npon  the  care  with  which  they  regulate   heir  daily  hfc^ 
Treaiment.-Patients  snhjcct  to  this  aiVec^ion  should   live  a  .pnot 
life  .?S  particularly  excitement  and  sudden  mnscnlar  exertion.    D nr- 
t'   1  e  at  aei  :,itrite  of  amyl  should  he  inhaled,  as  advised  hy  Laude 
Br^inon       From   2    to   5   drops   may   he   placed   upon    cotton-wool   in  _ a 
S    r  or   i^on  the  handkerchief.    This  is  frequently  o    great  ..vice  in 
c         ck,  relieving  the  agonizing  pain  and  distress.    Snhjects  of  the  dis- 


CONGENITAL  AFFECTIONS  OF  THE  UKAliT. 


7(55 


n. 

lot  iiifi'o- 

oxtiTini- 

s.     Some 

olToo,  and 
irt:  First, 
in  wliich 
i^ocondly, 
,-ere;  and, 
){  anjiina. 
c,  at'coni- 
cy  to  syn- 
ff'ma,  due, 


•lorosis   or 
iiivavialdy 
I'ofinot^is  is 
r,  may  be 
ro^nosis  is 
rtorio-sclc- 
lany  years. 
■  daily  life, 
vc  a  (piict 
:ion.    Dur- 
l)y  T.auder 
-wool   in   a 
t  porvice  in 
of  the  dis- 


onso  «houl.l  carry  ll.e  rrrlrs  of  the  nitrite  of  an>yl  with  then.,  and  use  them 
lu  0     .       .uVati.m  of  an  attaek.     In  son.e  u.stan..s  ,    ••  nUnte  oi  a...  1 

;    0   .owe,!...,  t'..n,h  ,iven  freely.    H  ^t    >n  a  nunu  e  or  two  .Ue 
,ot  obtained  in  this  \\av.  chloroform  slnndd  at  once  l,e  jiisen      A  1.  u  m 

Lit::;;:!    .ron.,.iy  and  .ive  ,reat  reli.-f.     f'^^^^^^ZZ'^ 
.,  l.vimdermie  of  morulua  may  be  administered.     In  hovero  ami  u\n.xu 
;.;•';!""  patient  Inay  display  remarkable  resistance  to  ,l,e  action  oL 

^'^n'tiie  intervals,  nitroglycerin  niay  he  ,iven  in   ^^^^\;^;-'\^;j-^: 

^i-;:ixr;^';.;;v;;^ai;;;;:;rt;'n 

'"'^;;chard  reeomn,ends  the  iodi.les,  believin,  that   their  i;-'-^;;;;  -;; 
i,,n,H>n,...s  the  arterio-sclerosis.     Twenty  jzram.,  three  time,  a  d.u   .na>_^bc 

g 
nic 


l.',„-  tl„.  iwul.M.ll-iliii.  Ill''  liralTlifllt  must  !«■  .iM'.-rlcl  I..  111.'  ?n.l.,l 
the  Franklinie  form. 

VI.    CONGENITAL   AFFECTIONS   OF   THE    HEART. 

The^e  have  onlv  a  linnted  clinical  interest,  as  in  a  larjie  proportion  "f 
thoT  i       "an^malv  is  not  compatible  with  life,  and  m  otlu.s  notbm, 
r    1       \  .  ,.,.,ne.iv  the  defect  or  even  to  relieve  the  symptoms. 

„f  ,l,.vc.l..,.„R'..t  m-  from  i„n„mmat„r.v  |„.„cossi,-...,1.K-a,.hl.>,  .onalmu  . 
Occasionally,  as  in  a  ease  reported  by  Holt,  tin  cliiKi  uvc . 


-T" 


r 


1 
J 

!,•* 


I.ISHASKS  OF  TIIK  CIUCULATOUY  SYSTEM. 

,  1  „,..  i.,,,|   ,n:.v  l-c  soon  an.l  f.'lt  I'.^.tin-  l-n..,Ul>  tl..  .kin  in  iho  cpi- 
p'nl   v!;;::.!      -nns mrant  was  livo  .uuu.l.  -Ul  at  the  .lal.  ol  .xa.n.na- 

%)  Anomalies  of  the  Cardiac  Septa.-Tlu..,.tn  of  ';"•'  -'-^';;;  -;.;; 

ri;,-;::;j;,r:;:::;:;itt;;f;:j 

„      h-.v,<  «  valvular  slil  vvlii.' av  In-  lai>'<'  '■"""^•l'  '"  "'I'""  "": 

;:,:;ii;;:l'».ii«'i  N.'i.i-'.in.,..r ...an ..ni,n,.„„  i-h..— ■' 

'''N:i"';=:':::l";;^;wi::.i""^-'i v"'^ ,rr"";:;r:i*::;;: 

::;sr;rtrt:;,,;vts:^i;r-;:  J 

„rili(T  ;,r  of  ll...  I..1I11S  ai-lori..>ii»  "I  tl"'  n^•lll  v.'iilii.l.. 

"'"  ,    Anomalies  and  Lesionsotthe  Valves.-Nnn.r,., ,.,...-;    >   ^^ 

i:';:;^!  ,       ,  Im;^;  im^a...!  <..•  .lnninis,u..l  in  .unniK.      Su,.nnunerary 
r.,  ont     an.  .no,;  rmi.u.nt   in   the  pnlnx-nary  artery  tha,>   m  tlu-  a  n ta 
r^:or;:;nu.tinu.s  (ive'v.lves  have  hcen  foun.1      The  segment.  nu.y  be  ot 
o„ual  Hi/,...  hnt.  as  a  rnle,  the  sni.enuunerary  valve  is  small. 

ln<teM(l  (.!■  three  Iher.'  n.av  he  only  two  semilunar  valves.  <>■.  a>  it  i> 
ior^TtV   i      ri.l  nnulili.,;.     In  my  experience,  this  is  most     re.iuen 
He  a      i.    vake.     Of  ^1   i.-tanees  only  ^  oeenrre.!  at  tiie  ,m  inoiiary 
i    "      T     >         the  valves  have  nnite.l.  an.l   fr.>,n  the  ventrK.nlar     aeo 
h       eith      no  tni..e  of  .liviMo-i  ..r  els.  a  .li.ht  .depression  nnlieatin,  wh^ 
11  k\i   ion  ha.l  o..urn..l.     Fr.m.  the  aortic  si.le  there  is  usnally  to  be  se  n 
"^^1:0  of  division  into  two  sinuses  of  ^'alsalva.    Then,  has  l.ena^^ 
cnssion  as  to  the  origin  of  this  con.l>t...n.  ^vholher  it  1.  u         '";        >^^   V 
or  ulH.th.M-  it   is  n.M  .lue  to  en.l.icar.litis,  f.etal  or  pos  -natal.      •  li\  ^" 
lo.    -^.^nnent  is  usuallv  tlii.-kene.l.  but  the  fact  that  tins  anomah    j-  .  1 
'"hln  the  f.etus  .ith.mt  a  trace  of  sclei^sis  or  en.hu.ar.li..s  slu.ws  that  it 
„-,iv    in  ^.m^e  cases  at  least,  result  from  a  .levc-loiuneiital  e>  i<u. 
""■(-  nnJlv   this   is   a    very   iinp.u.,ant   c.u,.nital   '^^'-^   ;;;;";^.;;^^ 

jr:;h!ei:iw';;oi.;;.,;.ieathres^^ 

''•^'l^:e'lHtle  fenestrations  at  the  margins  of  the  sigmoi.lvaU.s  have  no 
.ignifieance;  they  occur  in  a  considerable  proportion  of  all  bodie. 


CONGKN'ITAL   AFFECTIONS  OP  TllK  IIRAUT. 


^ii»» 
i(>i 


(he  cpi- 
xiimimi- 

■Ics  and 
liut  two 
lie  aw\- 
('inl)vni>c 
■d  to  tlio 
liiiit  the 
ill  ions  of 

V  chisiiig 

iiji  stt'iio- 

si'l»tuin. 

many  i'^" 
tho  coii- 
.ns.  The 
]:\r  lirart. 
on  ol'  tlio 
,VM  as  tho 
liis.  Tho 
)uln\nn.iiy 

ics  of  tho 
ial  oriik'os 
rniiniorary 
llio  ai>rta. 
may  ho  of 

>\\  as  it  is 
(  i'roi[Uont 
IHihiionary 
ifular  I'aoo 
till},'  whoro 

to  he  soon 
hoon  a  dis- 
ir.  anomaly 

Tiio  com- 
naly  is  mot 
lows  that  it 

injr  to  the 
two  f total 
iuid  in  15 

iicctly  from 

vcs  have  no 
adios. 


Anomalies  of  tlio  aurioulo-vonlrionlar  valvos  aro  not  ofton  mot  with. 
FcBtal  endocarditis  mav  o«oiir  oith.  r  at    llu'   arlHial   or  aiinniio-von- 
tri.ular  ..lilioos.     It   is  noarlv  always  of  tho  chroMi.'  or  sclorotic  variety. 
Vorv  rai'olv  iiidood  is  it  of  tl'io  warty  or  vorriiroso  form.     Thoro  aro  little 
nodular  hodios,  som.'tinios  six  or  oi-ht  in  numhor,  on  tiio  mitral  and  tri- 
cHpid  s.-inonts— th.'  nodules  of  All.ini— wliioh  roi.rosont  the  ivmaina  of 
f„.tal  striuturos,  and   must  not   ho  niistakon  for  ondo.ardial  out^'rowths. 
Tlio  littlo  roundod.  Inad-liko  luoniorrlia-ios  of  a  doop  imrido  o..lor.  wliioh 
iiro  vorv  oommoii  on  tho  hoart   valvos  of  ohildron.  aro  also  not  to  ho  mis- 
taken for  tho  i.nxhiots  of  omhioarditis.     In  f.otal  ondoearditis  tin'  so-monts 
are  usuallv  thiokonod  at  tiio  odKos,  slirunk.'u.  and  smooth.     In  tlio  mitral 
nud  trieiispid  valvos  tho  cusps  aro  found  uiiitod  and  tho  ohonho  tnidinoa' 
iiro   thiokonod   and   slu.rtoiicd.      In   llio  somilunar   valvos  all   traoo  of  the 
so^rmonts   has   disap|)oaivd.    lcavin<r   a   still'   mciiihranons   diaphra-m    por- 
fcratod  hv  an  oval  (.r  rouiuh'<l  orilico.     It  is  s(.ni.'tiiuos  vorv  dillicidt  to  say 
whethor  this  comlition  has  result. 'd  from  hHal  ondoearditis  or  whether  it 
is  an  error  in  dovolopmont.     In  vorv   many   instaiieos  tho  i.roeossos  are 
oomhinod:  an    anomalons    valve    hooomes    tho    s.'at    of    oliromo    selorotu: 
chancres,  and.  aooordinj,'  to   h'anohfuss,  ondoearditis  is  more  oomnion  on 
tho  r?<;iit  side  of  the  heart  only  because  the  valves  aro  hero  most  (dten  the 
seat  of  dovolopmontal  errors. 

Lesions  at  the  Pulmonary  Oriflce.—>7r'»n,s/,s'  of  this  orilho  is  one  ..t  tlio 
ccmimonest  and  most  imi.ortant  of  eon^'ollital    hoart   all'oetions.     A  slow 
endocarditis  causes  n;radiial  union  of  the  segments  and  narrowin<i  of  the 
„rilleo  to  such  a  dejiroo  that  it  only  admits  tho  smallest-sized  prohe.     In 
<(.mo  of  the  cases  the  smooth  momhramms  condition  of  the  eoiiihined  seg- 
ment-^ is  siioh  that  it  would  apj.oar  to  ho  the  result  of  faulty  (level.. pnient. 
In  some  iiistanoos  voKetati.nis  dovoh.p.     The  comlition  is  compatihh'  with 
life  for  many  voars,  ami  in  a  considorahlo  proportion  of  tho  cases  of  hoart- 
di-^oa-^o  ah..vo  the  tenth  vear  this  lesi.m  is  present.     With  it  there  may  ho 
defect  of  tho  vontrieiilar  septum,     rulinomiry  tuhoroulosis  is  a  very  ccmuiK.n 
cause  of  death.     Ohliteration  or  ohrsia  of  tho  imlmoiiary  onlice  is  loss  fro- 
(,uont  hut  a  more  serious  c.mditi.m  than  ston..sis.     It  is  associated  with  do- 
foct  of  the  vontrieiilar  septum  or  pat.'iicy  .d'  the  foramen  oval.'  and  p.T- 
bi.tonce  of  the  ductus  arteriosus  with  hyi.ertroi.hy  of  the  right  heart.    Se- 
nosis  of  the  onus  arlcrw.m  of  tho  right  ventricle  exists  in  a  .■onsidorahle 
proportion  of  tho  cases  of  ohstructi.m  at  the  i.ulnionary  onfico     At  the  mit- 
Lt  a  dovolopuK-ntal  error,  it  may  he  combined  with  sclerotic  changes.    The 
ventricular  soptiim  is  imperfect,  the  foramen  ovale  is  usually  open,  aii.l  the 
ductus  arteriosus   patent.     These  throe  lesions  at  the   pulmonary   orifice 
constitute  the  most  inii-ortant  groiii.  of  all  congenital  «irdiac  ailections^ 
Of  181  instances  of  various  congenital  anomalies  cilloctod  by  1  eaoock  ll.i 
cases  came  under  this  category,  and.  accnling  to  this  author,  -n  S(i  per 
cent  of  the  patients  living  beyond  the  twelfth  year  the  lesion  is  at  this 

orifice.  ,  .      d       \  e ,  ^ 

CuiKicnitnl  ksions  of  the  (wriir  orifice  aro  not  vorv  frequent.     Uauclituss 

has  collected  '24  cases  of.  stenosis  and  atresia;  stenosis  of  the  loft  conus 

arteriosus  may  also  occur,  a  condition  which  is  n..t  incompatible  with  pro- 

4» 


T 


msKASKS  OF  THE  riRrrLATOBY  8Ysti:m. 


IS 
1,1 


i 


TC8 

symptoms  of  ^;;;^^^^^ ^.uu.^^  a  r..atu,.  that  tin- 

f.,r  c...nf-'...itMl  lu.art-l.soaso.  1.'  >"",;!  .„,;,,,,,,„•  c-.,ll.u..l  to  tl>o 
,arlv,  .illuM  tlK.  lirst  w..k  ol  ''  ;;,;;:'3>^,;;:,;  ;,  ,„„,  i„sla,u.s  there 
lips,  nose,  ami  ears,  a.u  »;;";-,,;„;  ,,,,i  i„  ,i,,  „,„Ht  extreme  grade, 
i,  i„  addiuon  a  genera    .lu.  '  -       '     ^^j  ^j^,^,,  ,„.,  ,„ay  only  he  ,n- 

tlH-  ^Ui"  i^  "  --^  C.  '  ;te  ..  n  ,:;.n.tu,;  is  low.  Dyspn.ea  on  exertjon 
tense  on  exertion,     ihe  f^<^""  ;''   '    ,       ,  ,,,.  ;,,  the  nunil)cr  of  the 

and  eongh  are  eonnnon  ^v-1'  ;;-•;)  ^j;  Va,,,...  In  a  ease  of  (iih- 
K„l  corpuseles  has  l.een  m-e  1  Kv  ^^  ^^«  «  1  lo.>.1-eor,n.seles  to  the  eulue 
.,nV  there  .ere  a  hove  .„h    >•;>;;,;,,  ,,,,,Jv  a  lethargy  of  both 

nun.l  and  hody.      1 1^^^    !"ni  ^     cyanosis  has  been  mueh  dis- 

with  in  any  other  alleetion  .^^"^'^^rxi  eon>a.stion  of  the  venous  bvs- 
cus.ed.  Mu,^agni  -f-'r-'di  t  ^J^^^^  ,,  ,  ,aper,  one  of  tlu3 
tern  due  to  ohstruetioM,  and  tl»s  Mtvv  \  1  ,      ^,„^,.i,,^,,', 

able>t  that  has  been  written  on  '1>^';\;  ,,;,,,,  ,h.,ws  that  elosuro 
n.eent  analysis  of  75  eases  ol  eongen.ta  ^'^^^  ^^^^^j^  ^^^.^  ,,,,  ,en- 
of  the  pulmonary  on  iee  and  pa  e  ^  ,^  ;,Uv  ass.u.ided  with  eyanosis, 
t,i,ular  septum  arc  ^-/^I'T.  "  , H  e  blood  owing  to  dimiu- 
and  bo  coueludes  that  the  <1'''"'"^    ^  '     ,.,,,t.,r.     Another  view,  advo- 

.,,„,  uiug  function  'V'^'r  ,,"  '  l!* ScI  orati..n  was  due  to  the  ad- 
,atod  by  Wil ham  """f '  : ,  ^  ^^  j  /  „.ia,  hlood;  but  lesions  may  exist 
Tuixture  in  the  heart  of  ^^^'!'' ';"''"'  ,j  ,,-„aueing  cyanosis.  The  .,ues- 
^vhieb  permit  of  vory  free  nuxtu  e  ^^  '^\; ;,",;, i;„,,i  ,,  ,,ttled.  Variot 
tion  of'the  cause  of  cyanosis  ^^y^^^^^  '  ,::  ot  entirely  cardiac,  but 
has  recently  made  the  ^f^'^'Z^^^^C^^U.  circulatoiT  system,  and 

uuscles.  „     i,;i,ir,..i    cvino'^is    with  or  without  en- 

Diagnosis. -Tn  the  case  ..f  Sl*^'^"^^'"- ;>';,„'  ,r  are  sutlieient.  as  a 
lar-Sn.^t  of  the  heart,  and  the  f -^---;^,^  ^  ^^  The  cvanosis 
nd^.  to  deternune  the  presence  '^^^f -'[^  '^^f  ^  ^^  ^  it  is  a  symptom 
gives  us  no  clew  to  the  precise  "''*"  /  J'  ^y  ,,,tain  conditions.  The 
common  to  many  lesions  and  >*  "^'^>  j  ;'^^'""  ;",  ,,vcr.  not  always  pres- 
nuirmur  is  usually  systolic  m  charaete  •  ^„,    ,^.„i,^,  ,,ions  in 

ont.  and  there  are  instances  on  '--"  /^  ^^  ^      ^^     ^,,\,y,  or  three  in- 
.hich  the  oxamiuation^u>w.^  n..rm     h  a^^^  ,^^  ,,.^ 

stances  fo>tal  endocarditi>  ha^  I*  nv  ";V  ;  ^         ,.,„.rob(.rated  sub- 

of  a  rough  systolic  munuur,  and  *      ^^j^      ^    '^^^..^t  in  a  majority  of 
scpient  to  tbe  ^'i-'^V'^V  "f    I      Tl  e  f  vent  nuiy  be  caused  by  abscess 

:;;rS  -L^-lfrlm.:::*  ^^:^^^  tms  so^  to  enter  upon  elabo- 


mm 


CONUJKMTAIi  AIM'HCTIONS  OF  Till':    UK  MIT. 


(00 


■ty  yoarfl 

iiinmaly. 

cciiis  ill 
tliul  tin- 
yMoiiyiiH 
i  npi>oars 
lmI  to  tlin 
icea  thoro 
i\L'  gradof* 
ily  1)1'  in- 

1   t'XlTtioIl 

)or  of  tlie 
sc  of  (lil)- 
tho  ciiliii^ 
!iy  of  both 
rarely  nu't 
iiuiih  dirf- 
I'lious  pys- 
one  of  the 
Morrison's 
\at  flosuru 
il  the  ven- 
|\  cyanosis, 
;  to  (limin- 
.•ii'W,  advo- 
to  the  ad- 
i  may  exist 
The  nuos- 
L'd.     Variot 
cardiac,  but 
system,  and 
I  l)lood-cor- 

withont  en- 
iVu'icnt,  as  a 
rhe  cyanosis 

a  symptom 
it  ions.  The 
always  prcs- 
al  lesions  in 

or  three  in- 
tlu}  ]>rescnce 
)l)orated  snb- 
1  majority  of 
}d  by  abscess 
r  upon  elabo- 


rate details  in  diiVcrential  diagnosis  between  the  various  conjjonital  heart- 
Icsinns.      I  herealistract  the  coinhisions  of  lloclisin^ier: 

"(1)  In  childhood,  loud,  rou^di,  nuisieal  liearl-MUirmurs,  with  normal 
or  only  sli^dit  increase  in  the  heart-dnlness,  occur  only  in  congenital  hcart- 
di.-easc.  The  ac<|iiired  endocardial  defects  with  loud  hearl-miinniirii  in 
voiini;  children  are  almost  always  associated  with  j;rcat  increase  in  the 
'heart'^dulness.  In  the  transposition  (.f  the  larjje  arterial  trunks  there  may 
he  DO  cyanosis,  no  heart-murmur,  and  au  aliseiice  oi  hypertro|iliy. 

'•(•>)  In  younir  ciiihlrcn  heart-murmurs  witii  ^'ri'at  iiiereasi'  in  the  car- 
diac dulness"  and  feelile  apex  beat  su.trgest  congenital  changes.  The  in- 
creased dulness  is  chicily  of  tlie  right  heart,  whereas  the  left  is  only  slightly 
altered.  On  the  other  hand,  in  the  acquired  endocarditis  in  ehililren,  the 
left  iu'art  is  chielly  all'ectcil  and  the  afiex  beat  is  visible;  tiie  dilatation  of 
the  right  heart  conu's  late  and  docs  not  materially  change  tiie  increased 
strength  <if  the  aju-x  beat. 

"(;5)  The  entire  ahscnce  of  murnuiis  at  the  apex,  with  their  evident 
presence  in  the  region  of  the  auricles  and  over  the  i)ulmoiiary  orillcc,  is  al- 
ways an  important  element  in  diiVcrential  diagnosis,  and  points  rather  to 
seiitum  delect  or  pulmonary  stenosis  than  to  endocarditis. 

"(t)  An  abnormally  weak  second  ]ndmonie  sound  associated  with  a 
distinct  svstolic  murnuir  is  a  synijitom  which  in  early  childhood  is  only  to 
be  explaiiied  bv  the  assumption  of  a  congenital  pulmonary  stenosis,  and 
possesses  therefore  an  importance  from  a  point  (d'  dill'erential  diagnosis 
which  is  not  to  be  underestimated. 

"  (.-))  Absence  of  a  palpable  thrill,  despite  loud  murmurs  which  are 
lieard  over  the  whole  pra.'eordial  region,  is  rare  except  with  congenital  de- 
fects in  the  septum,  and  it  speaks  therefore  against  an  ac((uired  earduio 

all'ection.  .  ,    .,  ■   .      c 

••(C)  Loud,  especiallv  vibratory,  systolic  murmurs,  with  the  point  ot 
maximum  intensity  ove/ the  ui)per  third  of  the  sternum,  associated  with 
a  lack  of  marked  svmpt(mis  of  hyi)ertrophy  of  the  left  ventricle,  are  yery 
important  for  the  d'iagnosis  of  a  i)ersistenee  of  the  ductus  Botalli,  and  can- 
not be  explained  by  the  assumption  of  an  endocarditis  of  the  aortie  valve." 
Treatment.— The  child  should  be  warmly  clad  and  guarded  from  ail 
circum-tances  liable  to  excite  bronchitis.  In  the  attacks  of  urgent  dysp- 
nu'a  with  lividitv  blood  should  be  freely  let.  Saline  cathartics  are  also 
useful.  Pigita1i^  must  be  used  with  care;  it  is  sometimes  Ijenelicial  m  the 
later  stages?  When  the  compensation  fails,  the  indications  for  treatment 
are  those  of  valvular  disease  in  adults. 


I  <' 


!• 
',,■»• 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

III.    DISEASES  OF  THE  ARTERIES. 
1.    DEGENERATIONS. 

In  the  former  tho  mUma    »  ^^^       „^  ,,terio-.dorosis;  hero  >t  ..a 

.tance;  this  is  connnonly  ^^    ^,^,,f  ^t  tlu-  smaller  arteries  ami  eap.l- 

tninsrormation  of  the  ''"'l''^»^^'^''\\    ",  l^^,,  i,,  the  glomeruli  of  the  kulneys. 
l,nes  hyaline  n.otamorphos^.soUene^en^^       ^^         ^^^.^^^^  ,^ 

It  is  m.t  to  he  conloumle     ^-,  ,1;;'^,  ^^  ,,,  ;,  ,,riously  re,.u.led  as  due 
occur  in  the  same  s.tuatu.   .  ;"'  ^^^^^    ,,,a    i.valine    meta.uorplios.s 

to    coagulation    of    an    '^J^-;'^,^  ^^^  la,  Uke  Urn  last  .Uh  We.gert's 
of  leucocytes  or  ot  frbnn.     Un.  .uuaanc 
fibrin  stain. 

„.    ARTERIO-SCLEROSIS  iArteno-capiUary  FiLrosi^. 

1        ; .  ..«  mi  incleMendent  atfeetion— a  gen- 
The  conception  of  artmo-sd^^  as^n^md  .  ^^^^^  ^^^^^^^^_ 

eral  disease  of  the  vascular  sj.tc       }^^        ^.^^^^^  ,,  eircun.scribed,  be- 
Deflnition.-A  cond.tu)n  "^  tb»l^^n    -  ^^^^  ^^^^^.,^  .^,^j 

ginnh.^  in  the  i"tima^,---iu-vt  r,pon  V^^^^^^^  j,,,,,,  leads,  in 
tdventitia,  but  -^^^^^J:^^^X:^:::^':f^oron.  and  to  endarteritis  de- 
the  larger  arteru^,  to  w  luu 

lormans.  .       ,    ,.      ,,rr,cc<^s  artcrio-sclerosis  is  an  accom- 

Eti0l0gy.-(1)  As  an  >"-^"^- J^^^^^    Z  natural  wear  and  tear  to 
paninmnt  of  old  age,  ai.d  ^^^'^';^X^^  vascular  question,  which  l,as 
vhich  the  tubes  are  sul>iccted.    ^^«",^^  '^j^^;;^  ;,  ,„iy  ,,  ohl  as  his  arto- 
,ocn  well  expressed  -/  ^  ^^i;  ,^    ,,/,Srily  or\econdarily  through 
rics."    To  a  majority  of  men  deatu  cm  |^,.,ioiogk.al  arterio-sclerosis 

this  portal.     The  onset  of  what  may  be    .      d    b.v        .  ,      .^^^^  ^,^. 

epends,  in  the  first  place   upon  <1>;  M";        ;;X  ,pon  the  amonnt  of 
1,,  ■)  which  the  individual  has  inhented    .  n     sec  1  ^^^^ 

':2r  and  tear  to  which  he  has  ^^^  ^-  ^^^  J^,,,,,.,^,...^.  .ets  in 
inost  important  role  is  shown  m  the  case    in  ,^  etiological  fac- 

early  in  life  in  individuals  -  ;  ^^  ^^^^^^/i 'Vf  tw«.ty-eight  or  twenty- 
tors  can  be  found.  Thus,  for  i"^*'^"^;"^  ,  ^  ^^^^  ^  ^,.,,,  of  forty  may  prc- 
Lc  may  have  the  arteries  ^^ ;^  ra.n<A.^^^^  ^^^^^,^^  ,„,, 


ARTERIO-SCLEUOSIS. 


«  I 


pccn  in 
'alcifica- 
[  is  asso- 
0  metlia. 
ilii'ation, 
isLlri  and 

r  vessels. 
H)us  sub- 
•0  it  is  a 
iivl  capil- 
3  kidneys. 

prono  to 
,h1  as  duo 
inoTpliosis 

Weigevt's 


.)n— a  gon- 

^cTibcd,  1)0- 

iiiedia  and 

ss  leads,  in 

irteritis  dc- 

:i  an  accom- 
and  toar  to 
1,  which  has 
as  his  arte- 
rily  through 
ci'io-sclorosis 
e  (vital  ruh- 
('  amount  of 
101-  phiys  the 
t-rosis  sets  in 
iological  fac- 
it  or  twenty- 
)rty  may  i •re- 
Entire  fami- 
_a  tendency 


which  cannot  he  explained  in  any  other  way  than  that  m  the  make-up  of  the 
machine  had  material  was  used  for  tlic  tuhmg. 

More  couununlv  the  artcrio-scU'rosis  results  from  the  ha.l  use  of  good 
vessels,  and  among  the  circumstances  which  tend  to  produce  this  condi- 
tion are  the  following:  ,     ,      -,  ,  1  1  T     .1,,.    .,n 

(")  Chronic  Inlo.nrcdions.-\\<-o\w],  lead,  gout,  ami  sypluhs  play  an 
imiioVtant  role  in  the  causation  of  arterio-sclerosis,  although  the  precise 
mode  of  their  action  is  not  yet  very  clear.  They  may  act,  as  1  raui.e  si.g- 
eests.  by  increasing  the  peripheral  resistance  in  the  smaller  vessels  and  i.i 
this  wav  raising  the  blood  tension,  or  p..ssibly,  as  I'.right  taught  they  alter 
the  .piality  of  the  blood  and  render  more  dillicult  its  passage  thn.ugh  the 

'"'"The  poison  of  svphilis  and  of  gout  may  act  directly  on  the  arteries,  pro- 
ducin.^  (leuenerative  changes  in  the  media  and  adventitia. 

en  On'm(/(/W— Manv  auth.n-s  attribute  an  imi'ortant  part  of  the  etiol- 
o>n-  of  arterio-sclerosi.  to  the  overiilling  .-'  the  blo.)d-vessels  winch  occurs 
wiuMi  unnecrssarilv  large  (luantities  of  food  and  drink  are  taken.  1  articu- 
larlv  is  this  the  case  in  stout  persons  who  take  very  little  exercise. 

(1)  Ovrrwnric  of  Ihc  wnsrks,  which  acts  by  increasing  the  peripheral  re- 
sistance and  by  raising  the  blood-iu'cssure.  ,     •     „ 

(5)  Renal  Discase.-Tha  relation  between  the  arterial  and  kidney  lesions 
l,a.  been  much  discussed,  some  regarding  the  arterial  degeneration  as  sec- 
ondarv,  others  as  primary.  There  are  certainly  two  groups  ot  cases,  one  m 
whicirthe  arterio-sclerosis  is  the  iirst  change,  and  lie  other  i"  wl'U'li  it 
appears  to  be  secon.larv  to  a  primary  atVedion  of  the  kidneys.  The  lormer 
occurs    I  believe,  with' much  greater  frcpiency  than  has  been  supposed. 

Morbid  Anatomy.-Thoma  divides  the  cases  into  pnnmry  arterio- 
sclerosis, in  which  there  are  local  changes  in  the  arteries  leading  to  dilata- 
tion and  a  compensatory  increase  of  the  connective  tissue  of  the  int.ma; 
sero,uhrry  arterio-sclerosis,  due  to  changes  in  the  arteries  which  fol  ow  in- 
creased resistance  to  the  blood-llow  in  the  peripheral  vessels  Ihis  n- 
creased  tension  leads  to  dilatation  and  to  slowing  oi  the  blood-stream  and  a 
secondarv  compensatory  devi'lopment  of  the  intima. 

In  a^studv  of  41  autopsies  upon  arterio-sclerotic  cases  from  my  wards, 
Councilman  follows  the  useful  division  into  nodular,  senile,  and  dilluse 

""r'/i  Xo,lulnr  Form.—^n  the  circumscribed  or  nodular  variety  the  ma- 
crosc(v,H<'  cliantres  are  very  <.haraoteristic.  The  aort^  prese.its,  m  the  eariy 
.ta-es.  from  the  ring  to  bifurcation,  numerous  flat  projections,  yellowi.h 
or  vellowish-white  in  color,  hemispherical  in  outline  and  situated  particu- 
lariv  about  the  orifices  of  the  l)ranches.  In  the  early  stage  these  patches 
are'scattercd  and  do  not  involve  tlie  entire  intima  In  more  advanced 
srrades  the  patches  undergo  atheromatous  changes.  The  material  constitu t- 
incr  the  button  undergoes  softening  and  breaks  up  into  granular  material, 
eonsistin-  of  m<.lecular  dchris-ihe  so-called  atheromatous  abscess. 

In  the  circumscribed  or  nodular  arterio-sclerosis  the  primary  a  teration 
consists  in  a  d.-gcneration  or  a  local  infiltrati.)n  in  the  media  and  adven- 
titia  chielly  about  the  vasa  vasorum.     The  aifection  is  really  a  mesarteritis 


«^ 


,1 : 


M 


Vf 


;;- 


i 


^-2  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

•     .    ■,        Ti.nc.  f1vin.-v^  Irad  to  the  woakoninji  of  the  wall  in 

°T  V.:s  ^.  :,:";:„^;:;!;.:r;.  ":-;;r""^  ;;;';;:c;",:s: ;.:;:; 

gist  of  a  molecular  dhn..     U    }  i  >.  >  ^  .^^^j^,^^^  ,^^    . 

l:;rri.anee:n.n...l;n^^ 

Sll  ^rS-r'-s'u^a:;.;^!;  of  tUo  liver  ana  kianeys  ...any  a. 
^Cn^os  these  ehanges.  Senile  changes  -'e  eo.nmon  m  otlun  o:,a,^ 
The  heart  n.av  he  small  and  is  not  necessarily  hypertroph  ed.  In  .  ot  U 
^:.  of  Ccmncihnan-s  series  there  was  no  enlargen.ent.     Brown  atrophy  . 

""T)DilTu^e  Arteno.rkro.i..-^ho  process  is  widespreaa  tl^onghout  the 
n  J.    ,n       /hnnches  in  the  for.ner  usually,  but  not  necessarily  assoemlea 

}^         Tl...  vonn-u-^t  was  a  negro  of  twentv-three  ana  the  oldest  a  man  ot 
!^;     i  e-2^d^n  "  e^y  p^^alent  amon,  negroes;  less  than  50  per  cent 
c.e'in  whiu"    whereas  the  ratio  of  colored  to  white  patients  m  the  wards 
"one    on'     The  aiVec.tion  is  met  with  in  strongly  built,  muscular  n.en 
^       a      •;  mailman  remarks,  they  rarely  present  ou  the  auto,,sy  tal  e  sigi 
of  general  anasarca  or.  if  cvdema  exists,  it  has  come  on  durmg  U  e     >t  ^^  v 
div<  of  life      The  aorta  and  its  branches  arc  more  or  Ic^s  dilate    ,  tl.c 
h    ;     s    letimcs  more  than  the  trunk.     The  intinia  may  he  snu..Ui  a m 
how  verv  ^li"ht  changes  to  the  naked  eye;  more  .ommouly  there  aie  .cat 
'^::,  :;;:atcd  areas  of  an  opa.p.c  white  color  s.nue  of  which  may  have  un- 
dergone atheromatous  changes  as  in  the  senile    orm 


M 


A  RTERIO- SCLEROSIS. 


773 


-  wall  in 
[•e  in  the 
ill  thiik- 
'  nodular 
is  really 
ular  1)1' t- 
Is  up  aiul 
isdiuoncc 
if  smaller 
LMi  on  sec- 
:he  media 
hicli  may 
ciilarly  in 
Iheued  by 

md  tortu- 
ibes.     The 
aks  down, 
•hich  eon- 
11  they  are 
itima  may 
ssures  and 
ibi   are  de- 
coats,  par- 
usually  ac- 
ler  organs. 
In  i  of  U 
atrophy  is 

nghout  the 
',  associated 
illy  middle- 
's series  be- 
;y  and  fifty- 
st  a  man  of 
50  per  cent 
n  the  wards 
useiilar  men 
,■  table  sipis 
the  last  few 
dilated,  the 
sinooth  and 
ere  are  seat- 
lay  have  un- 

)lic  and  hya- 
,d  elastic  ele- 
lothelial  con- 


nective tissue,  which  is  parlicularly  marked  opposite  areas  of  ailvanecd 
degeneration  in  the  media.  The  small  arlnics— tliose  in  tiie  kidneys,  for 
exanipk — show  "a  thickening  of  the  wall,  due  to  the  formation  of  a  homo- 
geneous hyaline  tissue  within  the  muscular  coat.  This  tissue  contains  but 
few  cells,  is  faintly  striated,  and  stains  a  light  brown  in  the  osiiiic  acid  used 
in  the  hardening  solution.  In  many  of  the  smallest  vessels  nothing  can  be 
seen  of  tlic  clastic  lamina,  in  others  only  fragments  can  be  made  out,  in 
others  it  is  preserved.  .  .  .  'i'he  muscular  ilbrcs  of  the  nu'dia  show  marked 
atrophic  changes.  Fatty  degeneration  of  the  cells  can  be  nuule  out  both  in 
i'rcsh  sections  and  after  haideniiig  in  i-'lcmming"s  solution.  The  nuclei  are 
thin  and  atroi)hic  and  vacuoles  are  sometimes  seen  in  them.  In  some  ar- 
teries the  muscle-libres  have  almost  disai)])eared  and  the  media  is  changed 
into  a  homogeneous  tissue,  similar  to  thai  in  the  tiiickened  intima  "  ((.'oun- 
eilnian).  The  degeneration  of  the  media  is  most  marked  in  the  smaller 
arteries.  The  cajiillaries  are  thickeiied.  particularly  those  of  the  ghmieruli 
of  the  kidneys,  which  are  often  obliterated  and  involved  in  extensive  hya- 
line degi'ueration. 

It  is  in  this  group  of  cases  that  the  heart  shows  the  most  important 
changes.  The  average  weight  in  the  cases  referred  to  was  over  1.30  grammes, 
and  there  were  two  cases  in  which  without  valvular  dif»t'ase  the  weight  was 
over  800  granunes.  Fibrous  myocarditis  is  often  ]>resent,  particularly  when 
the  coronary  arteries  are  involved.  The  semilunar  valves  are  sometimes 
opaque  and  sclerotic,  and  may  be  incompetent.  The  kidneys  may  show 
extensive  sclerosis,  but  in  many  cases  the  changes  are  so  slight  that  macro- 
scopically  thev  might  be  overlooked.  They  may  be  increased  in  size.  The 
capsule  is  usually  adherent,  the  surface  a  little  rough,  and  very  often  pre- 
sents atrophic  areas  at  a  lower  level,  of  a  deep-red  color.  Increased  consist- 
ence is  always  present. 

SrUrosi:^  of  the  puhiiouarn  artcrij  is  met  with  in  all  conditions  which 
for  a  long  time  increase  the  tension  in  the  lesser  circulation,  particidarly 
in  mitral  valve  disease  and  in  emphysema.  Sometimes  the  sclerosis  reaches 
a  high  grade  and  is  accompanied  with  aneurismal  dilatation  of  the  primary 
and'"set^)ndary  branches,  nu»re  rarely  with  insullieiency  of  the  pulmonary 
valve.  In  a  remarkable  case  of  a  young  man  of  twenty-four,  reported  by 
IJomlx'rg  from  Curschmann's  clinic,  the  pulmonary  arteries  were  involved 
in  laost  extensive  arterio-sclerosis;  the  main  branches  were  dilated,  and  the 
smaller  branches  were  the  seat  of  the  most  extreme  sclerotic  changes.  On 
the  other  hand,  the  aorta  and  i'.s  branches  were  normal.  The  heart  was 
greatly  hvi)ertrophied,  and  the  clinical  symptoms  were  those  of  a  congeni- 
tal heart "art'ection.  In  many  cases  of  arterio-sclerosis  the  condition  is  not 
conlined  to  the  arteries,  but  extends  not  only  to  the  capillaries  but  also  to 
the  veins,  and  mav  properly  lie  ternu'd  an  aiujio-sidcrosix. 

Sclerosis  of  the  \i}\\\i^—phh'hi-sderosis—\9,  not  at  all  an  uncommon  ac- 
companiment of  arterio-sclerosis.  and  is  a  condition  to  which  of  late  a  good 
deal  of  attention  has  been  jiaid.  It  is  seen  in  conditions  of  heightened 
])lood-in-cssure,  as  in  the  portal  system  in  cirrhosis  of  the  liver  and  in  the 
])ulmonarv  veins  in  mitral  stenosis.  The  alTected  vessels  are  usually  dilated, 
and  the  intinui  shows,  as  in  the  arteries,  a  compensatory  thickening,  which 


^■A 


( 


?  i 


Ml 


-74  DISEASES  OF  THE  CIRCULATORY  SYSTEM. 

is  particularlv  marko.l  in  thoso  ro-i.ms  in  whi.h  the  im..liii  is  thinned. 
The  neu-l'orn".ed  tissue  in  the  endophiehitis  may  undergo  hyahne  de^renera- 
tion  and  is  sometimes  extensively  cahMlied.  In  a  case  ot  td.ro.d  ohhtera- 
tion  of  the  portal  vein  of  lonj.  standing.  I  found  the  ^^'^^^l^. ;:'  '^^l^';^^ 
dilated  gastrie,  splenie,  an.l  n.esenterie  veins  extensively  cj.le, hed.  AV  tho 
c.xi.tin-  arterio-selerosis  the  peripheral  veins  may  he  selerotie,  u>uallv  m 
,.onditions  of  dehility,  hut  oeeasionally  in  young  persons 

Syrnvtoms.-! mreasnl  Tension.-'Vh.  pressure  with  which  the  hhmd 
il„ws  in  the  arteries  depends  upon  the  degree  of  peripheral  resistance  an. 
the  force  of  the  ventricular  contraction.     A  high-tension  i-ulse  may  exist 
with  verv  little  arterio-sclerosis;  hut,  as  a  rule,  when  the  ^"•''"l'^'^"   '^J^^  ';;-" 
persisten't,  the  sclerosis  and  high  tension  are  found  together      Ihe  pul^t 
wave  is  slow  in  its  ascent,  enduring,  suhsides  slowly,  and  in  the  mterva  s 
U-twe.M,  tlie  he  's  the  vessel  remains  full  and  firm.    Jt  may  he  very  dilhcult 
,„  ,,,Ht,,ale  the  ]nilse,  and  the  (irmest  pressure  on  the  radial  or  the  tem- 
poral arterv  n  :y  not  he  sutlicient  to  annihilate  the  pulse  wave  ''''.v-h      ';- 
,oiut  of  tm.-Mire.     This  is  not  always  a  sign  oi  high  tension.        he  anas- 
onu.tic  or  recurrent  pulse  may  he  felt  even  when  the  tension  is  low,  as  m 
the  early  stage  of  typhoid  fever.     Pressure  on  the  u  nar  artery  at  once  oh- 
literates^t  *    The  sphvgmographic  tracing  shows  a  sloping,  short  up-stroke, 
no  percussion  wave'and  a  slow,  gradual  desc-ent,  in  which  the  dicrotic  wave 
is  very  slightly  marked.    It  may  he  dillicult  to  estimate  how  much  ot  the 
hardness  and  iirmness  is  due  to  the  tension  of  the  hlood  withm  the  vessel, 
and  how  much  to  the  thickening  of  the  wall.     lUit  il,  for  example    when 
the  radial  is  compress,.d  with  the  index-finger  the  artery  can  he  Icll  heyon.l 
tlie  point  of  comiiression,  its  walls  are  sclerosed. 

llupcrh-ophi  of  the  llcarl.-ln  conse.iuence  of  the  peripheral  resistance 
and  increased  "work  the  left  ventricle  increases  in  sixe  and  some  o  tiie 
purest  examides  of  simple  hyi.ertrophy  occur  in  this  condition  Ihe  cham- 
her  mav  he  little,  if  at  all,  dilaled.  The  apex  heat  is  dislocated  m  advanced 
cases  an  inch  or  more  l.eyond  the  nipple  line.  The  impulse  is  heaving  and 
forcihle     The  aortic  second  sound  is  clear,  ringing,  and  accentuated. 

The  comhination  of  increased  arterial  tension,  a  palpahle  thickening 
of  the  arteries,  hypertrophy  of  the  left  ventricle,  and  accentuation  of  the 
aortic  second  sound  are  signs  pathognomonic  of  arterio-sclerosis.  Prom 
this  period  of  estahlishmcnt  the  course  of  the  disease  may  he  very  varied. 
For  years  the  patient  mav  have  g.iod  health,  and  he  in  a  condition  iUiah)- 
gous  to  that  of  a  person  with  a  well-compensated  valvular  lesion,  rhero 
may  he  no  renal  symptoms,  or  there  may  he  the  passage  ot  a  larger  amount 
of  urine  than  nmnial,  with  transient  alhuminuria,  and  now  and  then 
hyaline  tuhe-casts.  The  suhsequent  history  is  extraordinarily  diverse,  de- 
pending upon  the  vascular  territory  in  which  the  sclerosis  is  most  advanced, 
or  up-nTthe  accidents  which  are  so  liahle  to  happen,  and  the  sympDins  may 
he  cardiac,  cerehral,  renal,  etc.  i,.nf„ 

(ix   c,i,.,Uar.—Th(i  involvement   of  the  coronary  arteries  may   lea  t  to 
the  various  symptoms  already  referred  to  under  that  secti.ni-thromhosis 


*  The  student  is  referred  to  Ewart  On  the  Pube,  and  to  his  larger  Heart  Studies. 


A 


ARTERIO-SCLEROSIS. 


«  to 


Ihinnocl. 
ogonora- 
()l)lit('ni- 
'  fXreatly 
Witliniit 
dually  i'l 

ho  lildod 
nice  ami 
lay  oxi^t 
has  ht'ou 
ho  pulse 
intervals 
•  (lillioiilt 
Iho  tein- 
Vdiul  the 
.'ho  aiias- 
i)\v.  as  ill 
onco  oh- 
ip-stroko, 
otic  wave 
oh  of  tlio 
he  vessel, 
])le,  wiion 

it  ItOVdllll 

resistance 
no  of  the 
L'lie  cham- 

advancoil 
aving  anil 
latod. 
hickening 
ion  of  the 
:is.  From 
TV  varied, 
ion  aiialo- 
m.  Tliere 
or  amount 

and  thou 
livcrso,  de- 

advauced, 
ptoms  may 

MV  lead  to 
thrombosis 

t  Studios. 


with  sudden  death,  fil)roid  degeneration  of  the  heart,  aneurism  of  tlu'  heart, 
rupture,  and  angina  pectoris.  Angina  pectoris  is  ii.-t  uncommon,  and  in 
tlic  true  varietv  is  almost  always  associated  witli  arterio-sclerosis.  A  sec- 
ond imp.irtMU.  group  of  cardiac  symptoms  results  from  tiic  dilatation  which 
ultimatelv  mav  foll.)w  the  hypertrophy.  The  patient  tlicn  presents  all  the 
svmptoms  of  cardiac  iusutlicieiicy— dyspmea,  scanty  urine,  and  very  often 
serous  clVusions.  If  the  case  has  come  under  observation  for  the  lirst  time 
tlio  clinieal  picture  is  that  of  chr(mie  valvular  disease,  and  the  existence  of 
a  loud  blowing  murmur  at  the  apex  may  throw  the  practitioner  olf  his 
guard.     .Manv  cases  terminate  in  this  way. 

{■i)  The  (Tirhral  symptoms  of  arterio-sclerosis  are  varied  and  important, 
and  embrace  those  of  many  degenerative  processes,  acute  and  chronic 
(which  follow  sclerosis  of  tlie  smaller  liranches),  and  cerel)ral  liaMiiorrhago. 
Transient  hemiplegia,  monoplegia,  or  ajihasia  may  occur  in  advanced 
arterio-sclerosis.  Hecoverv  may  he  i-erfcct.  It  is  ditlicult  to  say  ujioii 
what  these  attacks  depeiui.  Spasm  of  the  arteries  has  been  suggested,  but 
the  condition  of  tlie  smallest  arteries  is  not  very  favoral)le  to  this  view. 
I'oaliodv  has  recentiv  called  attention  to  these  cases,  which  are  more  com- 
mon than  is  indicated  in  the  litoratiii'o.  \'ertigo  occurs  fiXHiueiitly,  and  may 
be  either  simple,  or  is  associated  with  sU.w  pulse  and  syiicoi>al  or  epilepti- 
form attacks  ((irasset,  I'hurcli). 

{'^)  Hciial  svmptoms  su])ervene  in  a  large  number  of  the  cases.  A  sclero- 
sis, patchv  or'diil'uso,  is  i)resent  in  a  majority  of  tlie  eases  at  the  time  ()f 
autopsv,  and  the  condition  is  practically  that  of  contracted  kidney.  It  is 
seen  in  a  tvpical  manner  in  the  senile  form,  and  not  inriv(|uently  develops 
earlv  in  life  as  a  direct  seipienee  of  the  dilVuso  variety.  It  is  often  dillicult 
to  decide  clinicallv  (and  the  (piestion  is  one  upon  which  good  observers 
might  not  agree  iii  a  given  ease)  whether  the  arterial  or  the  renal  di>euso 

has  been  primarv. 

(1)  \mon-'-  other  events  in  arterio-sclerosis  may  be  mentioned  gangrene 
of  the  extrendties.  duo  either  directly  to  endarteritis  or  to  the  dislodgment 
of  thrombi.  Respiratory  symptoms  are  not  uiuommoii.  particularly  bron- 
chitis and  the  svmptoms  associated  with  emphysema. 

Treatment.— In  the  late  stages  the  conditions  must  be  treated  as  they 
arise  in  connection  with  the  various  viscera.  In  the  early  stages,  lieforo 
anv  local  svmi)t.mis  are  manifest,  the  i)atient  should  he  enjnmed  to  live  a 
quiet,  well-regulated  life,  avoiding  excesses  in  food  aiul  drink.  It  is  u.^u- 
allv  be<t  to  oxph.in  franklv  the  condition  of  atVairs.  and  so  gam  his  intelli- 
gent co-operation.  Special  attention  should  be  pai.l  to  the  state  of  t  lo 
bowels  and  urine,  and  the  secretion  of  the  skin  should  be  kept  active  by 
dailv  baths  Alcdiol  in  all  forms  should  be  prohibited,  ami  the  lood  should 
he  re<tricted  to  plain,  wholes<une  articles.  The  use  of  mineral  waters  or  a 
rosid.-nce  everv  vcar  at  one  of  the  mineral  springs  is  usually  serviceable. 
If  there  bus  been  a  svi.bilitic  historv  an  occasional  cour.^o  of  iodide  ot  l)o- 
tassium  is  indicated,  and  whenever  the  pulse  tension  is  high  nitroglycerin 

mav  be  used.  .  •  ,    i 

"in  ca<e^  which  come  under  observation  for  the  first  time  with  dyspnirn, 
slb'ht  lividitv,  and  signs  of  cardiac  insufficiency,  venesection  is  indicated. 


( << 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 

liitrh  tension,  strikin-  vvliff  is  alTorded  by  the 


In  sonio  instanci's,  witli  vory 
abtlraitit.n  of  .'(»  ounces  of  blood. 


HI.    ANEURISM. 

Tl.o  followin"  forms  of  aneurism  are  usually  reeojznized: 

vessel,  or  saeeiilar.  runture  of  all  tbe  eoats,  and 

(/*)  Tbe  false  aneurism,  m  whien  tntie  is  luiuun. 
tbe  bbHKl  is  free  (or  eireumseribed)  in  tbe  t'ssmj-.  ^.^^^^  ^^^ 

,  ^rV^'^^'''^:'^ -?i;:r:;''di:s^:^  Jwon  l;;:  br;-  Henee  t,.  name, 
tbe  internal  eoat.  i^^';";  :;;,,,,,,,,  ;,,  tbe  aorta,  persisting  for  years, 
dissecting  aneurism.        '>;';;',;;  ,"'i„,  ,  ,.,„„aunieation  is  establisbed 

;.:r  '::::«..*  wi... ......i,.,.  ..'u....-  ».„.,,,.,,,, ,.,,.,,,,... 

:;uo,':' ;.;:«;;  iiiXr  o„so  i,,  wwd,  .1.0  „,vc„.ic  nn.,u-e .».  rccog. 


iMM 


by  the 


arterial 
ilatatioii 
culatctl. 
11  uf  the 

)i\H,  ami 

ration  of 
;io  nanus 
I'ur  years, 
tablished 
'  we  have 
ieati(ni  is 
>ious,  and 

?  pradual 
)\  arterid- 
ularteritis 
IS  to  form 

tlie  media 
liis  is  t!io 
frc(inently 
he  process 
ken  ])hiee. 
Ihe  impin-- 

In  a  ease 
sverse  tear 
the  vessel, 
iroeess  was 
'rcsh  trans- 
u'terio-scle- 

vessels. 

vessel  and 
le  proximal 
;;\\\^',  laeer- 
nin>r. 

en  specially 
•enrrence  of 
d  hy  several 
'  was  recog- 


AXEUIIISM, 


<  I 


ti-nsive  "-rowtii  of  microiorci  was  present. 

„  V     V,v,,n,k„l,k.  i,>*(m.™  ..t  il  in  •>«'  P"''--,,.,.  .„s  ,,n..r,l,..l  1.      Ih 
i;,,,;  Tl Ki..«  .■lun.h,.,,,  »1,„  li,;s.  h '«"■■"-";";,''' 


Si:;r;*n;';:L:;:!"!;;™::^.;:=^ 


-,t^,r,::;::,:u„l"r^^: ".'i    ,  - ■-"- 

carotid,  in  (i  the  external  iliac  artery  (Oswald  A.  Ln-unO- 
ANiauisM  oi'  TiiK  TiioitAric  Aohta. 
The  eanses  which  favor  the  developmetU  of  af ->-l^-'^iM;;;:^;;;;„;;: 


risms  of  the  thoracic  aorta  vary  gr 


4t         ,....   ■.....•uhu'      Thev  mav"he  sinall  and  sitnated  just  above  the  aortic 
them  are  saccu  1,11.      iih\  iiu.,>  ,>,.,>ipr.t-  ovt(>rnallv  and   orcnitv  a 

ri„,,.     oil..,.   Sonn  l,uro  tnmor.  »';;         'X',' ,       ,        '  ,,.,,.,,.11,,.  r- 

,i„„  „f  11,0  „,Tl,  .„«>•  '""'I'^r  '';,;'„"'„„„-  i,„„  ,l„.  ,,l.n,ral  cvily 

™  j.!:;;r  iiir^:^  rtiio  ,;;i::,:»^  i. «-.  u , n,. > 

lesion  producing  the  pressure;  and,  lastly,  aneurisms  i 


M* 


•''TT 


!1 


DISEASKS  OF  THE  CIRCULATORY  SYSTEM. 

« to 

^„„,,    tun.ors   with    w..ll-nK,vk..a    vrcssuro    sy.nptoms   ""•\/^"";7'^,, ;';""; 

b*::;;t;:;n^;;i'tt;:^c;:';\::=;is^ 
S-:r:;;r;:,.;:x"S;';j;::;r;:;^^^ 

.  ,,„.,„■;.,„>  ii,   Ihis  »in,„li"n  i„„.v  cause.   ,"...1.   .I,sl...,ili.>.i  "1     " 
:;  r    ;       ,'.   i,  .1...1.  ».■,!  1..  n...  i.^tt.  an.l  -"".ti .■  .,..,n..•.;M"^^<•.-■ 

:;  J :!;;»" i  ™-i"«  «'■'"•«  f "- '?:  r  ,;■:;;;::.  "T,:t 

;;rt^::::^,;rt';;;:;:™:':..i:;i;;u;^  ";;;-"< ^- -^ 

'"■;MT;:;.;:r7;^r;™:rrr^nX....,i™,,n. 

,„„sl  ',„„ „lv  l.„.k.,„,l.  l.m  ll.oy  „,ay  snnv  t„r.-,„,l.  '"  "';    '  ^  "  ; 

V  no  m-ans  infm,>u.ntlv  oauso.  death  in  ancunsni,  ami  a  c-ndition  M 
>  Montreal  olnerai  llospi       ."O  wore  in  the  hab.t  of  ternnn,  - 

L  nl  Piuhi-^is      Oceasionallv  ononnous  aneuns.ns  (leveh.p  m  th.^  s  t   a 

rim'  1::.  into  ,..1.  vlenv.,  extending  ^^twoen  the  .n.u  >ru™  .^^ 
vortehnv;  they  may  persist  for  year.    The  sac  '-^  ^^  ^  '^   .;   .^  ^,  "     ! 
■     notch.     The  innominate  artery,  les.  commonly  the  kit     ',>  '^     '  , 

cl.vian  n,av  he  involved  in  the  sac.  and  the  rad.al  or  caro  ul  iml>e  nia  e 
.W  or  etardod  IMvssnre  on  the  sympathetic  n,ay  at  t.rst  cause  d.lata- 
;!r^j;:;l;^nently  contraction  of  the  pnpil.     Son>etnnes  the  thoracc 

'"at3d:S 'and  transverse  portions  of  the  arch  are  not  inf,.e,nently 


n 


MM 


T 


Ill>    iUlll 
-  of  llic 

I  iiliove 

lUll    1111(1 

•  ()•    tlio 

a  largo 
r  at  tho 
odm'iii;^ 

to  I'oin- 
^  of  tho 
ml  caiis- 
,ko  place 
Itli  have 
from  till' 
sternum. 
I  of  tho 
:sing  Iho 
lMio  right 

Tho  in- 
i  Tiilitiiro 
oiiuiiiinly 

growth  i;^ 
stcrinim, 
110  aiul  to 
,  ooi'iirrod 
von  wlioii 
i   proses  lire 
le  traohoa 
1"  a  i)arox- 
oftoii  in- 
f  lower  or 
bronolior- 
cc?s  wliieli 
ion  whioh 
ling  anou- 
this  pitiia- 
ini  and  tho 
the  sternnl 
1  and  sul)- 
Iso  may  I  to 
luso  dilata- 
10  thoracic 

ifiequontly 


ANEURISM. 


779 

tmiior  prows  upward, 


involved  tngother.  n?unlly  without  the  l.ranohos; 

-  ::;t:;;i::<;'/i:''?;"."'//".  r^>ri.n ,  „.  ...-The  .e  project. 

,,  ,  ,  left  and  backward,  an.l  often  ero.les  the  vertel.ra.  Irom  '  u.  tin  o 
the  sixth  dorsal,  causing  great  pain  and  soniet.n.es  compression  ol  ,h..  ...  1 
,,  l.vsphagia  is  c.onimon.  Trossuro  on  tiie  hn.m  n  may  mduee  Ino  i- 
c  e  ta  >•  vilh  retention  of  secretions,  and  fever.  A  tumor  may  app. 
;.xternali;-  in  the  region  of  the  soapula.  and  hero  attain  an  eimnnoi.  ..e. 
Death  not  infreuuentlv  occurs  from  rupture  into  tiio  pl.'ura. 

)  L  L.L  ./  L  Descendin.,  Tl.rnnr  .l.,./..-;i'ho  arg..  num her 
.eeur llose  to  th..  diaphragm,  tho  sac  lying  upon  or  to  tl-  U  ;" M  ^l.;-  k. 
„,.  ,h,  l.^vor  d..rsal  vertehne,  which  are  olten  ero.led.     1  he  sac  n.av  icacli 

a  lar.'o  si/.e  and  i'orni  a  very  large  tunnn-  m  tho  hack.  ,,.,,;..,, 

Diagnosis  and  Physical  Signs.-/».s/.r/.,H.-A  good  hgh    s    >- 

«ential;  cases  are  often  overlooked  owing  to  a  hasty  uispeet.on.      In    nan> 
^^^^^\i  is  nc.itivo.    on  citiier  side  of  the  sternum  there  may  ho  abm.r- 
1    on    due  to  disloeation  of  the  heart,  to  deformity  of  the  tli.jrax, 
;     to  retraction  of  the  lung.     The  aneurismal   Vf^^^^^-^^^^^^yj^^ 
tbe  level  ..f  the  third  rib  and  most  commonly  to  the  right  ol    ho  Mc.nuni 
til  r  in  tho  lirst  or  socmd  interspace.     It  may  he  only  a  d.lluse  heaving 
Hse  Jithout  any  external  tumor.     <)ften  the  impulse  -)--■;   ;';y 
,vlen  the  chest  is  looked  at  oblhiuely  m  a  lavoraido  light.     ^\  hen  the  m 
;,„m„ato  is  involved  the  throbbing  niay  pass  into  the  "-'^^ '^ 'M;!-;;;;^ 
at  the  sternal  notch.     Posteriorly,  when  ,u.lsat.on  occurs,  it  is  i.io.^l  c  nn 
n  .  n  V  found  to  the  left  of  the  spine.     An  external  tumor  is  present   m 
VCses,l.rojecting  either  through  the  upper  part  of  the  sternum  or    o 
he  right,  ;lelinios  inv.dving  the  siernum  and  costal  --t'la^es  on  bo 
sides  forming  a  swelling  the  size  of  a  cocoa-nut  or  even  larger.      Ihe  skin 
i    thin   ofte,rhlood-stained,  or  it  may  have  ruptured,  exposing  the  la.iii.KO 
of    he  sac.     The  apex  beat  may  be  much  disloc.atc.l.  partuularly  when  the 
sac  i!!^ largo.     It  is  more  cmmonly  a  dislocation  from  i.ressure  than  Irom 
enlartremeiit  of  the  heart  itself.  ,    ,  ,        •      i  i  „ 

iV,//.,//.«.-The  area  and  degree  of  pulsation  are  best  <1^'  -••"'-f     ^ 
palpation.     When  the  aneurism  is  deep-seated  an<l  not  a,.parent  •'^'^'■'  ''      ' 

0  bimanual  method  should  be  used,  one  hand  -V^^- ^^  ^'^  ^ 
other  on  tho  sternum.  When  the  sac  has  perloratcd  he  <;  ■  -^^,^\^- 
impulse  is,  as  a  rule,  forcible,  slow,  heaving,  and  expansile  Iho  ^^-^^^2, 
lav  be  very  great  if  there  are  thick  lami.ue  beneath  the  skin;  more  rarely 
Ts  s  soft  and  fluctuating.  The  hand  upon  the  sac,  or  on  th.-  region 
n  which  it  is  in  contact  with  the  chest  wall,  feels  in  niany  cases  a  diastolic 
^ock,  often  of  great  intensity,  which  forms  one  of  the  valuable  p., s^c 
«i.nis  of  aneurism.  A  systolic  thrill  is  sometimes  present,  not  so  often  in 
icular  ancHirisms  as  in  the  dilatation  of  the  arch.  The  pulsation  may 
sometimes  he  felt  in  the  suprasternal  uotc-li.  _ 

P,,,„,,,-„„._Tlic  small  and  deep-seated  aneurisms  are  m  tins  respect 
necrative.    In  the  larger  tumors,  as  soon  as  the  sae  reaches  tlic  '^I'ost  vNall, 
"here  is  produced  an  area  of  abnormal  dulness,  the  position  of  which  de 
nds  uiLi  the  part  of  the  aorta  alfccled.     Aneurisms  ot  the  ascending 


rink 


-r 


I  \ 


ui 


i|i 


,,0  UISKASKS  OF  TIIF.  CIRCULATCltY  SVSTKM. 

over  a  tliiU  n-mn,  i^  a  111^111^.  ^ysto  c  imirimir 

rarely  .ni^s.l  in  lar,.  '--'-•-  y).^^,;;  i:",',,,,,^  ,,^0  the  diastolic 

'"•-'  -  •-•"";;!:;■  ^'"  :::;;;t  i^       '  -uK.uvis,naisa..  w.,. 

t,.  avtevies  hcyond  ,1..  --'--^^^I^^X^'riht  and  left  ra<lial, 
,nay,  for  instan..,  '7' "-'•'-1''!^  i  «^  n  lar.o  thoranc  an.nrisnu 
both  in   volnnu'  and  t.nu'      A     '''>^"''    ,.:,.•   „  ..ft,,,  ,,„iso  in  the  al.- 

:;;-i^::,:;;,;r!i;;H;i:::sw^ 

*"•■> »-;  ''""';";v;.";';;r'r ii  ;;:r  •  i  oia.;;;,:;!:;,,  „f  .ho ,.. 

iiliiiiis§i3 

o'f  aortic  insulTicicncy.  fvichea  as  pointed 

Occasionally  a  systolic  nuirmiir  may  be  beaid  in  the  tiachea,       i 


London  Lancet,  1891. 


JBBW^ 


ANEL'UISM. 


781 


of  the 

niitlillo 

of  the 
;  intfV- 
givL's  a 

.     Kvi'n 

0  t'aick-     f 
f  liciU'd      ■ 

(IllK'UDll 

niiirmur 
diastolic 
lie  iiiur- 
\  With 
sound   irf 

pidso  in 
.  Tln'i-o 
ft  radial, 
mcurisni, 

1  llu'  al)- 
this  in  a 
s  a  woU- 
ta  I  was 
ihhinp;  in 
0  circnhi- 
on  of  tho 
.f  the  pa- 
'ithor  the 
ad  a  very 
!)a1ily  was 
stole,  and 

•isms,  was 
v  niv  eol- 
il.  Oliver 
t  position, 
st  the  full 
id  tluiml), 
iatation  or 
felt  trans- 
)ns  I  liave 
!ated  anou- 
;  dllatatiou 

as  pointed 


out  hv  Pavid  Drnn,mond.  or  oven  at  the  patient's  n.on.h.  -l;-;;!-";;'^ 
This  is  either  the  sound  eonveved  fro.n  the  sue.  or  js  prodn.^ed  hj  the  a.r 
n,  it  is  driven  out  of  the  win.l-pipe  during  the  s\>tole. 

;   ;,^    ,'     ..r  up  the  ne..k,  son.etin.es  alonj,  t!>e  npper  .ntereos.al  nerves. 

'J/    re  nits  eil  u.'  fn.n.  the  .lir..et  pressure  on  the  w.nd-p.pe  -r  .j    .- 

?  ed  wi  h  hronel,iti<     Tl-e  exiH-etorat ion  in  these  instanees  is  ahundant 

1  i  d  u    .    •  1.  ...p.eu.lv  il   lH.eon,es  thiek  and  tnrlud.     l>an.svs,nal 

;,;  .  uUar  l,ra.!en.  r,n,in,  eharaeter  is  a  eharaeter.st.e  syn.p  o,n 

:  ne  eaJ.s.  partieniarly  when  ti.ere  is  pressure  on  the  reeurrent  la.jn- 

^SZ^X  ..;  Ihe  eou,h'n>ay  have  a  peenliar  wheezy  quahty-.he      goo.o 

""^1;;;,....  whieh  is  eonunon  in  cases  of  aneurisn>  ••;/''; '';;'-7;;|;:: 
tion,is^...t  n..cessarily  assoeiated  with  pressure  on  *  -  ^^  ^  ^  ;  '  . 
.eal  nerves,  hut  n.av  he  .lue  direetly  to  eonipress-m  ol  he  t,a  1  aa  .  c 
t  on..hn<       It    n,av   occur  with   nu.rkcd   stndor.      Loss  ol   voiee  ad 

,.  .:  eoL.uJnces  of  pressure  on  the  reeurrent  laj^n^ea  .  usual  y 

1;::  ,:;;;■  induein,  eilhcr  a  spasn,  in  the  n.uscles  of  the  lelt  voeal  co.d  or 

^'"''rardv<i<  ..f  an  ahduetor  on  one  side  n>ay  he  present  without  any  synip- 
,on'       1  ■  s  nore  particularly,  as  Sen>on  states,  when  the  paralyt.e  con- 
ruture-unervene  that  the  attention  is  called  to  larynj^cal  syn,  .ton.s. 
''"Z.;Z  :  in  thoracic  aneurisu.  nu.y  con.o  fro.n  (.)te  so  U^am     - 

!rvr';:;tri:::;=;;i";;rEr:^rErs 

t  ti:  of  the  inn,  tissue.     The  1  Jeedin.  n.ay  he  pn>U.e    .;,.       V^o^- 

forationinay  he  made.  i  +,.  w    ;<  nfu^n  nn<nnal  in 

Heart  S>imrhni..-Vam  has  heen   referred  to,  it   i^  «".^";?"- "''  ' 


m^ 


DISKASES  OP  THE  CIRCULATcmy  SYSTEM. 


iii 


11, 


;.4r 


{' 


I',: 


nrc  gnim'tiinci'  infoiniiHciit,  (  mu  r 

Auun.r  otluT  .i^'ns  an<l    ^^''''i;'"''"'-';        ,,,         ,•  th.  .-iKV.or  vena 

,,,,.     A  curiuus  i.lu.n..nu.n..n    '      "        '"  ,„^,  ,,„,i,  ot  whi.l.  two  ov 
„l'  tit.  Ilnp.rs  a.ul  .n.m-vin^'  m  tlu;  "  "  '^  "  '.     ,,,,i,i  .UsU'iUiou 

-npu.  lun. n  -hu.  -uy -', ';;,;;";;;;!  S,  L^  mvohe  tuo 

!:^;i;-'r;:;^:rt  :?>::: --^  --^ •--^' 

j.n.liicinj:  instantaneous  death.  •     ,     ,     li,,),]^,  to  occur  in  }:''"\vths 

,,,,ssure  on  the  syn.pathct.c  ^  ,ku  u  >'l^   >     "  ,„r,,,  „,  Uk- 

fro.n  the  aseen.ln,^'  p-rt-on  ol  "u  •■  „,; 'vavial.le.     H  the 

lower  eervieal  P-^'';"';;-;;;;t^:^;nu  1    i-in  "'  il-  vaso-.lilator  tihres  an.l 
iiorve  18  sunply  irntatel,  the  t  '  /^^n  ^^,,^.,1^,,,  ,„ilor  of  the  same 

dihaation  of  tlie  ,.u,.,l.     ^  .th  t    >  :-  Z^-^^^f  ^,,,.  ,!u„.,pinal  hranehe. 

.ide  of  tlic-  face.    On  the  other  h  n.l   '   ;^;^   .^^;;,^^,^.  „f  ,,,„,;,  t,,,  iri.  eon- 

.au.es  paralysis  of  ^^;;^ ^^^J^^l  X^,  .u.sin,  congestion,  and 
tracts,  the  vessels  on  the  snU   ol  ti  c  >  ^,^^^^^,^,,„^  ^^^  ,,, 

h,,vc  wc.ll.„mrla..l   l.h.V«™l  ^.'B''        '  '     ,  ,  ,    ,,„„  „,«  ...ending  poltion 
„„,,b,  tiK.  ..n,.nr,sn,  „1  ,*;/.<  ."I  >' '    „  ' '  mvs  Von,  ll.c  transv.^c  arcli. 

eral  good  observers.  .,     mst-mce  of  this,  Mhich  is  common 

(")  Si.i,kni,mn>u   ^^'^-^>;;:^^^^^tJ,,,^    One  which  came 

i-  the  ahdom.nal  aor'  ^  ^^   !"  .j"    ,,,,^,11  presented,  without  any 

..rikin,  in  tlu-  tl,tol,l,.ng  "' » ^o  »    H'''  '        '"™'''  '"""""""'  "" 


;ijC 


ANFA'UISM. 


:>:\ 


^r 


frniii 


ich  liiH 
lor  voiuv 
•liil)l)iiig 

two  o\- 
islcntion 
olve  tlio 
aiUu'sum 

s;u'  may 
iiy  cases, 

gniwths 
al  t»r  the 
:  It  the 
liliri's  and 
the  t^ame 

branches 
'  iris  con- 
-tinii,  ami 
Kin  to  see 
ill  lor,  re<l- 

vi\.  Many 
lilc  others 
luUn'nt  rc- 
ng  portion 
rse  arch, 
lent  throb- 
ily  referred 
ade  by  sev- 

ii?  common 
ivhich  came 
nthont  any 
.    The  con- 

causo  great 
jute  forcibly 

ind  pulsates 
ausilc  pulsa- 
•  wliich  is  so 
is  not  to  be 
ticiilarly  the 
go  aneurisms 
nurs  uiay  be 
ated  thoracic 


tumors  mid  lifto  tho  diagno>i-  m.,y  he  impo-Mble.  I  imve  already  n- 
terr.'d  to  the  .a.-e  uhieli  was  r.-ard.d  by  Sknda  as  nnenri.«m  and  hy  Hp- 
IM.l/er  as  tiiiiinr.  'I'he  jiliy-iral  muiis  may  he  jnd. ■Unite.  The  ringing 
adilie  second  s..nnd  is  <d'  great  impnitaiie..  and  i>  rarely,  il'  ever,  heard 
over  tiinior.  Tracheal  tugging  i-  lieiv  a  valuable  sign.  I'ressure  phe- 
nomena are  less  common  in  tiininr.  wheivas  pain  is  iikhv  fre(|UeiiI.  '1  he 
general  appearance  of  the  patient  in  aneiiriMii  is  much  belter  than  in 
Uininr,  in  which  tlieiv  may  he  ea.diesia  and  .iilargemeiit  of  the  ^laiuU  in 
the  axilla  nr  in  the  neck,  lleallhy.  -tn.ng  males  who  have  worU.d  hard 
;iii,l  lia\e  had  svphilis  are  ihe  most  common  .MibjeiMs  of  aiieiiriMii.  Oeia- 
,-iunallv  cancer  of  tlie  (e,-opliagii>  may  sinmlale  aiieiiri  -m.  producing  pn  s-uie 
,,11  the'leil  hronchiis,  and  in  one  iiislaiuv  al  llie  I'hiladelpliia  liospilal.  willi 
a  hu>kv.  Iira/.eii  cough,  the  >ymplHiii<  were  \ery  suggestive. 

(r)'  I'lilsnliiii/  J'lniris!i.—  \n  ca>es  dl'  cwpiiniut  nrn'xxUnllx,  if  llie  pro- 
jcting  tumor  is  in  -he  n'eighhorhond  of  the  heart  and  pul>al.'s.  the  coudi- 
'lioii  may  ivadilv  he  mi^takei!  for  aiieuriMii.  The  absence  of  the  heaving, 
linn  di>tenlioii"aiid  (d'  the  dia>Iolie  shock  would,  logeth.'r  with  the  his- 
tory and  iIh'  existence  of  iileural  elViision,  determine  the  nature  of  the  ease-. 
If  iiccessarv,  |ainctuie  mav  he  made  with  a  line  hypodermic  nee.lle.  in  a 
majority  o"f  the  ca.ses  uf  pulsating  pleiiri-y  ihe  llin.hhing  is  .lilViiM'  and 
widespread,  moving  the  mIioIc  .-idi'. 

Prognosis. — The  null<M,k  in  thoracic  aneurism  is  always  grave.     Liie 
may  be  lU'olongcd  b.r  some  years,  but  the  palieiUs  are  in  constant  jeopardy. 
Spontaneous  cure  is  not  very  infrctpient  in  the  small  sacculated  Inmors  of 
the  ascending  and  thoracic  porticms.     Th.'  cavity  hecunies  Idled  with  lam- 
in;,,  ,,r  ilrni  lihrin,  which  beedine  more  and  nnu'e  ih'iise  ami  lianl,  the  sac 
shrinks  considerably,  and  linally  lime  salts  are  (h'posite-l  in  the  old  tibrin. 
The  lamina'  (d'  librin  mav  lie  on  a  level  with  llie  lumen  of  llu-  ves-el,  caiis- 
in--  complete  .ililiicrali.;ii  of  the  sac.     The  ca-es  uliich  rupture  externally, 
as^i  rule  run  a  rapid  course,  althongh  to  this  there  are  exceptions;  the 
sac  mav  contract,  beciuic  linn  and  hard,  and  the  patieiil  may  live  b.r  live, 
(,r  even,  as  in  a  case  mentioned  by  llalbnir.  bir  ten  years,    'idie  cases  which 
liavc  lasted  huiirest  in  niv  experience  have  been  those  in  which  a  saccular 
aneurism  has  I'.rojeeted   irom  the  ascending  arch.     One  patient  in  :\Iont- 
real  had  been  km.wii  to  have  ancuriMu   for  eleven  y.-ars.     The  aneurism 
may  be  enormous,  occui.ving  a  large  area  .d'  the  chest,  and  yet  ble  b..  pro- 
l(.ii"..ed   for  manv  vears.  as  in  the  case  mentioned   as  under  the  '.-are   ot 
Skoda  and  Oppol/er.     One  of  the  most  remarkable  instances  is  the  case  ol 
directing  aneurism  re|.ort.'d  bv  Crahaiu.     The  patient  was  invalided  alter 
the  Crimean  War  with  aneurism  .if  the  aorta,  and  bir  years  was  under  the 
(iliservation  of  J.  11.   Kiehardson,  of  Toronto,  under  whose  care  he  died 
in  1885      The  autopsy  showed  a  healed  aneurism  of  the  arch,  with  a  dis- 
se.^ting  aneurism  extending  the  whole  length  of  the  aorta,  which  formed  a 

double  tube. 

Treatment.  — In  a  lavL'o  proportion  ,d'  the  eases  this  can  only  He  pal- 
liative Still  in  everv  instance  measuivs  siuuild  be  taken  which  are  known 
to  iinmiote  (dotting  and  coiis.didatioii  within  the  sac.  In  any  large  series 
of  cured  aneurisms  a  considerable  majority  of  the  patients  have  not  been 


rs-i 


IHSKASHS  OF   THE  ClUCULATOUV  SYSTEM. 


I 


I 
i' 

ill 


■  k 


1^ 


>     V:  . 


11' 


„.,,,„U,y.  is  that  a.lv.sM    '>          'j  j^  ^^„  ^ost  is  essential  and  shonM 

ti,l,  oi^vhieh  are  rest  ami  a    e.tn  t    l  ^  ^^^  ^,,^,  .i.ijj-   number  ut 

far  as  possible,  be  absulut...      "  '  ^^,,^,„  „.,  ,,,,tion  whateNer 

i  ,,!:;^,eat  ■    .hen  a  j.at.ent  .  --;';:  ^j,,  ,,,,..,.1   advantages  o 

,,„,,ts  to  -''•^y/'">"7"tu        >1  o  be  enjoined.     Ti>e  diet   adu.ed  ^ 
this  plan.     Mental  U'-H't  >1>' ;•   I  ^^^^  ,'  .,,,„^,,,  ,t  bread  and  hnttei 

!l„,i,U  is  extren>ely  ^''^r"  j^  /'i:; ^^      m.es  of  meal  and  .  or  1  unnees 
and '^  ounees  of  n.    k;  l"'' •^"  ''. '  ,;  „U  ot  bread  and  2  onne.s  ot  m.  k. 
,,.  ,„ilk  or  Clare.,  .or  ^"l'^  ■,,;,„,„,  ,,,1  is  thon,ht  also  to  rend 
This  \,w  diet  diminishes  the  bloo  i  ^'""  ,  .  i.iood-pressure   with  n 

h "blood  more  fibrinous.  It  -'^-^^  >  !,his  treatment  should  he 
Uu.  sae,  in  this  "---•/-;:;;;:  fforsons  of  a  ,ood  deal  of  men  a 
pursm.l  for  several  months J.ut.  *  x     1  ,^^^,^  ,^  ivnv  weeks  at  . 

Slmina,  it  is  impossil.le  to  earry  ^         J^'^,  );   ,,,  ,he  saee-ular  form  o 
ti,ne.     It  1^  a  form  oi  ^-;',^;:''.  .,,,,,;;.>, in,  .ith  the  aorta  b>   a 
aneurism,  and  in  ^^^^ .^'    '^    ^^^.^  ,f  ,onsolidation  are   burly  goo.L 
comparatively  smaU  onhc     ^^^^^^     ^,^  ^,,,  liquids  are  the  nnportai  t 
Unquestionably  rest  and  the    -  !"      .^,^.  J^  .quantity  of  lood  may 

,„,;s  of  the  treatment,  and  a  ^   j'    >  ;;^^,^;,,  ,,  thoroughly  earned  out 
he  allowed  with  advantage.     U    '"^     ':,;['  ^,  y^^.,  ,  ve,V  quiet  bfe,  n.ov.n- 
he  patient  should  at  any  rate  be  ad  .>  -^^^^  ,,,,  ,,„.,ily  exeite- 

^,out  .ith  deliberatior.  ^f , -^  ^e:;^!:"  and  constipation  and  strain- 
nient.     The  boNvels  should  be  1^' l>t     ^^  y^^^^  „,•  ,,otassium,  as 

inl  .bould  be  carefully  avoided.  Ot  "-'  •;^,  j^.^,,,  ;,  .loses  of  from 
S;ised  l,y  nalfour,  is  of  great  v>d.  j^-^jll^/l^e  not  necessary.  The 
10  to  15  or  20  t^rains  thrH-  tn.-  a    •  >•   1    '._  ^^^  .,^^,,^,,i„,  u.e  seere- 

n,odo  of  action  is  not  wel  -f  ^  ^f  ,,m;,;„,,„  the  blood-pressure,  oiS 
tions  and  so  inspissating  .^''^  ";\'  ;,;',  ,,,,a  contraction  of  the  sac.  he 
,s  Baltour  thinks,  l.y  causing  tlu  ken    .  ■  '  ,       ,,^.,n  ^i,,  relief  of 

^j.    striking  elfect  of  the  "f  ^^^^^    ?,    ^^    "  ,"  svp'>ilitio  cases  are  more 
he  pain.    The  evidence  is  not  ^"^     '^^    '    j  ,  ,„;, Lures  have  little  value 
L  Jnted  by  it  than  the  '^-^fl^if !  ,,^     ,  '^phe  large  tumors  with  wi  e 
unless  the  sac  is  ot  a  suital-le    ->»^^^.,^^         ,;,„  .f  ihe  aorta  may  be 
,,,,U.s  communicating  ^v.tl  ;^'     "     ,,-^L  ,,uhout  the  slightest  mdu- 

treated  on  the  most  approved  V  ;^"^  .  ,^f  ^,,,  throbbing.     A   patien 

^,ee  other  than  -'^-'^'^V'^    '^^      7;     ,-  '  -'^"^'^  '"  ^''^  "'"'  ''t 
^vith  a  tumor  projecting  mt..  the  '^^'^  "^  ^  ^^^^^.     a,,,,;,,,  ^vhich  time  ho 

.   ^ufm^l  treatment  for  more  ^''-.;;;;  ,    ;"'^;^^.  .^l^ations  were  greatly  re- 

also  took  iodide  of  potassium  1  >^1'.     '    ;     '     ,  ^^^,^.  eontiratulated  ourselves 

auced  and  the  area  .vf  ^^^^l^''  ^l  lien  death  followed  rupture 

that  the  sac  ^vas  probahly  ^«"  <^  '^ .;    '  ^  ^,^i     juiid  blood,  not   a  shred  of 


mm 


AXKUIJISM. 


iS.> 


u  I'ouiiil 

I'ii'd  out 

L  should, 
mhor  of 
vliaU'M'i". 
linens  of 
l\i:^o»l  l)y 
ul  liutU'V 

I    OUIU'OS 

ol'  iiiilk. 
Ill  rmtli'i' 
I'o  within 

slioulll    111' 
ol'  ll\i'nt:ll 

vi'i'k^  i>t  "■ 
r  i'onn  ot 
liorlii  hy  ii 
lirly  iiond. 
impovliiut 
:  food  may 
•arried  ovit, 
ifc,  moving 
dily  oxfito- 
and  t^tniiu- 
)iassium,  as 
ist's  ot  from 
■essary.  The 
lo-  iho  Bccre- 
|iir>sui'o,  ov, 
lu'  sac.     Tli*^ 
the  relief  of 
ises  are  more 
•0  little  value 
)rs  with  wide 
(orta  may  he 
\v^\\\vA  indu- 
r.     A   patient 
lie  most  i-ijlid 
vhieh  tiiue  ho 
■re  "iri'atly  ve- 
ated  ourselves 
lowed  rupture 
„,i   a  shred  of 
■iv  seeuis  to  ho 
,  advise  a  man 
id  worry.    Our 


jirofessioii  has  oHVied  many  e.\ani|dis  of  i^ood  work,  tlioroiiglily  and  eon- 
hcicntiousiy  carritil  out,  hy  nun  with  aneuri.-m  ol'  the  aorta,  who  wist'lv, 
i  think,  |iret'erred,  as  did  the  late  Jlihon  l^'a^'uc,  to  die  in  harness. 

i^iiniii'dl  Mi'dsiiri'.i. —  in  a  lew  cases  consolidation  may  lie  [ironioled  in 
the  sac  liy  tlu'  introchiction  ol'  a  foreign  liody,  sneh  as  wire,  lioise-hair,  or 
hy  the  condiination  of  wiring''  and  ek'ctrolysis.  ^loore,  in  ISdl,  first  wired 
a  sac,  i»uttinjf  in  v'S  h'ct  of  line  wire.  Death  occurred  on  the  tilth  day.  Cor- 
ladi  jiroposcd  tiie  condiined  method  of  wirinj^  with  electrolysis,  wliich  was 
lirst  ur^cd  liy  IWirresi  in  liS71».  Jlis  patient  lived  for  three  and  a  hail'  months, 
ilorsi'-hair,  walcli-sprin^x  wire,  catgut,  and  Florence  silk  have  hccn  used. 
Dr.  Ilunner  has  collected  for  nie  the  statistics  of  Jloore's  uu'tiiod  (wiring), 
<il  which  there  were  i;!  ea.^es,  S  of  tiioracie  aneurism,  all  fatal;  5  aneurisms 
ol'  the  alidomina!  aorta,  '-.'  of  wliich  wei'e  successl'iil.  Of  Id  cases  treated 
liy  wiring  ami  electrolysis  (Corradi's  method),  all  were  thoracic;  of  these, 
the  cases  of  Kerr,  {{oscnstirn,  D.  D.  Stewart,  and  llershey,  all  American 
cases,  were  successful.  'I'lie  most  favorahle  cases  are  those  in  which  t'le 
aneurism  is  sriceiilated,  hiit  this  is  a  point  not  easily  determined.  an<l  often 
from  a  sac  particularly  favorahle  for  wiring  there  may  he  secondary  pro- 
j'eetions  of  great  thinness.  In  a  case  of  alidominal  aneurism  recently 
operated  upon  hy  jlalslcd  all  the  conditions  were  very  favoralile,  and  the 
man  seemed  doing  very  well  when  sudden  death  occurred  on  the  third 
day  from  TU])ture  of  a  small  ])rojcction  of  the  sac  through  the  dia[)hragm 
into  the  pleura. 

Oilier  Siiniplciiift  rt'</iiirlii(i  TirdliiiniL — I'ressure  on  veins  causing  en- 
gorgement, iiarticularly  of  the  head  and  arms,  is  sometimes  ])n)m])tly  re- 
lieved hy  free  veiu'section,  ami  at  any  time  during  the  course  of  a  tlu)raeic 
aneurism,  if  attacks  of  dyspniea  with  lividity  supervene,  hleeding  may  he 
resort e(l  to  witli  great  lieneilt.  It  has  tlie  advantage  also  of  proni])tly 
checking  tiie  pain,  for  which  symptom,  as  already  mentioned,  the  iodide 
of  |uitassium  often  gives  relief.  In  the  iinal  stages  morphia  is.  as  a  rule, 
necessary.  DysjUKca,  if  associated  with  cyanosis,  is  hest  relieved  hy  hleed- 
ing. Chlorohirm  inhalations  may  he  necessary.  The  ([lU'stion  sometimes 
comes  up  with  reference  to  tracheotcuny  in  tiu'se  cases  of  urgent  dyspnoea. 
Tf  it  can  lie  shown  hy  laryngoscopic  examination  that  it  is  due  to  hilateral 
ahductor  jiaralysis  the  trachea  may  he  opened,  hut  this  is  extremely  rare, 
and  in  iu>arly  every  instance  tlie  urgent  dyspniea  is  causi^l  hy  pressure 
ahont  the  hifurcation.  When  the  sac  a])])ears  etxernally  and  grows  larg(\ 
an  ice-cap  may  he  applied  npon  it,  or  a  helladonna  ]ilaster  to  allay  tlie 
pain.  In  some  instances  an  elastic  sujiport  may  he  used  with  ailvaiitage, 
and  T  saw  a  physician  with  an  enormous  external  ant'urism  in  the  right 
mammary  region  who  for  many  months  had  olitained  great  relief  hy  the 
elastic  su])port,  passing  over  the  shoulder  and  under  the  arm  of  the  oppo- 
site side. 

Digitalis,  ergot,  aconite,  and  veratrum  virido  are  rarely,  if  ever,  of  serv- 
ice in  thoracic  aneurism. 


7SG 


DISEASES  OF  TUB  CIRCULATOUY  SYSTEM. 
AMCI-UISM    or   TilK    AunoMlNAL    A.UTA. 


.,r  the  cvliac  axis.    Tin.  va.K;.N    .  '■        '^^^^  \iavlhulouu.w-.  Hosinlal,  ^j> 
^,^^     ,,, ,,,  ,US  case,  uf  ao.U.  ^^     "     ^^  ^  ^  ,,  ,,,in.nu  or  sa..ulal..l. 

and  inav  cause  .unnl..u^>  ami  ^  '  •-      -  ,,^,     ,.um.     M-.vo  cnunm.nl>  tlu 

t  inav  i.ass  into  tlu'  thorax  and  hu.^t    •>»!  ^^  ^,^,1.,,,;^,  tumor,  ^vuich 

^,      ;  c!n  the  anterior  wall  ;>-    I'-J^  ^  ;'  ,    ,,  l.rt.     The  tumor  may 

,uun  symptom.  Qie-ns  — Inspection    may    ^ho\v    maiked 

Diagnosis  and  I'l^y«^°^;^„^\^,^f,- •„„,    ,  ddlnite  tnn.u-.     A    hrdl 

,H,l.ati.m  in  the  epigastric  7'!";/ "";;,,,  ,,,„„silc.  and  sonu'tunes 
.  „ot  uncommon.  The  pulsaUon  ';-'',  ^i,  ^..n.ardium.  On  pa - 
,:hle  .hen  the  sac  is  lar.e  an     jn  -^;^„    •';,.,  ^  ,..„,,  ,,c,rce  of  .hjl- 

1-^'-^  '>  ''''/'"":'  """;"  r:.      1     nu-!Js  wiU,  that  or  the  left  h   ,e  ol    lu 
u-  on  percussion  xvhich  "^^''^">  '^'^'7, „„,„.  ,,    ,,.  ,,   rule.  audd)le,  and  i> 
^;;„,     (In  aus<.dta,ion    a  svstohc  nu,n,  ,  a.  ^^^^__^^^^_^    .^ 

.Huetinu.s  hcst   heard   '^  /  >  ^j^.  '\  „,,  ,r  the  couuuoncst   of  cluneal 

tl  Hi'^itr  /"-"•  -^-"  '•'-  ^i/('::(:  ;:i     The  Ihrohhin,  a.n1.. 

;•„,  Attention  to  th.s  ;"';'.  ^^^;;^ '!i,;,,trium;-  as  Allan  Burns  caUs 
__the  "prcernatural  pulsatmn  .n  <  1  ^^  ,„,,icularlv  in  ^vomen.  In 
it-is  met  .ith  in  all  ncurasthemc  -*"'  ^^   ;  ^  J^  j^.  ^„,,,„;i„.  tl>.  throbbing 

iLvmia.  particularly  in  ^;;^^^:X7X'^-^^^  --  -^'>  ^^^'^^  ^T""; 
niav  he  very  ^'vcat.  In  '>*  -  ^  th'^^n^  ol'  the  ahdominal  aorta  not 
,baoes  from  a  duodenal  nicer  the  '  '"  "  ,,„„„„„nicated  a  pulsation 
^iv  .hook  violently  the  -'>;  ^^  'J^  i,  "l^.^.tihle  t.  any  one  sitting 
to  the  hcd.  the  shock  ot  which  was  ^''^  '  '-^^j^^.^.J^  ,,■  ,1,,  pancreas,  or  ol 
pon  it.     Very  fvcMuently  a    mm.  •  '     ;,;,  „f  the  aor.a  and  may 

the  left  lohe  of  the  l.vcr  is  l-'^-l  ^  '  :^  ^^,  J,  ^,„  ,,,,i,,,.,  .xpansile  nn- 
he  conf.mndcd  with  ''•;!'"''':^";,  /  ;^.;  1  ^.v  ,..sition,  in  which  the  tumor. 
,,ulse  and  the  cxamina  .on  ''^^/^^^^^^Vi  i<  -t  then  communicated,  suf- 
l:  a  vnle.  falls  fonyard,  and  -  ^  i;;^.:,,,,,  ...eurism.  though  usually 
iiee  for  differentiation.     1  he  tun  or  01 

llxed.  may  ho  very  freely  ^^-^f^;  -^  i,,a.     A  few  ea.es  heal  spon- 

The  outlook  in  abdominal  ancuii.ni 


r 


iborhotid 

(.-ic   lllK'U- 

spital,  'io 
icfiilati'il. 
Yovtcbia' 
pi  gia,  (iv 
iKtnly  tlu' 
lor,  \vun.4i 
iiiivor  luay 
loft  hypo- 
1  high  iq) 
YX'  withiuit 

lUnv,  pass- 

lt()lu^.  l>ar- 

vcry  t'oi'i- 

iw    luavked 

..     A  thrill 

soiiH'liinos 

111.    On  l>iil- 
Tveo  ul  «uil- 

1(.1)L'  (if  the 
lihli',  ami  i^' 
occasiiHially 
t  of  clinical 
,,  hu  ninein- 
a  thrill  or  a 

unless^  there 
unisih'  piilxd- 
•()hl)iiig  aorta 
1  15uriis  call?' 
1  women.  In 
llie  throbbing 
overe  Invmor- 
nal  aorta  not 
(1  a  pulsation 
iiy  one  sitting 
lancreas.  or  o 
iicirla  and  may 

cxininsile  ini- 
ich  tlie  tumor. 
lUiuicaU'il,  sul- 
thoimh  usually 


ases  Ileal  spo"- 


ANEL'llISM. 


787 


taneou^lv  l>ratli  niav  result  from  (a)  romph'le  ohlitcratum  of  Die  lum.-n 
by  clots';  (h)  con.pr.-ion  paraj-K-ia;  {<)  rupture  (which  is  almost  the 
rule)  eitlier  into  the  pleura,  retroperitoneal  ti>Mies.  pentonanim  or  the  in- 
testines, very  eouu.uuily  the  duodenum;  (</)  by  euiholisui  ol  tlie  superior 
mesenteric  arterv,  producing  infarction  of  the  intestines. 

'Phe  hrnlwrnl  is  such  as  alreadv  advised  in  thoracic  aneuriMU.  W  lien 
,lu.  aneiiriMii  is  low  down  pressure  has  been  successfully  applied  in  a  ca.e 
l,v  Murrav,  of  Newcastle.  It  must  he  kept  up  b-r  many  hours  under  cliloro- 
fonn.  The  plan  is  not  without  risk,  as  patients  have  died  from  bruiMiig 
and  injury  of  the  sac. 

Ankiiusm  or  Tin:  r.i!.\Miii;s  of  thi;  Audominai,  Aokta. 

The  ctrlior  (i.vis  is  it.-elf  not  iiifrcipieiitly  involved  in  aneurism  of  the 
Tuvt  portion  of  the  alidominal  -.xovUx.  Of  its  branches,  the  splnnr  arlrnj  is 
oceasionallv  the  seat  of  aneuriMU.  This  raivly  causes  a  luiiior  laige  ..nougli 
to  be  felt;  Sometimes,  however,  the  tumor  is  of  large  size.  1  have  reported 
a  ca-e  in  a  man.  a-e.l  tliirtv,  who  had  an  illness  ,.f  several  mouths  dura- 
tion -evere  cpi-astric  pain  and  vomiting,  which  led  his  physician.-  in  New 
York  to  dia-nose  gastric  uh-cr.     There  was  a  deep-seated  tumor  m  the  lell 


bvpochondriac  region,  the  (hilii 


ess  of  which  merited  with  that  of  the  spUnMi. 


There  was  no  pulsation,  but  it  was  thought  -ui  one  occasion  thai  a  hniit 
wa<  heard.  The  chief  >vmpt>uns  while  under  ohseivation  «ere  vomiting, 
-evere  ei.i"astric  imin,  occasi..nal  ha'inateiiiesis,  and  liually  severe  Ineiuor- 
rjiao-o  from  the  bowels.  An  aneurism  oi  the  >pleuic  artery  the  sixe  oi  a 
cocoa-nut  was  situatcl  hetw.eii  the  stomach  above  and  the  transverse  e.don 
low,  and  extended  to  the  left  as  far  as  the  level  of  the  navel.  J  he  sac 
Mtained  densely  laminalc.l  llhriu.     It  had  perhiratcd  the  colon.     J  have 


no 

001 


twice  seen  Miiall  aneurisuis  .m  the  splenic  art..ry.  Of  ■,'■'  lu-^tanccs  ,.t  aneu- 
rism on  the  branches  of  the  ahdominal  aorta  .Mdlcted  by  Lebert,  K)  were 
of  the  splenic  artery. 

Vmnirism  of  the  hniuHe  arlrn/  is  very  rare,  and  there  are  only  10  or  K 
he  svmntoms  are  extremely   indelinile;  the  condition 


cases  on  rt'co 


id. 


could  rarelv  he  diagnosed'.  Jn  the  case  reported  by  K'oss  and  inyseU,  a  man 
aoed  twentv-one  had  the  symi.t.mis  of  pyaemia.  The  liver  was  greatly 
enlar-ed,  wei-hed  nearly  r..(i()n  grammes,  and  presentc.l  iniiumerahle  sniall 
.ilwce<.e<  \n  oval  aneurism,  half  the  size  of  a  small  lemon,  invdved  the 
right  and  i-art  of  the  left  branches.  In  d.  I',.  S.  dack^ou  s  *  ca.-e  the  anen- 
risni  perforated  the  hepatic  duct. 

\  few  cases  of  aneurism  of  the  suprrlnr  wrsnihrir  nrlrr,/  are  .m  reconl- 
Tbe  dia-niosis  is  scarcely  i.ossihle.  Plugging  of  the  branches  or  ol  t  le  maiii 
stem  may  cause  the  symptoms  of  infarct i<ui  of  the  bowels  which  have  al- 
ready been  considered. 

Small  aneurisms  of  the  rniol  avln-ij  arc  not  very  nurominoii.  Large 
linnnrs  are  rare.  The  sac  may  miitnre  and  give  rise  to  extciisiv..  rctro- 
])oritoneal   hicmorrhage. 


*  Moaicul  :M;igazijie,  1834.  iii. 


«■* 


TS8 


DISEASES   OF  THE  CIRCTLATORY  SYSTKM. 
Ain'Kiiio-vr.N'Ofs  AN-i;riiisM. 


Til  ilii-  form  tluTi.  is  alinnnnal  .•.Miuuui.i.-ation  l.ciwcii  an  artery  and 
a  vrin  Wlu'U  a  lui.u.r  lies  UvUuvn  the  tw..  it  is  known  as  varK:o:^c  anou- 
ri-iu-  when  llu'ic  is  a  dirtrt  (■..m.nuni(ati<.n  witiiout  tumor  tho  voin  is 
tluHiv  .lisl.iulcd  and  the  ((mditi.m  is  known  as  aneurismal  varix. 

An  anenrism  of  the  ascen.ling  porti.m  of  the  areh  may  open  d.re'lly 
into  th..  vena  <ava.  Twenty-nine  eases  of  this  lesion  have  heen  ana  yxed 
l,v  PepiKT  an.l  (irillith.  Cyanosis,  .edema,  and  fireat  distenti.m  <.l  the 
veins  of  the.  npiH.r  part  of  ll>e  hody  are  the  most  frequent  symptoms,  an.l 
.K.v.iop,  as  a  ruK.,  with  suddenness.  Of  the  phys.eal  si-ns  a  thr.  1  is  pus- 
..„t  in  s.,me  cases.  A  eontinuons  murmnr  with  systohe  inlensilieation  is 
„f  .,,,,at  diaunostie  value.  In  a  reeent  c^ase,  after  the  existeneo  for  s<wne 
time  of  pre;>ure  svm|.tnn.s.  intense  eyanosis  developed  with  en,..rgeme,it 
„f  tiie  veins  of  the  head  a.ul  arms.  Over  the  aortie  region  there  was  a 
lond  e.mtinuons  murmur  witli  systolic  mtensiheation.  „,,„•„,,, 

\  mai<.ritv  of  the  eases  of  arterio-venous  aneurism  and  ot  anoniisma! 
varix  result  fnun  tin'  accidental  o|.enin-  of  mi.  artery  ami  vein  as  in  vene- 
section. Mild  are  met  with  at  the  hend  of  the  ell.ow  or  sometimes  in  the 
temporal  region.  The  c.mdition  may  persist  for  years  without  cansmg 
any  trouhle.  Vnlsation,  a  h-ud  thrill,  ami  a  cmtinm.us  humming  murmui 
are  usually  lU'eseiit. 

CONOKNITAL    An  lU' IMSM. 

Tn  cnnsecnienco  of  failure  of  i.ro]H>r  development  of  the  elastic  coat  in 
many  places  in  the  arterial  system,  multiple  aneurisms  may  develop        a 
the  well-known  case  dcserihed  hy  Kussmaul  and  Maier,  nprn,  many  of  .he 
mediuin-sixe.1  arteries  there  were  nodular  prominences,  whicli  coiisiste(l  ol 
thickenin-  of   the   intima  and   inliltrati.m   of  the   adventitia  and   of  the 
media,  wHh  a  nuclear  growth  which   in  ,.laces  lo.,ked  quite  sarcoiiYtous 
Thev  called   it  a  case  of  jwrinrlcrilis  luMsu,  and   Kppingcr  holds  that  it 
l.el.m-^s   to   tlie   categ..rv   which   he   makes   of   congenital    aneurism.      .\s 
manv  as  (i:!   aneurismal   tnmors  have   l.een   found    m   one   case.      In  tlie 
Miiafler  hranclies,  such  as  the  coronary  and  the  mesenteric  arteries  oriii 
the   i.ulmonarv   arteries,   there    may   he   numerous   elongated   or   saccular 
aneurisms  varVing  in  sixe  from  a  cherry  to  a  ha.el-nnt       1  u^e  arc  true 
aneurismal  dilatations,  ami,  acc.rding  to  Kppinger  s  carelul  study,  the  wall 
ccmsists  of  the  intima  and  the  adventitia,  the  elastic  lamina  having  disap- 
peared     The  c.ndition  has  heen  met  with  in  chiUlreii.     S.mu'  <d  the  cases, 
however,  have  heen   in  adults;  hut  the  term  as  apjilied  hy  Kpinnger  ex- 
presses, and  prohahlv  c.n-re.tlv,  the  deep-sealed  fundamontal  error  in  de- 
velopment which  must  he  at  the  hasis  of  this  condithm.    A  favorite  situatmn 
is  in  the  coronary  arteries;  a  case  has  heen  reported  hy  Oee  in  a  hoy  ol 
seven. 


I 


vtcry  ami 
•()<o  aiieii- 
ic   vein   i^ 

X. 

II  diro'  lly 
1  aiiiily/.t'il 
i>n  ot  tlu' 
itoms,  and 
ill  is  itri's- 
lifation  is 
'  for  some 
iforgciiu'iit 
1010  was  a 


anonrisnia! 
IS  in  vonc- 
ncs  in  the 
lit  oaiisiii.i;' 
ig  uuirniiir 


itic  coat  in 
.'volop.     In 
lany  of  the 
•onsistod  of 
1111(1    of   tlio 
irconiatous. 
>l(ls  that  it 
urisiu.      As 
;o.     In  tiu> 
torios  or  in 
or   saccular 
'SO  are  truo 
lly,  the  wall 
ivinjr  (lisap- 
if  the  cases, 
ppinger  ex- 
I'rror  in  tle- 
■ito  situation 
in  a  l)oy  of 


SKCTION    Vill. 

KS  OF  THE  BLOOD  AND  DUCrPLKS^^ 
GL/VN'DS. 


I,    AN/EMIA. 

,\v  KMU  n.av  he  .leline.!  as  a  rcliu^tion  in  ihe  amount  <.f  the  hloo.l  as 
.,  wliole  or  ..!■  it's  eorpuseles,  or  of  certain  of  its  more  importan     c.nstitn- 
;,;        u'     a     aihumin  ami   luvmogiohin.     The  comlition   may   he  genera 
,; Vh  .1      The  former  alone  we  are  here  eonsi.lenng.     It   ,s  interesting  t 
not  wever.  that  the  pallor,  particularly  of  tiie  laee,  whieh  is  one  ot  tno 

t'     r  kin.^    vmptoms  of  amemia.  is  just  as  eharaeleristic  ol  h.cal  amvnua 
Z:  ,o      i..ld   or    o  nausea,     'nu're  are  persons  persistently   pale  without 
;  u:,  Jnmma  in  whom  the  comlition  niay  he  due  to  ,ii    en  e     p.^uha    Ui. 
(),„•  kiiowle.hM.  is  not  vet  sulliciently  advanced  to  rla.>  l\  sati.lactoiiiy 
„,/  '   ,  nus  of  amnnia.     The   following  provisional  grouping  may 

!I:   made:   (1)  Seeondary   or  symptoiiiatie  amemia:  (^)    primary,  cssonfai. 
or  cytogenic  ana'inia. 

Si:(()Ni»Ai!Y   An.i:mi.\. 

r,„U.,-  this  division  comes  a  larg.-  ,.roportion  -i; ;>n  ' J^--     ''^''"  '•"""^^- 
i 


i 


\ 


\ 


I 


HO 


I.ISHASKS  ..F  THE   BLOOD   AN'D  DrcTI.KSS   (iLANUS. 


the   la 1    :nv   ,v„.l,!y    .vston-l     ,y    f '-",;';',,      ,,^.,,   hut    it    .nay 


MEAt*  NOBM. 
NUMBER  OF 

WHITE 
CORPUSCLES 


BLACK,  JIED  CORPUSCLES 


RED,  HAEMAGLOBIN. 


IlLUE.  COLOKUESS  CORPUSCLES. 


C,  VHT  XVlI.-Illustvatos  th.  rapidity  ^vith  whivh  a.Kv.nia  is  pvclu-ed  in  purpura 
hanuorrhagira  and  tlu'  gradual  r.rov.ry.* 


sclos.    Tlu'  acromiKiny- 


'riu'sp  are 
th  ;i  small, 


■uv  palor  than  normally.     Xurh-at.Hl  r.'.l  ror 

;j  after  th.hammrrl.a,.:,ln.yar..lmwovor.n.,™ 
,„„1,  h,Hli,.s  .f  alH,ut  llm  sam..  HZ.  as  a  m.rmal  r..l  .-n,  pu>.  1. 

tlK.  su.nnu-r.    Tl.c  blood-cMUint   was  lUeu :    Kcd  uo.pnsLl.  , 
r),.")00 ;  lia-inoglobiu.  94  per  cent. 


KMltS   of 

Ic.-linnl 

it    iniiy 

il.    TIk' 


HA^  NORM. 
NUMBER  OF 

WHITE 
:0RPU8CLC9 


1PU8CLE8. 

pui'puni 

-comiKiny- 
('  oi'  severe 

vhiipe  may 
ithoT  more 
'  may  bo  a 

eoriniHcles 
ost  alway:^, 

Tlu>>;e  are 
ith  n  small, 

lic>  Imil   spent 
to  cMiviiuseles, 


AN-KMIA.  701 

round,  deeply  staining  miclcns.  Free  nnelei  may  lie  found.  The  eolor- 
less  eorpuseU's  are,  at  lirst,  increased  in  nunilier.  'I'iiere  is  a  moderate 
leueocytosis,  tlie  dillVrential  eonnt  siiowin--  an  iiieiea-e  in  the  niuhuaudear 
neutrophih'S  with  a  diniiiuitiou  in  the  small  mononffdear  eleim  nts.  Dur- 
iiiii-  reeovei'V  the  le\ieoeytosis  diminishes. 

'^The   reduction  in   hlenioghihin   i.-^  always    prop..itionalrly   greater   than 
tliat  in  tile  c(ir|)uscles. 

in  some  in>lances  a  rapidly  fatal  anaemia  may  f-dlow  a  MUgle  severe 
hinnorrhauc,  or  rei.eated  small  lueniorrhages  as  in  purpura.  Here  the 
appearances  of  tlie  red  corpuscles  are  much  the  >ame.  except  m  the  total 
al)senee  of  nucleated  red  cori)Usclcs. 

Tiu.  leucocytes  in  these  cases  are  usually  reduced  in  nund.er:  the  ]ioiy- 
,u„.l,.ar  .dements  are  i.resent  in  a  relatively  dimini>hed  proportion,  while 
the  small  moiioniudear  forms  are  iiiinieroiis.  The  autopsy,  m  these  cases, 
reveals  usually  a  total  absence  of  any  regenerative  activity  on  the  part  ol 

the  b(,ae-inarro\v.  ,    ,     ■  4. 

(•.')  .Vna'inia  is  fre.pu'ntiv  produced  by  long-contniiied  drain  on  the 
nlhuminous  materials  of  the  "blood,  as  in  chnmic  suppuration  and  I'.riglifs 
disease.  I'ndonged  lactation  acts  in  the  same  way.  Kapully  growing 
tumors  may  cause  a  profound  aiuemia.  as  in  gastric  cancer.  The  charac- 
ters of  the"hlood  here  may  l)e  much  the  same  as  in  the  acnti'  cases.  I  sii- 
ally  though,  the  poikiioevtosis  is  much  more  markeil;  in  severe  cases  it 
may  be  excessive.  'I'he  I'.resence,  however,  (.f  the  very  large  corpuscles, 
sucli  as  one  sees  in  ]icrnicious  anu'iiiia,  is  not  noted,  the  average  size  ap- 
pearin-''  to  he  rather  smaller  than  normal. 

Nucleated  red  corpuscles  are  iisnally  scanty.  In  h.ng-continued  clironic 
secondary  aiuemias  occasional  larger  niu  leated  red  corpusclo  may  lie  seen, 
bodies  with  larger  palely  staining  nu.dei:  in  some  of  these  cells  karyo- 
kinetic  figures  occur.     Nticloated  red  corims.des  with   fragmentary  luudei 

may  also  be  seen. 

"The  leucocytes  may  be  increased  in  number,  tluuigh  m  some  severe 
chronic  cases  tliere  may  1h'  a  diminution. 

(:?)  Aiuniiid  from  iiiiiiiilioi).—T\\\^  may  be  brongbt  about  by  defective 
food  snpi.lv,  or  bv  conditions  wliich  interfere  with  the  iiroj.er  reception 
and  ]n'eparation  o"f  the  food,  as  in  cancer  oi  the  (esophagus  and  chrcmie 
dyspejtsia.  The  reduction  of  the  blood  mass  may  lie  extreme,  but  the 
plasma  suffers  proportionately  more  than  the  cor]mscles,  which,  even  in  the 
wasting  of  cancer  of  the  (esophagus,  may  not  be  reduced  more  than  one 
half  oiMliree  bmrths.  In  some  instances  the  reduction  in  the  plasma  may 
be  so  great  that  tlic  cori)ns(des  show  an  a])parent  increase. 

(1)  Tn.vir  niKnina,  induced  by  the  action  o(  certain  ]>oisons  on  the 
blood,  such  as  lead,  mercury,  and  arsenic,  among  inorganic  substances, 
and  the  virus  of  svidiilis  and  malaria  among  (Uganic  poisons.  They  act 
either  by  directly  (Icstroying  the  red  Idood-cu'pUM  les.  as  in  malaria,  or  by 
increasing  the  rate  of  ordinary  consumiition.  The  anaunia  of  pyrexia 
may  in  part  be  due  to  a  toxic  aition.  but  is  also  caused  in  jKirt  Ity  tlio  dis- 
turliance  of  digestion  and  interference  with  the  function  of  the  blood- 
making  organs. 


rill* 


['.t2 


Ul:iEASKS  UF  TIIK   UL.uM.  ANL   niTTLKSS  (II-ANDS. 


I'uiMAiiV   ..1!  K>m:ntiai.  An.kmia. 
1.  Chlorosis. 
Deflnition.-An  an;...uiM  m1  unkn-uvn  oau-o,  occurriufr  in  ymnig  girl., 

making  orpins,  a>.ou.iH. I    "  ■',,,,  i„||„„„,,s.  |iarli."laily  ihUn.sis 

,,.,11.1  «,.,Mn.tii>  .;.;■"";-   ,„',,•, "s,„,,i,„..!.  i.  mi,.|i..w  |..nii...i 

::;^  ';;;:::;;;;u;:;:'Si:;";;:.;;  a'lLuv.  a.v,.,„.,iii™.  (iiyimwi-i)  ^t  ...^ 

1111.1  ll"'  '«■  <■!■  ' '■"\"  ' ',;'■'..    1  in     1    I  ml  ••'■'•lain  »riu.vs  have 

-;r'%,,^-'=i:;:^::.s*:;:::">rr;i,';i-:';.^ 
Sn:^'i-i:^i,:;:,;i:;;;;:':i;:;.M.^^ 

a  vicl  uhic.h  always  apiH-avo.l  In  ,uo  Ik^.U...  con.Hler.ug  ti.e  guat   tu 
Svmptoms.-(^0  GeneraL-Thc  synM-fnn.  of  HiIoiom^  an  tho  c 

;;=::;::::,,ir;:-k;;i-:,i:rr3a3^;^^^ 
;:-;;r;;:;-^!;lJ;:^r;;~ 

h  m!i  ru  n..)      Tho  sul.i.d.  .ouM'lain   of  bm.lhU.ssnrss  an.l   val,nta- 

l;::!  ':,:a  ;;;.:;:'nay ..  a  n.n.i.u.y  - '■--•>^— ;;i:!r-;;,  't;" 

U-an  to  tho  suspicion  of  hoart  ov  lung    ;;;;-/";   ^^i^^;„n   ofton 
«\volling   of   the   ankle?   may   sug,uo>l    no]  Initio.      n^^  , 

chanc^o;  an.l  the  girl  hooonus  low-spirito.l  an-l  -rn  ahlo.     1  he  c>c.  ha^c 
pm^i  r  hvillianA-  an.l  the  solovo1i..<  avo  of  a  hhnsh  oolov 

■'    1\_        '  .    ,      -r,    -^ 7>7 7        'I'l,,.      .Iron      as      0X11T0SS0( 


a  pen.liar  hvillianov  an.l  the  so1ov..1h.<  avo  ol  a  oiu.sn  o.mo 

^?>)  Special   Features.-7>V...?.--Th..    .Imp    J^-^'' J^  ^.t  th    e^o^^^ 

Jol  am  Duncan,  in  1S(m.  fust  callcl  attontu-n  to  tho  fact  that  the  e..cn 


AX.KMIA. 


IM 


ing  girls, 
u. 
than  of 
soon  tnu' 
lul  !«(.■  VI' li- 
es, wliicli 

1    I'illl^C   of 

ho  l)l(io(l- 
on  !)[  tl>o 
elilovosis 
\v  pitinti'iT 
ill)  oi  IIk' 

il   girls  of 
rooms,  oi" 
iiiuU'i'  the 
[  I'rc'sii  air, 
and  iierv- 
ritri's  havo 
hluro^c  par 
0  in  :Mont- 
ion.    Men- 
L'nrc.  not  a 
\\\  [ilays  an 
due  to  the 
argo  howi'l, 
'  great    fre- 

rc  those  of 
icreascd    in 
;ct  of  hivm- 
•c'llow-green 
designation, 
gnientation, 
e  color  may 
(Ml  exertion 
iiid   iialiiita- 
which   often 
he  face  and 
sition    often 
ic  eyes  have 

looks    pale, 
at  the  essen- 


tial fealnre  was  not  a  linsit  n.hi.'tinn  in  ll...  nnnilu.r  ..f  tlir  .■or|ui>rlr^,  hut 
„  Muanlilative  ciiange  m  ihr  lurinoglolnu.  Tlir  ,nr|.nM.|es  ihr.usrlves  louk 
,,,1,.  In  (■.;!  conM'.utivi.  niM's  exannned  at  my  cnnie  i>y  Tiiayer,  the  average 
„,,,„,„,,  ,„,,,  ,,,|i,i,,  iHillimeIre  of  tiie  red  l,l..od-.'or|.useies  was  -l.nin.,..  1  1, 
,„■  over  SO  per  .•.■nt.  uheivas  the  iMMveutage  of  luemoglolnn  lor  llie  total 
luimli.r  was  VLW  per  ei'iit.  Tlu'  aeeompaiiying  eliart  ilhi>trates  well  the.e 
Mrikin-^  dilVerenees.  There  may,  however,  he  well-marked  actual  amemia. 
The  lowest  hlood-e.umt  in  llie  series  of  eases  referre.)  to  ahove  wa-  l.'.i.;--\nii(^ 
Tliere  luav  lie  all  tlu'  pliv^i.al  eiiaraeteristies  and  symptoms  ,.1  i.roi.uiiu 
•uaemia   with   the   nuudier  of  the   hlood-eorpuseles  nearly  at   the  normal 


MKAS  NORM. 
NLMBER  OF 

W  H  i  T  E 

CORPUSCLES 


'..A«K,  HED  CO?iPU3CLE8 


RED,  HAEMAQLODiN. 

CiiAKT  XVIII.— Chlorosis. 


BLUE,  COLORLESS  CORPUJCLES. 


standard  Thns  in  one  instanee  the  glohnlar  richness  was  over  85  per 
;ent,  with  the  luvmoglohin  ahout  r.5.  No  other  form  of  a^^^-f"^^ 
this  feature,  at  least  with  llie  same  constancy  and  >n  the  same  degiee  J  he 
importance  of  the  reduction  in  the  ha.>moglohin  depends  upon  the  fact  that 


:!^ 


-iOi 


ni 


SKASKS  OF  THE  UhnOD  AND   DITTLKSS  r.LAXnS. 


l,ai.  iilsc  Ihtu  .Irl.Tumud  l.y  c.h'IhhmI  .m.il\.i.      i 

--■V'';;;:t:t;,:i,.;r.';:;;;;i,:i:::^»''-^-;.-;^^^ 

■  '      I  ■..,'   I„n.,«  <it  ml  l,l...»l-..'ll-'  »"■  ""<  "*  '■ "•"■  "'"'.""   ""'7 


clilo'.'dsis.      Ill 

to  exist.     In  the  dlluT  t 


•  two  in-tiinccs  the  iieiditv  was  iiorniiil  or  a  triile  m- 
'"  ^'"T  ;;;.;;;::::;;;■:,•  i''  .1  oven  .inlial^ie  attaeks  ...ay  l..  ass.u.i. 
:;;r:i,h  •..;'      1    '      :::  a  eo,n,nu„  syiup.u.n.  an-l.  as  already  ineii- 

;|:;:j;;:;.;le,,  n.a!.e..  as  a,,  .ii,..naiU  ^c^^^ 
\  tuainritv  of  chh.rntie  <riils  who  weai   loixts  liau    ,a,ii  j 

;',;:;;.„  ,i,e  .omaeh  .in ..  .omHi  veHieaiiy  if'-' -;-;.;;';; ''",:! 

,.  verv  iiu.eh  dilated.     The  motor  power  is  usually   \sell  uta.iRd. 
ont.wi.  with  palpahle  ri-ht  kidney  is  not   une(uuin..n 
•'"  ;  )  CkcJatory  Symptoms.- 1  Ml  pi.  at  ion  of  the     -j    ;;;:;-/-         ] 
,i.„      ,„.,  „„v  ,„,  ,1...  most  distressinjr  syinpl-u.  oi  whieli  the  p,  t u  nt  uuu 
;  ;        ,..,enssion  niav  show  slight  ii.erease  in  the  transverse  dulne...     A 
S   li.  uiurinnr  is  heard  at  the  apex  or  at  the  ha.,  more  -;>•••'" 

,„t    in  ...Ntreme  eases  at   hoth.     A  diasfdu'   mumun    »  .an  Is 


the   latter,  hut    ii 

hoard.     The  syslidie  nnirmur  is  ii 


snallv  loudest   in  the  sirond  left    intiT- 


'lie   exact 


-,>^<.,l'  ^oMce    where   there   is  sometimes   a    distinet    imlsation. 
:;il:         id    ';;::,  I  stil!  in  dispute.      nal.our  holds  U,at   ..  pi^Uie^^^^ 
the  m  tral  orifiee  hv  relative  insutVieieney  of  the  valves  m  the    lilat  d 
,^    i       o      1,     ventrhle.     On  the  ri.ht  side  of  the  neek  over  the  ,u,ula 
"         V  ntinuous  murmur  is  heard,  the  Lnit  ^k  duOA,.  or  hu,nuun,-,op 


murmur. 


"'tk'  pulse  is  nsnally  full  and  soft.     Tulsa  ion    n  tlu'  1-       >'    d  u. 
sometimes  seen.     There  is  a  lendeuey   to   thromh-sis  m   the  ^■    '  .  t 

;  onlv  in  the  fe.noral  hut  in  other  instanees  in  the  i-^>  -'-■;; 

.,,  the  th'romhosis  may  he  multiple.     Kx,.epv  m  the  smuses    tl  tun 

i    randv  serious.     Tuekwell  has  n-ported  an  instance  m  whu.l    tl,  U' 

nLi.u  of  the  ri,ht  axillary  artery  with  the     ,ss  of  a      >-"  -j^  ' 
of  the  fino-ers.     T.rayton   Hall  has  recently  ealled  attention  to  the  nnpo, 
tanco  of  this  feature  of  chlorosis.  .„„„i.,i 

As  in  all  forms  of  essential  anaMuia.  fevc.  is  not   uneonnnon.     Ksp 

attention  has  of  late  l.een  directed  to  tins  In-  Irench  write,..     U,lo.ot,e 


A  N.EM  I  A. 


;'.).-. 


pntiont*  MilTcr  fiviinnulv  I'nmi  !hm.I;u1i.'  inu\  n.'iinil-i;i.  Mluch  may  Le 
,;,rnNV-nuil.  rUv  haiMU  an^l  IVrt  miv  nlicn  .oM.  l)t.iiimt...i:nii.hui  is  cum- 
Inun  ■  ll\>l.Ti.al  .nMinlr>ti.li.ms  luv  n..t  inln.niciit.  Mrnstnml  disturl)- 
,nuvs  iiiv"  v.TV  cnniiiKm-iinu'iK.rrhnM  ov  (ly~iiirMnirlur;i.  Willi  the  iiu- 
prnvcMiriit  iii'tlir  1)1(10(1  c.iidilioii  this  luiu'lioii  is  UMiiilly  ivstorc'.l. 

Diagnosis.— 'rhc  groon  si.kncss,  as  it  is  scmcliitic^  ciillcl.  is  iii  many 
i,Htan.(-  nr(.-niz...l  at  a  {iiaii.v.  The  \v..  ll-iK.urislud  .■(MidilKm  oi:  the 
„i,|  ,|„.  ,„.,.uliar  (■.Hiii.lc.Ni(m.  wliicli  is  most  maikcd  in  iiruiu'ltrs,  and  the 
ululc  ((!•  Iihn^h  scleroties  arc  very  eharacteri>tie,  A  .^icial  dan-vr  exi>ls 
in  ini^lakin-  tlie  a|.|.aiviit  anaMuia  of  llie  early  sta.ue  ..r  pulnumary  tiiher- 
,.„1(,M>  Inr  e'hl(.r.(si>.  .Mistakes  ol'  tliis  soil  may  olteii  he  avoided  hy  the  very 
simple  \r>\  riirni>he(l  hv  allowinir  a  drop  of  hlood  to  fall  on  a  wiiite  towel 
,„.  a  pi,,,.,.  ,,r  1,1, ,11111-  I'.Mper— a  delieieiiey  in  Inemoglohin  is  readdy  api'ie- 
,.i.„,„|  'i-|„.  palpitation  of  tiie  heart  and  shortness  of  hreatli  liv.pieiitly 
^u"'H'<\  h-art-diseasc.  and  the  .edema  ot  the  I'eet  and  ^'Mieral  pallor  eause 
ll,rcas..s  to  he  iniMaken  for  I'.ri-hfs  di.-ease.  In  the  -veat  majority  of 
n,sc>  the  eharaeters  of  the  Idood  readily  separate  rhlor<..-is  Iroiii  other 
iiiniis  of  ana'iiiia. 

•2.  Idiopathic  or  Progressive  Pernicious  Anamia. 

The  di-ea-e  was  liivt  dearlv  deserihed  hy  Addison,  who  called  it  idio- 
naihie  amemia.  Channiit^'  and  (iusscrow  (h-erihcd  the  ea.-es  oeeurnnjr 
noM  partmn.  hnt  to  liieriner  we  owe  a  revival  -d'  intere.^t  in  the  siihjeet. 

Etiology.— 'I'he  existence  of  a  <ei>arate  di.-ease  worthy  ot  the  lerin  |.ro- 
.,n..<ivc  pernicious  amvmia  has  hen  donhted.  hut  there  are  un,pie.~tioiiahly 
r.i.,..  in  which,  as  A(hlisoii  savs,  there  exist  none  of  the  usual  eauK's  or 
,,;,„coinitaiits  of  aiuemia.  Clinically  there  are  .several  dilVerent  -roups 
\vhich  present  the  characters  of  a  progressive  and  pernicious  ana-inia  and 
a,v  ctiolo-icallv  dilVerent.  Thus,  a  fatal  aiia'tiiia  may  he  .hie  to  th.'  invs- 
cMice  (d'  parasites,  or  niav  follow  haMiiorrha-e.  or  he  ass.,eiated  with  .•hroiii.- 
a„.o,,hv  of  the  stomach:  h.,t  wluii  w  have  excluded  all  th.'se  caus.s  there 
,„„ain<  a  -roup  which,  in  tlm  words  of  A.hlison,  is  characterized  hy  a 
"..rin.ral  aiuemia  ...■.■urriu-  without  any  discoverahle  cause  whatever,  eas.s 
in  which  theiv  had  heeii  no  prcvi.ni.  loss  of  hloo.l.  no  exhanstm-  diarr.i.ea. 
,10  ..hlorosis.  no  purpura,  no  renal,  splenic,  miasmatic,  -land.dar,  slrunmns, 

or  mali-nant  disease."  ,     .       ,  ,.  . 

Idi.ipathio  ana.mia  is  wid.^ly  distrihut..!.  It  is  ol  liv.pi.Mit  .K.curi.Mu.e 
in  the  Swiss  cantons,  and  it  is  not  nnc.mnion  in  this  country.  1^  f'';;f;;^ 
,„i,hllc-aood  persons,  bnt  instances  in  children  have  heen  d.'scri hed.  (.nlhtli 
i,H,„,l„n;  alumt  10  oases  o.-crrin-  iiiid..r  twelv.-  years  of  a-e.  Iho  youngest 
pati.Mit  T  have  seen  was  a  -irl  .d'  twenty.  Mal.'s  are  more  livpiently  af- 
U-tcd  ihan  f.>males.  Of  mv  '27  cases,  10  w.MV  iVmales  and  17  were  males. 
Of  110  oases  o.dleot.'d  hv  ('.Mipland,  T.fi  wre  in  m.'ii  and  ..f  m  women. 
Sinkler  and  Kshner  -iv.>  3  oases  in  one  family,  th.'  fatluM-  and  two  -irN;  the 
father  had  symptoms  of  iiosterior  solorosis.  i,,^,,,;.. 

With  the  following  conditions  mav  he  associated  a  profonnd  ana-mia 
not  to  lie  distinguishe.l  olinioally  from  Addison',  idiopathic  form: 


i 


'»■■  , 


«■* 


VM\ 


niSKASKS  oi 


.  THK   ni-(M»l)   AND   DrCTLF-SS  (ILANI)S. 


(,/)    riniiiiiinil 


„„,,  ,.,„.,„n/;..,..-TI..  sy,„|.l"..;,'  ""'V  .I.-V..I.T  .imms 


utrnpliv. 

(,)'  /'(;/v(.si7cs.— Tlir  nil 


~'    ■  ■  '  vlo-tnlllll   iinil 


„,„,  his  st...K...l  l-..t...'s  .l.nwc.l  tl...t  t  ^^.,„     ,,,„,,,v  .1,...  t.. 

in.,,  i,.  tlu.  liv...-.  an.l  '  '^/'f''^;,  '.  ,!',,, ,,,..,, .1  l-v  tl..  .x.h.siv.. 
i,„.rc.asc.,l  l.a..,..>ly..s.  '1  Ins  hns  '-'V^*'  ;;  „  ,  „,„  ,„:i„,  ..x.,rt...l  is 
,.l,smatin,.s  ul   llu„l...'.  wl...   ';-;'':„'';,'    Tl...  !nn..„  lint  ..rtl..' 

n,„l,y  ,astro.,,...s„„al  <'^  :      "  ;;\   I      ,;.„,  ,,„.,,  .1,.,,  .U.nM  ..,„.. 


ti.ms  un.lf,'  \vln«l'  it  is  i.,'(Hiur...i. 


•lil;,<'('S — cliii'lly 


tioiis  mi'.> .    <"■■ .  ,  ,,  ,.,,,,il  a,'v    ia'„>i>i'rii;,^t'> — .•im-..,> 

Stuc.k,uan  s,i-.st.  ll.:.l   nv^M.,\  >    ;"     ;  ,,,   ^,,„  .i.^aM',  ul.uh 

i„,„,,„l-_,.lay  a,i   i,.ir.;ant    -Z.   m       <  '  ; ^     '     ,  ,,,,„  ,,  „,,  ,iv..v. 


On  the  otlic-  Imml.  1 


,.iiiu.  i<.  111*.  M\vi  *''•"  "";  '■■■*'"'''' " 


I'  ili('  discasi'  IS  m 


,lrf,.,,iv..  l.u,„.^..•...■>l-.    "  ""■',',„,,,,  ,,,  ,..,,...,.,»,..  llnit  llK.  l.v,.m- 

"r,"'"'""":  1.:.' ;":;  .I"' h'^^  w^  , „„...,,,„ 


lie  imisrics  (illfii  are 
"a'ln- 


Morbid  Anatomy.— hh' 

,.f  tlu.  skin  is  inH.M.,1   in  a  .naj-vity  oi     he  .-j,^':  ^^^^^^^^^ 

i,„,„..ly  n.l  in  .nU;  lik.   -•-:'1''^'>';''  ;,'',,,.  'Th,  iH.avt  is  nsu- 

,„v  la,.,o.  ilal.l.y,  and  H„,tv      In  •;•-•--':      ,''*'„  „;.,  ,.„•,.     Tlu 


rhe 


imisclr  snbstmioo  of  the  lu-art  is  mtcns.-ly  laity,  and        a  1  a         ..      •    ^,„_ 
,„1(),-.     In  no  aa'octinn  do  we  s.v_in( 

Inn, us  s 

1 

1 


,vo"o\tro,no  fatty  dojivn<',-ation 

s  is  iio,',„a 


..rm  sonu.  caL  of  fatal  anaann,  the  -•';•'-  ^^  J',,:  ^  ':,,..,,. 
,,,i,.l.  Tn  the  oas.  d.soribod  l.y  Henry  7'  J;^'^^,  '',,",,  .trophy  of 
l.ad  a  i^n.ootl,,  cuticular  appeurunco,  and  theie  ^^a^  .on,, 


AN.KMIA. 


.'.>7 


.1 

uvins 

MnlV 

'• 

tllllS 

V 

I'linl 

a 

.     IVv 

('lice  'il' 
mil  iinil 
I'liiia. 

|inrlinll, 

(lex  ri|i- 
(,Miiiicki' 
r  ill  tilt' 
V  dill'  ti) 
■xlfiisivf 
•ri'ti'tl    is 
It  of  tilt' 
idiictiiin. 
ililioii  ol' 
tcil   with 
ii'd  caiif^i' 
iKilysis   is 
he  coiidi- 

«— (liii'ily 
sc,  wliii'li 
till'  liver, 
-isili.  and 
H'asc  is  in 
(•(iriuiscU'S 

lu'  lui'iiK'- 
iiu'ss.  can 
U'>is.  >inci' 

k'liiDn  tint 
;  (il'tfii  art' 
iw.     ihi'iii- 
■art   is  iisu- 
•j  dnu'lmis 
Idt.     Tlu' 
in-ht-ycllow 
itiiiii.     Tlu' 
J  is  normal, 
sivcly  ati'd- 
j  nu'iidiraiii' 
atrnpliy  of 


tlir  s.'civtiii^'  liiliiilcs.  Till'  liver  may  lie  eiilar;:ed  aii<l  fatty.  In  most  of 
my  aiitoiisi^.s  it  was  normal  in  .>i/e.  Iml  usually  fatty.  The  iiuu  i.s 
in  e\(e.-.<.  a  strikiii.L'  eoiitra.-t  to  the  eumlilion  in  eases  of  .•.ei'omlary  ameinia. 
It  is  deiio>ilcMl  ill  the  outer  and  middle  /ones  of  the  lohiiles,  and  in  luo 
s|.iriinen.s  which  I  evaiiiined,  MriiH'd  to  have  siicli  a  di.-trihntioii  that  the 
hile  ea|iillaries  were  distinctly  outlined.  This.  Hunter  states.  i>  a  special 
and  characteristic  lesion,  possihly  peculiar  to  pernicious  anaemia.  A.  .1. 
Si'ott  examined  for  me  the  livers  in  l.')  coiiseeiit  ivc  aiit(.ii>ies  wilhoiit  liiidiii-- 
(except  in  pernicious  aiia'inia)  this  special  dislrihiitioii  (d'  jM-nieiit. 

The  spleen  shows  no  important  cliiiii^tes.  In  one  (d'  ralnnr  Howard's 
cases  the  oi-an  weijiiicil  only  1  ounce  and  ")  drachms.  The  mm  pi-nieiit 
is  iisiiallv  ill  cNiess.  The  lymiih-vlands  may  he  of  a  ileep  red  color.  The 
timoiint  of  iron  pi.Linienl  i^  increased  in  the  kidneys,  chiclly  in  the  coii\o- 
liilcd  tnlmles.  The  hone  marrow,  as  |ioiiite(l  out  hy  II.  ('.  Wood,  is  ii.-iially 
red,  Ivniphoid  in  character,  showiiijr  j,'reat  niimheis  of  niicl.'iited  red  cor- 
piisi'les.e.-peeially  the  lar-'er  I'ouns  called  hy  I'llniich  ,ui;;-antohIasts.  ('Iian.uvs 
in  the  ;:an-;iion Cells  of  the  sympathetic  have  heeii  reported  on  >ever;''  oc- 
casionsT  Lichtheim  has  foiiml  sclerosis  in  the  posterior  columns  of  the 
cord.  I'.nrr  docrihed  a  series  of  ca>es.  The  suhjcct  is  referred  to  a-:iiii 
under  (liseasc>  of  the  spinal  cord  ( rinveisity  Med.  Maj:a/.ine.  ISM.".). 

Symptoms.— The  patient  may  have  heeii  in  previous  piod  health, 
l.ut  in  manv  ca>es  there  is  a  history  of  uastro-intcstiiial  disliirhaiice.  mciilal 
shock,  or  worrv.  The  dc>criptioii  .uiveii  hy  .\ddi.-on  piv-eni-  llic  chief 
features  (d'  the"  disease  in  a  masterly  way.  "  It  makes  its  approach  in  >o 
slow  and  insidious  a  manner  that  the  path'iit  can  hardly  lix  a  date  to  the 
earliest  IVeliim-  of  that  laivunor  which  is  shortly  to  hecome  .-o  cxtivm.'. 
The  cmnitcnaiiee  -cts  pale,  the  whites  of  the  eyes  hecome  pearly,  the  Gen- 
eral frame  llahhv  rather  than  wasted,  the  inilse  peHia|.s  laruc  hut  rcmark- 
ahly  soft  and  cmnpressihle,  and  occasionally  with  a  sli-ht  jerk,  especially 
under  the  sli-htcst  excitement.  There  is  an  increasin,tr  iiidi>position  to 
exertion,  witli  an  nncoinfortahle  feelin--  of  faintness  or  hreatlile.<sness  m 
attempting  it:  the  heart  is  readily  made  to  jialpitatc;  the  whole  surface 
of  the  hody  presents  a  hiaiiched,  smooth,  and  waxy  appearance;  (ho  lips, 
j;-unis.  and'ton-ne  seem  hlo-.dless,  the  tlahl.iiicss  of  the  solids  increases,  the 
aiipetite  fails.  ..xtreme  laiitriior  and  faintness  siipervnie.  hrcathles-^ncss 
and  palpitations  are  produced  hv  the  most  trillin-'  exertion  or  emotion; 
some  sliu-ht  .edema  is  prohahly  perceived  ahout  the  ankles;  the  dehdity 
becomes' extreme— the  palii'iit  can  no  loii.irer  rise  from  hed:  the  iiiiikI  oc- 
oasi.mallv  wanders;  he  falls  into  a  prostrate  and  half-torpid  state,  and  at 
Icnt'th  exiiires:  nevertheless,  to  the  very  last,  and  after  a  sickiu'ss  of  several 
months'  diiraticm.  the  hnlkiness  of  the  .reiieral  frame  and  the  amount  ot 
oliesity  (d'len  present  a  most  strikin>r  contrast  to  the  failure  and  exhaustion 
observable  in  every  other  resjieet." 

The  /j'A/oJ.— The  corimscles  may  fall  to  one  fifth  or  less  of  the  normal 
number  Thev  mav  sink  to  r)(U).(10()  per  culiic  millimetre,  and  in  a  case 
<d'  Quincke's  the  number  was  reduced  to  143,000  j.er  cubic  millinietre. 
The  hivmio-dobin  is  relativelv  increased,  so  that  the  individual  ^dobular 
richness  is'i.lus,  a  condition  exactly  the  opposite  to  that  wliich  occurs  m 


'I 


.    I) 

I, 


(98 


DISEASES  OF  THE   BLOOD  AND   DUCTLESS   OLANDS. 


,hlorosis  nnd  the  ....■nndnrv  aniviuia,  in  which  ih.  vov].u^.u\av  ruhnoss  in 
coloring  imlt.r  is  minus.  The  ivlativ.  iur.vase  ,n  tia-  haMn.,>;- o  nn  ,s 
,vl.l.ahrv  assooialcl  Mill,  ih.  avra,-.  incvas.  in  the  s.x.e  oi  the  ml  hloo.l- 
;,.,.pu-c.ies.  Tho  accompanying  chart  iUnslratcs  these  ]H,n,ls.  Micn.soop- 
,,allv  the  rc.l  hlood-c'orpuseie.  present  a  great  variation  m  size  and  here 
....„  l,c  seen  lar-e  giant  forms,  megalocytes,  which  are  olten  ovoid  in  lorm, 


110.; 


iOO,; 


90,; 


80.^ 


70,; 


I  - 


r..o(i(i,ooo 


•1  .nno.ooo 


Stl'T.  OCT. 


110^ 


100;t 


OO.l 


so:s 


MEAN    "iOHM. 

NUWiJoH   OF 

C0HPJ5CL.E5 


BLACK,   RED  CORFLSCl-Et, 


RED,  HAEMOGLOBIN. 

C'haut  XIX.— IVrniriniis  aiKi'miti. 


BLUE,  COLORLESS  CORPUSCLES. 


nici-^iirin-  S.  11,  or  even  15  /.  in  .lianieter— a  eircnmstanee  which  TTenry 
regards  as  indicating  a  reversi.ui  t..  a  lower  tyi.e.  Laaclie  tlimks  these 
paUiognomonio,  and  they  .■ertainly  form  a  constant  leature.  I  iiere  are 
also  .mall  round  <h.11s,  microcytes,  from  •>  to  (i  /.  in  diameter,  and  ol  a 
deep  red  c.lor.  The  corpuscles  sliow  a  reniarl<ahle  irregularity  m  Inrm; 
thcv  are  elomrated  and  rodlike  or  pyriform;  one  end  of  a  corpuscle  may 


ino«s  in 
oliin   is 

I  Ijlood- 

1(1  tliciv 

II  Idiin, 


uo^ 


100;t 


00,1 


so:s 


-Of. 


001 


30,{ 


-4- 


10;{ 


30;« 


•20% 


10,< 


MEA't    "lOHM. 

NJWatH   JF 

00Hi*J&^-E5 


!I.E5S  CORPUSCLES. 


icli  TIcnry 
inks  tlicso 

TIUTL'    ill'O 

iiiiH  of  il 
;  in  I'di'ir.; 
)usck'  may 


AX.EAIIA. 


Till) 


ri'tiiin  it*  slinyio  wliilo  tlic  other  i-  iiniinw  nnd  oxtoinlcil.  To  this  condition 
of  irrr^iiliii'ity  Qiiiiuke  gavo  tiif  iiiiiiic  itoikilocytosis. 

Xiiclciitcd  red  l)lood-cor|iiisilcs  tire  iilmost  iilwfiys  ]ii'('scn(,  as  pointed 
out  liy  l'"Jirlieli.  ISesides  the  onlinary  form,  wiiicli  is  of  the  sami'  size  as  tin; 
eommoii  curjiiiscle  and  whieli  has  a  sinall.  deeply  stained  iiiicK'iis  (nor.'iio- 
hhists),  ihi're  are  very  large  forms  with  palely  staining  niielei  (gigaiito- 
lila>ls),  which  reseiuMe  siniieuhat  the  iai'U'er  megaloeytes.  i'ihiiieli  re- 
gards the  presence  of  tiiesi'  as  almost  distinctive  of  progressive  periiii'ioiis 
aiuemia.  Tliongh  these  large  forms  are  most  characteristic,  occasimially 
forms  cliiHcly  siniilar  to  them  may  he  found  in  the  graver  secondary  an- 
aemias— e.g.,  liotlirioccphalns  ameniia,  anchylostomiasis — and  in  lenka'inia. 
Karyid<inetic  figures  may  lie  seen  in  these  liodies.  Ifed  c()r])uscles  with 
fragmenting  nuclei  are  I'ommon  in  pei'iiicioiis  ana'mia.  'I'lie  leucocytes 
are  generally  normal  or  diminished  in  niinilier:  and  in  the  graver  cases 
a  marked  I'elative  increas(>  in  the  small  mononuclear  forms,  with  a  diminu- 
tion in  the  pidyniiclear  leucocytes.  i>  (il'teii  noted.  'I'lu'  hlood-plates  are 
either  ahseiit  or  very  scanty. 

The  ciirdio-vascular  .symptoms  ai'c  important  and  are  noted  in  the  de- 
scription given  aliove.  iheniic  murmuis  are  constantly  present.  The 
larger  arteri<'s  pulsate  \isihly  and  the  throlihiiii;  in  them  may  he  distress- 
ing to  the  jiatient.  The  pulse  is  fidl  and  frepieiitly  suggests  the  water- 
hammer  heat  of  aortic  insulliciency.  The  caoillary  |)iilse  is  fre(jueiitly  to 
he  seen.  The  superlicial  veins  are  often  ])romiiient,  and  in  2  cases  1  have 
seen  wt'll-niark'cd  pulsation  in  them.  I  hemorrhages  may  occur,  either  in 
the  skin  or  from  the  mucous  surfaces.  K'etinal  lueimn'rhages  are  common. 
There  are  rarely  sym]it(niis  in  the  respiratory  organs. 

(Jastro-intestinal  .symptoms,  such  as  dyspepsia,  nausea,  and  vomiting, 
may  be  present  throughout  the  disease.  Diarrlnea  is  not  iiifr:'(pient.  The 
urine  is  usually  of  a  low  specific  gravity  and  sometimes  pale,  hut  in  other 
instances  it  is  of  a  deep  sherry  color,  shown  hy  Hunter  and  .Molt  to  he 
due  to  great  excess  of  nrohilin.  Fever  is  a  variable  symptom.  For  weeks 
at  a  time  the  temperature  may  be  normal,  and  then  irregular  pyrexia  may 
develop.  Nervous  sym])toms  may  occur,  iium!)ness  and  tingling,  and  oc- 
casionally sym|itoms  resembling  thosi'  of  tabes.  I.epine  re|»H'ts  a  case  of 
extensive  jiaralysis. 

Diagnosis. — From  cldorosis  the  disease  is  readily  distinguished.  I 
have  not  seen  a  case  in  which  the  two  diseases  could  have  lieen  confoiiiided. 
Several  jioints  in  tlie  blodd  examination  are  of  especial  inijiortance,  namely, 
the  relative  increase  in  the  ha'inoglobin  and  the  presence  of  megaloeytes 
and  of  the  large  forms  of  nucleated  re(l  blood-c(U'piiscles.  the  gigantoblasts 
<d'  F'hrlicli.  I'oikilocytosis  may  occur  in  any  severe  aiaemia.  The  separa- 
tion <d'  the  dilVei'i'iif  clinical  forms  abdve  referred  to  can  usually  I)e  made. 
The  ])rofound  secondary  aiia'iiiia  of  cancer  of  the  stomach  may  sometimes 
ho  jmzzling,  but  the  skin  is  rarely,  if  ever,  lemon-tinted,  and  the  blood  has 
tlie  characteristics  of  a  secondary,  n  jirimary,  ana'mia. 

Prognosis. — In  the  true  Addisonian  cases  the  outlook  is  had,  though 
of  late  years  on  the  arsenic  treatment  the  yn'ojHirtion  of  recovery  has  in- 
creased,   yiy  personal  experience  of  progressive  pernicious  ana-iuia  to  Janu- 


g„0  msHASES  OF  TlIK  m.OOIl  AKI>  nfCTLBSS  OLANIW. 


,v,m?im'.i  i"  f""'^  i'"'i"'  '"'■  '"■•:'"'  •''■:!!'' 


Ui;  llu'  VL>iiuuiun,ii-  IS  ca? 


remainod  in  iio.-.l  lu..  uu  loi  -/  '  '  •>  ; ;;  ;i^  ,p,„  ,,,,nainin-  10  were 
,.,,  ,..st  .,l.t  nl:  -,-:";:  ;^;;,r  the  iir.t  attack;  one  had  an 
d..d.  S.x  ol  th..e  alal  -  ^^^^^^^^^^i^^,.  ,^,,,1,  two  year.,  bulurc  th. 
interval  ot  i>early  ^l'>'-  >*-  '  ^^f  jj:;'^\.,,,,,,,,,a\.nuM.letc.ly.  and  died  in 
return.  One  patient  u.  lu..,-.  al  '  ^J;'  j^  ,^.^  ^„,,i^.,j  j,  ,,,,  (iuyV  llos- 
IS').;  or  cancer  or  the  s.on>aeh      h    ^    ^J^    >    ^      ^,^,j^  ^,,,„^  ,,  ,  ,,.,,,t 

l''^''l  I'^'l'"^'^^'.  '7"'"";  Uu'e  "^        e      aVhh  ar.enie  in  ISSU.  venuuncl 
,„i,lc.  states  tu>t  --"^     -    j^' ;     ,,^  ,,,,^,,,,,  ,,,ae  an  apparently  .un- 

"''^^'  "'"'  ""■'•  '  '"r   •  ■.,...     u  inc's  and  political  dnties.     So  char- 

plete  recovery  and  rcsun.cd  '       ^  ^^ ;  ^  ^,  ,' ^^^  ^^    ,,„,,  Mackenzie,  in  his 
,,,teristie  are  recurrcnc.s  m  tlu^  '^"^  /;  ;,i,,,/,,i.  ,,1     .i„.  pernicious 

l.,,t„,„,  eon.i.lercd  then,  under  "  -l'^^' '. '".     .^';;;^,,,,,  Uii    The  ,.res- 
— '•    '''"^'  ^'^'""'""""i;,:  t   ';  :  ^  l        ilist^uU  to  'l.  indicative 

;:r:;;;;;i.;;;:;:;::^'-";;- 
;rs::il^::^r;::s;;'hr^i^:^^^^^^^^^ 

be  also  an  unlavorahle  si-n.  ,,,„,.,,■„  __'nic     traunialie 

Treatment    of    An8enua.-> -..;'/..    •     "       •  .^ 

1     1      t    .nwl   with   nh'Utv  (d   jiond    IihkI   and    m^u  .ui 

,,a.es  do  'f^- ;"";,,         J  ;nnar;ra,.idi,v  with  which  the  n.uMual  j.cr- 

readdv  restored.      1  he  i  xtiao mniaiN       1        •  .,„v  medication  what- 

eenta,e  of  red  hi i-;n»-l-';  ;;';;;;    :.":',.,.. .e   should   he 

ever  is  an   iniporlaut   lesson.      1  he  "'   -'^    ^  .,,,.„        .lependiu,^ 

souo-ht   and   the  necessary   '•><l'-'*''7\7\.  j,   \,;' Ji    .^  i,/i.,,i,,  u's  dis- 
„„  ;,,„  drain  on  the  allunuiuous  -J^-f;;^        ^    ^  nl       and  so  Ion, 

--  ^"i"-f  :;•  ;;;;vr:inp;t:nd:  r::;."  ti.; ::^uai  hiood  condition. 

as  the  cause  keep>  u).  it  is  impo..     '  ...airi^hiin-'  fo..d.     When  de- 

''^rr-^^^^^  •"■  ':r''e;:::;::rirtif  ^^t  -irtin:ii^nucosa  not  much 

pen.lent   on   orpunc   chan-cs   m   iiu    ,.,  ^^^^  ^^^ 

food,  an  open-air  hie.  and  iron.     A>  a  luu    u 

;;::"::::;::;:;;::::r;;;;;.:^5^^^^^ 

,„.o  „t  H.I0V0*  <I"'"V' '-^'f;  ::,',,     i',,i,,ls'l,,.|on.  ihoy  .ro 


1 


AN.EMIA, 


Sdl 


,^.rll(  i.Micv  of  available  iron  in  tlu'  fond.     linn-o  lidicves  that  it  is  the  sul- 
uluir  whh-li  interferes  with  tlie  (li-e>lioii  and  assimilation  ol   tins  natiira 
in.n       The   snlpiii.ies   are    pn-duee.!    in    tlie   proee.-  .,f    fermentation   ami 
,i,.,„„iiio.-ilion    in   the    fares,   ami    interfere   with    the   a>>imilatiou   of   the 
j^,,,,,„.,,  |,,„„  ,,„uaine.l  in  tiie  fo.„l.     liy  the  administration  of  an  uiorganic 
,,,,|,,„,,iinn  of  iron,  with  wlueh  tlie>e  siilphhles  unite,  the  natural  ui-anie 
|,„„l,i„,„ious  in  the  food  are  spared.     In  studyin-  a  niiiuher  of  charts  ol 
chlorosis,  it   is  seen  that  there  is  an  increase  m  the  red   lilnod-corpusclcs 
under  tlie  inlluemr  of  the  iron,  and  in  some  iiistames  the  jih.hular  rich- 
ness ri<c<  ahove  normal.     The  increase  in  the  hicmool„l„ii  is  slower  ami 
the  ma.ximuni  peirenta-e  may  not  he  reached  for  a  Ion-  time.     1  have  lor 
vear.s  in  the  treatment  -d'  chlorosis  used  with  the  -ivatcst  success  i.laml  s 
pills    made  and  -iven  according-  to  the  formula  in  .Nu'iiieyers  text-hook, 
in  which  each  pill  cmitains  •.'  -rains  .d'  the  sulphate  -d'  iron.     During  the 
Jir<t  week  one   pill   is  -iven   three  times  a  day.  in   the  second    week,   two 
pill.-  in  the  thinl  week,  three  i-ills,  three  times  a  day.     This  do<e  shouhl 
he  continue.l  for  lour  or  live  weeks  at  lea.sf  l)ef,)re  ivductiou.     An  impor- 
tant  feature  in  the  treatment  of  chlorosis  is  to  persist   in  the  use  of  the 
i,„i,  f„r  at   least  three  months,  and.  if  necessary,  suhscpieiitly  to  resume 
it  in  smaller  .loses,  as  recurrences  arc  so  common.     The  diet  slunild  con- 
.i<t  of  o-ood,  easily  di-ested   food.     Special  care  should  he  directed  to  the 
lM.wels'"and  if  constipati(.n  is  iiresent  a  saline  purge  should  he  given  each 
niornin-      Such  stress  does  Sir  ,\ndrcw  Clark  lay  on  the  importance  of 
constii.ation  in  .dilorosis,  that  he  states  that  if  limited  to  the  choice  oi  one 
dru-  in  the  treatment  of  the  .liscase  he  wiuild  choose  a   purgative,      iiie 
.rood  inllucnce  of  alkaline  ^valers  in  ass„ciation  with  tli.'  treatment  hy  iron 
fm«  heen  note.l  hv  von  .laksdi.     In  many  instances  the  dyspeptic  symiitoms 
may  he  ivlieved'hv  alkalies  and  a  treatment  directed   toward  a  luoderato 
suporacidity.     Dilute  hydrochloric  acid,  manganese,  phosphorus,  and  oxy- 
I'cn  have  t>een  recoinmended. 

'  Tmilmciil  of  I'miirinus  .lm///N'-/.— Since  the  introduction  i)y  l.yrom 
I'.ramwcll  of  arsenic  in  this  alTcction  a  hirgv  nundu.r  of  cases  have  heeii 
lemporarilv.  a  few  permanently,  cured  hy  it.  It  should  he  given  as  l-owler  s 
,olution  in  increasing  doses.  It  is  usually  well  home,  a  id  patients,  as  a 
rule  take  up  to  •.'<>  minims  three  times  a  day  without  any  disturl.ance. 
1  us'uallv  heuin  with  ;l  minims  and  increase  to  .'.  at  the  nid  ol  the  lirst 
week  to"  10  at  the  end  of  the  second  week,  to  lo  at  the  .'ud  ol  the  thin! 
week!  ami.  if  necrssary,  go  np  to  -u  nr  -n.  In  a  case  in  which  the  iw.very 
persisted  for  nearlv  three  vears  the  .lose  was  gradually  iucivas,..l  to  -W 
minims  Th.'se  patients  s.vm  to  stand  the  ars..nic  extivm.dy  well,  it  is 
sometimes  hetter  home  as  arscnions  a.'id  in  i-ill  form.  A  omilmg  and  diar- 
rhoea are  rare;  oocasi.mally  luitlin.'ss  .)f  the  fa.-  is  prcduccd.  aiul  m  som.' 
cases  pi-menlation  of  th."  >kin.  ,      ,.     i  •  n 

Eost  in  hed  and  a  li-h:  hut  nutritious  di.d   (givm-  the  Io.kI  m  small 
am.nints  and  at  fixed  intervals)  are  the  lirst  indi.ations.     T  always  prel.'r 
to  heoin  the  treatment  of  a  case  of  ,,ernici..us  amemia.  what..ver  the  grade 
uiav  he   with  rest  in  hed  as  .me  .d'  the  ess.Mitial  ehmieiils.      I  he  hencficia 
effect  of  massa-e  has  heen  slmwn  liy  J.  K.  Mitcludl.     T  have  ahandoned 


802  DISEASES  OF  TllK  BLOOD   AND   DUCTLESS  GLANDS. 

the  use  of  m-tnl  injections  of  (liicl  ).loo(l.  Iron  rarely  mts  well  in  this 
l',.rni,  iMit  in  a  case,  "in  whieli  tho  arsenic  disagrees  it  may  lie  tried.  Lone 
„„,Pow  has  been  -..connnen.K.d.  It  is  hot  -iven  as  a  -ly.vnn  extract.  1 
liave  not  seen  an,,  bendit  lollow  its  adminislratioii.  Inhalations  oi  oxygon 
may  be  tried. 

II.    LEUK/EMIA. 

Definition.— An  alTeetion  characterized  by  persistent  increase  in  tlio 
white  Mood-corpnscU.s.  associated  uiHi  chan-es,  either  ah>ne  or  together, 
in  tiie  spleen,  Ivmi-iiatie  glands,  or  bone  marrow. 

The  di<ea-c.  was  described  almost  simultaneously  by  ^  irehow  and  by 
Bennett,  who  gave  to  it  the  name  leueocythienua.  It  is  ordinarily  seen  in 
two  main  tvites,  tiiough  comliinations  and  variations  may  occur: 

(1)  Soleno-meduUarv  Icuka.mia,  in  which  the  changes  are  especially 
localized  in  the  spleen  ami  the  bone  marrow,  while  the  blood  shows  a  great 
increase  in  elements  which  are  <leriv(.(l  especially  Inmi  the  latter  tissiio, 
a  condition  which  ^liiHer  has  termed  "  myehemia."  Khrbch  prelers  to 
call  this  type  of  the  disease  "myelogenous  leulva.mia,  lielievmg  the  part 
„laved  bv  "the  si.lcen  in  the  process  to  he  purely  passive.  . 

V>)  lAinphatic  IciikaMuia,  in  which  the  changes  are  chiefly  h.calized  in 
tlie  lymphatic  apparatus,  the  blood  showing  an  especial  increase  m  those 
elements  derived  from  the  lymi)li-glands.  ,  •  ,    ,,      t 

Etiology.— We  know  notliing  of  the  c.mdltions  nnder  which  the  dis- 
-ise  develops  It  is  not  uncommon  on  this  continent.  Of  '-it)  cases  ol  which 
J  have  notes,  to  .lanuarv.  lS->.-i,  11  occurred  in  Montreal,  'i  in  Pluladelphia, 
ami  i;}  in  hospital  and  lu'lvate  work  in  I'.altimore.  It  does  not  seem  more 
imnient  in  tiie  soutiiern  jiarts  of  the  country. 

The  disease  is  most  common  in  the  middle  period  of  liie.  1  lie  yonng- 
est  of  mv  pali.'nts  was  a  child  <.f  eight  months,  and  cases  are  on  record  of 
the  disease  as  earlv  as  the  eighth  or  tenth  week.  It  may  occur  as  late  as 
the  soventieth  vear.  Males  are  more  i)r()ne  to  the  alVection  than  females. 
Of  mv  cases,  17  swrv  in  males  and  !)  in  females.  I'.irch-llirschfeld  states 
that  of  '200  cases  collected   from  the  literature,   i;;5  were  males  and   Go 

females.  , 

\  tendency  to  lueniorrhaixe  has  been  noted  in  many  cases,  and  some 
of  the  patients  have  snlfered  repeatedly  from  nose-bleeding.  In  women 
the  disease  is  most  C(mimon  at  the  climacteric.  There  are  instances  m 
which  it  has  developed  during  i-regnancy.  The  case  des(.ribed  by  J.  Cbal- 
nier<  Cameron,  of  Montreal,  is  in  this  respect  remarkable,  as  the  i>atient 
passed  through  three  i.regnancies,  bearing  on  each  occasion  n..n-leuka'niic 
(liildren.  The  case  is  interesting,  too,  as  showing  the  hereditary  ciiaraetc>r 
of  the  arrection,  as  the  grandmother  and  mother,  as  well  as  a  brother,  suf- 
fered from  svmptoms  stronglv  suggestive  of  leuka'inia.  One  of  the  pa- 
tient's (.hildrcn  had  h'tikamiia  before  the  mother  slu.wed  any  signs,  and  a 
second  died  of  the  disease.  At  the  last  report  this  patient  had  gradually 
recovered  from  the  third  confinement,  and  the  red  blood-corpuscles  had 
risen  to  KOOO.OdO  j.cr  cubic  millimetre,  and  the  ratio  of  white  to  red  was  1 


LEUKJ2MIA. 


8U3 


to  -ioO.     Siiiijrcr  lias  rciiiirird  ii  casr  in  which  a  lu-altliy  iiiotiuT  Itoro  a  U'U- 

l<a'niic  cliilil. 

:\Iaiaria  is  hclicvi'il  liy  some  to  1h'  an  i'tinhio;iciil  factor.  01'  l.")0  cases 
analyzed  hy  (iowers,  there  was  a  history  of  malaria  m  30;  in  my  series 
there  was  a  history  in  at  least  !).  Syphilis  ajipears  in  some  eases  to  have 
l)een  closely  associated  with  leuk;emia.     The  disease  has  followed  injury  or 

a  hlow. 

The  lower  animals  are  suhji'ct  to  the  alVection,  and  cases  have  been 
deserilied  in  horses,  dogs,  oxen,  cats,  swine,  and  mice. 

Morbid  Anatomy.— Tlie  wasting  may  l)e  extreme,  and  dropsy  is 
sometimes  jiresent.  There  is  in  many  eases  a  remarkahle  condition  of 
polya'Diia:  the  heart  and  veins  are  distended  with  large  hlood-elots.  In 
Case  XI  of  my  series  the  weight  of  blood  in  the  heart  ehanihers  alone  was 
(IV'O  gramn\es."  There  may  he  remarkahle  distention  of  the  jjortal,  cerebral, 
])uhnonary.  and  snlnutalieons  veins.  The  Idood  is  usually  clotted,  and 
the  enornious  increase  in  the  leucocytes  gives  a  pus-like  apjiearance  to  the 
eoagula,  so  that  it  has  happened  more  than  once,  as  in  Virehow's  memor- 
able ease,  that  on  opening  the  right  auricle  the  observer  at  lirsl  thought 
he  ha<l  cut  into  an  al)scess.  The  eoagula  have  a  peculiar  greenish  color, 
somewhat  like  tiie  fat  of  a  turtle.  The  alkalinity  of  the  blood  is  dimin- 
ished. The  librin  is  increased.  The  character  of  the  corpuscles  will  bo 
described  under  the  symptoms.  Charcot's  octohedral  crystals  may  separate 
from  the  blood  after  death.  The  s])ecific  gravity  of  the  blood  is  some- 
what lowered.     There  may  be  ])ericar(lial  eechynioses. 

In  the  splcno-medullary  form  the  spleen  is  greatly  enlarged.  Strong 
adhesions  may  nnite  it  to  the  abdominal  wall,  the  (liai)hragm.  or  the  stom- 
ach. The  capsule  may  be  thickened.  The  vessels  at  the  hilus  are  enlarged; 
the  weight  mav  range  from  'i  to  IS  pounds.  The  organ  is  in  a  condition 
of  chronic  hyperplasia.  It  cuts  with  resistance,  has  a  nniiorndy  reddish- 
brown  color,"and  the  .Mal|)ighian  bodies  are  invisii)le.  (irayish-white,  cir- 
cumscribed. Ivmphoid  tumors  may  occur  throughout  the  organ,  contrasting 
strongly  with  the  re.ldish-brown  matrix.  In  the  early  stage  the  swollen 
spleen  pulp  is  softer,  and  it  is  stated  that  ru])ture  has  occurred  from  the 
intense  hvpera-mia. 

In  association  with  these  changes  in  the  spleen,  the  bone  nuirrnw  is 
involved,  the  lieno-medullary  form  of  the  (Jermans.  The  essential  change, 
indeed,  in  the  disease  appears  to  be  the  extraordinary  hyiu-rplasia  of  the 
red  marrow,  and  the  apiiearanco  of  an  liyper])lastic  cellular  tissue  in  regions 
where  in  the  adults  the  marrow  is  fatty.  Instead  of  a  fatty  tissue,  the 
medulla  of  the  long  hones  may  resemble  the  consistent  Tuatter  which 
forms  the  core  of  an  ahscess,  or  it  may  be  dark  brown  in  color.  In  Pon- 
fick's  case  there  were  luTmorrhagic  infarctions.  There  may  be  much  ex- 
pansion of  the  shell  of  hone,  and  localized  swellings  which  are  tendt'r  and 
may  even  yield  to  firm  i)ressure.  iristologically.  there  are  found  in  the 
meilidla  largo  nnmhers  of  nncloatod  red  corpuscles  in  all  stages  of  develop- 
ment, nnmerons  cells  with  eosinophilic  grannies,  both  small  polynuclear 
forms  and  large  almost  giant  mononuclear  elements.  There  are  also  many 
lari^o  cells  with  single  large  nuclei  and  neutrophilic  grannies— -the  cellules 


«■* 


^^,4  DISKASHS  (.F  THE   BLOOD   AND   DUCTLESS  GLANDS. 

,,,.l.,llaivo.  of  Cornil-Uu.  »,/./,.,'..  .l.iM,  a,v  found  in  iUM    Cront 
,„unl.ers  of  pulynn.Kar  l..n..ucytrs  ;..v  also  pivscnt,  a>  ^^.\\  a.  a 
iiunilKT  of  small  nioiiiinnclcar  I'lcMicnts.  ,1,,,;,..,,, 

„  tl>e  Ivn.nl.atic  lo,>ns  nf  tl,.  .lisras.  tluuv  .s  a  .uvnrral  lyn>pln.tu   cn- 
1,,-n  u  K.1,   is  nsnallv  ass-u-iatcl  with  a  ...Ttain  a.nuunl   o     cnlar,.- 

^V    1  ,lH       Icrn      iM  .mlv  one  of  n>v  cas.s  was  \\n'  splonic  ..nhn-vnu.nt 
"""    ;         n  J    f       npl.ali.'  l-.ka.uia  tlu-  crvvical,  axillary,  nu^.n. 

;;::;.';:  iZ^-nx,  ana  n.onth  n.ay  l.o  .nlar,.a.     Nnn>uous  nuto..  nu,y  1. 
f.mml  in  llu'  small  cells  of  Ihf  lyniphatie  tissue. 
,,.., .......  a.. u..^^ 

rir";  f!;  r  ?  ;   e  l  ^    ac'lna  ^:^n>.spK.nie  on.entum.     The  thyn.s 

.       V     >        ed,  though  it  has  been  enlar,.!  in  sonu.  of  tho  oas.s  o    .,eu 

v..  -tie  leuka.uia.    'Pho  bono  mavr.nv  in  these  eases  n.ay  be  rephued  b 

1;  l^mi^loia  Itsno.     :sueleatea    n.!    eovpuseles   ami    the    nonnal    .vanula, 

„,aiTow  elements  nu.y  l)e  jireatly  rean.ra  m  mnnl.er 

The  liver  mav  be  enhu-ed,  and  m  a  ease  aeserd.ea  by  ^^eU  li  it  nv   i- 
over      M-.nas:    The  enlar,en,ent  is  nsually  .lue  to  '-^   ^j-    ;;;;;;;•     ' 
j,^(iU,,^^^.  ,,     The  eoUnuns  of  liver  eells  are  wule  v  separatea  by  .l^'"-; ,        ' 
;;S  are  partly  within  ana  partly  ontsiae  the  loludar  eapdlar.es.     Iheu 

may  be  delinite  leiiknmiic  {growths.  .     ,,     ,  ,,-.   ,  i.;,i,,„v<  .„•(• 

-There  arc  rarelv  ehanjres  of  importance  ,n  the  Iuul^s.      1  he  k,dncy>  au, 

often    lr.ed  and  pale,  the  eapillaries  ,nay  be  distended  -th  leneo.  ^, 

,,,1  u,„Ua.nHe  tnn.ors  may  oc-eur.     The  sk>:-  n>ay  l,e  u.vohed.  a.  in  a  ..->. 

'"l^ilbvllde'tults  in  the  organs  are  not  ..onnnon.  They  w..re  present 
i„  j  ;  1  of  the  1^  auto,,sies  in  n.y  series.  In  15.  eases  eolleeted  by  ,..  e  s 
there  were  onlv  115  instances  of  leukaMuic.  nodules  .n  the  l.ver  ami  10  m 
li  vs.  These  new  growths  probaldy  develop  frunj  leneoc-ytes  wlneh 
I'u-elhe' capillaries,     iiiz.ozero  has  sh-wn  that  the  cells  wluch  eou.pose 

them  are  in  active  (issicm.  , 

Symptom3.-The  onset  is  insidions,  and,  as  a  rule   the  l-»-n    se     . 
aavh^ffor  proo-ressive  enlaro-ement  of  the  abaonien  an.l  shortness  ol  bi  a 
;;    ;;;  tbelnhir^ea  .lands  nr  the  pallor,  palpitation,  an     o t lu- r  symp  o    s 
„f  ,,„„„i,.     i-ieeain^  at  the  nose  is  connuon.     ^-^^  ■'o-.ntot.nal  s^     pt^ 
mav  nreceae  the  onset.     Occasionally  the  iirst  symptoms  are  ol  a  ve.y  sn. 
^nXe.     m  one  of  the  eases  of  n,y  series  the  boy  playea  l-™-  Uo 
vs  before  the  onset  of  the  ilnal   ha.naten.esis:  ana   ,n  -.ot h..  e  m^  a 
.id,  who  had,  it  was  snpposea,  only  a  slight  chlon,s,s.  a,,    o    t  .,     1     m 
orrha,.a.   from  the  stoniaeh   before  any  susp,ei.>n   Inul   been   a.ousul  a. 

the  trne  condition.  ,     ,.    n     *     .      „c  <i,,.  .1i<e-)<e- 

Amvmia  is  not  a  necessary  nccompauiment  ol  all  stajio  oi  the  discas.  , 

the  subieets  mav  look  very  healthy  ana  well. 

A.  has  been  slatea,  the  aisease  is  most  commonly  seen  m  t^^o  main 
tvpes,  though  eondiinations  may  occur. 


LEUK.HMIA. 


S05 


(1)  Spleno-medullary  Lenkremia. 

This  is  much  llif  (■(Uiuiiniic-l  ty|H'  .if  tli(^  (li^'iiso.  Tho  ,i:r:i(liial  m- 
oiviisc  ill  the  vulimic  of  the  ^|)il■^■ll  i>  the  inn,-t  inniiii iiciit  sviupldiii  in  a 
in;ij(.rily  of  ihc  ciiscs.  I'ain  and  tcndcrnc--^  aiv  cnmniun.  ihnii.uli  the  pni- 
^■R'ssiv("  cnliirucni.'nf  may  liv  painless.  A  civakin.L;-  fremitus  may  lie  iVll 
on  pal|)a(inii.  The  enlarged  m'-an  extends  duunward  In  the  ri,i:iit,  ami 
may  he  felt  jnst  at  the  cnsial  ed-v.  or  when  larue  it  may  extend  as  far 
(ivt'i-  as  the  navel.  In  jnany  eases  it  (,eeu].ies  fully  one  half  of  the  ahdo- 
men,  reaehinjr  to  the  pnhes  helnw  and  e\lendin,i;'  heyond  the  middle  line. 
As  a  rule,  the  edizc  in  foine  the  notch  or  notclu's,  can  he  felt  distinctly. 
Its  size  varies  <:reatly  from  tinu'  to  tin\e.  It  may  he  percept ihly  lari^'er 
after  meals.  A  Inemorrliaj:!'  or  fi'ee  diarrluea  may  reduce  tiie  si/.e.  The 
pressure  (d'  the  enlar.^'ed  oruan  may  caii-e  di>tre>s  after  eatin.ii';  in  one  case 
it  caused  fatal  ohstruction  cd'  tlu'  howeN.  A  mui'iuur  may  sometimes  lie 
heard  over  the  spleen,  and  (ierhardl   ha~  de.-crilied  a  puLsitioii  in  it. 

'/•//('  piilsr  is  usually  rapi<l,  soft.  .  ompressihle.  hut  (d'ten  full  in  volum<'. 
There  are  rarely  any  canliac  sympt-mis.  The  apex  lieat  may  lie  lifted  an 
interspace  hy  tho  enlar<:cd  .spleen.  Towaid  the  close,  as  a  conse.inence  oi' 
the  feehle  circulation,  ledema  n\ay  occur  in  the  feet  or  there  may  he  .^'cn- 
eral  anasarca.  Ihemoriha.ue  is  a  oonnnon  >ymplom  and  may  ho  either 
late  or  early.  There  may  he  most  extensive  pnrpuia.  Kjiistaxi!!  is  the  most 
freipient  form.  il:emopiysis  and  ha'iuatiiria  are  r;ire.  lUeeding  from  the 
o-iims  may  he  present,  ifa-mateniesis  proved  fatal  in  two  of  my  cases,  and 
hi  a  third  a  lar<ro  <rrehral  hinnorrha-c  rapidly  kiUi'd.  The  lenkivnuc 
retinitis  is  a  ])art  of  the  hn'morrhai^ic  m;inifestati(Uis. 

Local  j,'anj;rene  may  develop,  with  siixiis  id'  int.'use  infeetion  ami  hi,<:h 
fever.  Tlfero  aro  very  few  pnlmonary  symptoms.  Tin-  .shortness  of  hreath 
is  due,  as  a  rule,  to  the  anaemia.  T(i\vard  the  end  there  may  ho  (odema  of 
the  lun-s,  or  pneumonia  may  carry  olT  the  i.atieiit.  Tho  fiasiro-intestinal 
svmptoi'us  are  rarely  al)sent.  Nansea  and  vonntini:  are  early  features  in 
s'ome  ca^es.  Diarrluea  may  ho  very  troiihle-<mie,  even  fatal.  Intostinal 
luemorrha-e  is  not  e(mim<m.  There  may  he  a  dysenteric  process  in  the 
colon.  Jaundice  rarely  occurs,  ihoii.uh  in  one  case  of  my  scries  there 
were  recurrent  attacks.  Ascites  may  ho  a  prominent  symi)tom,  jirohahly 
due  to  the  presence  of  the  splenic  tumor.  A  louka'inie  peritonitis  also  may 
he  present,  duo  to  now  <,n-o\vths  in  the  memhranes. 

Tho  nervcnis  system  is  not  often  involvi'd.  Headache,  dizziness,  and 
faintinfr  spells  are"  duo  to  anamiia.  The  patients  are  usually  tran-piil  and 
rosi'nied.     Sudden  ccnna  mav  follow  ceiehral  haan.n'iiia.uo. 

The  sjiocial  senses  are  often  atVected.  There  is  a  i.eculiar  retinitis,  due 
chiefly  to  tho  extravasation  of  hlood,  hut  there  may  he  ajrfirefiations  of 
leucocytes,  forming  small  louka'inie  .growths.  Optic  neuritis  is  rare.  Doaf- 
iioss  has  freiiuently  hcen  ohserved;  it  may  ajtjiear  early  and  possihly  is  due 
to  ha'niorrhaii'o. 

The  urine  presents  no  constant  chan.ires.  The  uric  acid  excreted  is 
always  in  excess,  and  possihly,  as  Salkowski  su-uests,  stands  in  direct  rela- 
tion "to  the  si)lenic  tumor,  or  to  tho  ahundant  leucocytes. 

Triapism  is  a  curious  symiitom  winch  has  heen  present  in  a  large  nura- 
50 


I 


f 


SOO  WSKASKS  OF  Till?   m.nnn  ANl.  IHMTI.KSS  (.l.ANPS. 

!■  \-,\,'<   .■•!>.(■<   Ill'  till'  first  sviiii»t(>in.    Vva- 

s:',:;;:i;;:r^^;^;;;.r;;';:.::;....;;:.:-» -•■■■' --"■• 

"' -^'-'iT '-r-r ;;j;.:'t'rf  ;;;x;  Tu;;t::;;;;r = 

iilU'vnatc   with    l.n.lon-cl    iiiUi\al> 

'''%,^T  r^ll  tWm<  of  ilu'  disc..'  the  .lia,nosis  must  lu'  ni.!.'  l^v  t!,o 

„•„,,.„,  ,,  ,„u,  ,.,.  e.ul.u.  -;;^;^^^    ^    ^::^^^^^^^^  K,uka',ni;.  tlu'  pro- 
;;:::;:;:rVo:;:ni  h,^i.;;^^  the  nunib./ot  U'ueu.yto.  has  .....h...  that  of 

lows:  The  small  nmnoiiiu.U'ar  H;!"'^ ;;;;,  1     ,!    ,",',,,   in  nnnnal  or 
,,,,,  „,  ,n'a,ly  .liuun.lud.      ^ '>;,-"  ^'^ a  're  t    to,:,l   imre:,se,  and 
i,,rea.ea  relative  I'-r''-';:,.-;;,    '    ^    '^^.^  i.e.llilood-slide.     The  poly- 
thoiv  iiresen..e  is  a  ^^;;^-^  j^     '     ,     j,,    Ivtion;  more  fre,uently  they 
nuclear  lunitrophilcs  iiia\   he  "."""'*',.,',.,.,, ^„  ^i,^,,.  ,„;iv  fonn  hut  a 
ave  relatively  dimini.hcd    and  ••"';;-  ^Xd      iercn^es  in  size  bo- 
small  proportion  of  the  colorless  '■'^•'     "'^    J'    ;\  ,,^^,.,.  tlu'  same  is  true 
twoeu  individual   l-ly>>>'''->'' ^^'^''^^  ;/, 'j     ^    jur^  o    the  blood  in  this 
of  the  oosinophilcs.     'Phe  most  ''•'^■•7       :^';,   ^   ^  m  t  occur  in  nornral 
form  of  leuka'mia  is  the  l-resence    -y'^^^^;  ^    '         ^^^      ,,,,i  ,,,  ,,,lR,.l  by 
,,1      They  "i;P:-t;;^^^,  ;:•■;:;;;;;:,,•';.;  :rth.;\he  lar.e  mono. 
Ehrlich   miirlnrntrs.      Ihe\    au   en,  1  .  _  .  ,,,,c  u'ance,  but  dilTer  I'r.mi 

,^„,.,,„,  u,„,,u.vtcs,  and  are  similar  to  ^l'^'' ''''',  '\\^.  .„,„  iH'ulrophilic 
them  in  the  fact  that  the  pn.toplasn,  ^  ;:'',;,f,,^  ,,,,,,  ...Lnts 
j^vanules.  MviHer  has  recently  ound  ^''^  /,-,S;\' ;,,,,,,,,.,,  These 
ti,h  karyokinetic  li.nrcs  ,n  '-'-;- j';;/;^  we  I  o  tlu' '^  cellules 
,,Ody  correspond  to  the  niyeloc^e>ol.hw.^^^ 

,, -nullaires  ••  -d'  ( 'ornil.  •'''l>-'>^'^'^''^\ /:'':;,'  ,  ,,  ,„„;,  „  considerable 
^.  Mastzellen.-  are  al...ys  1--^'^  ^i  'h  <  V  <  '1  '<-'"-•  '^"^ 
„„,„,,,,,.  The  ,.n-am.les  do  not  f^'^''Vv  in'-unlar  elements.  These 
„,.  cells  may  be  recognized  as  l-'X"-  ^  .;  "^  [  H'c.lc'Vtes  of  normal 
,.,'11^    which   lorm  only  about  <^.i^  pel   n  .u   01   10  . 

1..1. >■ '-  "■7.""";' ' :;■■";;: ':;:;:',;  ::o:;r'':'i:vn,,,.,. k.,,. 

N,„.U,,l...l  r.'.l    ''''■■''-'■"7'' ''■  r-  7  J  ;■;    I,  I,,,,,,.,.  ,„,l.r  m,.Wi.  «»,.■ 
Tl,c«.  .re  »«i»lly  "  .lornml.lBt*,    U„    "       ""        '^,,„J  „,„,   (,,,,„„,„,,,1 

,™„,,i  „,,.  <o„„„n>,.  wlul,.  I  n«.  l^'!-';'"';;','^';  ,,X;  V     ,  ,,, |.,.„,,m«V,; 


,    IViv 
is  nut 

i;i  iii;iy 
rv    luiiy 

l,y  t!i(> 

!    liono- 

iionnul 
)-7,t>(it»; 
till'  pro- 
.■  iU'c  in- 

that  of 

s  as  ful- 
•elatively 
oi'inal  or 
>:iso,  ami 
Mie  poly- 
iitly  thoy 
•111  but  a 
1  size  be- 
10  is  true 
)d  in  tliis 
n  normal 
calli'il  by 
■o-(.   inoiio- 
ilTor  I'roiu 
'utro\ibilic 
•  olcincnts 
w.     Those 
,>  "  coUulos 
L'  g'ramib's, 
iiisi(li'ral)le 
xturo,  and 
Its.     These 
of  normal 

0  numbers, 
uclci,  some 
rrajiinented 
\i>re  is,  as  a 
-(•orpnsc'les; 
Tlie  liaMiio- 
The  accnm- 
vniously  en- 
lav  be  men- 


LEUK.EMIA. 


Sc'i 


tinnnd  tlie  fccldcncss  of  the  aiiio'lioid  inovcnicnt.  as  notdl  liy  Cafavy,  whuli 
may  hv  accounted  for  l.y  ihc  lar-r  nund.cr  of  niononiicii'ar  elements  present, 
the"  puivnnelear  alone  |.ns.-e>sin--  this  power.  The  hjood-jilates  e\i.-l  in  van- 
able  nlinilKM>:  liiev  may  be  remarkably  abundant.  The  librin  u.'twmk 
l,et\v(rn  the  corpn.H'h'S  is  usually  thick  and  .h'liM'.      In  bloo<l-slides  whuh 


MPAN  NORM. 

NUMQE"!  OF 

WHITE 


BLACK,  RED  CORPUSCLES. 


RED,  HAEMOOLOBIN. 

CiiAKT  XX.— Lcuku'inia. 


BLUE,  COLORLESS  CORPUSCLES. 


iire  kept  for  a  short  time.  Charcot's  oetohedral  crystals  sei)aratc.  and  in  the 
hh.od  of  leuka'iuia  the  luenioglobiu  shows  a  remarkable  tendency  to  crys- 
tallize. 


I 


mm 


SOS 


1)1 


SEASES  OF  THE  HLOOD  AND  DUCTLESS  GLANDS. 


:>.  Lymphatic  Leukffimia.  i    ;„  i„  t   i  ..f  mv  ^rri.s 

lis  in   ll...lf:kn.  .  <li>*.i.*.      ' m  •  ,        ,,  ,,|,,,„„i,,  ,,,,,,, 

iHiku'inia  isolfn  iiinic  nipi.!  niul  l.il.il  m  H    (oii,,. 

,n.,v  ncciir      It  is  mop'  c.unmon  111  VdUiiji  sulMirt^.  •      iiv.r 

,        1        n,nrilu,M.  in  tlio  >plrno-nR..liillavy  I'on...     'N"'  ■"'••■'■"^*'  '"  ^''^ 
"''"'■'■'"">   ''  "  ,.,.,!  •,.  in  tlu>  i.rcmlin--  lonn:  a  i.r<M«"rti"n 


„tlKT  forms  ol   U'licocytrs   hnn- 

V  cases  over  UN  yvr  cent  ot  all  tlie  U'luo- 


->'''i-  l'-r''''';'\ '"';'''',,,...  ns  n,i.ot  has  pointed  out.  tins 
,v„s  ^-'''V^-''';'''-  :,,',■  :<n  IK  •  lnrm>.  while  in  others  the  lar.o 
rT  :  ';  il  ,  :  S  ,  a  '  a  .olvnudear  leucoey.e^-prcaominate. 
IvmphocvCs — ccll>ne,iiiy  as  i.h^l  «    i  M,.,,i,„.v(r.^  -ive   not 

^:.Jno,.hiles  an.l   n.uleate.l  red  cor,mscles  are  rare,     ^lyelocytc,  au 

^'"tI^c  ,nuv  mv..l..'enous  cases  withont  associated  enlargement  of  tho 
s,de  n  a,r   .r        Tlu.  most  extreme  hyperphisia  of  the  Inme  .--r-.w  u.y 

.f^I)lel'll    iiii     Kill.  .  .         ^(..riinui       1'l   )^.     aiU     11  IT 


expansions 


C.ml.ined  I'ornis  of  leuka'iiiia  ma} 


V  (•cciir.  Ihnii-h  Ihey  are  not  eonimon. 


('(iml.inedlornis  Ol  leni^, .■„..„  .......    •.  ■         ,,•,,■,.,1       il,,,v   tl'e 

,,„„  Mich    in>taiice  occnrrci   at    the  Johns    Hopkins    llo^pU.  1.      ""\  ';, 

-k'n;:.;:-S:'l^';,:::;iir;:n,,;"^^;^ 

voiinlpersons.     Fussell  and  Taylor  have  collected     (1  oases  Iron,  the  lite...- 
'~  T.,.,  r.,t.,l  ..vent  occnr<  in  two  or  tliri'c  months. 
'■  Dii^nos  S-  t        '..nition   of  leukemia   can   be  determined    on  y 
...  ^- So   Si  examination  of  the  Idood.     The  Ciiii.d    eatures  niay    . 
i,,„,,,,  ,ith  tlio>e  of  ordinary  splenic  an.cn,ia,  or  "     '  ^^^    ^    !,      V 
\„  inten-tin-  (p.otion  arises  whether  real  in<Teas(     11  the   luu  uytv. 
;  h  c  i.i:;ion  of  the  existence  of  the  disease.     Thus,  lor  '-tance     n 

e     "<    who.e  chart  is  oivon  on  pa?o  807,  tl...  patient  came  under  ol.ei   .1- 
i   n    in   S Itemher.   l.s^:;...   with   -'.OO.).*).*..    ih.I   hlood-corpu.des   per   cn-i 

iK.r  enl.ic  millinietre-a   jiroportion  of  1   to  -1.     .\>  ■ '"^  "     . 
!hrou,hont  Septemlu.,-,  Oc.oher.  ^^oven.her.  and  ^^^:  :^^;  {^^^^^^^ 
,„aint^incd.     Early  in  January,  nnder  treatment    -       '^ ^ "    ;        ,,    '  ,,„ 
cornnscles  he-an  to  decivase.  and  j:radiially.  as  sIionm   11    »!'     *"    ; 
lal  ratio  was  reach..d.     At  this  time  coi.ld  i,  he  sa,     ^^^^^^^^  tC 


") 


I1()1)(;K1NS    DISKASK. 


SUl) 


still  prcsnit    ill   nmulKTs  Miiruinit,  at  iiiiv  yM<\  i"  sujr<;(>st.  if  tlie  piUii'iit 

lliul   cnin.'   Ull'l.T  oliMTVillinll   lol'   till'   lil'sl    lillM',   lllill    Icll  kl.'lllill    IIU-Ill   OLTlir. 

J'.y  Kliilicir,-  iiiciIkmI  of  l.loud  (•Viiiiiiiialioii  n  coiKlilinii  of  Iciicui'^losi.s  liUi 
n'adi'ly  lie  (li^lin-ui^ll(  d  Innii  that  of  Iciika'iiiia,  for  iii  all  nnlinary  l.'iieo- 
cvIom's  the  iiKivasc  takes  placi'  h.I.'I.v  ill  ill.'  |M>lyiiii(lrar  iiciitr.>|iliilir  cfHv 
The  iTiiiarkaMc  "  ^ivcii  (■aiiccr  ""  '>r  clilnriniia  is.  acionliii'.'  to  Dock,  "a 
lyiniilioiiiatoiis   prom-s  similar   in    it>  .■la>^i.al    IValiiiv.   to   Inikaania   aii.l 

[isci'.do-lciika'iiiia." 

Prognosis.  — IN'fovcry  ocfasioiially  oc.iii>.  A  ;:ival  majority  of  the 
cases  prove  fatal  within  two  or  three  year>.  Infavoiahle  si,uiis  are  a  teiul- 
ciicy  to  haiiiorrha-e,  pei>istciit  diarrliiea.  early  dropsy,  and  high  fever. 
1,'eniaikahle  variations  are  di.-i)layed  in  the  course,  and  a  transient  iiii- 
proveineiit  may  lake  place  for  weeks  or  even  iiamths.  The  pure  lymphalie 
I'orm  seems  to  he  of  parlicular  malignancy,  some  cases  inoving  fatal  iii 
ironi  six  to  ei-iil  w(rk>;  hut  there  aiv  exceptions,  and  I  have  recently  seen 
a  case  in  which  the  diagnosis  was  mad.'  ten  years  ago  hy  W.  II.  Draper. 
The  i.atieiit  has  had  enlarged  glands  ever  since,  and.  though  not  aiuemie, 
the  leucocyH's  were  -J  l-.'.dtn)  per  ciihic  milliiiu'tre.  ahove  i)U  per  cent  of 
them  licini;-  Ivmpliocvti's. 

Treatment.  — Fresh  air,  good  diet,  and  ahsteiitioii  from  mental  yvorry 
and  care,  are  the  important  geiieial  iii.lications.  The  UuHmlio  nmrhi  can- 
not 1)0  met.  'I'here  are  certain  remedies  which  hav.'  an  inllueiice  upon  the 
disease.  Of  these,  arsenic,  given  in  large  diws.  is  the  iiest.  1  have  re- 
peatedly seen  improvement  under  its  use.  On  the  other  hand,  there  are 
curious"  remissions  in  the  disease  which  render  therap.'Utical  deductMms 
very  fallacious.  I  have  seen  such  marked  improvement  without  sp.rial 
treatment  that  the  iiatieut,  from  a  hed-riddeii,  wretched  condition,  recov- 
ered strenu-tli  enough  to  euaMe  him  to  attend  to  light  duties. 

Quiniire  may  he  given  in  cases  with  a  malarial  history.  Iron  may  he 
of  value  in  some  c:iscs,  as  may  also  inlialati<ms  of  oxygen. 

Kxcision  of  the  leiikaaiiic  sjileen  has  lieeii  performed  V  1  times,  with  1 
,.i,,.overv— the  case  .d'  Franzolini.  Ku^-.l!  gives  the  >tati>lics  of  H'o  cases 
„f  spleiiectomv  with  IS  deaths.  Of  the  cases  of  >iiiiple  hypeitroi-hv,  -JS 
ill  number.  l»  recovered.     Of  Ki  cases  of  lloatiug  s[>lec!i,  15  recovered. 

III.    HODCKIN'S    DISEASE. 

Definition.— .Vn  alTeclion  characteri/.ed  hy  progressive  hyjicrplasia 
of  the  lymiih-ulands,  with  anamiia,  ami  occasionally  the  deveh)pment  of 
seeondarv  Ivmphoid  growths  in  the  liver,  si.leen,  ami  other  organs.  The  dis- 
ease has  also  tlie  names  psridln-kiihiwin.  (/nimil  luiiiphnilniiniin,  and  aileiite. 
'  lIod.d<in  the  \velld<n.nvn  morhid  anatomi>t  <d'  (iny's  llosiiital.  first 
descrilH'd  cases  in  detail,  and  l)y  tlie  labors  of  Wilks.  Virclmw.  r.illroth. 
and  Cohnlieim  the  disease  attained  definite  recognition.  ^  ^ 

Etiology.— A  majority  of  the  cases  are  in  young  iiersons.  Tn  Gowcts 
table  of  1()<)  cases.  r.O  were  under  twt'iity  y.'ars,  IM  between  twenty  and 
forty,  and  30  above  forty.    Tliree  fourths  .d'  the  cases  are  in  males.    In  a 


I 


(■ 


810 


I.ISKASKS  (.K  TllK   BL()..1>    ANU    I.K'TLr.SS   <iI,ANl)S. 


•lit 


^:^r-:;::r:;;i^J:n:;;r;:^f;::\::,;;:;:rl;::.:r>;;:;^^^ 

Morbid  AnatU.vv,,.  /,,;„.-.. -.-I" ;.  I;-;;;-;:    ,;■ ;  • 

;:;-;;^'^;;:';,:;:;:;:K';:::';:^:::i;.;;i:^^^::t■'r''^''^^ 

,     i        <■    ,u,.s.  ami  tlu.v   mav  1.  tni.nl   a.  nmliiiuuus  ;'l'--      '^  "" 

:s;;::',,:!;:::ni:=^t':;;:,:;^™':;;£.:;q- 

V  rroun.l..l  l.v  llu.  ..n-wtlis.  a.ul  Ik.  but  littl.  .■oin,uvs....l.        u  n 
iio^lntmor  ;iu..lia.,in,nii  the  inassos  may  pcvforato  tlm  s.cnuui.  and  ap- 

''^'';;r;;;;/:;::;;:!n:r:;:;up.t,.on.i..o,..ito.^ 

V..1  .1    111.1  may  form  a  c-oiitiiumus  cliain   from  tlm  .  ,a,.lin.uiii  "'    '   '    '^ 
;  laK  ami  .xt.ml  into  tlm  pelvis.     Tim  gland.  -;7  --i-- j^' 

nlwv<  involve  the  sacral  or  lumbar  imrvrs.  or  impin.irc-  n,.<,,   tlio  iliac  ^an 
r:;i.;i;;;ily  thoy  adhere  to  the  ntcrns  and  broad  'i^';-;  ^^ -^  ;'  .;  ^^l 
late  llbroids.     1  saw,  some  year,  ago,  one  ol  tiic  ->    '        '^    ^       ;>,;,,, 
oologi^t.  of  Germany  perform  lai.arotoniy  ...  a  ^"^V  i         ,         d  el 

11,    dia.nmsis  of  invomatoi.H  t.in.ors  of  the  nterus  had  bee.  •"■"    • 
lilmllk  the  mesenteric  or  hepatic  lymph-,la..ds  may  lorn,  large  abdominal 

^"";;;;/...;;,W/,  the  chief  change  is  an  increase  in  the  cell.  ^^-^_ 
out  thickclin.  of  the  rcticnhim.     Tn  the  early  stage  there  ,>  >      1^     >1- 
phisia  and  the  relations  of  the  lymph  paths  are  --"  '^-■'  ".^     ,      ''", 
glands  are  .-atly  cmlarged   the  .mrmiU  a,x.n^^^  ^^^^^ 

::i^r  i;z;;rr';h;;  i.:;:i;.r;^;"^         -  --  >^  -- 


■~i 


lIoDliKlNS   DlSKASi;.  811 

(li>tiiut.  mid  tlii'iv  is  pniliMliI}'  an  iiiciva.-rd  .IfVclopiiu'iit  nl'  the  adciinid 

li-^lh'. 

Sphrii.  Ill  :.")  IMT  Cfllt  nl'  tin-  casi'^  (•(.llrctcil  h\  (|..\ViTS  tills  or^'illl  WHS 
li\pcitrn|ihiiil.  and  in  ."''i  <d'  iIicm'  it  lavsciilni  iyniplinid  nrowtiis.  'I'lic  fii- 
lai-cniriil  is  raiciv  )1V^'A\,  ami  ddcs  not  a|'pr"\iinalc  M  thai  of  ih,'  larp' 
|,.iika'inic  >pl('cii.  "  The  Ivnipiini.l  liimnis  Inriii  -l•avi^ll-\vllil.■  ImmHcs  niiiK- 
iii;:  in  >i/c  liniii  a  pea  In"  a  waliinl.  and  iiiav  iv>cinM.'  lyiii|ili-,-laiids  in  ap- 
pearaiUM'  and  r(,n,-i>l(airc.  ili.-ln|n-irally,  llu'.v  (■un>iM  nC  lynipli  ciipus- 
clcs  ill  a  lilnniis  rcliciiiiiin. 

'I'hf  niarn.w  (d'  the  Inii^-  1m. nc-^  iiiny  lir  (■(.nvcitcil  iiil..  a  rah  lyniplinid 
tissue;  in  a  IVw  instances  tlie  pvnid  loiiii.  siidi  as  is  iiioiv  ((iinnion  in  Ifii- 
kaaiiiii.  Iia^  liceii  fniind.  Tlic  tnns.ls  may  he  iiiv.dvcd  and  llic  fnllirlcs  at 
1|,..  viH,\  nf  ihf  tnii;;nr,     ( tcca-ii Mial ly  MH-.indaiy  ^loullis  aiv  .-rcii  in   tlic 

iiit(  .-tines. 

The  li\er  isidteii  eiilar-cd  and  may  |>re>eiit  scattered  lyniplKud  iiiinurs. 
The  kidiicvs  arc  (.ccasii.naily  iiivnlved  and  arc  tiie  >cat  of  nrowllis  similar 
to  thnsc  in  llie  spl.'cn  and"li\er.  The  inn-s  aiv  (.ccasioiially  diredly  at- 
liick,,!  fnan  tlie  hioiichial  ,uiaiid>  a!  ihe  rent,  and  >ec(m(lary  m.diile-^  may 
he  Iniind  tlinm-lmiit  their  siiiotancc.  I'leiiral  eiriisiniis  are  iml  uncniii- 
1,1,. 11.  Invnivcinent  ..f  the  iicrvc.ns  system  is  rare,  I. lit  iiarajde-ia  may  l.c 
in.hiccd  i.y  iiiva,-ion  nf  tlie  spinal  canal.  The  ^kill  may  he  the  seat  (d' 
ademnd  j:r(.uth-.  as  in  a  ca-c  repdited  hy  ( irceiiricld. 

Symptoms.  — Knlar-iaiienl  nf  the  -lands  (.f  the  iieek,  axilla,  nr 
KV(.iii>  i^  ii-iiallv  the  liist  .ymptiiiii  imticed.  in  a  W'W  ca-es  the  amemia 
and  enii-titnlhiiial  ^vlnpt^ms  attract  attciitinii  hcfniv  the  olandiilar  m- 
volveineiit  is  evident.  When  the  tnaihle  heuins  in  the  deeper  .irrnnjis. 
pre^Mirc  elVccts  mav  he  lirst  m.tiecd;  thus,  paroxysmal  dy>pmea  with  pam 
in  tl„,  ,.h(-t  mav  iVmiH  I'mm  eiilar-ciiient  nf  the  hrniichial  .uiaiids  hel'i.re 
aiiv  phvsical  si-ns  can  he  detected.  (Kdema  of  the  feet  and  sli.w.tin.Lr 
paiiK  in  the  nerves  w.'iv  the  lirst  syini.timis  in  niie  can'  which  I  di-ccted 
inr  l{..<s.  and  in  annih..r  ca-e  at  the  Mniitival  (LMieral  llnspital  there  was 
i.arapl.-ia  frniii  pre.-siire  nn  the  c(.rd.  Such  iii>laiic.'<.  Imwevr.  are  ex- 
cvptinnaK  and  in  tli.'  niainritv  .d'  cases  the  swellin-  <>\'  the  siiperlicial  -land^ 
is  the  earli.'<t  svinptmn.  Kpistaxi^  has  ...■ca>iniially  lieen  noted.  hi,t  not  po 
fre.piently  as  in  leiikaania.  With  pr..-ressive  enlargement  ol  tlie  -lands 
the  patient  hecomes  ana-mic.  _ 

r^nallv.  the  cervh'al  -rmip  is  lirst  alTceted.  and  it  may  he  impossihle 
to  dicidewhctliev  tlm  enlargement  is  syphilitic,  tul.erciilous.  or  lynipliad- 
ononiatoiis.  One  side  is  lirst  afl'ected  as  a  rid.',  and  it  may  he  moiitlis  or 
even  as  in  one  of  niv  cases,  three  years  l.eiore  the  allVrtioii  extends  to 
other  -roups.  T'ltirnatelv  lino-e  tnniors  may  devclo].,  wliudi  ohliterate  the 
neck  inid  extend  npoii  tlie  slnnilders  and  over  the  clavudes  and  sternnm. 
The  tracliea  is  surrounded,  uivat  dvspiKea  is  j.n.duced,  and  not  mlre- 
.pientlv  tra.dicotomv  is  neco^ary.  In  the  later  sta-es,  the  skin  hecomes 
inv(dved  and  nlcerates.  The  axillary  -ronp  may  form  lar-e  tumors,  which 
enmpress  the  hrachial  or  axillary  veins  and  cau^e  swellin-  .d  the  arms. 
The  in-iiinnl  -lands  mav  lorin  lar-o  or  even  i.endnlous  tumors. 

In  the  th.micic  -iaiids,  as  mcnti.med.  the  various  .irronps  may  bo  m- 


M* 


} 


1  ■ 
'"  i 


gio  l.ISKASES  OF  THE  BLOOD  AND   DUCTLESS  GLANDS. 

atcil  aiHl  a  \ii\   (\uii.  i^^  ^U'luiim  was  a 

-■^■'''•■ni:;:;:;-:;';;i;r:;:;::;n,,iJ'::!;;;;n:^;M..,,,,,i.,..  .,.;...■ 
r;;:;:;:"t:'';^;i;:;:;;;.^:;irr;L  ;m^  i^^ 

,„,„„„,„  „r  .lu.  skin,  .M,.h  --^1    '"•'-,,, ■';,„',,:„•,„  „„  .i„. 


„I  ,1,.  r-l^n'lH.     TlH.v  nuy  "■"""     ■ '    . "  ,      ,\i,.,|,|,  „„„•   Imii.i*  voiy 


„,v  l.e  involv.l.  an.l  iu  a   f.w  ;-^;;;;;:;:;  ^j;;;,,;,- ,,,,,,,,, ous  onlar,.- 

10  111'  iiiv  call's  tlu' 


'nimi<'h  pvi'scnl  in  a  iiiajorHV  o 

....IV  ..,.,■  i..*...<- 1...- 1  '■""""■■' '":; '"";"'" .;:',;,  .„,,„...i,..  ...,.y 

l;:;t";;;t^;^^;:;L;l  ,;5 

„,  „„„ui,s.     TlK'V  won-  .nesont  i.  (  a.e  I  (t  im  , 

an  apyroxia  oV  tvn  ..r  rU'v.n  <1^>>>-  ;      ^^^  „nco,mnon 

Tlu-  (lisroslivo  svmi>t()iiis  air  uMiallx  not     i-    i^^"'     " 
^,^  ,,,,.1  ,i,;,„,i,.  i,;  ih,  „vii>..     ll.a.la..h..  .■..l.lH,.<s.  an,l  .u  m.        th 

^.,ri.,i,.,1  will,  the  aiia-niK"      '.Vlirimn  and  coma  may  cn>iu'.     D  .U 

to  ,m-nve  of  tlu>  dmi.ls  on  tl.e  cervical  sympatlictic.      1  in   >Kin  "''^^ 
l;:,!;;Uo  sl^ondarv  lvn,,halic  tu„u>rs.  hron.in,  may  .ucur.  and  occa.onalh 
a  most  intense  an.!  tronl,l.>so,ne  i.nm.ao.^  ^^ 

■nino-Tiociis  —  \  t\il)emi  iius  adenitis  ina\   at  1ii:-t  no  ^">   "  '" 
Sr'rhe  chief  points  of  distinction  are  a.  follows:  Tuhore.lor. 


(liffc 


IIODGKIN'S  DISEASE. 


813 


.-..leniti^  is  more  eoiinnoii  in  tl.c  voun-  iin.l  iinclvcs  llic  siilimnxiUavy  ^^voxv> 
of  olan.ls  inoiv  ImiiK'nllv  tliaii  tlu.sr  (.f  tiu'  anterior  an.!  i.n>trrior  m'vical 
iriln-ies  whicl.  aro  nsnaliv  nWvvivd  lir.t  in  llu,l-knrs  (li>ras.'.  llu-  cn- 
lar-cnuMit  niav  last  lor  vi'ars  in  a  -ronp  witiioul  (.Mcn.hn-.  '!'!..■  Imnchcs 
an'ol'trn.  wliVn  small.  \sMvd  to-vthcr  and.  most  imiiortant  ot  all,  trml 
.,,  ,,p,j,„rati— a  I'caturc  raivlv  swn  in  \vuv  lympliadciioma.  rxcrpl  wlum 
it  has  attain..,!  vrv  lai-v  si/.r.  Slrirt  limitation.  t„  nn..  side  ol  tluYuyk 
„r  to  thf  axilla  is  sn-iicslivc  of  tnl.c'ivulons  disease  rather  than  lympliade- 


iioma. 


'i'here  is  an  aente  tuherenlous  adenitis,  whieh  may  involve  the  lymiih- 
.-lands  or  the  neek.  prodnein-  enonnons  enlargement.  .\  man,  a-ed  twenty- 
iour  w  <  admitted  to  the  Cleneral  Ih.spilal,  .Mo.Ureal,  with  -reat  swelling 
„'■  the  eervieal  <dands  on  hoth  sides,  tonsillitis,  and  slonnhin.i:  pharyngitis, 
with  irre.nilar  i'ever  and  diarrh.ea.  The  ease  v.as  at  lirst  re-arded  as  one 
of  Hodokin's  disease.  The  oeeiirreiiee  of  ri-ors  and  intermittent  pyrexia 
i<  ill  favor  ni  IvniphadeiK.ma.  There  are  eases  in  vvhieli  it  may  lor  a  time 
he  inn.,ssihle  to  make  a  diagnosis.  When  the  -lands  are  only  inoderately 
enlai-ed  on  ..ne  side  of  the  ne.-k  or  axiHa,  they  s^houUl  he  removed,  and  the 
dia"nosis  can  then  he  tliorou-.dily  ostahlished. 

"prognosis. --Iteeoverv  is  verv  rare,  'i'he  eonrse  of  the  disease  is  ox- 
trenielv  variahle.  Karlv  alid  rapid  growth  in  the  mediastinal  groups  may 
produee  i.ressiire  eiVects-iuid  canse  death  hefor.'  the  development  is  ex- 
treme In  some  eases  the  enlargements  sprea.l  rapidly  and  group  alter 
„,,,up  heeomes  involved  in  a  few  months.  These  aente  ease  may  run  a 
eonrse  in  three  or  four  months.  Chronie  eases  may  last  f.>r  three  or  f.mr 
Year<  Period^  of  (itiii'seeiiee  are  not,  nneomnioii.  The  tumors  may  not 
onlv  eea^e  to  "row  hut  uraduallv  diminish  ami  even  disappear,  without 
s,,e'eial  treatment,  rsuailv  a  eaehexia  develops,  the  aiKemia  progresses, 
and  there  are  dropsical  svmploms.  The  mode  of  death  is  usually  by 
asthenia:  le.-s  eommoiilv  hv   pressure   from   a  tumor:  and   oeeasionally  m 


coma. 


Treatment.— Wl urn  small  and  localized  the  glands  should  he  iv- 
mov.Hl  Local  applications  are  -d'  douhtfnl  heiielit.  l  have  n.-ver  seen 
special    improvemc'iit    follow   (he    persistent   use   of    iodine   or   the    various 

ointmeiils.  ,      ,  i  ,        •         ■     ■ 

Arsenic  has  a  positive  value  in  the  disease.  It  should  he  given  in  m- 
ereasiim-  doses,  and  stopi^ed  -.hen  unpleasant  eireets  are  niaiiilest..d.  L  he 
iv^nlts'liave  in  manv  instances  heen  striking.  Due  allowance  must  he 
mrtde  for  the  lluctuations  in  the  size  of  the  gr.iwths  which  occur  si.onta- 
„eoiwlv  111  elVects  from  the  administration  of  iM.wler's  solution,  even 
for  months  at  a  time,  are  rare,  but  T  have  had  a  cas<.  in  whu-h  neuritis 
followed  the  use  of  f,  iv  T,  j  TTlxviij  within  a  pc-ri^.d  of  less  than  three  months. 
Eeeoveri  have  been  reported  under  this  treatment  I'ersonally.  no  in- 
stance of  recoverv  has  cone  under  my  notice  in  the  •  >  ol  which  L  have 
notes  ri.osnhorus  is  nrommended  hy  flowers  and  l..oadhent,  and  shoul, 
he  u^ed  if  the  arsenic  is  not  vvel'  Ixu'ne.  Quinine,  iron,  and  eod-livor  oil 
are  useful  as  tonics.  Ever,  f.ossible  means  must  he  taken  to  support  the 
patient's  strength. 


bU 


DISEASES  OV  THE   I'-EooD  AND  DUCTLESS  GLANDS. 


IV.    PURPURA. 


1^ 
it  I 


i 


1 


Strictlv  spoakiuLT.  ruvprna  i>  a  .ymyUnu,  not  a  cl..c.ase;  l.ut  uncloL  tin. 

K     ,vn<:ition^  .d'  th.  M.u.d   into  th.  >kin.      In   the   pivs.nt    .tate   ul   uu, 

n  ;      1    'a  sUistac-torv  cla.sili.-atHm  .-anno,   h.  .nad.      Kx.Uuhnj.  syuM-- 

,,.,„••.    W    Wh  -nu.n^  all  tonus,  inc'liulii.-  haMuoplnha.  imhUt 

nk  tlu.  iniKl  purpura  siiui-lex  an.!  th.  ,nnst  intrns.  purpura    urmuvrMa^Ka 
tl     F.  A.     lon'uanu  cun.i.l.vs  Humu  all  (.xe.pt  l'--Pl;.  ->  un,!.. 
Hlin.^  worh,,.  niarvlos,,..    Th.  ia,rpuri.  .pots  vary  Inun  1    o   .  u.    1 
anu.t.r.     \VlH.n   s.nall  an.l   pin-poiut-liko   tlu-y   ur.   .alk.!   petcvh 
d,  .    th.v  are  known  as  m.hyn>os.s.     At   (irst  lu;,^ht  ,v.l  u>  n.k., 

^  "  1.   i  da;k<.r.  ana  gradually  t.de  to  bruwni.h  sta,n.     'lU.y  do  not 


dit^aitiicar  on  i)rcs;ur( 


1  !)('  csti- 


u  all  .as.,  of  purpura  tlu.  coa;.ulation  tinu.  ot  the  hlood  shou..,  ,e  e.  - 
„v,t  Wri.d,,):  luA .oa,uloHu.,.r  i.  a  usHul  clinu.al  ,ns  runu;nt  o,  .ho 
:tl  .     N;rn.al  hi 1  elo,.  in  th-  tuhes  in  fnun  three  ,o     ve  uunutes 


mi 


an( 


Dnrno-^e      .soi'nia    iilooo  eim.  m  lo.-  n....-  ...  ^ 

;  rorn>s  of  purpura  th..  eoa.ulation  tin.  is  retarded  to    eu  or  hiteeu 
„„t.s,  and  in  Inen.ophilia  i.  ha.  keen  delayed  to  hlty  nnnules. 

Till.  foUowin-i-  is  a  provisional  o-roupm--  .4  the  eases.      _ 
Symptomatic  Purpura.-(^0  Infectious.- In  pya.nna  sc^p  .cann.a 
[Sonant  c.ndo.ardilis  (parli.-ularly  in  the  last  alleefon),  eeehynioses 
„„v   ,,,  ;„,.v    ahundan,.      In    ty,,hns    fever   the    rash    is   always   pnrpur,e. 
Measles,  scarlet  lever,  an.l  more  partieularly  small-l.ox,  have  eaeli  a  vaiietv 
diaraet.'ri/.ed  1)V  an  ext.'usive  i.urpurie  rash. 

(h)  Toxic.-Th..  vims  of  snakes  produces:  ^v.tll  -rcat  rapiddy  extiava- 
sation  .d-   ld..od-a   cm.Iiti.u,   which  ha.  keen   very  carefully   studie.l   hy 
Weir   Alitehelk     Certain   m...licMn..s.   ,)articularly   c.pad.a.   .pnnme.    hella- 
d..nna^  m.'rcrv.  .-ru'ol.   an.l   ih..   iodid.'s   oecasi.mally,  are    l.dlowe.     hy  a 
i.etechial  rash."   i'urpura  mav  f.)llow  the  nse  of  comparatively  small  .loses 
of  io.li.le  of  polas.ium.     It  is  n..t  a  v.ry  .■..mmon  occurrence,  c.)nsl.erln,^' 
the  <Mral  fiv.  .u.icv  with  wlik^h  th..  <lru,^  is  empl.>y.Hl.     A  fatal  event  may 
1,„  ..au^.d  ).v  a  small  am.>unt.  as  in  a  ...<.■  reporle.l  by  Stephen  Mackenx.c 
of  a  chil.l  w'hi.h  .li.Ml  aft.-'  a  d..se  .>f  -2.1  grains.     An  erythema  may  prec.-.  e 
the  Inemorrha-e.     It  is  n..t  always  a  simpl.'  purpura.  luil   may  he  an  a.aite 
f.hrile  erupti.n.  ..f  gr.-at  int..nsiry.    In  S..pt..inher.  ISDl,  a  man  agvd  lorly- 
eioht  was  admitt.Ml  und..r  my  e,uv  with  art..ri<.-s.-l..r..s,s  an.l  .Ir.-psy.      1  h. 
laUer  vi<.l.l.-d  rapi.llv  to  .liuitalis  an.l  .liuretin.     When  ,.,.nval..^.H.m  he  was 
order..;i  i.nlide  of  p.^tas-ium  in  1<>-Lrrain  d..ses  three  tinu.  a  day.  ami  t...,k 
in  f.Hirt...>n  days  -1^..  f^rains.     lie  had  hi,h  fever,  cryxa.  swellm,  .d     ne 
throat,  and  the  most  ext.'nsive  purpura  over  the  wlu)U;    H,dy.        lule,   tlu> 
diviskm.  too,  comes  th.'  i)urpura  so  .d't.'n  ass,.eiated  with  .launduv. 

(OCachectic.-Tnder  this  lu.ulln..  are  h.^st  deserih..d  t  le  instances  .,f 
punuira  whi.-h  dev..lo,.  in  the  cm^titutional  distnrlKnice_..f  cancer.  tuU- 
eul.Us,  ITod.kin"s  dis.-ase.  llrighfs  dis.Mse.  scurvy  and  m  he  deh,ld>  d 
.,1.1  a.n>      In  tlu.e  eases  the  sp..t's  are  usually  conhned  t..  the  extremities. 


I'L'UPUUA. 


bi: 


They  limy  lie  v(>rv  aliuiidiint  on  the  h>\\vv  liinlis  and  aliout  tlic  \yrist~ 
and"  hands.  This  (•(.iistitntcs.  pmhaMy.  llu'  fomiiK.iicst  variety  ol'  tlie 
(li>casc,  and   many  examples  of  il   can   he  seen   in  the  wards  (if  any  hu-e 

hnsjiilah 

{i/)  Neurotic— One  variety  is  met  with  in  eases  ol'  organic  diMV.se.  It 
is  the  so-ralK'd  invelopatliie  piirpiira,  wiiieh  is  seen  (leea.-ionally  in  h)c.)- 
iiKilor  ataxia,  partieuhirly  f(.lh)wiii,ir  atlaeks  of  tlie  li.ulmiino-  j-ains  and, 
a^  a  rnU'.  inv(dvin<r  the  area  of  tlie  sldii  in  whieh  the  jiaiiis  have  iuvn  nnisl 
intense.  Cases  liave  l)een  met  with  also  in  acute  myelins  and  in  transverse 
myelitis,  and  occasionally  in  severe  neiiral.uia.  .\noiher  form  is  the  re- 
markahle  hysterical  condition  in  which  stigmata,  or  hleeding  points,  apiiear 

np(Ui  the  skin. 

(r)  Mechanical.— This  variety  is  most  freipiently  seen  in  venous  stasis 
or  anv  form,  as  in  the  jiaroxysms  ol'  whooping-cough  and  in  e[ulepsy.^ 

Arthritic. — 'I'his  form  is  characterized  hy  involvement  ol'  the  joints. 
It  i.~  usuallv  known,  therel'ore.  as  rheumatic,  though  in  reality  the  evideiicu 
upon  whicii  this  view  is  liased  is  not  conclusive.  Of  --'(H)  eases  oL'  |Uirpura 
analv/.ed  hv  Stephen  .Mackenzie,  <;i  had  a  history  (d'  rheumatism.  For  the 
present  it  seems  more  satisfactory  to  use  the  designation  arthritic.  Three 
groups  of  cases  mav  he  recognized: 

{,!)  \  mild  forin.  often  known  as  Purpura  simplex,  seen  m-ist  com- 
inonlv  in  chih  n,  in  whom,  with  or  without  articular  pain,  a  crop  (d' 
purpiiric  spots  appears  upon  the  legs.  h>ss  commonly  upon  the  trunk  and 
aims.  As  pointed  out  liv  Craves,  this  form  is  not  infre.pieiitly  associated 
with  diarrlnea.  The  disease  is  sehloin  severe.  There  may  he  loss  of  ap- 
petite, and  sli-ht  amemia.  Fever  is  not.  as  a  rule,  i.irseiit.  and  the  pa- 
tients get  well  in  a  week  or  ten  days.  These  cases  are  usually  regarded 
a>  rheumatic.-  and  are  certainly  associated,  in  some  instances,  with  nii- 
doiihted  rheumatic  manifestations:  yet  in  a  majority  of  the  patients  whi.h 
I  have  seen  the  arthritis  was  slighter  than  in  the  ordinary  rheumatism  ot 
children,  and  no  other  manifestations  were  l"'''^^'"t- 

(h)  Purpura  (Peliosis)  rheumatica(N'//-;/)/r/yr.s'  />i.sM.sr).— This  remark- 
ahle  all'ecti.m  is  characterized  hy  multiple  arthritis,  and  an  eruption 
which  varies  greatly  in  character,  sometimes  pitrpiirir,  mmr  C(unnionly 
a^-ociated  witli  uri'cnrio  or  with  cn/lliciiin  c.nulalirKiii.  The  disease  is  most 
nmimon  in  males  lietween  the  agVs  of  twenty  and  thirty,  it  not  infre- 
,|ucntly  s.'ts  in  with  sore  throat,  a  fever  from  lOT'  to  10:!°,  and  articular 
]iain>.  '  'I'he  rash,  which  makes  its  appearance  tir.-t  (.11  the  legs  or  ahout  the 
alTeeted  joints,  may  he  a  simple  luirimra  or  may  show  ordinary  urticarial 
wheals.  In  other  instances  there  are  nodular  inliltrations,  not  to  he  distiii- 
giiished  from  erythema  nodosum.  The  comhiiiation  of  wheals  and  purpura, 
^he  piirpuvn  inilnnis.  is  very  distinctive.  .Much  more  rarely  vesication  is 
met  with,  the  so-calUd  pnnphi<inu1  piirpiini.  The  amount  of  o'denia  is  vari- 
ahle;  occasionally  it  is  excessive.  In  one  case,  which  I  saw  in  Montreal 
with  "Molson.  the' chin  and  lower  liji  were  enormously  swollen.  teii-(\  glazed. 
and  dceplv  ecclivmotic.  The  eyelids  were  swollen  and  purpuric,  wliile 
scattered  over  tlie  cheeks  and  ahout  tlio  joints  were  niimenms  spots  of 
purpura  urticans.    Those  are  the  cases  whicli  have  been  descrihed  as  frhrihi 


f 


u 


U 


5! 


ii 

:  f. 


810  DISEASES  OF   TllK   BLOOD   AND   Dl'CTLESS  GLANDS. 

purpnnc  mlnna.    The  tomi-orature  raii-f,  in  mild  cases,  is  not  high,  but 

'The-  urine  is  sonietinus  reilueed  in  auKUint  and  may  he  ali.inninou^. 
The  ioint  alVections  are  usually  flight,  thou^di  associated  with  much  imm, 
,,.,rtieularlv  as  the  rasli  comes  out.  Uelap^es  may  occur  and  the  di^^easo 
n.av  return  at  the  san.e  time  tor  several  yc.ns  m  ^iu;c..ss,on. 

The  .lia'H.osis  of  Schilnlein-s  disease  oilers  no  diihculty.  ihe  associa- 
tion of  mulUple  arthritis  with  purpura  an.l  urticaria  is  very  eharacteristjc. 
In  a  case  which  1  saw  with  Musser  there  was  .ndo-per,car<l.tis,  and  t  lo 
question  at  first  arose  whether  the  patient  had  malignant  endocarditis 
with  extensive  cutaneous  inrarcl.s.  .      ,         <•     i    „,.,,;.. 

Schilnlein-s  lu'liosis  is  thought  hy  most  writers  to  he  of  rheumatic 
origin,  and  certainlv  many  of  the  cases  have  the  characters  <.t  ordinary 
rheumatic  fever,  plus  purpura.  I'.y  uiaiiy.  however,  it  is  regarded  as  a 
ouvial  allVction,  of  which  the  arthritis  is  a  manileslation  analogous  to 
that  which  occurs  in  luemopliilia  -md  in  sc.irvy.  The  freciuency  witii 
which  sore  throat  prece.les  the  attack,  and  the  occasional  occurrence  oi  .'n- 
doearditis  or  peri<-arditis,  are  .-ertainly  very  suggestiv.-  of  true  rheumatism. 
The  cases  usuallv  do  well,  and  a  fatal  evc'ut  is  extreiiicly  rare  llie 
throat  symptoms  mav  persist  and  give  troiihle.  In  two  instances  I  have 
seen  necrosis  and  sloughing  of  a  in.rtion  ol  the  uvula. 

(r)  Henoch's  Purpura.— This  variety,  seen  chielly  111  children,  is  char- 
acterized hv  (1)  relaiises  or  recurrences,  often  extending  over  several  years; 
(•>)  cutanemis  lesions,  which  are  those  .d'  erythema  multiforme  rather  than 
of  simide  iHirpura;  Ci)  gastro-intestinal  crises-,)ain.  vomiting    and  diar- 
,1,,,,,.   (1)   joint   imins  or  swelling,  often  trilling;  (o)  ha-morrhages   from 
,lu,  niucu,;  memhranes.     ^Vhen  fr..m  the  l<idiiey.  an  intense  haMuorrhagic 
nei.hritis  mav  supervene,  which  proved  fatal,  with  the  symptoms  ot  acute 
T.rio-ht's  disease,  in  one  of  mv  cases,  and  hecanie  chronic  m  a  case  under 
1)  W  rrentiss     Anv  (.ne  or  two  of  the  above  symptoms  may  be  absent;  the 
intestinal  crises  with  enlargement  (d'  the  si)leen  may  be  pivsent  and  m-ur 
tor  months  before  the  true  nature  of  the  trouble  becomes  manliest.      Ihis 
form  has  an  interest  in-  connection  with  the  angio-neurotic  oedema,  winch 
is  also  characterized  bv  severe  gastro-intestinal  crises.     The  prognosis  is.  as 
a  rule,  good:  3  of  the  11  cases  which  1  have  reported  died.- 

Purpura  Hsemorrhagica.— I'nder  this  heading  may  he  consul- 
ered  the  cases  of  verv  severe  piu'imra  with  luvinorrhages  from  Ihe  mucous 
membranes  The  affection,  known  as  the  lunrhus  manihsii.'^  of  ^^  erlhof, 
i.  nio«t  cmnmonlv  met  with  in  young  and  delicate  individuals,  pnrti-u- 
larlv  in  oirl--  l,ut  cases  arc  described  in  which  the  disease  has  attacl;ed 
adults  in'  full  vi-or.  After  a  few  days  of  weakness  and  debility,  pnr])uric 
.nots  apiiear  on  the  skin  and  rapidlv  increase  in  numbers  and  size.  Tdeed- 
in.r  from  the  mncons  surfaces  sets  in,  and  the  ei.isiaxis.  ha'inaiurin.  and 
hamiopivsis  mav  cause  profound  ana-mia.  Chart  XXT  illustrates  the  raj.id- 
itv  with'  which 'anmnia  is  produced  and  the  gradual  recovery.  r>oath  may 
take  place  from  loss  of  hlood.  or  from  haMnorrhage  into  the  brain.     Slight 


*  Am.  Jour,  of  the  Mcil.  Sciences,  December,  1805. 


PUIU'L'KA. 


SIT 


fever  usually  aecompiuiies  the  disease.  In  I'avoral.le  cases  the  alToction 
terminates  in  from  ten  days  to  two  weeks.  Tliere  arc  instanees  ol'  iiurpuia 
lKemorriia,uiea  of  .L'reat  niali<,maney,  whicii  may  prove  fatal  within  iweiity- 
1,,,,,.  iii.iirs — jiiir/iiini  (iiliitiiKUix.  This  form  is  mo>t  commoidy  met  with 
in  eliildi-en,  and  is  eharaeterized  liy  cutaneous  hiemonliaires,  wliich  develop 
witli  <:reat  rapidity.  Death  may  occur  hil'ore  any  Ideedin.u-  takes  plaee 
from  ti:e  inncous  memiiranes. 

In  tiie  tlidiiiinsis  of  purpura  luemorrha,<,dca   it   is  impmlant   to  exchide 
scurvy,  wliich  niay  he  done  by  the  et)nsideration  of  the  previous  hcahh, 


MEAN  NOHM. 
NUMBER  OF 


CORP^.&CLES 


BLUE,  C0L0ALES6  CORPUSCLES. 


BLACK,  RED  CORPUSCLES.  RED,  HAEMAOLOBIN, 

Chakt  X\1.— Illustnit.'s  tlie  rapidity  with  which  iiiiicmia  i-^  [iruLliu-i'd  in  purpura 
lia'iniirrliagica  luul  the  j,M'a(lual  rcecjVLM'V. 

the  cireunistance-;  under  wliich  the  di^  ,ne  dt'vdnps.  and  liy  the  ah-euce 
of  swellin,^  i.f  the  uiinis.  The  maliji-nant  forms  of  the  fevers,  particularly 
sniall-jiox  Mid  measles,  are  distinguished  hy  the  prodromes  and  the  higher 
tcmi»erature. 

Treatment. — Tn  symptomatic  luirjiura  attention  slunild  he  jiaid  to 
the  conditions  under  which  it  develojis,  and  measures  should  he  employed 
to  increase  the  strength  and  to  restore  a  iiormal  hlood  conditiim.  Tonics, 
good  food,  and  fresh  air  meet  these  indications.     In  the  simple  purpura  of 


if^ 


?    i 

9  i 
111 


gl8  I.ISEASKS   OF  THE   RLCOD   AND   DUCTLESS  (".LANDS. 

.„.  ,lK>,   a>....in„..l   with  sl„h,   av,i,.,>lnr  \-"''l-,  ■'-•"'^'  '"  ^[IJ 

^::i:i-;;!:;;rr,,,,r;,;ii.:::'ri;\;:;;';:™;;S^^ 
n;  s  :;„:'  u,r;:^ ..„,«.,. ^'^^-^-^^ !r\r^:t 'i':i:<^: 

|„iir  ,I„>>1  1..  llHli.l'i  -   ;„l,.,li  i.ili  i.r  tlio  .iirl'nn  cli.isi.l.'  is  f"l"'- 

;:;;;:'t';;f''Ti:l;;;;;;^l:;:'-i^-''M.■.-"^., - 

ILOlOliliTlA.ilC  I.ISEASES  Ul'  THE  SL'AV-lii.liX. 

,.  syphilis  H^orrhagica  ^^'l^^^^'::^ ,!:;l!'  ^Z,  ^  ^Z 

';■;:''  i;;;r; ;";;::;:;.  '■.^-»«"--^"-  -' ''' r  "r 

;;;;:;;''' ^t';::;':r:  t:r::; :.;L,..,,,™.,;,„.i„.,„.inu.,™, 

vf  ,niv..  .v.-liililicchan-cs  in  llir  livor  and  ..thcr  nroau-. 

,1,,  nrw-lH,rn    which   .ura.ionally  .Icvclops  i.i   riH.U.m.c   i(  uu   n    Ixm.L    n 

,',.:■•  a  v.n-  fatal  ain.tK.n.  .iii.h  sCs  in  n>nally  a'-U  ih.     .nr  h 

V    .!•  lilV      Th.  . hihl  hr..onu.s  jaun.li.r.l,  an.l  th.'.v  arc  nr,u W.l  j;a.t,o- 

U-   n      <vnn.,on,<.  with  l.v.r.  jaun.licc,  raphl  ,vs,.irat ,on.  and  sonictinn. 

!'„"  "  nrin.  contain,  aihun.in  and  hlood-coh.vm,  .natter-,nc- 
;;';n:;h,hin.    Th..  di....  has  t.>  he  distin^nish.!  fnnn  the  -;;i  -  -  - 

....natmnnn,  with  whici,  there  nmy  son,etnne.  he  '^''-'    '  /    "  ^;  ""^^  '   ; 

nnttcr  in  the  nvine.  Tlie  post  nx.rteni  shows  an  ah^cncr  ol  ai  >  siptu 
::;:,l;;i.::,;;\he  nnd,i,ieal  vLsels,  mn  the  s.dee,.  i.  ^^^f^^^'^^^Z 

,„,„,,il',,,„   l,a,,nonhaues   in   dilVerent   parts.     N-nie  <-a>e.  ha^e  >!«  " '»   " 

a  n'utd  decree  aente  fatty  defeneration  of  the  internal  ovgans-the  ..- 

'■''':5']i^ri)^'Mac;iiosusNeonatorum.--.\,.nrt    fmn,   the  eonunon   viseer,! 
Ivvnonhan...  the  result  of  injuries  at  birth,  hleedin,.  from  one  .>r  nvn 

;      Hae;.s  is  a  not  uneonunon  evnt  in  the  new-hovn    particularly  n, 
hoiital    tuaetiee.      Fovtv-five   cases   occurred    in    (U-.O   del>veru.>   ((  •    ^^  ■ 
T  w       .    .     The  hleedin,  n.ay  he  from  the  navel  alone    hu     n.ore  con - 
u^lv  it  il  general.     Of  Townsend's  50  cases,  in  .0  H-    'l;-!  --    ';  - 
tho  bowels  (nu'hrna  .r.n.l.nn.).  in  11   Iro.n  the  stonuch    "^  ^^^        ^  .^  1^ 
,„„uth    in  1-^  from  the  nose,  in   IS  from  the  navel,  m  ■>  fmm  tin    nua 
^.e  bleedin,  1n.,ins  within  the  first  week,  but  ,n   rare  ,ns  :nn  . 
obn-ed  to  the  se  ond  nv  third.     Thirty-u...  of  the  cases  died  and      0 
.     ,.  .Iclay.cl  to  duration,  death   occuriTn-  in 

recovereil.      l  lie  (ii>ta>t    i.    u.  nam  .       „  i       i,i      Tim  i-inture 

from  one  to  seven  days.     The  temperature  is  oiten  elevated.     Ihc  natuio 


\': 


ILEMOPIIILIA. 


811) 


of  the  discMso  is  iinkiH.WM.  A,^  a  nilc,  notl.in-  alm..iinal  is  Inuiul  post 
mortem  The  jiviu'val  ami  not  lo.al  naimv  of  Hie  alVeetioii.  its  sell-limiled 
,haraeter,  tlie  iMv.eiiee  of  lever,  and  tlu'  ..reat.r  ,nvvale.iee  ol  tl..;  .liseaso 
in  hospitals,  suji-ist  an  infeetioiis  ori;:in  ('!'""  r.send).  Hie  l.leedinj;  may 
bo  n<soeiate.l  with  intense  luemato-eiioiis  jamnliee.  Not  every  ea>e  ol 
bleedin''  from  the  stomaeli  or  bowels  l^ebm-s  m  this  rale-oiy.  I  leeis  ol  the 
.e^oplia-ms,  stomaeh.and  duodenum  have  been  loinid  in  the  new-liorn  dea.l 
of  mrhrmt  nmualnnim.  Tlu'  child  may  <lravv  the  Idood  fnun  the  breast 
..,„d  Mibse(iiientlv  vomit  it.  In  the  treatm.'iit  the  external  warmth  niu.t  be 
„,.,ji,,.,i,„,,l_  ,,,„i  j„  f,H.l,le  infants  tli.'  runrnisi:  may  be  u^ed.  Camphor  is 
reeommended  and  ergot  in  hypoilermieally. 


V.    HiCMOPHlLlA. 

Definition.— An  hereditary,  .■onstiliitioiinl  fault,  eharaeterized  by  a 
tendenev  to  uncontrollable  ble'edin--,  eitlier  spontaneous  or  from  sli-lil 
wounds,"  sometimes  associated  with  a  b^rni  of  arthritis.  The  coa-idalion 
time  of  the  blood  is  usuallv  much  retar<led. 

Kavlv  in  the  centnry  several  physicians  of  this  country  ealle.l  attention 
to  tiie  occurrence  of  iirofuse  luemorrha-e  from  sli-ht  caii>es.  ["he  tact 
that  fatal  luvmorrha-e  might  occur  from  slight,  trilling  wound^  had  been 
known  bM-  centuries.  The  recognition  of  the  lamily  nature  ol  the  dis.-ase 
is  due  to  the  writings  of  J'.uel,  Otto.  Hay.  Coates.  ami  others  in  this  coun- 
try.    The  disease  has  been  elaborately  treiitcd  in  the  monographs  ol  J-egg 

and  Grandidier. 

Etiology.— In  a  majcu'itv  of  cases  the  di^pr.sition  is  hereditary.  1  lie 
fault  may  be  ae(iuired.  however,  but  nothing  is  known  of  the  cundilions 
under  which  the  disea^'  may  thus  ari>e  in  healthy  stock. 

The  liereditarv  transmission  in  this  disease  is  iviutirkable.  In  the 
\indeton-Swain  familv.  of  K'eading.  Mass.,  there  liave  been  ca-es  b.r  nearly 
two  centuries;  and  F.  F.  r.rown.  of  that  town,  tells  me  that  instances  liave 
ah'oadv  occurred  in  tlio  sev.'uth  generation.  The  usual  mode  ol  trans- 
mi-ion  is  through  tlie  mother,  wlio  is  not  herself  a  blee.Ier.  but  the  daugh- 
ter of  one.  Atavism  throngh  the  b'male  alone  is  almo>t  the  rule,  ami  the 
dan-ditcrs  of  a  bleeder,  thonuh  healthy  and  free  from  any  tendency,  are 
almost  certain  to  transmit  the  disposition  to  the  male  ollspnng.  1  he 
alVection  is  much  more  c<uum..n  in  males  than  in  females,  the  prop,ul!on 
boin.v  estimated  at  11  to  1.  nv  even  F!  to  1.  The  teiid.'iicy  usually  appears 
with'in  the  first  two  vears  of  life.  It  is  rare  bu'  mandVstati.ms  to  be  <le- 
l,ved  until  the  tenth  or  twelfth  year.  Families  in  all  conditums  ot  lile  are 
niVected.  The  ble.'der  families  are  usually  large.  The  members  are  heallliy- 
lookintr.  and  have  (inc.  s(d't  skins.  i        -i    i 

Morbid  Anatomy.— No  special  iieculiarilies  have  been  .l.'scrilied. 
In  «omo  instances  chanros  have  been  bnind  in  the  smaller  vessels;  b\ir 
in  others  careful  stndies'have  been  negative.  An  unusual  thinness  of  the 
vossol^-  has  been  noted.  Tla^movrhages  have  Imtu  bmnd  in  and  abont  the 
capsnles  of  the  joints,  and  in  a  few  instances  inllammaiion  of  the  synovial 


,r" 


I.ISKASHS  OF   TllH    ULOOD   AND   DUCTLESS  GLANDS. 

M.rfaoe..     Tlu-  nature  of  tla-  di.oaso  is  ...uldrnuin.  .1  mihI  wo  -In  not  y.t 

■  ,      '■  u.tlH.r  it  (l.iH.n.l.  upon  a  i-ec.uliav  irailty  ..i  the  hloocl-vcs.ols  or 
!:;r  ;;''uliari,y  n.  tlH.  n  Ji.u.ion  ot  ,lu.  1,1o.hK  wluHM-™^^^ 

lu-il  tlu-oiiil'ii>  lorniiition  in  a  woiuul. 

SvmrjtomS.-lVnallv  i.a..no,.ir,li:.   is  n,:t    notr.l   n,   the  v\uU\   unt,l  a 

,,i,lT,f..3is  ioliowcl  l.'serious  or  unc.outrollal.le  luvnorrha,.    or  spon- 

,;  l,K.,lin.^  oc..-urs  an.l  presents  insuperable  dillieulfes  >u  ,ts  arre.t. 

T  n      on.sTnav  l.e  grouped  nn.ler  tl.ree  divisions:  external  1.  ecun,r.. 

'  „,a„e,u<    and    irannmtie;    interstilial    hleed.ngs,    petechia-   and    ereh.N- 

'      nd    .he  Joint   alVeelions.      The   external    hleed,n,:s   n.ay    he   4-u- 

„,..;,.    l„„   n,n  ;    ...nnnonly  they  follow  euts  an.l  wounds      In  o3-l  ca.  s 

r      lidier)  tie      uief  hleedings  were  epistaxis.  l-ii.;  Innn  the  n.outh,  -lo; 

.  ,     ,.;  1, Is,  3(1;  nrethra,  1(1;  lungs.   K;  and  u,  a  W.   .nstances 

iSn,.;  rron.  the  skin  of  the  Lead,  the  tongue,  linger-tu.s,  tear-papdla, 

■  .vcli.N   external  ear.  vulva,  navel,  and  serotuui. 

"'  T  a-unatie  h.e.d.ng  n.ay  result   Inun  '''--'  -^^-  -7^:'-/^?,:,.:;:; 
Iho  Idood  n.av  he  dilVused  into  the  tissues  or  diseharged  externalh.     iuual 
1      i     <  ha\e  pioved  fatal,  sueh  as  tlu-  extraetiou  of  tec-th,  e.reumc.s.on, 
r;:!::H!on.    \.  is  po.silde  that  there  n,ay  he  loeal  'l^^-^s  w   .eh  n>ake 
blmlin.^  f.'on.  eertai..  pa.1s  of  the  hody  n.ore  da.igerous      I  .Have.  Ag.u  u 
;      ,;,d  to  ...e  the  ease  of  a  hleeder  who  had  always    .  ed  tro...  euts  and 
;;::.;;;;.  ahove  ,he  ..eek,  ..ever  f..o..,  .1,0..  helow.     The  '«-f^  ^  «  ^i;!^ 
l,,.v  o../in-.     It  n.av  last  for  l.ou.s,  or  eve..  n.a..y  days      Kp  staxis  nun 
V    fa?  i..  twentV-four  ho.....     In  the  slow  hleedi.,g  i.-.n,.  the  mucous 
„.faee.  la.'.-e  hlund  iu.no.-s  .n:.y  for,..  a..d  p.'ojeet   f.'o...  the  >.ose  or  mouth, 
,,,„,„.   ,vn.a.'kahle-looki..g  >tr..et...'es.  a..d   .Lowing   that   the   hood  has 
,,,   ,„;;,„.  .,r  ..nag-.latio...      The   inte.'sti.ial   l.aM..orrhages  may   bo  .pou- 
t„H„L,  or  .n:,v  .vsul,    f.'on.  i.,,i.u'y.      P.lechia-  or  la,^e  extravasat.ons- 
l,.vn.-'toniata— n.av  occu.'.  the  latter  usually  f.dlow.ng  l)lows.  _ 

■  rp,,,  („•„„  alVeHio.is  .f  ha.n.ophilia  aiv  ren.a.'kahle.  Tl.e.v  n.ay  s....ply 
,,,  „i,.  or  at.aeks  wh.eh  eo.ne  o,.  s..dde..ly  with  feve.-.  ^1-^^^^%';^-;;^ 
1,1,  acute  .•h...n„ati>....  The  lai-er  jo.nts  a.'e  usually  allcclcd.  A.th.il.. 
mav  usher  i.i  a.,  attack  of  hu'i.ior.'hage.  .  ■  1 

'So  far  a<  the  exaniination  of  the  hlood  goes,  no  changes  ol  spoc.al 
,„„„„,,„  ,,,,,,  i„,„„  „„„.d.  When  the  hlecling  has  hcen  seve.-e,  it  .s  th.n 
and  wal.MT.  hut  at  the  hcgi.,ning  ..f  the  bleeding  the  blood  is  rich  in  cor- 
ini-;cles  a..d   coaL;-.. kites   li.'.nly.  ' 

Diagnosis.'-!.,  the  .liag..osis  n\'  the  co.,ditio.,  the  tan..ly  tcndencv 
i<  in.po.lnnt.  A  sin-h.  ,„u-ont. ■..liable  haM..o,'rl.age  in  child  .n'  adult  is  not 
to  1k' ranked  as  l.aMnophilia:  but  it  is  o..ly  when  a.i.erson  shows  a  marke,! 
tendency  to  multii.lv  l.aMnorrhages.  sp...,ta,.eons  or  tra..mat.c.  wh.eh  tnid- 
;„H.v  is  not  t.ansito,:v  b.,t  persists,  and  pa.lieularly  if  there  have  been  .io„.t 
alVe'cthuis,  that  we  n.av  cnsider  the  conditi.m  ha'.noph.l.a  Such  condi- 
li.nis  as  epistaxis,  recurring  for  ycars-if  no  other  haunor.'hage  occurs- 
,.,.  n.curriU-  h,eu.atuvia  f.'om  one  kid.icy,  which  has  been  ^P<'l<en  "f  a. 
n.iilatcral  real  l.a....ophilia.  have  no  association  w.th  the  t.-ne  d.>oaso. 
IMiosis  .•henn.atica  is  an  adVctio.,  which  touches  haMno,.h.l.a  ve  v  clo>cl  , 
particularlv  in  the  relation  of  the  joint  swellings.     It  may  also  show  .tsolt 


\[ 


SCURVY. 


S-21 


le  nor- 


in  PovoT 


•al  ,nomlu>rs  of  a   fannly.     Th.  .1i;.;:no..  fn„u  th.  various  fomn 


(.r  ])iirinira  is  u-iially  I'a-y. 


list    Mcciliu':.      Tlio 


ill..  tiTiinnalioM  o    the  ^'MUtli  \v\\.      i  m    >   n- 

,   ..,  1    '  Hnuur  of  hi.  ou.l.vM.^  ll.c  l.n.K.n.v;  Im,    .1    n.ay   i-vrM^t      . 

Sm    :.  ,       slH.vn  in  ,1...  .a.,  of  (.Lvv  ApplHon,  ,1,.  1,M  -P"'''-    ;    ^    ^ 

„  U  ;.h.r,  who  .li...l  al  an  a,lvan.v,l  a;:.,  of  ha.nunha,..  Iron,  ^>  '-l"^^^ 

ih,.  act  ol'  imrtiirition  hrin-'s  with  it  spinal  (hm^rcrs. 

should   he   guanh.!    fn-u.    injury,   a.ul   op.ratious  o     all    '"  ^      '       \, 
,,v:.ll..l.     'fu.  .laughters  slu.ul.l  n..   n,arry,  as  >t  .s  thn-u.h  ,lu.n  tlut  th. 

^"'l;^;:,:  i;;i:;n':r-wouu.,,l>as  o..urr.l.  al,so,u..  n.t  an,l  .ou.pr.s.ou 

.ho^a  i  •       .0    viJa,  au,l  if  t!u.s.  rail  tlu.  styptics  ,uay  he  u.nl.     in  ep  .- 

CO  '  annic  an.l   pUlic  aci.l   n.ay   Ik-  tried  heforc   -sortu,,    o   plu,- 

u        Jnternallv  or-ot  soeuis  to  luue  done  ^n.u.l  m  several  ca^e..     Lc,^g 

Idmlin.'  after  all  other  means  liad  laile<l.    (.elatii     n      !>.        - 
iron  and  arsenic  should  be  freely  used. 


eat  debility, 


VI.    SCURVY  (Scorlutus). 

T^oflnition-\  constitutional  disease  characterized  by  -reat  dehility, 
.iti^:Sr^l-^  condition  of  the  „.,  and  a  tendency  to  ha.uor- 

'^' mioloev -The  disease  has  been  known  from  the  earliest  times    and 
l..^'S-U-larly  in  arnues  in  the  field  and  an.ong  sa.lors  on  Ion, 

'"^'rr;,.  the  early  part  of  this  century,  owin<x  hn-ely  to  the  efforts  of 
Liud';;;;d  to  a'hnoiae  of  the  condUions  upon  ;;:;;i;^^^t,,e     .se^  d. 

""'Th^'dt^i^c^eyelops   .heneyer   indiyiduals   haye   subsisted   for   pro- 
longed p^i^dsuj^n  addict  in  which  fresh  yegetable.  or  the.r  subst.tutcs 


^^ 


rrf 


i';; 


t  a 


i   !' 


co.>  DISHASHS  (.K   TIIK   IM-OOD   AND   DITTLESS  (ILAKDS. 

,„,,  ,,,,ui„.      An   inM,llln..nt   .liH   api-av<  t-.  1h.  nn  .ssmtial  .■KMurnt    i.j 

I         ■     .,,  li,.ut<  iM  tlu.  I'.MMl  wl.i.l.  a.v  s„,.i.li.-l  l.v  l.vsh  v.-..|al.l.'>.     M  •  t 
^         ,,..,•     r.<  nut  v.'t  lurn  (l..|init.lv  .l.trrnunr.l.     (larnnl  l.ol.l. 

:  7u;::i :    .  :•    -  ">■ "-  i-ta-u.  saus.  (..iu.rs  i,..i>..vc.  ti... 

.    ",     .       c   n     <  tlu.  al.M.>ur  or  ,lu.  urpum.  sails  invsont  in  Iru.ts  and 
r  M         PI        vl  n  ha.  ina.K.  a  v.rv  nuvful  stu.ly  uf  the  .uh,,...t.  h.  - 

One  of  tlu.  nu.st  inteivstin-  ot  m.-nt  lact>  ulat.n     to  ■       V^  i,,,,,,,,,,,,. 

,,,„,,    ,>,,,„,nrv  of  it   in  chil.hvn.  n>  .•onn..rtH.n,  a.  a  luU.  vsUh  nnp    1^ 
di..,.     It  ^vill  Ik.  n.l\.r,v.l  to  nuuv  fullv  in  a  suhseduu,. 

1„  oi.nosition  to  this  ..hrnucal  view  .t  has  heon  nr,..,!  1 11     la  di.ca.c 
,,,,„,.  ,1  ,l..n.ls  npon  a  si-erili..  (as  vet  nnknown)  .nuTo-or^.n  m   . 

,■     ,,'     rnitel  States  seurvv  has  lu'euiu..  a  v(.ry  rave  .li^eaM-       1  o  11  < 
,,..      a  <  in        .  s  aport  towns  bailors  are  now  an.l  then  a.lnuttea  .Uh  >t^ 
'^:      n    house    outlnvaks  oec.a<ionally  oeenr.     A   very  K-at   nuMe  -e 
!•     Ji^M        ,'ulation  of  a  low  ,nul..  has  in  eertain  distnels  n,a   e    he     .- 
.eta    all  nneonunon.     In  the  nnnin,  distr.ets  ol   ^'--^'^^      ,^ 
un.anan.  l^ohennan,  and   ItaUan  settU-s  an;  not  '"'^     '  ,,      ;^^^    ; 
^IHirew   has   re..ently    reported    fi   ea.s   n,    (  luea.o    '""     '    ' "'       ^^'^ 
roh.      lie  as<-evtained  that  in  a  lai-e  pro,,uvtio„  „1  the  ea>es  the  del  j 

.posed  of  hread,  stron,  colVee,  and  n.eal.     (.eeasuu>ally  one  n.e    >    nU 
,J,,  „„.„„  ,u;,e  .•ell-to.d<.  people.     One  ol  ^'-  -^    '  -^     >  \^^ 

1  i,,ve  ever  <e..n  was  in  a  womao  with  ehronu-  dyspei-suu  xn  ho  had  mci 
L::-;:;a:;:u>nths  emeHy  on  lea  and  iu^ad.     ^;;--  y-;;^^.;,-''^-^.^ 
i,ot  infminenl  in  the  lai-e  hnnhenno-  eani'ps  m  the  OthuNa  AalU>        >    . 
;;:  \L  llu.  Uepon  of  nu.  Anu.riean  Pa-diatrie  Socu.ty,  we  nn.t  >nle.  thai 
iiiV-mlile  «enrvY  is  on  the  iiuTease  m  this  country.  . 

.,.      of  Itnssia  seurvv  is  endenue.  at  eertain  seasons  rea.dun^  epi- 
,,„  ie  io     o   s:  and  the  leadin,  authorities  upon  the  disorder,  now  in 

t;;;  emuJrv.  are  ainu.l   unanimous,  aeeordin,  to   UolVuiann,-^   u,  regaid- 

'""otl'r'flXrrpiav  an  imporiant  part  in  the  disease,  parlieularly  p|^s- 
i.,1^  ^n  o  1  inllnenoes-olererowdiii,.  dwellin,  in  eoR  ^^--Vj^^;^ 
d  in-olonecd  fali,n.c  nndor  depressing  innuenees  as  dnrincr  t  e  ot  t 
of  an  arnn-:  An,on<r  prisoners,  mental  depressum  plays  an  \'">I  '^"^  ; 
1  s  slat.]  Ihat  epidJniics  of  the  disease  have  ^'-l^^  ;>:''"  ^^/;i^ 
•  conviot-.hips  n>  muh  to  Xow  (-aledon.a  even  when  the  ^lK«tjwwmpl^ 

"  'Ti;::i;;:;:,:t;^^n;,  i^U^sl^d^^  F.  a.  Hoffinnnn  d^O:!),  a  work  to  which  the 
stiulont  is  rofornMl  for  the  best  exposition  of  this  group  of  disordors. 


SCl'llVV. 


cut    in 

■tuc  dl' 

Wliiit 

1  holds 

\C    1 1  lilt 

its  ;iiul 
•ct.  lit- 

llHtlltl'S 

iiin'  (Ti- 
lly i>ni- 
l  which 

XCl'SS   (if 

rol'oiiiitl 
urine  is 

UlKlUUt. 

tfi'ii  the 
uijivoiK'r 

}  (lisi'iise 

To  the 

with  it. 

inci'cii-e 

the  (lis- 

iiniii  the 

iittaeked. 

tirely   to 

diet  was 

eets  with 

stie  eases 

lad  lived 

urvy  was 

V.    Jiidj:- 

i lifer  that 

hin.il'  epi- 
r,  iti>\v  in 
a  regard- 

irly  I'liys- 
)  ([Viarteis, 
lie  retreat 
irtaiit  role. 
he  French 
,vas  amply 

to  which  tho 


823 

it.     It   is  an  inler- 


sullicieiit.  Nostalgia  is  soiuetiiiics  an  important  ehnieiit 
...ing  fact  that  prolonged  starvation  in  it.clf  d-o  not  necessarily  ean.e 
...urN  V  Not  one  of  the  prof..Monal  fasters  of  late  years  has  displaved  an> 
scorlmtic  svmptom.  The  di.ea.e  attacks  all  ages.  Imt  the  o  d  are  more 
su<ce,.tilde"to  it.     Sex   has  m  special   iiUUieiice.   hut   during  the  siege  ol 


were  great  I  v   m 


excess  of  the 


i-cs  are   marked,   though 


-usce| 

Paris  it   was  noted  that   the  males  attacked 

leiuales. 

Morbid  Anatomy-.-^Tkc   aiiatomical   chau,' 
,,v   no  means  specilic.  and  are  chielly  tln.e  associated  with   Inemorrhag. 
'hie  Idood  is  dark  and  iluhl.     Th.'  >ui.roM'opi''='l  alterations  are  those  ol  .i 
<evere  aiuemia,  without  leuco..ytos,s.     The  hacteriologieal  e.xaminati.m  has 
,„„   vielded  anvthing  very  positive,      rnu^tically   tlieiv  are  m.  changes  in 
,he  idood.  either  anatomical  or  chemical,  whi.-li  can  he  regarded  as  pec  il- 
i,r  to  the  disease.     The  skin   shows  the  ecchymoses  evident   during  hie. 
-P,,,,,,  „,,  l^MiuHThages  into  the  miis..les,  and  oc,.a.ionally  ah...it  or  even 
i,„.,  the   joints.     Ihemorrhages  occur  in   the  internal  organs    parliculail> 
„n  the  se'rous  memhranes  and  in  the  kidneys  and  hlad.ler.      I  le  gums  are 
swollen  and  soiiu-tinies  ulcerale.l.  so  that    in  advanced  ca.es  the  teeth  are 
loose  and  have  even  falhu  out.     Tlcers  are  occaMoua  ly   met   with   m  tic 
i,,,,„„  ,„„i  ,,,i„„.     Ihemorrhages  into  the  mucous  mciiihrancs  are  extreiiuMj 
eounuon.     The  spleen   is  enlarged  and  soft.     Parenchymatous  changes  are 
con.^tant  in  the  liver,  kidneys,  and  heart. 

Symptoms. -The  disease  is  insidious  in  its  onset.  !•  arly  symp  om> 
are  Ic^s  in  weight,  progivssively  developing  weakness,  and  pallor  \  cry 
.oon  the  g.inis  are  nolhcl  to  he  swollen  and  spongy,  to  Ideed  easily,  and 
in  eKtremo  cases  t..  present  a  fungous  ai.pearan.'c.  1  liese  changes,  le- 
:;  rd  d  as  characterislic,  are  sometimes  ai.ent.  The  teeth  may  heeome 
loose  and  even  fall  ont.  .\ctual  necrosis  of  the  , aw  is  not  common  i 
hreath  is  excessively  foul.  The  tongue  is  swcdlen,  hut  my  he  lel  I 
„„,  ,„,,,,   furred.     The  salivary  glands  are  .-ceasiona  ly  enlarged,     liai- 


oiThau-es  heneath  the  mucous  memhranes  oi  the  nioiit 


1  are  common.     The 


.Kin  oeco.nes  ,lry  and  rough,  and  ^^-^^y^^'^:^^ T^  T^'^'^Tnil^i^^ 
„„,  „„,„  ,.„  the  arms  and  trunk,  and  particularly  into  and    hoi  t    he  1  ai  - 
f„,li..U.s.     M'hev  are   petechial,  hut    may   heconie   larger,  and   when  suhen- 
a   eons  uiav  cause  distinct  swellings.     In  severe  cases    ].articularly  in  the 
W  ,  there  mav  he  elVusion  hetween  the  periosteum  and  t  le  hone,  torni  ng 
i,.;.:nilar  nodJs,  which,  in  the  case  of  a  sailor  f"".  ..whalmg,  vessel  w    o 
.    ,u.  undc.r   mv  ohservation,  ha.l   hroken  (h.wn    .,d   l-rmed  ioul-h.okm, 
loi";      The  sli.ditcst  hruise  or  injury  causes  Inemorrhages  mto  the  injured 
,nrt"    (Edema  ahout  the  ankles  i<  eoiun.ou.     The  "scurvy  sclerosis      seen 
oftenest  in  the  le^s,  is  u  reinaikahle  inliltration  of  the  sulKUitaneous  tissms 
:;!d  muscles,  forming  a  hrawny  induration,  the  skin  over  which  may  lu^ 
l>lood-stained.     Ihemorrhages   from  the  mucous  ^';'''"^''-''';:;;;'';y';;,     '  ] 
sfint  symptoms;  epistaxis  is.  how.wer.  frecpient.     Thvniop  yMs  and  ha  mat. 
;^l-  "  ..comn  on.     Ihematuria  and  hleeding  from  the  howels  may  1  e 


niesis  are  uncommon 
]iresent  in  very  severe  cases 


n^,^:.  oHh;  ii^iWand  feehleness  and  ^rr^.^^^^yoU^l^^.^ 
,,,  nvominent  sympton-.s.     A  luemie  murmur  can  usually  he  hea.d  at  the 


^^ 


■^ 


iff 


824 


DISKASKS  OF  Tin:   HLOOD  AN1>   DICTLKSS  OLAXDS. 


Ml 


! 


lm-0.  llii'inorrlia-ic  infardi.-n  of  the  liui-s  lui.l  splrcn  l.iis  Iktu  .IcmmmIu'.I. 
l.V.,,in.t..rv  sv.ni.t..i..s  niv  nut  .-.mninn.  'VU.  -.^^yvUW  is  miimnnl  au.l 
,„vi,'.'  t..  tlu.  "muv.u.ss  of  11.0  ^Mun.  ihr  patiml  is  m.alil.  ty  ..Jirw  llu'  Inu,  . 
Ccn.UnatiuM  is  iu.mv  fivqurnt  ti.a.i  .iianiiuM.  I'aiii,  U■.Hi..■u^^s,  ...•  suvll- 
i,,.,  i,/ii,,  juints  w..,v  pir^oM'  i>.  Ki  ol'  Mcllrow's  l"'  .as.s.  '11,.  urnu.  is 
olTcn  all-inninnns.  TIh'  .•hanj.n.s  ii.  its  .....niM.^iti.M.  a.v  m-t  nmstni.l:  il... 
siKrili.  ji-iavitv  is  l.i-li;  tiu>  (■..l-r  is  .irrpcr;  an.l  th.  ,.ims,.halrs  a,v  ui- 
emi-nl  Tli/statciiU'iits  \viti.  ivl'dciur  K.  the  iuni-niuc  (■..iistitiUMiIs  aiv 
c.ntnuli.tory.     So.no  say  the  i.l>n>i,hatr>  and  i-otash  atx-  (U-H.R.nt;  uiluis 

tliat  thi'V  arc  intMvasccl.  ■       i ,  i,  ,    .,,,,1 

TluTo  aiT  menial  .Icp'-'^^'""'  in.lillViv,KT,  m  sonu-  cas-.s  hradaclM'.  .ua 
i„  ,h,  lator  sla-is  .U-lirinni.     Cases  of  eonvulsions.  of  liennpU-ia.  and  m 
uu.uin,eal  l.a.n;rri>a,a.   have  he...   .h.se.Mhed       Ke...a..kahle   oe.. ia.^  >v...p- 

to.ns  iu-v  oeeasionallv  n.et  with,  such  as  ni^d.t-hl....lness  ,„•  dav-hl,nd.u.». 

In  advaneed  eases  i.eerosis  of  the  hones  ...ay  o.'e...-.  and  ...  yo..n^^  pel- 
sons  eve..  sei,a...tion  of  the  epi,.hyses.     There  are  i.-stamrs  ...  wlm  .     ho 
eartihtjies  have   .eparaled    fro..,   the   ster........      1  h..   ealh.s   o  la   leeentU 

ropaired  fraet..re  has  hoen  known  to  u.nle.-o  destrnetnm.      I'ever  .s  not 
prU.it,  except  in  the  h.ter  stages,  or  when  seconda.'v  „>lla...n.at.o..s  .n    !.. 
i„,,r..al  o.-ans  appea.-.    The  temi-erature  ...ay.  in.hr.l.  he  sou.elnnes  hrlow 
i,„nnal.     Aeiit/  aHhritis  is  an  neeasional  eo.iipiiealion. 

Diagnosis. —No  dilllci.ltv  is  i..et  in  the  .veo-nition  of  senrvy  when 
a  m....).rr  ..f  persons  are  alVeetVd  lo-ether.     In  isohited  eas.'s.  however   the 

di^ea-^e  is  di-tin-M.ished  with  diir.eultv  from  certain  lorn.s  ol  jmrpura.  li.e 
association  with  n.a.iifest  i..snllicieney  in  diet,  and  the  rap.d  amel.ora- 
tion  Avith  suitable  food,  are  points  by  which  the  diagnosis  can  be  readily 

Prognosis. —The  outlook  is  jrood,  unless  the  disease  is  far  advanced 
;„h1  the  conditions  persist  which  lead  to  its  dcvcloinnent.  The  n.o.lal.iy 
now  is  ra.'elv  great.  Death  results  from  gradi.al  heart-failure,  occas.onaly 
from  sudden  svncopo.  Meningeal  haa.iorrhagis  extravasalK.n  into  tiie 
serous  cavities,  ■eiitero-colitis,  and  other  intercurrent  allections  may  p.'ove 

'  Prophylaxis.— The  regulations  of  the  I'.oard  of  Trade  re(piiiv  that  a 
sulllcient  supply  of  antiscorbutic  articles  of  diet  be  taken  on  each  slui.;  so 
that  now.  except  as  the  result  of  accident,  the  occurrence  ol  scurvy  is  rare 

Treatment.— The  juice  of  two  or  three  lemons  daily  and  a  varied  diet, 
witli  l.lentv  of  fi-esh  vegetables,  sulliee  to  cure  all  cases  of  scurvy,  unless 
far  advanced,  \yiien  the  sto.nacli  is  much  disordered,  sn.all  (luantit.es  ot 
scraped  meat  and  milk  should  be  given  at  short  intervals,  and  the  lemon- 
juiec  in  gradually  increasing  (p.antities.  A  bitter  tonic,  or  a  steel  and  hark 
mixture,  mav  be  given.  As  the  patient  gains  in  strength,  the  diet  may  1)0 
more,  liberal  and  he  mav  eat  freely  of  potatoes,  cabbage,  water-cresses  and 
lettuce.  The  stomatitis  is  the  svmi.tom  which  causes  the  greatest  distress. 
The  permanganate  of  potash  or  dilute  carbolic  acid  forms  the  best  moutii- 
wash.  rencilling  the  swollen  gums  with  a  tolerably  strong  sohition  ot 
nitrate  of  silver  is  very  useful.    The  solution  is  better  than  the  solid  stick, 


!{-.: 


<?..  ^  ^%. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


1.0 


I.I 


1.25 


IIM    illlM 


I 

i; 


I4£  liM    {12.2 


1.4 


|3.6 

i  m  11112:0 


1.8 


1.6 


--J 


%..'%. 


Photographic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


m 


i 


0J>. 


CIHM/ICMH 

Microfiche 

Series. 


1 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  canadien  de  microreproductions  historiques 


^sm, 


lAMita 


1^^ 


•mi 


SCURVY. 


825 


as  it  iViK-lK'S  to  the  creviiTS  ln'twwii  the  gramilatidii.-f.  The  const ipat ion 
wliieh  i.s  so  cuiiuiion  is  ln'st  livatiHl  with  laiyv  cnriiiala.  For  other  con- 
ditions, sncli  as  lucmorrhagcs  aiul  ulceration^  ^uital.lle  measures  must  be 
(,in}iloyed. 

IKFANTlIiE   SCL'UVY   (liitrlawx  JJi.siiisc). 

As  in  adults,  scurvy  may  occur  in  children  in  eonseciuence  of  imper- 
fect food  supply. 

W.  r>.  t'headle  and  (ice,  in  London,  have  described  in  very  young  clnl- 
dren  a  cachexia  associated  with  luemorrhage.  rheadle  regarded  the  cases 
as  scurvy  ingrafted  on  a  riekety  stock,  (ice  called  his  cases  periosteal 
cachexia.     Cases  had  previously  been  regarded  as  aeute  rickets. 

A  few  years  later  I'mrlow  made  an  exhaustive  study  of  the  condition 
with  careful  anatomical  oh  ervation^..  The  alfection  is  now  recognized  as 
infantile  scurvy,  and  in  Cierniany  is  called  I'.arlow's  I)i:-ease.  Tiie  Ameri- 
can Pa'diatric  Society  has  c(dlected  (liS'.i.s)  in  ibis  country  iu 4  cases.  Of 
tiiese,  the  hygienic  surroundings  were  good  in  v'ii!*.  A  majority  of  the 
patients  were  under  twelve  months.  The  jiroprietary  foods,  j)articnlarly 
malted  ntilk  and  condensed  milk,  seem  to  be  the  most  important  factors  in 
l)roducing  the  di.sease.  There  are  instances  in  which  it  has  developed  in 
breast-fed  infants,  and  in  others  fed  on  the  carefully  prepared  milk  of  the 
Walker-tiordon  laboratories. 

The  following  is  a  general  clinical  summary,  taken  from  Barlow's  lirad- 
shaw  Lecture,  LSi)4; 

"So  long  as  it  is  left  alone  the  child  is  t(deraldy  (piiet;  the  lower  lind)S 
are  kept  drawn  up  and  still;  l)ut   when   placed   in   its  bath  or  otherwise 
moved  there  is  continuous  crying,  and  it  soon  becomes  clear  that  the  jiain 
is  c<mnected  with  the  lower  "liml)s.     At  this  jieriod  the  ui)per  limbs  may 
be  touched  with  impunity,  but  any  attempt   to  move  the  legs  or  thighs 
"■ives  rise  to  screams.     Next,  some  (>bscnre  swelling  may  i»e  dett'cted,  tlrst 
on  one  lower  limh,  then  on  the  other,  though  it  is  not  absolutely  synnnet- 
rical.  .  .  .  The   swelling   is   ill-delined,    liiit    is    suggestive   of    thickening 
round  the  shafts  of  the  bones,  beginning  above  the  epii>hyseal  junctions. 
Gradually  the  bulk  of  the  limbs  affected  l)ecomes  visibly  increased.  .  .  . 
The  position  of  the  limbs  becomes  somewhat  dill'erent  fnmi  what  it  was  at 
the  outset.     Listead  of  being  Hexed  they  lie  everted  and  immol)ile,  in  a 
state  of  pseudo-jiaralvsis.  .  .   .  Al)ont  this  time,  if  not  before,  great  weak- 
ness of  the  back  becomes  manifest.     A  little  swelling  of  oik'  or  both  scap- 
nhv  mav  appear,  and  the  upper  limbs  may  show  changes.     These  are  rarely 
so  c(nisiderable  as  the  alterations  in  the  lower  lind)s.     There  may  be  swell- 
in..-  above  the  wrists,  extending  for  a  short  distance  up  the  forearm,  and 
some  swelling  in  the  neighborhood  of  the  epiiihyses  of  the  humerns.    There 
is  symmetry  of  lesions,  but   it  is  not  absolute;  ai:d   the  lindj  afVeetion  is 
generally  consecutive,  though  the  involvement  (d'  one  limb  follows  very 
close  upon  another.     Tiic  joints  are  free.     In  severe  cases  another  symp- 
tom may  not  be  found— n'amelv,  crepitus  in  the  regions  adjacent  to  the 
junctions  of  the  shafts  with  the  epii.hyses.    The  upper  and  lower  extremi- 
ties of  the  femur,  and  the  npper  extrennty  of  tlie  tibia,  are  the  common 
51 


V..U 


■^ 


826  DISEASES  OF  THE   HLOOD   AND   DUCTLESS  GLANDS. 

Sites  of  .uel,  fraduvo.;  l.ut  th..  u,,,.,.  ..ul  of  the  •>-';;;-;-^^;;|r  l!:,:^ 

tlu.  iipiHT  li'l.    ^^ltllm  a    ia>     i  i  (.onjuiu'tiva  may 

amrs,  tl,<..,j;l,  tl.cy  may  bo  ot  lo-  ^•'^"^>;,     ''".....    re.pott  to  tin-  con- 

..t,,w   f....tinv  i^  tho  iivofoiiiul  aiiivmia  winch   i>  iU'\tioiHu       . 
""^'  t-  n  1  t.    tho  amount  of  lin.l.  involv.nu.nt.     As  the  case 

antenna  -  l'-"^'  ";,,;,'',,,,,, ,,^.1  or  sallow  tint,  which  is  note- 
prneeeds,  tluMC  i^  a  '^       y^;       '  ^^-^  ;,  ,,,,1,11,1,0,1  hruis.-like  occhy- 

wuvthy  in  severe  case.,  and  ^'"^    "^^^  ,        .^,      l^nmciatiun  is  not  a 

moses  may  appear,  an.    n>ore  la,  h  '^'^  J^^^^:^.^^  .^j.  „,,„,„i,,  failnre. 
,..rked  feature,  bnt  -^ •'-■;'  l^^^^rXu  n  fc  1         a  dav  or  two,  when 

::;sS;;=E;Sss^ 

en  t}  m  moving  u  .^   ^j  ,^,,  ^vphilitic  psendo-paralysis.  ma} 

r  '"'Tn:;:;;!;i  u Uh  U      l  l   '    :  ^o/m<;t'ion  is  i-e  or  less  sudden  in 

be  coniounded  ^^'^  '     ;    ;"    V     ,^,^,^    ,^^^,  ^o  a  solution  of  continuity  and 

!:;.;S  ::;  t;:r:ant:.  :^  ^"^  '^  the  d.physis.    There  are  u.nally 

-^^^^r;tl  i: -Im^Ii-a  ::;,;=%  -ravasation.  whi.  causes 
the  thickening  and  tenderness  in  the  shalts  o    the  hone..     In  .omc 
>;t.nires  there  is  ha«morrha,>:e  in  the  intramuscular  tissue. 
^^"t;  F.;>hvlaxis  is  moM  importan,.     The  various  propr,.aiTorm>o 
l.,^ra  .lilk  'ind  i.re^erved  foods  for  infants  should  not  be  n.e.i.      ]  u, 
Z^':''r:^^t^^l  substituted,  and  a  teaspoonfi.l  of  me,vt-ju,c. 
o    J  avY  niav  be  .iv.n  witli  a  little  mashed  potato.    Orange,iii,ee  or  lemon 
JdS'Z^id- be  ,^en  three  or  four  times  a  day.    Recovery  is  nsually  prompt 
and  satisfactory. 


VIl. 


STATUS    LYMPHATICUS.    LYMPHATISM. 


condition  mot 
„ill,  d.U-flv  in  <l,il.lr,M,  „n,l  yo,,,,,  ;:Z.n^>:'<«M  i\u'  l.""l>l;»tic  jrl..* 


Much  attention  has  been  i«ud  lately  to  "  ^""J';"^^  ";;^ 
:h  chiefly  in  chi 
d  lymph  tissue; 
lymphoid  bone  m 


^ite 


.■-A 


STATrS  LYMPIlATICrs.     LVMl'IIATLSM.  g27 

boon  found  as.^ociatod  v.itli  vkkvU  and  will,  livi..|,laMa  of  ihv  hoart  and 
aorta  Dio  ^j.ocial  intnvst  li.s  m  the  fact  tliat  tliivso  patlu.lo-ical  condi- 
tions liavu  birn  met  with  fn^HR'ntiy  in  cmsos  of  >^ii(Mfii  death.  I'ahauf 
and  otliers  of  tiio  \  ieima  .shool,  who  liave  written  extensively  (,n  the  ^uh- 
jeet,  hel.evo  tliat  individuals  with  this  liyoerplasia  have  louvre,!  puwers 
oi  resistanee,  and  are  particularly  liahle  to  paralvsis  of  the  heart  The 
conditin.,  has  n(,t  leeeived  luueh  attention  in  Kiiuland  and  in  this  coun- 
try An  ex.rllent  account  of  it,  hy  .lames  Kwin-,  appear..!  in  the  .New 
loriv  .Medical  dournal  of  duly  10.  iMi;. 

Anatomical  Coh(lition.-(;, )  L!jn,ph.;,hnnh.~'V\u'  pharvn-.'al,  thoracic 
and  alHlojnmal  ur„„,,s  are  most  fre.pientiv  allected.  The  cervical  axil- 
lary an.l  m-umal  are  less  commonly  involve.l,  hut  ihcse  -lands  ,nav  s'how 
sli-ht  enla.^remcnt.  The  lymphatic  structures  of  the  alimentary  tract  tho 
...snos  ol  tho  tonsils  the  ad.moid  structures  in  the  upper  pharynx,  and 
tho  .ohtary  and  a.mnmatcd  follicles  of  the  small  and  lar-o  intestines  are 
usually  nn.ch  .mhu-cd.  The  hyperplasia  of  the  intestinal  Ivmphatic  struc- 
tures may  ho  the  most  remarkable,  the  individual  «lamls  standing  out  like 

C;)  'V''';';--l-:i'hirgement  of  this  or-an  is  usuallv  moderate  in  d.Mn-eo. 
IJio  .lalpjolnan  hodios  may  show  very  prominentlv,  and  wh.-n  aiuemic  may 
look  Ilk."  hu-e  tubercles.     The  organ  is  usuallv  soft  and  hvpciu'inic. 

(r)  J  he  //////«„,•  rs  enlarged,  and  may  nu.asure  as  nnuli  as  JO  cm  i„ 
length.     It  looks  swollen  and  soft,  and  on  section  may  exude  a  milky  white 

(d)  The  hone  marrow  has  boon  found  in  a  state  of  hyperplasia,  and  tho 
yellow  marrow  of  tin'  long  bones  in  young  adults,  anVl  even  in  pers„„s 
between  tho  ages  of  twenty  and  thirty,  has  b.^en  found  roi-laeed  bv  red 
marrow.  Among  other  associate,!  cnditions  of  this  ron.lilullu  himuhdica 
as  1  has  been  ca  led  are  hypoplasia  of  the  heart  and  aorta  and  enlargement 
ol  the  thyroid  gland.  In  a  large  number  oi  the  cases  in  children  rickets  is 
coincident. 

The  diaf/nnsis  of  the  lymphatic  constitution  is  not  alwa-s  easy  En- 
largement of  tho  superficial  glands,  with  hypertrophy  of  the' t.uisils,  shnis 
ot  slight  swelling  of  tlio  thyroid,  dulnoss  over  tlie  sternum,  with  si-n^'^of 
cnlargonieiU  of  tho  mesenteric  glands,  are  among  the  most  imporiant  fea- 
uros.  Signs  of  hypoplasia  of  tho  vascular  system  are  still  nn.re  uncertain 
though  Quincke  believes  that  in  such  instances  tlio  loft  ventricle  is  dilated 
and  the  perij)heral  arteries  may  1)0  much  smaller  than  normal  Tho  sub- 
jocts  are  usually  ill-dovolo])ed  and  infantile  in  conformation. 

Smhlvn  Death  in  the  sfahis  h,,„ i,}, a tinis.— What  has  directed  the  at- 
tention of  writers  more  particularly  to  this  condition  is  tho  fre.iucncv  with 
which  It  has  boon  found  in  eases  of  unexpected  death  from  very  trilling 
and  inado.iuato  causes.  A  good  deal  of  attention  was  directed  to^tho  sub- 
.loct  by  tho  doatli  of  tho  son  of  Professor  Lan-hans.  of  licrlin.  immediately 
alter  the  preventive  inoculation  with  the  antitoxino  of  diphtheria  In 
another  child  death  occurred  un<1er  sindlar  eircumstancos.  The  condi- 
tion has  also  been  met  with  in  a  nunii)er  of  cases  of  sudden  death  under 
ana>sthotics,  and  I  know  of  one  instance  during  anaesthesia  for  adenoid 


Is 


I. 


m\ 


I^tffe 


828  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

rr.  wth.     C'l^c-  of  RU1.1.MV  .lonih  of  iHTs..!..  ill  tlu'  watcT,  who  havo  fallen 

ih  r'  '"^oup  .     cases  ofsu.lclen  deatl.  in  childron  w.thuut  roeog- 

'"■  '"■'"""    ,,       .       ;.rt»i„  ,.t  tlio  ,«M,-n  ,l.all«  .luring  conv.',.«c„c.o 

„„„,o,ni..al  iV,,l.M«  -m-",  !';"■'>■  «■"*';;„  „.     t  way  .u.l.Ion  ,lo»tl.  is 

'  1,  M  i-'ic  oonstilutim,  l,.,v.  a  <li.„inislu,l  vital  v,.,,rta,.<'i.,  and  a,» 
;:',l,i:iirr'"t,,  fatal  cna,..  ,.«,!..■  ..vainarily  very  ina.lo.,K,tc  c.catmg 
causes. 


vn 


1.    DISEASES    OF   THE    SUPRARENAL    BODIES. 


1.  Addison's  Disease. 


Definition -A  constitutional  alTeetion  eharaeterized  by  asthenui,  de- 
pre^S^n^  on,  irritability  of  the  ston^ach,  and  P'^n-tat.on  of  ^ 
^n.  Tnbereulosis  of  the  adrenals  is  the  eonnnon  "-'^;;"-;^  ^^^J^j 
liooont  observations  indieate  that  the  syn>pton.s  are  due  to  lo..  oi  function 

of  the  snitrarenal  bodies.  ^^  p,,,-'^  TTn^nit-il 

The    eeofrnition  of  the  disease  is  due  i"  A'ld.son    of  ['^'y    /    '  *    ' 
.vho'e  niono,;.,,.!,  on  The  Constitutional  and  J  „eal  Kfleets  of  Disease  of 

Orc^!;^o!:^f^alysis  of  18.  eases  11.  .ere  males  -^ '^^^:;- ^^^^  ^^ 
ioritv  of  the  eases  oeeur  between  the  twentu^th  and  the  f.utietli  >ear.     A 
^  S.niial  ease  has  been  described  in  .l.ieh  the  sl.n  luu    ^^^^^ 
tint     The  child  lived  for  ei-ht  wec.ks,  and  i-ost  mortem  the  m  len.  1.  v\crc 
nd  to  b    large  and  cystic.     Injury  such  as  a  blow  npon  ^^^^^^-^^ 
or  bade    and  caries  of  the  spine,  have  in  many  cases  preceded  the  atta 
Th      i  "oa'c  is  rare  in  America.    The  number  of  deaths  dnr.ng  the  consu 
V  "r     son  was  OO-'-.O  n,ales  and   -10  females.     Twelve  cases  have  come 
under  mv  i^ersonal  observation.  9  in  men.     One  ease  was  m  a  negro._ 
""nJ^bid  Anatomy  and  Pathology.-There  .  rarely  em^^^^^^^^^ 
or  ana^mia.    "Rolleston  *  tluis  summarizes  the  condition  of  the  suprarenal 
bodies  in  Addison's  disease:  


*r.ul.tom«n  T...t„ros.  Koyal  Pollo.o  of  Pln.ioians.  British  ^^^^^^;^' 
i,  to  which  the  student  is  referred  for  an  exhaustive  consideration  of  the  entire  question. 


Mtti 


DISEASES  OF  THE  SUPKAUENAL  BODIES. 


821) 

"1.  Tho  fil)ro-oas;ooiis  lesion  diic  lo  liiI,i.,vulo>is— fur  tlio  cominono^t 
oon.litu.a  lo.md.  )>.  .Simple  atrophy.  ;i,  Chnuue  interstitial  intlanima- 
tioii  leading  to  atrophy.  4.  .Alalignant  .lisease  invading  tjio  eapsules  in- 
elndmg  Addison's  ease  of  malignant  nodule  ecnipre.-sing  the  snprarenal 
vein.  ,).  JJlood  extravasatcd  into  the  .'■iipra renal  bodies.  ().  So  lesion  of 
the  .snprarenal  hodie.s  themselves,  but  Miessure  or  inllammation  involvimr 
the  semilunar  ganglia.  " 

'•  The  iirst  is  the  only  common  can.se  of  Addison's  disease.    The  others 
witli  the  exeeption  of  simple  atrophy,  niav  be  considered  as  very  rare  "      ' 

Among  other  anatomieal  features  the  condition  of  the  abdominal  sym- 
pathetic has  been  sju'cially  studied.  The  nerve-cells  of  the  semilunar 
ganglia  liavo  been  described  as  degenerated  and  deeply  pigmented 
and  tho  nerves  sclerotic.  Tho  ganglia  are  not  nncommonlv'  entan-rled  in' 
he  cicatricial  tissue  about  the  adrenals.  The  spleen  has  occa.^onallv 
been  iound  enlarged;  the  thymus  may  have  persisted  and  be  larger  than 
normal.  " 

It  is  difTicnlt  to  explain  satisfactorily  all  the  svuij-toms  of  this  remark- 
able disease.    The  t^vo  cliief  theories  which  have  been  advanced  are  brielly 
as  follows:  (a)  That  the  disease  depended  up<.n  the  loss  of  function  of 
the  adrenals.    This  was  the  view  of  Addison.    The  balance  of  experimental 
evidence  is  m  favor  of  the  view  that  the  adrenals  are  functional  glands 
which  Inrnish  an  internal  secretion  essential  to  the  normal  metabolism 
Schafer  and  Oliver  have  shown  that  the  human  adrenals  contain  a  very 
].(.werful  extract,  which  is  not  to  be  obtained  in  cases  of  Addison's  dis- 
ease; they  have  also  studied  the  toxic  eifects  on  animals  of  the  extracts  of 
the  glands.     In  the  cases  in  which  the  adrenals  have  been  found  involved 
without   the  symj)toms  of  Addison's  disease,  accessory  glands  may  have 
been  present;  while  in  the  rare  cases  in  which  the  symjitoms  of  the  disease 
have  been  present  with  healthy  adrenals  the  .semilunar  ganglia  and  adiacent 
tissues  have  iieen  involved  in  dense  adhesions,  which  may  have  inte'rfered 
readily  with  the  vessels  or  lynipha.ics  of  the  glands.     On  this  view  Addi- 
son's disease  is  due  to  an  inade(piate  supply  of  the  adrenal  secretion    iust 
as  myxa'dema  is  caused  by  loss  of  function  of  the  thyroid  gland     "  Whether 
the  deliciency  in  this  internal  secretion  leads  to  a  toxic  condition  of  tho 
blood  or  to  a  general  atony  and  ajiathy  is  a  .piestion  which  must  remain 
open      (Kolleston).     (h)  That  it  is  an  alfcction  of  the  abdominal  sympa- 
hetic  system,  induced  most  commonly  by  disease  of  the  adrenals,  but  also 
by  other  chronic  disorders  which  involve  the  solar  plexus  and  its  .rancrlia 
According  to  this  view,  it  is  an  affection  of  the  nervous  .system    and°the 
pigmentation  has  its  origin  in  changes  induced  through  the 'trophic  nerves 
The  ])ronminced  debility  is  the  outcome  of  disturbed  tissue  metabolism 
and  the  circulatory,  resj.iratory,  and  digestive  svmptonis  are  due  to  im- 
plication of  the  i)neumogastric.     The  changes  found  in  the  abdominal 
sympathet'c  are  held  to  suiiport  this  view,  and  its  advocates  nr^re  the  occur- 
rence of  pigmentation  of  the  skin  in  tuberculosis  of  the  peritonaeum   cancer 
of  tlio  pancreas,  or  aneurism  of  tho  alidominal  aorta.     Bramwell'  tliinks 
that  the  symptoms  may  lie  in  part  due  to  irritation  of  the  sympathetic  and 
in  part  to  renal  inadequacy. 


830  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  OLANDS. 

Svmptoms.-ln  the  words  (,f  A.ldisnn,  tl.o  cLnrac-tcristic  symptoms 
„ro  •  aiKunia,  K-H-'nl  lant,n,nr  or  .IcLility,  rnuarkal.k;  i\rhK..u..s  oi  the 
hvan'<>  action,  irrital.ility  of  tlie  stonmch,  and  u  i-cculiar  change  oi  color 

"'  'ri.c  (.'"set  is,  as  a  rule,  insi.lions.  The  feelin-s  of  weakness,  as  a  rule, 
l.recede  the  pigmentation.  In  other  instances  the  gastro-iutestimU  symp- 
toms, the  weakness,  an-l  the  pig.n.M.tation  come  on  together.  Ihere  are 
a  few  cases  in  the  literature  in  which  the  whole  process  has  been  acne 
following  a  shock  or  some  special  depression.     There  are  three  important 

symi)toms  of  the  disease:  ,      n    .     ,,      in      ..*f„„ 

(1)  rh,,„nih,li..  of  (he  ^7,■(/^-This,  as  a  rule,  first  attracts  the  a  ten- 
ti.m  of  the  patienfs  friends.     The  gra.le  of  coloration  ranges  Iron,  a  l.gh 
vellow  to  a  deep  brown,  or  even  black.     In  typical  cases  it  is  d.llnse,  bu 
always  deeper  on  the  exposal  parts  and  in  the  regions  where  the  normal 
pigim.ntatil.n  is  more  intense,  as  the  areola-  ot  the  nipp  es  and  about  the 
genitals;  also  wherever  the  skin  is  compressed  or  irritated,  as  by  the  waist- 
b.,nd     At  first  it  may  be  conlined  to  the  face  and  hands.     Occasionally  it 
is  al)sent.     Patches  sliowing  atrophy  of  pigment,  leucoderma,  may  occur. 
The  i.i-nuentation  is  found  on  the  mucous  membranes  of  the  nunitli,  con- 
junctiv;<,  and  vagina.    A  patchy  pigmentati.m  of  the  serous  membranes  has 
often  b..eii  found.     Over  the  dilVuscly  pigmented  skm  there  may  be  li  tie 
mole-like  spots  of  deeper  pigmentation.     The  pigmentation  of  the  skin 
alone,  unless  the  mucous  membranes  are  also  involved,  is  rarely  suliicicnt 
in  itself  to  make  the  diagnosis  clear.  ..,      ^i^    i 

(•.')  aastn>-i>itr>^{inal  Symphins.—Tho  disease  may  set  in  with  attacks 
of  nausea  and  vomiting,  spontaneous  in  character.  ^r<.ward  the  close  there 
mav  be  pain  with  retraction  of  the  abdomen,  and  oven  features  suggestive 
of  peritonitis  (Kbstein).  An  intense  anorexia  may  be  present.  Ihe  gas- 
tric symptmns  are  variable  throughout  the  course;  occasionally  they  are 
absent.     Attacks  of  diarrluea  are  frec^uent  and  come  on  without  obvious 

cause.  .    .     p    i  e  i} 

(3)  Is-Z/fcnm— This  is  iierhaps  the  most  characteristic  feature  ot  the 
disease.  It  mav  be  manifested  early  as  a  feeling  of  inability  to  carry  on 
the  ordinary  occupation,  and  the  patient  complains  constantly  of  feeling 
tire.l  ThJ  weakness  is  specially  marked  in  the  muscular  and  cardio- 
vascular systems.  There  may  be  an  extreme  degree  of  muscular  prostra- 
ti.)n  in  aii  individual  apj-arently  well  nourished  and  whose  muscles  feel 
firm  and  hard.  The  cardio-vascular  asthenia  is  manifest  m  a  feeble,  irregu- 
lar action  of  the  heart,  which  may  come  or.  in  paroxysms,  in  attacks  ot 
verti-'o  or  of  svncope,  in  one  of  which  the  disease  may  jirove  fatal,  llead- 
ache^iJ  a  frcpient  symptom;  convulsions  occasionally  occur.  Mc:N  unn 
has  described  an  increase  in  the  nrinary  pigments,  and  a  ])igment  has  been 
isolated  of  verv  much  the  same  character  as  the  melanin  of  the  skm. 

Ana'inia  was  a  svmptom  si.ecially  referred  to  by  Addison,  but  it  has 
been  present  in  .,  marked  degree  in  only  one  of  my  cases     I  saw  an  in- 
stance  in  rhihulelphia,  with  J.  C.  Wils.m,  in  which  the  diagnosis  at  first 
was  not  at  all  clear  between  Addis.m's  disease  and  pernicious  ana?mia. 
The  mode  of  termination  is  either  by  syncope,  which  may  occur  even 


DISEASES  OF  TIIH  SLTKAJiCNAL  IJODJES. 


831 


early  in  tlic  distasis  l.y  ^-radual  pro-ir.^sivc  asllp'iiia,  or  hv  tlie  dcvolonmeut 
"I  tuh.rciil.,!!^  lesions.  1„  t\v„  .ast-s  1  liavi'  kn..\vi,  a  noisy  doliriuni  with 
urpMil  dysj.rid'a  to  precede  tlie  I'atal  evtiit. 

Diagnosis.— I'i-ii,enhitiou  ol'  the  .^kin  is  ii„t  (oiifmod  to  Addison's 
disease.  Die  hdlouing  arc  the  coiiditious  uhi.h  may  givo  rite  to  au  iu- 
irease  in  the  jiii^MK  nt: 

(1)  -Vhdoniiiial  -rouths-tuherele,  cancer,  or  lyniplion.a.  ]n  tubercu- 
losis ol  tile  i.critona'uni  pigmentation  is  not  uncommon. 

{■i)  rregnaney,  in  whicli  the  discoloration  is  usually  limited  to  the  face 
the  so-called  „ias,j„r  dcs  fvwnirs  cncriiilcs.  I'tcrine  disease  is  a  common 
cause  ol  a  i^atchy  melasma. 

(-•3)  Hepatic  disease,  which  may  induce  deOnitc  pigmentation,  as  in  the 
diabetic  cirrhosis.  More  commonly  in  overworked  per^ons  of  constipated 
luihit  and  with  sluggish  livers  there  is  a  patchy  staining  about  the  face 
and  forehead. 

(4)  The  vagal)ond"s  discoloration,  caused  by  the  irritation  of  lice  ami 
dirt,  which  may  reach  a  very  high  grade,  and  has  sometimes  been  mis- 
taken tor  Addison  s  disease. 

(5)  In  rare  instances  there  is  deep  disc(,loration  of  the  skin  in  mela- 
notic cancer,  so  dee})  and  general  that  it  has  been  confounded  witli  nirlasma 
suprarenale. 

((!)  In  certain  cases  of  exophthalmic  goitre  abnormal  pigmentation 
occurs,  as  noted  by  Drummond  and  others. 

(T)  In  a  few  rare  instances  the  pigmentation  common  in  sclerodenna 
may  be  general  and  deep. 

(8)  In  the  face  there  may  be  an  extraordinary  degree  of  |)igmenta- 
tion  due  to  innumerable  small  ])lack  comedones,  "if  not  seen  ii^a  very 
good  light,  the  face  may  suggest  argyria.  Tigmentation  of  an  advanced 
grade  may  occur  in  chronic  ulcer  of  the  stomach  and  in  dilatation  of  the 
organ. 

(iO  Argyria  could  scarcely  be  mistaken,  and  yet  I  was  consulted  this 
year  by  a  woman  in  whom  the  diagnosis  of  Adilison's  disease  had  been 
made  ])y  several  good  observers,  but  the  character  of  tlie  i.igmentation, 
the  length  of  time  it  had  lasted,  and  her  freedom  from  all  svmj)toms 
pointed  undoubtedly  to  argyria,  though,  so  far  as  she  or  her  physician 
knew,  she  had  never  taken  nitrate  of  silver  medicinally. 

In  any  case  of  unusual  pigmentation  these  various  conditions  must  bo 
sought  for;  the  diagnosis  of  Addison's  disease  is  scarcely  justifiable  with- 
out the  asthenia.  In  many  instances  it  is  dilTicult  earlv  in  the  disease  to 
arrive  at  a  definite  conclusion.  The  occurrence  of  faint'ing  fits,  of  nausea, 
and  gastric  irritability  are  imi)ortant  indications.  As  the  lesion  of  the' 
cai)sulcs  is  almost  aUva.vs  tuberculous,  in  doubtful  cases  the  tuberculin 
test  may  be  used.  In  a  recent  case,  a  robust,  healthy-looking  man  with 
symptoms  of  Addison's  disease,  the  characteristic  reaction  was  obtained. 

Prognosis.— The  disease  is  usually  fatal.  The  cases  in  wbieh  the 
bronzing  is  slight  or  does  not  occur  run  a  more  rapid  course.  There  are 
occasionally  acute  cases  which,  with  great  weakness,  vomiting,  and  diar- 
rhavi,  prove  fatal  in  a  few  weeks.    In  a  few  cases  the  disease  is  much  pro- 


m^ 


832  DISEASES  OE  THE  BLOOD  AN.)  DUCTLESS  GLANDS. 

Tm  vnv  iiwtiiiKC's  rcToverv  has  taken  pUico, 

:-:;s::-:;r,^:;:;:J«  f^^^^^        „... 

L,j. „i „„, time <»-.ur.  •"'"";:"';'>,„  J:»'A.-i"c ™j «"■>-'."- 

thrive  best  O.I  a  strict  nulk  ;'>;;'•  j,,,^^,-,,  ^he  researches  of  Schiifcr 

Treatment  by  Suprarrua   L.>ln.l       ;''  -       ,^f  ^,,^,  .lise-aso.    Kinni- 

nn.l  Oliver,  the  h.tter  used  the  ^la   .    n      a       ;      >  "        ,,,,^t,,,,     of  these. 

G  were  reported  as  cured  and  ii  "'V"'  I  m  '  p,tiont  was  greatly  benefited, 
^•hieh  one  has  been  "1"-'^  -I'^'Vith  n^  d  ^  HMred,^unl  he  was  alive 
gained  1.  pounds,  the  syjupt-nns  o    -    -    j^l  1,,,^  ^  ,,,,,  ,„,,,  .-ere 

S  r;;;ii:;XhiS;^r  .;::i^  to  ^t.  ot  the  .and.    Three  of  the 
tnbloiila  liiiiy  he  given  ilnily- 

2    Ol,u.;n  1)isi:as,:s  of  the  Svlaiucn-a.,  CArs.-T.F,s. 

;,.„,»„.»,.  into ...  ,u,.^  u  „„.  '"-™™;„;;:-:;™i;';li;;;,:::;'A" 

l!an»ay  i..f«rni.  '"^*''''^,"■'',''"      1  1;  ."»   „  foL.cs  and  1  in  a  m«lc. 

plete  recovery. 

IX.    DISEASES   OF   THE   SPLEEN.* 

*      ,.  ,llln,T  in  fever  the  ohronio  enlargement  of  the 

^r  ;i:^;i «;;,:;;;'  Sh;;.'-.'  "^^  ,ivor.^n^hoa^Mi;oa^ 


org. 


AUbutfs  System  of  Medicine. 


DISEASES  OK  THE  SPLEEN'. 


833 


pco  very  few  iii-^tiuircs  of  (liscjisc  oi'  tli(.  si,l((ii.     Tlioc  nH'cctioiis  hiivc  1 n 

fully  (Icsci'ilHd.  Iiut  llmo  ivmain  .^fVciiil  cuiKlitiKM,-  to  wliie  li  hiicl'  ivl'iTiiic' 
may  hv  iiiinlc. 

1.  ^Ii>VAi!i.i:  Sri.i:r.v. 

!Movalilt'  or  uaudciiiig  sidccii  is  Sfcii  iiio.-t  Iti'iiiiciiily  in  woiiiuii  llio 
sul)ji'fts  ol"  fiitiTojitosis.  It  is  occasionally  met  witli  wiilioiit  si^^iis  of  (li>- 
I)lacciiK'iit  of  other  or^r.,i,s.  It  may  lie  I'oiiiid  accidentally  in  individiialrf 
who  in'cseiit  no  symptoms  whatever.  Jii  other  cases  tlicie  are  drair^dn"', 
linoasy  l'eelin;;s  in  the  hack  and  side.  All  ;;rades  are  met  with,  from '"a 
sl)loeii  that  can  he  felt  comiilctcly  helow  the  mar;;in  of  (he  rihs  t(»  a  condi- 
tion in  which  the  tumor  is  fidt  as  low  as  the  pelvis;  indeed,  the  organ  has 
been  found  in  an  in<iiiinal  hernia!  Jn  the  lai.ue  majority  of  all  ca.sos  llio 
spleen  is  eidai'ged.  Sometimes  it  apjiears  thai  the  enlar<>-enient  has  caused 
relaxation  of  the  ligaments;  in  other  instances  the  relaxation  .seems  con- 
genital, as  movable  spleens  liave  been  found  in  dilferent  mendicrs  of  the 
same  fannly.  Possibly  traumatism  may  account  for  some  of  tiie  oases. 
Apart  from  the  dragging,  uneasy  sen.sdions  and  the  worry  in  nervous  pa- 
tients, wanderinj,  spleen  causes  very  few  serious  .'symptoms.  Torsion  of 
the  jtcdicle  may  pro(bice  a  very  alarming  and  serious  condition,  b.'ading 
to  great  swelling  of  the  organ,  high  fever,  or  even  to  necrosis.  A  \oung 
woman  was  admitted  to  my  colleague  Kelly's  ward  witb  a  tumor  supjioscil 
to  be  ovarian,  but  whicb  i>roved  to  be  a  wandering,  moderately  eidarg(.'d 
sj)lccn.  She  was  transferred  to  the  me(beal  ward,  where  she  (b'vcloped 
suddenly  very  great  pain  in  the  abdomen,  a  large  swelling  in  the  left  Hank, 
and  much  tenderness.  Ibdsted  operated  and  bmnd  an  enormouslv  enlarged 
spleen  in  a  condition  (d'  lU'crosis,  adherent  to  the  adjacent  parts  and  to 
the  aii(biininal  wall.  ]Ie  laid  it  o]ien  freily,  ami  largi'  necrotic  masses  of 
si»lcen  tissue  discharged  b»r  some  time.     She  made  a  good  recovery. 

The  ilifu/nnsis  of  a  wandering  s|)leen  is  usually  easv  uidess  the  origan 
becomes  lixed  and  is  deformed  by  adhesions  and  perisidenitis.  The  shajie 
of  the  organ  and  the  sluu'ii  margin  witb  the  notches  arc  the  points  to  be 
sj>ecially  noted. 

The  iiralnicnt  of  the  condition  is  important.  Occasionally  the  organ 
may  be  kept  in  position  by  a  jirojierly  aibipted  belt  and  a  jiad  under  the  left 
costal  margin.  IJeinoval  of  the  displaced  organ  ]uis  been  advised  and  car- 
ried out  in  many  cases,  and  nowadays  it  is  not  a  very  serious  operation.  It 
is.  Iiowever,  as  a  rule  unnecessary.  In  2  cases  of  eidarged  si)leen  under  my 
care,  witb  great  mobility,  causing  nuicli  discomfort  and  uneasiness,  Ilalsted 
completely  relieved  the  condition  by  reiilacing  the  spleen,  ])acking  it  in 
position  witb  gauze,  and  allowing  firm  adhesions  to  take  place.  I'.otb  these 
patients  were  seen  more  than  eighteen  months  after  tbe  operation  and  the 
organ  liad  remained  in  jiosition. 


.f! 


2.  IkTTTruK  OF  Tiir;  Spleex. 

This  is  of  interest  medically  in  connection  with  tbe  spontaneons  rup- 
tnre  in  cases  of  acute  enlargement  during  typhoid  fever  or  malaria.  The 
condition  seems  very  rare  in  tliis  country.    We  have  bad  instances  of  rnp- 


f 


ifllMki 


83i  DISEASES  OF  THE   RI-OOD  AND  DUCTLESS  OLANDS. 

,„e  of  a  ...larial  s,!..  r,il..;vin.  '7^:;;;;^:^ n;;;:'' h'S^X  I^la 
in  ty,.hoi.l  have  we  ''-^'V'     fu^^'t^       i  -        'V  —on.     Fatal 

in  Mauritius  rMptuiv  <.l  iho  splrc-.i  _i.  ^';^^^;^  ;•„,  ,  ,,v,,.KU.nMic 

;;r';     nn^^  !'<■  --'1.....  a,,  those  oi  l...uor.  >age  uUo  the  pen- 

;:„::^,n"  a.;;;  the  conait,ou  aeuuuul.  inuuediate  lai.aroto.uy. 

■S.    INIAUIT    ANU   AllSCKSS   OF   THK   SlT.KKN'. 

FmLoli  in  the  si.lenie  artories  eausn.^  infarct.  n>ay  he  either  infeetirc 
n    V  .,re  ween  most   fre.inently  i"  nhorative  en.h.ear.h  i.  and 

;:  :;"S.il;;L;:;:  i:;:u.ets  n.ay  !..so  ^<->i- 1,.  for..aui..n  .^  u.^ 

In  ti.l  hranehes  of  the  sj-lenie  ''^^^  ^  .^^  ,^^^,,,  ,^  .l^:  "rL:;^ 
infrequent  in  typhoj.l.     In  a  i'?     ;^    '^    ^j^'^^     t,>ol..,Meal  interest. 

mmmmm 

-1.    Sl'LKNIC   AX.T.MIA. 

This  c„„Ji.ion,  „™,lly  -.n,..l  .  J.C  ,,Jo,™  '--^.Jt-^^^';;^  S; 

ot  inaiaria,  TRKL    ,  n,.,-HH7ifC  spJeno-megahj.    A\  hiL^ 

;rSii.  "  «      ot™,  i',;t;:  ,0,.,,,/,  ».  ^.«.U  an  ,„,».„.»  n.„ciaM 

eon     vh  '  in  a  malarial  region.     There  are  cases,  too,  :n  f  ^    ;^^4  ^^^ 


1! 


DISKASKS  OK  THE  TriYROTD  fiLAXD.  cor, 

the  Htoiiijuli.  A  iMticnt  rrniM  ,(,iin:ii.;i,  ivIVrivd  In  mv  n  frw  yciir^  ii<'..  l.y 
Jlcn(l(Ts..n,  „(  Kin->|nM,  witlnHit  miv  iiuihiri,il  liist..rv.  \uu\  lin  t>ii(.nn..iN 
sj.l.rn,  lind  iia<l  scwnil  ntta.ks  ..f  i.rnfnnii.l  iiiiinnia,"  Iml   at   tho  tii.io  of 

obsiTvatK.M  lia.l  a  l\ |-,oiiiit   iirarly  n.^nnal.     I  see  many  mere  cn-es  of 

l.Miiiifivc;  si.|riio-iiic^r.,l_y  will,,, lit  lliaii  witli  aiiifiiiia. 

S  Wost,  ill  Alll.iitrs  Systc.iii,  -ivcs  llui  f..ll,nviiiK  ix»  the  main  fi'iiturcs 
of  qili-iuc  aiia'inia:  "Tlio  dinoaso  may  be  divided  into  three  i^Uiav^:  In  Hie 
initial  sta<re  tlie  symptoms  are  those  of  extreme  amemia,  with  <rreat  loss  of 
mnseiilar  power  and  some  wastin^^  of  musele,  thou^di  usually  without  emaci- 
ation. As  111  this  sta-e  the  disease  iiresents  no  specific  features,  it  can 
rarely  he  reconiiizcd.  The  second  sta<,'e  is  characterized  hy  jirorrressive  en- 
liirjremciii  of  I  he  spleen  and  hy  attacks  of  severe  pain  in  the  >pleiiic  re-ion; 
the  anaiina  i>  mnre  proloiind,  the  loss  of  streii;,rth  is  extreme,  and  the  pa- 
tients are  liable  to  repeated  attacks  of  bleeding',  especially  from  the  nose- 
the  temperature  is  now  usually  raised  and  of  hectic  character,  reachiiu' 
102°  or  more  in  the  evenin-  It  is  in  this  second  stage  that  the  disease  is 
first  reco^Miized. 

'Vin  the  last  stage  the  condition  is  one  of  progressive  nstlienia,  which 
ends^in  death;  there  is  in  it  nothing  especially  characteristic." 

The  blood  condition  is  one  simply  of  profound  ana-mia  without  in- 
crease 111  the  hMicocytes  and  n<.t  always  with  marked  jioikilocytosis.  The 
tendency  to  Ineiiiorrhage  is  marked,  both  from  the  mucous  surfaces  and  in 
the  skin. 

Anatomically,  the  only  special  changes  tJiat  have  been  noted  have  been 
a  peculiar  atroi)liy  of  the  :\lalpigliian  coi-jiuscles  in  some  cases. 

The  tri.atment  of  the  condition  is  that   of  other  forms  ^of  profound 


XI.    DISEASES   OF   THE   THYROID    GLAND. 

1.  Goitre. 

_      peflnition.-TTyportrophy  of  the  thyroid  gland,  occurring  sporad- 
ically or  endemically.  '■ 

In  this  country  sporadic  cases  are  common.  The  endemic  centres  rc- 
tc'rred  to  in  l'>arton's  monograi.h  (1810)  and  in  Ilirsch's  Geograi.hical 
ra  hology  no  k.nger  exist.  The  disease  is  very  prevalent  about  tiie  elistorn 
end  of  Lake  Ontario,  and  in  parts  of  Michigan  (Dock).  Kudcmicallv  it 
IS  found  particularly  in  the  mountainous  regions  of  Switzerland  and  in 
])nrts  oMtaly.  ^o  satisfactory  explanation  has  been  given  of  the  existence 
ot  tiie  disease  in  this  form. 

Anatomically  the  following  varieties  mav  be  distinguished:  (^0  Paren- 
chymatous, in  wliicli  the  enlargement  is  general  and  the  follicles,  usually 
newly  formed,  contain  a  gelatinous  colloid  material,  (h)  Vascular  in 
which  the  enlargement  is  chiefly  due  to  dilatation  of  the  blood-ve«el. 
without  the  new  formation  of  glandular  tissue,  (c)  Cystic  goitre,  in  which 
the  enlarged  gland  is  occupied  by  large  cysts,  the  walls  of  which  often 
undergo  calcification. 


836  DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 

,i,e  gland,  or  atV.vt  only  on.  L.be,  o   ^  -  ^  '   "    ;     ^  ,  ,^,,  ,rachoa, 

goitre  oans.s  no  — -'i;:;-,^^;,^      S       '-man  ^nd  .l,rcs.  the  vein, 
causing  dynpntea,  or  may  pa^-'  b  'iHatt'  \"^  ^  •         j.^   ,^.  proportion 

Those,  h<..ever,  are  -^'^1;;;-^™  ^    ^      T  rll'eUon  Luil'^on.e^ 

of  all  eases  no  serious  ^J''^'  oms    rt     ot^        oecasiouallv  oeeurs  ui  large 

ler  the  care  o    ^^^^■^^^^:^^.^,  to  deternune  the  .ause, 

bronehocele^.     In  ^''"l^";'^''",  ,  ,^,^  •  .;^|  ^.m,  pr.s^ure  on  the  vagi.    I  have 

and  it  luis  ].een  tlu>ught  to  he  '  f  ^'  •'';^'  ;\!   V^  i,.„norrha.'e  into  the  gland 

reported  an  ius..nee  m  wind.  >t -^       ,^';^^i'^;;;:'\^  ..lU.l.r  tLue. 

and  into  the  ^^i^^'^  ''-^^^^^^  '  ^l.Hng  the  aorta  and  perieardiun. 

of  tin;  neck  and  under  the  ^t'^"\'  "'  '•^,''\.,,^.i,,.,.,,,tor  slxndd  he  l.oiled. 

In  regions  in  v.lneh  S'-'^re  l^vva      the   1    nlu       s  ^  ^^^^^,^.^^  ^^^^^^ 

of  1'^  cases. 

2.  TfMoits  OF  TiiK  Thyroid. 

•    1      (n\    \denomata,  cither  simple  or  malignant. 

These  are  very  varied,     {a)  AUenomdia,  reported  hy  llav- 

The  latter  may  fonn  extens  vc  -^^j;^^.,,;^  ::!;,;;.,  rilie  lung-nd 

.vard  in  uhich  ^';fl---;;^.Sivhh  several  forms  have  heen 

a:Xd:T)1--  ^--^  ^  -'^''' '"'''' ''"'' '  '''' 

cal  interest.  .,i,on-int  or  accessorv  thvroid  gland  may 

It  inav  be  menti<med  that  tlie  aiicnani  (u  <u^<-        .       . 

reported  by  K  A-  ^  "'^  r,       ' '^  ^^  J      ti,,roid  occupied  the  entire   right 
which  an   enormous  c.vtic  acccoi^ 

pleura.  „     ,      i  ,  „  r.f  4i,o  1>m<c  of  the  tomjuc,  and  is 

3    Ekopiitii.vlmic  GoiTin:  {Parry  s  Dheasc). 

T..flnition-\  cli.oaso  characterized  by  exophthalmos,  onlargement 
Deullltion. — -^  ui. "..I"-  .  J.  .1      vn«cular  svstem.     it  is 

^'^^S;SalN0te.-Tn  tj.o  postlnnnc^s  ..Hin^^  ^ 

(1S05)  is  a  description  of  8  ^^-^^J^^  ^Mh  Heart.  "  In  the  first 
in  C'onnoction  Mith  1- n  argement  "^^  ^^  I'*;™  i,,^,..  u  The  eves  were  pro- 
casc,  seen  in  17SG,  he  also  dcscribos  the  oxophthalmo. 


1 


DISEASES  OF  THE  TIIYUOID  GLAND. 


83( 


in  9 


Inulc'd  from  llicir  sockets,  ami  llic  {■oiiiitctiamc  I'xliiliitcMl  nn  nppoaranco 
(if  airitatidii  and  distress,  especially  in  any  n\i!scnlar  movement.""  The 
Italians  claim  that  Flajani  descrilied  the  disease  in  I.SOO.  I  have  not  heen 
able  to  see  his  ori^dnal  aceoinit,  Imt  Mneiiius  states  that  it  is  niea;;re  and 
inaccurate,  and  bears  no  comparison  with  that  of  I'arry.  If  tiie  name  of 
any  jihysician  is  to  he  associated  with  the  disease,  undoiditedly  it  should 
lie  that  of  the  distinji'uishcd  old  I>ath  physician.  (Iraves  descrilied  the  dis- 
ease in  !!-!;!.■)  and  J  Basedow  ill  IS  10. 

iEtiology. — The  disease  is  more  fre(juont  in  women  than  in  men.  Of 
^HlO  cases  taliulated  hy  Mshner,  there  were  Kil  females,  'i'iie  aj^e  of  onset 
is  usually  from  the  twentieth  to  the  thirtieth  year.  It  is  son\etimes  seen  in 
several  mendicrs  of  the  .same  family.  Worry,  fright,  and  deiiressing  emo- 
tions precede  tiie  development  of  the  disease  in  a  nundier  of  cases. 

The  disease  is  regarded  liy  some  as  a  jiure  neurosis,  in  favor  of  which  is 
nrged  the  onset  after  a  ])rofound  enuition,  the  alisence  of  lesions,  ami  the 
cure  which  has  followed  in  a  fewcases  after  operations  upon  the  nose.  Others 
believe  that  it  is  caused  by  a  central  lesion  in  the  medidla  obhingata.  In 
sujiport  of  this  there  is  a  certain  amount  of  experimental  evidence,  and  in 
a  few  autopsies  changes  have  licen  found  in  the  medulla.  Of  late  years 
the  view  has  been  urged,  jiartictdarly  Ijy  Mocbius  and  liy  (Ireenlield,  that 
exophthalmic  goitre  is  primarily  a  disease  of  the  thyroid  gland  (/////'cr- 
ihijri'a),  in  antithesis  to  myxiedema  {(ilJn/ira).  The  clinical  contrast  lie- 
twcen  these  two  diseases  is  most  suggestive — the  increased  excitaljility  of 
the  nervous  system,  the  Hushed,  moist  skin,  the  vascular  erythism  in  the 
one;  the  dull  ajiatliy,  the  low  tem]ierature,  slow  pulse,  and  dry  skin  of  the 
other.  The  changes  in  the  gland  in  exo]ihthalmic  goitre  are,  as  shown  by 
Greenfield,  those  of  an  organ  in  active  evolution — viz.,  increased  prolifiTa- 
tion,  with  the  production  of  newly  formed  tulitdar  spaces  and  absorptinu 
of  the  colloiil  material  which  is  replaced  by  a  more  muciiuuis  fluid  (ISrad- 
shaw  Lecture,  18!);i).  The  thyroid  extract  given  in  excess  produces  symp- 
toms not  uidike  those  of  l'arry"s  disease — tachycardia,  tremor,  headache, 
sweating,  and  jirostralion.  lleclere  has  recently  reported  a  case  in  which 
exophthalmos  developed  after  an  overdose.  Use  of  the  thyroid  extract 
usually  aggravates  the  sym]itoms  of  exo]ihthalmic  goitre,  "^rhe  most  suc- 
cessful line  of  treatment  has  been  that  directed  to  diminish  the  ladk  of 
the  goitre.  These  are  some  of  the  considerations  which  favor  the  view 
that  the  symjitoms  are  due  to  disturbed  function  of  the  thyroid  gland, 
probably  to  a  hypersecretion  of  certain  materials,  which  induce  a  sort  of 
chronic  intoxication,  ^fyxa'dema  may  devchip  in  the  late  stages,  and 
there  arc  transient  anlenia  and  in  a  few  cases  scleroderma,  which  iiulicate 
that  the  nutrition  of  the  skin  is  inv(dved.  Persistence  of  the  thymus  is 
almost  the  rule  (Hector  ^lackenzie),  but  its  significance  is  unknown. 

Symptoms. — Acute  and  chronic  forms  may  be  recogni/ccd.  In  the 
acute  form  the  disease  may  develo])  with  great  rajiidity.  Tn  a  patient  of 
J.  H.  Lloyd's,  of  Philadelphia,  a  woman,  aged  thirty-nine,  who  had  bi'en 
considered  perfectly  healthy,  but  whoso  friends  had  noticed  that  for  some 
time  her  eyes  looked  rather  large,  was  suddeidy  seized  with  intense  vomit- 
ing and  diarrluea,  rapid  action  of  the  heart,  and  great  throbbing  of  tho 


"I! 
!> 


i 


r: 

H 


ii 
II 
II 


iK 


n 


S3S 


DISKASKS  Of  TIIK   BLOOD  AND   DUCTLKSS  GLANDS. 


nrtoriop.  Tlu'  fvcs  wciv  iironiiucut  and  starin;^-  and  tin'  tlivroid  glaiul  was 
I'oiind  imicli  ..■nhirucd  and  s(dt.  Tlic  oastio-intcslinal  Mniptoius  contin- 
ued, tlic  i>ulsc  bccanu-  nKU'c  rapid,  tiio  vomiting  was  incf.«>aiit,  and  the 
l.ati'fiit  died  on  tlic  tliird  day  ol'  tlu"  illness.  Only  the  alidoniinal  and 
thoraeie  organs  could  he  examined  and  no  elianges  were  Inund.  Two 
ra]iidly  I'atal  eases  o<eurred  at  the  rhiladeljihia  Hospital,  one  of  which, 
nnderK.  1'.  Henry's  care,  had  marked  cerchral  symiitoms.  The  acntc  cases 
ari'  not  always  associated  with  delirium.  In  a  case  reported  by  Sut  lilf 
death  occurred  within  three  months  from  the  (msot  of  the  symi-toms,  owing 
io  repeati'd  and  nncontndlahle  vomiting.  More  i'reipicntly  the  onset  is 
grailnal  and  the  di>ease  is  chrnnic.  There  are  four  characteristic  symptoms 
oj'   the  discasi — t'xophliialmns.    tachycardia,   enlargement    of   the    thyroid, 

and  tremor. 

7'((r/n/r(/n/i'/.— IJapid  heart  action  is  oidy  om.'  of  a  series  of  remarkable 
vascular  phenomena  in  the  di>ea>e.  The  i)ulse-rale  at  lirst  may  l)e  not 
moro  than  it.")  or  ](•(»,  i>ut  when  the  iliscase  is  cstal)li>lied  it  may  lie  from 
1(0  to  Kilt,  or  even  higher.  Irrtgularity  is  not  common,  except  toward 
the  close.  In  a  well-developed  case  the  visible  area  of  cardiac  pulsation  is 
much  increased,  the  action  is  heaving  and  finvible.  and  the  shock  of  the 
lieart-soiinds  is  well  felt.  The  large  arteries  at  the  root  of  the  neck  throb 
forciblv.  There  is  visible  pulsation  in  thf  jjeripheral  arteries.  The  capil- 
lary jiulse  is  readily  seen,  and  there  are  few  diseases  in  which  one  may  see 
at  times  with  greater  distinctness  the  venous  ])idso  in  the  veins  of  the  hand. 
The  throbbing  pulsation  of  the  arteries  may  be  felt  even  in  the  linger  tips. 
(tn  auscultatinn  murmurs  are  usually  heanl  over  the  heart,  a  loud  apex 
systolic  and  loud  bruits  at  the  base  and  over  the  manubrium.  The  soundri 
of  the  heart  may  lie  very  intense.  In  rare  instances  they  may  l)e  heard 
at   some  distance  from   the  ]niticnt;  according  to  (iraves,  as   far  as  four 

feet. 

E.niphlhabiins,  which  may  he  unilateral,  usually  follows  the  vascular 
disturbance.  It  is  readily  recognized  by  the  ].rotrusion  of  the  balls,  and 
jiartly  l)y  the  fact  that  tl'ie  lids  do  not  completely  cover  the  sclerotics,  so 
that  "a  rim  of  white  is  seen  above  and  lielow  the  cornea.  The  protrusion 
may  become  very  great  and  the  eye  may  even  be  dislocated  from  the  socket, 
or  both  eyes  may  he  destroyed  by  i)ano]>hthalmitis,  a  condition  present  in 
one  of  IJasedow's  cases.  The  vision  is  normal.  Graefe  noted  that  when 
the  eyeball  is  moved  downward  the  upjicr  lid  does  not  follow  it  as  in  health. 
This'is  known  as  Ciraefe's  sign.  It  seems  to  bo  rare;  it  was  not  itresent 
in  any  one  of  17  cas.'s  examined  at  my  clinic  (Oppenheimer).  The  palpebral 
iilKMlure  is  wider  than  in  health,  owing  to  spasm  or  retraction  of  the  upi)er 

lid  (Stellwag's  sign).     The  ])atient  winks  less  freiiuently  than  in  health. 

^loebius  has  called  attention  to  the  lack  of  convergence  of  the  two  eyes. 

rhanges  in  the  i)U]iils  and  in  the  optic  nerves  are  rare.     Tnlsation  of  the 

retinal  arteries  is  common. 

Enlnrijcmcut  ->/  //;,"  thiimi,!  commonly  develops  with  the  exophthalmos. 

It  may  he  general  or  in  only  one  lobe,  and  is  rarely  so  large  as  in  ordinary 

goitre.     The  vessels  are  usually  much  dilated,  and  the  whole  gland  may 

be  seen  to  pulsate.    A  thrill  may  be  felt  on  palpation  and  on  auscultation 


DISEASES  OF  THE   TIIVROTD   (.LAXD. 


s;vj 


a  loud  ?ystnli(-  iininiiiir,  or  iiu.iv  comiiiiTilv  a  Jiriiil  iJr  ,ll,ih},\     A  doulil.' 
iiuinniir  is  loiuiiion  ami  is  p.-itlioj^iioiiiniiic  ((iiillmami). 

TreiiKir  is  the  I'niirtii  ciiriliiiiil  svmpti.iii.  mikI  was  really  lii.-t  dcMrihcd 
liy  I'.asodow.  It  is  involuntary,  line,  alioiit  cij^lii  to  the  sccund.  It  is  of 
great  iiuportaiiee  in  the  dia<:nosis  of  the  eaiiy  cases. 

Ainonj,'  other  syniptonis  wliieli  may  ilevelop  are  arnvmia.  emaciation, 
and  slight  I'ever.  Attacks  oi  vomiting  and  diarrlnea  mav  occur.  The 
latter  may  he  very  severe  and  di.-tressing.  recni'ring  at  intc  als.  The  great- 
est complaint  i-  of  the  I'orcilde  throhhing  in  the  arteries,  oiten  accompanied 
with  unpleasant  Hushes  nf  heat  and  ]iroriisi'  perspirations.  Skin  symptoms 
are  iml  infrc(incnt — pigmentation,  which  may  he  intense  and  simulate 
Addi>oirs  (li>ease.  j)atchcs  of  U'Ucoderma.  or  atroi)hy  of  ]iigment,  and 
urticaria.  J'atches  of  solid  (edema  have  heeii  sei'ii.  Occasionally  myx- 
cedcma  has  heen  present.  In  llic  wry  acute  case  ahove  referred  to  urticaria 
was  a  ju'ominent  symptom.  Occasionally  jiruritus  is  an  early  ami  most 
distressing  symptom.  1  have  seen  one  case  in  which  it  ])crsistc<l  and  hecame 
almost  unhearahle.  Irritahility  of  ti'mper,  change  in  disposition,  ami  great 
mental  depression  have  heen  deserii)ed.  An  imjiortant  complicati'-  is 
acute  mania,  in  whi' h  the  patient  may  die  in  a  few  days.  Wcakn<>.^  of 
the  muscles  is  not  uncommon,  ])articularly  a  feeling  of  "giving  wav  "  of 
the  legs.  If  the  patient  holds  the  head  down  and  is  asked  to  lonk  up'with- 
out  raiding  the  head,  the  forehead  remains  smooth  and  is  imt  wriidJed,  a- 
in  a  normal  individual  (doU'roy).  A  feature  of  interest  noted  l)y  Charcut 
is  the  great  diminution  in  the  electrical  resistance,  which  may  he  due  to  the 
saturation  (d'  the  skin  with  inoisture  owing  to  the  vaso-motor  dilatation 
(llirt).  r>ry>on  has  noted  th(>  fact  that  the  chest  expansion  may  he  greatly 
diminished.  The  emaciation  may  he  extreme.  (;iycu>uria  and  alhuminuria 
are  not  infre(pient  complications.     True  ilialiet<'s  niay  also  develop. 

The  course  of  the  disease  is  usually  chronic,  lasting  several  vears.  After 
].cr*isting  for  six  months  or  a  year  the  symptotns  may  disap|)ear.  There 
are  rcmarkahle  instances  in  which  the  symptoms  have  come  on  with  great 
intensity.  f(dlowing  fright,  and  have  disa]ii)eared  again  in  a  few  days.  A 
certain  ])roportion  of  the  cases  get  well,  hut  when  the  disease  is  well  de- 
velo])ed  recovery  is  rare. 

Treatment. — ^ledicinal  measures  are  notoriously  uncertain.  The 
oomliination  of  digitalis  .ind  iron  may  he  tried,  ami.  when  there  is  anaemia, 
often  docs  good.  I  have  never  seen  any  advantage  frou)  the  use  of  aco- 
nite or  veratrnin  viride.  The  tincture  of  strophanthus  will  sometimes 
reduce  the  rapidity  of  the  liearf's  action.  Krgot  is  warndy  reconimended 
hy  some  writers.  I'.elladonna  gives  relief  occasionally,  aiul  should  l)o  ad- 
ninistered  until  the  dryness  of  the  throat  is  ohtained."  T  have  seen  one  case 
of  a]i]iarent  cure  under  its  use.  Xo  nu-asures  are  so  successful  as  rest  in 
1  ( (1  with  an  ic.'-hag  or  Leiter's  tu1>e  applied  occasionally  over  the  heart,  or, 
what  is  sometimes  more  agreenhle,  over  the  lower  jmrt  of  the  neck  and 
niannhrium  sterni.  1  have  known  the  i)ulse  to  he  reduced  in  this  way 
from  HO  to  !tO.  Flectricity  lias  been  n\ucli  lauded  and  instances  of  euro 
have  l)(>en  rc])orted.  In  many  cases  temporary  imi)rovement  cortainlv 
follows  the  use  of  the  galvanic  current.     Erh  states  that  the  anode  should 


dMk 


S40  DISEASES  OF  TIIF.   BLOOD  AND  DUCTLESS  GLANDS. 

1        1       1   nv..r  iho  cervical  si.ino  niul  tho  catluulc  upon  the  poriphcrd 
'^J       "Tir  -c  V  ui!l  cx.nu..  has  not  Loon  sueccsful.    Tho  tl^- 

"  .         /      ,    t      ov..;i  .•ui^l'a.torv.     The.  tmitmc-nt  of  tho  .h.oa.o  hy 

r;;.::  n;:;n:;;:^u;:;r.u:.c.o.rui  m  .....0  cases  (m^ssoo  up... 

,  ■•. MU-cs  ^cnn  to  „ircr  the  greatest  relief.     Honiova    o    one  loho  o    tic 

f^fi-;;;;;.:;:':::v';j;:.^!;;;r;,;;:l::;^i™£K^ 

svmpathetic. 

4.  :M\X(i:i)i;ma  {Mlnjmi). 

a  n.vxo.lematous  ....ndition  of  tho  suhcutanouus  t.ssuos  and  uioutal  fa.huc, 

ana-anato,nH.>lly  hy  atrophy  of  tho  ^^y-^^  f^^^  reco.nn.cl-cretinisn. 

Clinical  Forms.— Three  ^n-..ups  ot  ca>e>  n..\   ut  rcco^iu.c 
niyxceaenia  proper,  and  operative  niyxiedonui. 

CUET1N1S5L 

This  ren.arkahlo  in.pairn.cnt   of  nutrition  f.dlows  ahscnco  ^^^^^^^^ 
fnndion  of  tho  thyroid  .land,  either  con.endal  or  ^M-aru^^     '  ;  "^  ^   »o 
..uUoviv      There  i<  reinarkalde  retardation  ot  dovelopnc nt,  lean 

;:';(;».."*■.  -i  -  «"■ -'"-y  •iin'™i».-ti..n  .„  ...■,> ,  o 

;..,;<  ,l1v  .,lwent    it  niav  ho  atrophied  after  one  of  the  specific  levels,  or  t  it 
;;!!•  ;n::^^dcve;;nr.ith  .ollre.    Sin..  .e  have  learn.1  to  rc.jn,^  t  c 
disease,  it  is  surprising  how  many  cases  have  heen  reported.     I  ^^a.  able 
,    1'  ..-t  (i(t  ca.^e<  in  this  country  to  .^hly  1,  IStt..'" 

The ',  ^ Hi       is  rarelv  recognized  hoforo  the  infant   ,s  s.x  or  sov-ju 
,J  d      Then  it  is  noticed  that  tho  child  does  not  grow  so  rapid^ 

™d  is  not  hright  n,entally.     The  tonguclooks  ^-^f^^^^'^^;^'^^^ 
iiionth     Tho  hair  niav  ho  thin  and  tho  skm  very  dry.    I  suall>  in  tiie  en  i 
f      o'fir^  vo    •    nd  during  tho  second  year  tho  signs  o    c.otuusni  hoccuno 
„,, r'-o.!      The  face  i^  hn-o.  h^dvs  hloatod,  tho  eyelids  are  putfy  and 
:::Sl        ;ho-nJts!^;:o'thicl-    the  nose  looks  depressed  and^M-     Benti- 
tion  i^  delayed,  and  tho  tooth  which  appear  decay  early      Tho  a  donu n 
..lllon.  tho  logs  are  thick  and  short,  and  tlio  han   s  and  foe    arc     nde   d- 
,,,,1  ,,a  ,H„1gy.    Tho  face  is  pale  and  son.etnnes  '^^^ ^^;;fZdt 
'I'lH.  font..m.llo<  remain  open:  there  is  much  muscular  \\oaknc>>,  ana 
',     a    ^^    '^.p^^-t  it-1  .     Tn  tho  supraclavicular  regions  there  are  hu^o 
i'ds  of  hd     The  child  docs  not  develop  mentally;  there  are  various  grades 

of  idiocy  and  imhocility. - 

--r;;;:;;;^^;^^  Transactions  of  tho  Congress  of  An-orican  fhysi- 

ciaus  and  Surgeons,  vol.  iv. 


DISEAiSES  OF  TJIK  TIIYKUID  GLAND. 


841 


A  vory  inlciv.-tiiifr  ronn  is  Umt  in  whifli,  aftiT  the  iliil.1  has  tlirivtn 
niul  duvelopcd  until  its  iuiirtli  ur  lijili  vlmt,  or  tvni  latiT,  tlic  sviu|>t.>nis 
k't'in  after  n  fever,  in  eimseiiuence  of  an  alrojiliy  of  the  yiand.'  I'arki'r 
fciig^a'jtf'  for  this  variety  the  name  jnveiiik'  niy.xu'd'enia. 

Kiulnitir  nrliiiisiii  develnjis  under  h.eaJ  (■iniditions,  as  vet  Mnknown.  in 
association  witli  -'oitre.  Jt  is  met  witli  enielly  in  Switzerhind  and  parts 
of  Italy  and  I'raiiee.  The  eomnion  opijijoii  is  tiuit  it  too  is  associated  with 
loss  of  I'niiction  of  the  thyroid. 

The  ilidi/iKisis  (d'  cretinism  is  very  easy  after  <ine  has  seen  a  case  or  pood 
illustrations,  lidaiits  a  year  or  so  old  sometimes  Uvrnw  llahhy,  lose  Their 
vivacity,  or  .-how  a  ])rotiihcraiit  ahdomeii  and  lax  skin  with  slijilit  cretinoid 
appearance.  These  ndlder  forms,  as  they  have  I.een  termed,  are  prohaldy 
due  to  transient  Junctional  disturhaiice  in  the  jiland.  There  is  rarelv  any 
diiliculty  in  recogniziii<jr  tlic  dillerent  other  types  of  idiocy.  The  condi- 
tion known  as  faial  ridrls,  mhumlrophisia,  or  the  choinlrodtptroiihta  fuialis, 
is  more  likely  to  l)e  nnsiaken  for  cretinism.  The  children  which  survive 
birth  -iTow  up  as  a  remarkahle  form  of  dwarfs,  characterized  hy  shortness 
(if  the  lind)s  (ndcronielia)  and  enormous  onlar<iemcnt  of  the  articulations, 
due  to  hy|)er].lasia  of  the  cartilajrinons  ends  id'  tlie  hones.  J nf<iiit!Usiii~ 
the  condition  characterized  hy  a  j-reservation  in  the  adult  of  the  exterior 
form  of  infancy  with  the  non-appearance  of  the  secondary  sexual  ch.ir- 
actcr.s— cuuld  scarcely  he  nustaken  for  cretinism. 

MYXtEDE.MA   OF   ADULTS  {GullS  Disease). 

In  this,  women  are  very  much  more  frequently  affected  than  men— in 
a  ratio  of  (J  to  1.    The  disease  may  alTect  several  members  of  a  familv  and 
It  may  be  transmitted  throujih  the  mother.     In  some  instances  there  lia< 
been  lirst  the  ajipearance  of  exophthalmic  goitre.     Though  occurrin-r  mo-t 
commonly  in  women,  it  seems  to  have  no  special  relation  to  the  catamenia 
or  to  pregnancy;  the  symptoms  of  myx(edema  may  disappear  durin-^  j)r(-- 
nacy  or  may  develop  j.ost  imrtum.     .Alyxcedema  and  exophthalmic' .r„it're 
may  occur  m  sisters.     It  is  not  .so  cmimon  in  this  countrv  as  in  Kii'dainl 
Ihe  ."yniptoms  of  this  form,  as  given  1)y   Ord,*  are  maiked    increase   in 
the  general  Indk  of  the  Ix.dy,  a  firm,  inelastic  swellinir  of  the  skin,  whi<h 
does  not   pit   on  i)re,ssnre;  dryness  and   ronnjiness,  wliich   tend,  with  the 
swelling,  to  obliterate  in  the  face  the  lines  of  ,^xpression;  imperfect  nutri- 
tion of  the  hair:  local  tumefacti.m  of  the  Mn  and  subcutaneous  tissue- 
particularly  m   the  nipraclavicular  region.     The   i.hvsiognomy   is  altered 
in  a  remarkable  way:  the  features  are  coarse  and  lii(,a"d,  the  lips  thick   the 
nostrils  broad  and  thick,  and   the  mouth   is  enlarged.     Over  the  cheek- 
sometimes  the  nose,  there  is  a  reddish  imtch.    There  is  a  striking  slowness 
ol  tliought  and  of  mi>vement.    The  memory  bccmnes  defective,  the  patient- 
gn-(.w  inifable  and  suspicious,  and  there  mav  be  headache.     In  some  in- 
stances there  are  delusi(,ns  and  halhu  ;natioiis,  leading  to  a  final  condition 
of  dementia.     The  gait  is  heavy  and  slow.     The  temperature  may  be  below 


I 


Report  on  Myxa'deiim,  CliiiJL'iil  Sooit.'t.v"s  Transactions,  1888. 


rtB* 


842  DISEASES  OF  THE  RLOOT)  AXD  DUCTLESS  GLANDS. 

„„rini.l  Tho  functions  of  tlu-  lioart,  lun-s,  and  abdominal  nrpans  are 
nonnal  Ila-nmrrha-o  sonu-tinics  occurs.  AH.un.innria  is  somctuncs  pres- 
ent, more  rarciv  gly<.osnria.  n.<atli  is  usually  due  to  s,,me  intercurivnt 
disease,  most  fn^iuentlv  tul.erculosis  (Oreenlleld).  Iho  thyroid  gland  is 
dinnnishe.1  in  size  muf  mav  l.ec.une  comi-letely  atroplH.'d  and  converted 
into  a  fibrous  nuiss.  The  suh.utaneous  fat  is  ahundanl,  and  m  one  or  two 
instances  a  nvvai  increase  in  the  mucin  has  heeu  found. 

The  course  of  the  disease  is  slow  hut  projiressive,  and  extends  o,er  ten 
or  fifteen  years.  A  condition  of  acute  and  temporary  myxa'dema  may 
develop  in  connection  with  enlargement  of  the  thyroid  in  young  persons. 
Mvx.edema  mav  follow  exoplithalmic  goitre.  In  other  instances  the  symp- 
toins  of  the  two  diseases  have  been  coinhined.  I  have  reported  a  case  m 
which  a  A-oung  man  l.ecamc  bloated  and  increased  in  weight  enormously 
durin.'  tlure  ni.^ntlis.  then  developed  tachycardia  with  tremor  and  active 
delirium,  and  died  within  six  months  of  the  onset  of  the  symptoms. 

OPERATIVE   MYX(EI)EJL\ ;  CACHEXIA   STHUMIPIIIVA. 

ITor^lev    in  a  scries  of  interesting  experiments,  showed  that  complete 
removal  of  the  thyroid  in  monkeys  was  foUowed  by  the  production  ot  a 
condition  similar  to  that  of  myx.edema  and  often  associated  \v'th^l«^^"^-^ 
or  tetanoid  contractures,  and  followed  by  apathy  and  coma      ^^  hen  the 
,nonkeys  were  kept  warm  myxoMlcua  was  averted,  and   instead  of  an  acute 
nivxcx.dema,  the  animals  developed  a  condition  which  closc-ly  resembled 
crkinism.     An  identical  condition  may  follow  extirpation  of  the  thyroid 
in  man.    Kocher,  of  Bern,  found  that  after  complete  extirpation  a  cachectic 
condition  followed  in  many  cases,  the  symptoms  of  wliicli  are  practically 
identical  with  those  of  myxo.lema.     The  disease  follows  ""b'  '^v  -jtain 
number  of  total  and  a  much  smaller  proportion  of  ]>art.al  renioMl.  of  the 
thvroid  -daiid.     Of  408  cases,  in  (JD  the  operative  myxedema  developed. 
It'has  l^een  thought  that  if  a  small   fragment  of  the  thyroid  remains, 
or  if  there  are  a«-essory   glands,  which  in   animals  are   very   common, 
these  symptoms  do  not  develop.     It  is  possible  that  in  men,  in  the  aise. 
of   conilete  removal,   the  accessory  fragments  subserve     he   f'-^  - 
the  <dand.     Operative  nivxaMlema  is  very  rare  m  America,  I  ha\e  bcui 
^  e^o  find  oily  .  oases' in  this  country.     McOraw's  --;  relerrc      o  in 
previous  editions  of  this   work,   has  since  been   cured   ^^^th   the   tlnroid 

''^'^I;  ^Ih.innsis  of  nivxoMlema  is  easy,  as  a  rule.     The  general  aspect  of 

the  i.atient-the  subcutaneous  swelling  and  the  pallor-sugua>sts  I-nght  ^ 

d£.i^   which  may  be  strengthened  by  the  discovery  of  |f ---^  ^^j;^ 

bumin  in  the  ni'ine;  but  the  solid  character  of  the  swelling,  the  exceed- 

"l     u"s  of  the  skin,  the  yellowish-white  color,  the  low    emperature, 

lo  los^  of  hair,  and  the  dull,  listless  mental  state  should  sufiice  to  d.ffer- 

e     iat    the  two  conditions.     In  dubious  cases  not  too  nu.cli  stress  sbnild 

be  la  1  upon  the  su,.raclavicnlar  swellings.     There  may  be  marked  fibro- 

fatty  enlargements  in  this  situation  in  healthy  persons,  the  supraclavicular 

pseudo-lipomata  of  Verncuil. 


•gans  are 
iiies  pi'os- 
evcurrt'iit 
gland  i? 
convoi'ti'd 
no  or  two 

<  o>or  ton 
louia  may 
1^  pevrfons. 
the  synip- 
a  case  in 
iiorinoiisly 
uid  active 
onis. 


[  conipleto 
ction  of  a 
itli  spasms 
^Vllen  the 
)f  an  acute 

rcsoniljlod 
lie  thyroid 
a  cachectic 
practically 
,'  a  certain 
ivals  of  the 

developed, 
id  Tcniiiins, 
V  common, 
n  the  cases 
function  of 

have  hecn 
V'rrcd  to  in 
the   thyroid 

al  a:^pcct  of 
sts  P light •.-: 
?asts  and  of 
the  exceed- 
ompcratiire, 
ce  to  differ- 
tress  shonld 
arked  fil)ro- 
n'aclavicular 


DISEASES  OP  THE  THYMUS  GLAND.  §43 

Treatment.— The  patients  sufTer  in  cold  and  improve  greatly  in  warm 
weatiitT.      'i'licy  should   therefore   be  kept   at   an   ..vcii    t.^iMperatiire,  and 
should,  il  jiosMble,  move  to  a  warm  climate  during  tlic  winter  UKuitlis      l{o- 
peated  warm  baths  with  .siiaiiipooing  arc   usctui.     Our  art   lias  made  no 
more  brilliant  advance  tlian  in  the  cure  (.f  tlicsc  disorders  due  to  (li>turbe.l 
function  of  the  thyroid  gland.     That  we  can  to-.biy  rescue  cliil.lrcn  otlicr- 
wise  doomed  to  helpless  idiocy— that  we  can  restore  to  life  the  hopeless 
victims  of  my.\(edcnm— is  a  Iriumpli  of  experimental  medicine  for  which  we 
are  indebted  very  largely  to  A'ictor  Horsiey  and  to  liis  pupil  Murray    Trans- 
l.lantation  of  tlie  gland  was  first  tried;  tiicii  .Murray  used  an  extract  sub- 
eutan-ously.     Hector  Mackenzie  in   i.ondoii  and    llouilz   in   ( 'op(.|iiii.r,.ii 
introduced  the  method  of  feeding.     We  ,„,«•  know  that  the  gland,  taken 
either  Ires],,  „r  as  the  watciy  or  glycerin  extract,  or  dried  and  powdered 
IS  equally  ellicacious  in  a  majority  of  all  the  cases  of  myx(edcma  in  infants 
or  adults.     .Alany  preparations  are  now  on  the  market,  but  it  makes  little 
diirerence  how  tlie  gland  is  administered.     'J'lie  dried  powdered  glaisd  and 
the  glycerin  extract  are  most  convenient.     It  is  well   to  begin  with  the 
povdered  gland,  J  grain  three  times  a  day,  of  the  Parke-Davis  preparation 
or  one  ot  the  Hurrouglis  and  Welcome  tablets.     The  dose  niav  be  increase.! 
gradually  until  the  i)atient  takes  10  or  K,  grains  in  the  day.    \n  many  ca«es 
there  are  no  uni)leasant  symi.t(,ms;  in  otiicrs  there  are  irritation  of  the 
skin,  restlessness,  rapid  i.ulse,  and  delirium;  in  rare  instances  tonic  spasms 
the  condition  to  which  the  term  llujmidisin  is  ai,])licd.     The  results    .,s  a 
rule,  are  most  astounding-unparalleled  by  anvtiiing  in  the  whole  ran-^e 
ot  curative  measures.     Within  six  weeks  a  poor,  feeble-minded,  toad-like 
caricature  of  humanity  may  be  restored  to  mental  and  bodily  health     Loss 
of  weight  is  one  of  the  first  and  most  striking  elfects;  one  of  my  patients 
k)st  over  30  poun.ls  w.thin  six  weeks.     The  skin  becomes  moist,  the  urine 
IS  increased,  the  ])erspiratioii  returns,  the  tenipciature  rises,  the  pulse-rate 
quickens  and  the  mental  torpor  lessens.    Ill  effects  are  rare.    Two  or  three 
cases  with  old  heart  lesions  have  died  .luring  or  after  the  treatment;  in  one 
instance  a  temporary  condition  of  (Iraves*  disease  was  in.luced 

Tlie  treatment,  as  ]\rurray  suggests,  must  be  carried  .)ut  in  two  sta.'es— 
one,  early,  in  which  full  doses  are  given  until  the  cure  is  effected;  the  .rther 
the  permanent  use  of  small  doses  sulTicient  to  preserve  the  normal  m.^tab- 
ol.sm.  I  he  literature  of  thyroid  theraj^y  and  a  list  of  all  the  cases  of  nivx- 
nHlema  and  cretinism  treated  to  December  31,  1894,  are  given  by  Ueins- 
heimer.*  °  •'  •"^*"° 

XII.    DISEASES   OF   THE   THYMUS   GLAND. 

The  fmietions  of  this  gland  are  unknown.  It  is  a  suggestive  fact  that 
Ku  main  foiind  m  it  minute  .piantities  of  a  comi^oun.!  containing  iodine 
It  has  heen  thought  that  its  internal  secretion  has  an  influence  in  com- 
ba  ing  infective  agents.  -;,e  weight  of  the  organ  is  about  14  grammes 
at  birth,  about  20  at  the  ninth  month,  and  25  to  30  at  the  .second  ^^-ar 


♦  Die  Schild.lrUsenbehandlung,  MUnchcn,  1805. 


m^ 


f 


844  DISEASES  OF  THE   BLOOD  AND   DUCTLESS  GLANDS. 

-P,„,  ,„„„„.  ,|'t,.r  m.cl.in-  its  lai-est  size  nl.uut  thr  .nd  of  the  sccomi 
year.  j:ra.hn.llv  ^vast..s,  until  at  the  ti.no  of  puh^rty  it  i--^  n  ..ut.  latty  rem- 
nant in  whi.h,  however,  there  are  "  traees  of  .ts  onji.nal  .trn.tu.e  .n  tiie 
lorn.'  of  small  masses  ..f  thymus  eo.'imseles,  and  even  ot  couceiUnc  eor- 
'  .OS  "  ((Main).  A  eonq.l.te  ..onshleration  of  the  atVeetions  ot  tins  gland 
I  to  lie  fonnd  in  FriedLhenV  ren.arkahle  monoj-raph,  Die  l>hys,ologie  dor 
Thvmu-driisr    1S,-.S.     The  f..llo\ving  are  the  most  important  eonditions: 

"l  Persistence  of  the  organ  after  th.  lifteenth  year  inet  \vith  oeea- 
sionallv,  l.nt  under  eiveumstan.rs  so  varied  that  a  sat.staetory  explanation 
,annot"  he  oiVered.  It  is  said  that  the  .xistenee  ol  the  gland  may  he  d.te  - 
n.ined  hy  the  presenee  of  an  area  of  dulness  along  the  left  sternal  uordei 
irom  the  seeoncMo  the  fourth  rihs.  . 

II  Hypertrophy  of  the  Thymus.-The  size  of  the  gland  varies  widely, 
.0  that  it  is  dilhenlt  to  deline  exaetly  the  limits  between  pers.stenee  ijml 
enlargement.    The  eondition  is  of  interest  from  three  standpoints:  {a)  ihc 
MipiH^sed  oeenrrenee  of  tinjmir  aslhmi,  due  to  pressure  irom  the  enlarged 
•  dai'd    A  number  of  observers  have  attributed  the  symptoms  of  laryngismus 
^ridulus  to  pressure  exerted  hy  the  enlarged  thymus.    ^^^^y^'l^'^'^'l^y^X' 
o„nsider  thvmie  asthma  identical  with  the  laryngismus  stridulus  ot  Knghsh 
authors    ^^■\u.■,  as  a  rule,  have  laid  no  stress  whatever  on  the  association. 
There  can  he,  I  think,  no  question  that  the  ordinary  laryngismus  seen  m 
rickety  children  is  a  convulsive  alVeetion  and  is  not  the  result  o    compression. 
But  a  very  -reatly  enlarged  thvmus  may  seriously  hamper  the  structure, 
w  Uii^    ie^tlmrax.'  Jacolli,  in  his  monograph  on  the  gland  (Transiu.tjons  o 
U     Assodation  of  American  l>hysicians,  vol.  iii),  states  that  in  an  n.  ant  o 
eight  nu>nths  ^he  distance  between  the  manubrium  sterm  and    he  u    d-ud 
e.duinn  is  22  cm.,  a  space  which  he  tunics  might  bo  ^-nj^^^^^l   ^Jj 
an  enlarged  and  congested  thymus.     Siegel  s  case  also  points  to  the  possi 
l^litv  of  this  compression.    A  boy  aged  two  years  and  a  halt  had  had  for 
weeks  cough  and  bronchial  rales  with  dyspncea,  which  was  more  o 
"s  constant  ^ith  nocturnal  exacerbations.     Laryngismus  stridulus  m 
ia.M  osed.     Tracheotomy  was  performed  shortly  after  admission  ^vlthou 
relief   but  when  subsequently  the  anterior  mediastinum  was  opened  from 
,   ,  e        extending  th    incision  from  the  tracheotomy  wound,  a  piece  of 
th  mi  s  as  lar^e  as  a  hazel-nut  appeared  with  each  inspira  ion.     The 
Ind  w      drawn  'up  with  forceps  and  fastened  by  three  stitches  to  the 
f^     a  Zr  the  stermnn.    The  child  rested  quietly  a^fter  the  opendion,  had 
no  dys,ma>a,  and  made  a  complete  recovery  (lierl.  kUn.  ^\«^'l'-'    ;;•  *'  ?^  !. 
40)      From  a  child  ag..l   two  months  (dyspmnc  from  the  eighth  daj) 
Kocnig  removed  a  portion   of   the  thymus,  leaving  the  ^"1-terna  Ipar^ 
These  are  cases  that  go  far  t..  disprove  Friedleben's  dictum-r.  gichi  Una 

""';;;;  S;^:'^./.,.....  o,,,  ../..^  /....^-m  considering  tl,o  ques- 
tion of  the  so-called  Ivmphatic  constitution,  with  which  an  enlaiged  th  - 
n     is  usually  associated,  Ic  have  .;n,ken  of  the  occurrc;nce  of  sudden  lea  h 
T   o  t  n,p.-ot  eases  are  met  with  ..  the  literature:  First    such  instan 
as  those  described  by  firawitz,  Jacob,  and  others,  n.  which  y--^  -^.^ 
have  been  either  found  dead  in  bed  or  have  been  attacked  suddenly  vMth 


IHSKASKS  (IF   TIIK   TllVMl'S   (iI-A\I). 


845 


e  second 
.tly  IV Ill- 
re  in  tlie 
ilric  cor- 
liis  gland 
logic  dtii" 
litions: 
ilh  Dci'a- 
})hinatiuu 
bo  dt'tor- 
al  uoi'dur 

.'s  widely, 
:once  and 
:  {a)  The 

enlarged 
ryngit^ninri 
an  writer:? 
>!'  Kngli^^h 
ssociation. 
as  seen  in 
aipression. 
structures 
-actions  oL' 
1  infant  ot 
[.'  vcrteliral 
y  111  led  by 

the  possi- 
id  had  for 
IS  more  or 
iduhis  was 
)n  without 
lened  from 

a  piece  of 
tion.  The 
lies  to  the 
ration,  had 

IHiX),  No. 
ighth  day) 
ernal  part. 
s  gicht  Irin 

g  the  qucs- 
larged  thy- 
ddeii  death, 
■h  instances 
ung  infants 
.Idcnly  with 


dyspnren,  liave  became  (yaiintie  and  died  in  a  few  minutes.  In  siuli  cases 
the  liiymiis  lias  been  Iniind  greatly  enlarged,  and  i\vMh  lias  lurii  thoiiglii 
to  be  directly  due  either  to  pre»iire  on  the  air-passages,  pressure  on  the 
imeuniogastnc  (causing  spaMii  of  the  glouis),  or  pressure  on  the  great  ves- 
.-els.  To  the  sectuid  group  belong  the  ca-e-  in  adults  whi.li  have  been  de- 
scribed ni  late  by  Nordiuann,  I'altaiif.  ( )bliua(ber.  and  others,  in  which 
the  sudden  death  has  occurred  under  siuh  conditions  as  ana'sthesia  or 
while  balhing.  In  a  number  of  these  cases  not  only  has  tiic  tlivniiis  been 
found  enlarged,  but  the  spleen  and  lymphatic  tissms  gciieiallv.  The'  (pU'S- 
tion  is  one  of  cou.-idcrable  incdico-lfgal  iiiicre.-t,  and  has  Invii  spokm  of 
under  lAniphatism. 

l{ollc.~ton  reports  a  case  of  sudden  death  after  signs  of  cardiac  failure 
la.«ting  for  only  twenty  minutes,  in  which  there  was  hyperplasia  of  a  per- 
sistent tliynius.     'i'he  gland  with  the  trachea  weighed  I'l  ounces. 

(r)  y'lii/iiuis  dhunl  and  Kxiijildhalmic  ^'o(7/r.— That  there  is  some  asso- 
ciation between  these  conditions  is  nigi-d  on  two  ground-:  First,  the  per- 
sistence of  the  gland  in 'tiraves'  disease.  W.  W.  Ord  and  Hector  Mac- 
kenzie state  that  it  has  been  found  enlarged  in  all  ihc  ca.-es  recently  exam- 
ined at  St.  Thomas's  IIosj)itid.  licktoeii  ((includes  from  a  very  thorough 
study  of  the  question  that  the  coc.\istciice  is  more  than  accidJntal.  SeHi- 
ondly,  the  good  results  which  are  stated  to  follow  the  feeding  of  tiic  thymus 
gland  in  dravcs"  disease  arc  held  to  bear  out  the  idea  that  the  enlargement 
during  life  is  compensatory.  The  general  conclusion,  however,  readied  by 
Hector  :\Iackenzie  and  by  Kinnicntt  is  that  the  thymus  feeding  has  at  be.^t 
only  slight  iniliience  upon  (iraves'  disease. 

It  is  interesting  to  note  in  coniuriion  uitli  the  (piestion  of  enlarged 
thymus  and  sudden  death  that  two  of  Hale  While's  cases  of  e.xoiihthalmic 
goitre  died  suddenly,  and  aut<i]isy  showed  no  reasonable  cause  of  death. 

Among  other  conditions  wiili  which  enlarged  thymus  has  been  associ- 
ated may  be  mentioned  epilepsy  (Ohimachcr). 

in.  other  Morbid  Conditions  of  the  Thymus.— //(rH,7j);",i,7^-,s  are  not 
uncommon,  and  are  found  jiarticularly  in  children  who  have  died  of 
asphyxia. 

Tumurs  of  the  gland,  particularly  sarcoma  and  Ivmpho-sarcoma.  have 
lieen  frequently  described.  .Alany  mediastinal  tumors  "originate  in  the  rem- 
nants of  the  thymus.  Dermoid  tumors  and  cysts  have  also  been  met  with. 
Tuberculosis  of  the  gland,  chiefly  in  the  forin  of  miliary  nodules,  is  well 
described  in  Jacobi's  nionograjih.  Thci'c  is  a  wcll-autlienlicated  ea.¥0  in 
which  it  was  primary.  Focal  necroses  in  diphtheria  have  also  been  de- 
scribed by  Jacobi. 

Abscess  of  the  Thijmvs.—Buhok,  in  is.jO,  n<ited  tlie  occurrence  of  foci 
of  suppuration  in  the  gland  in  subjects  of  congenital  .syphilis.  Throughout 
it  round  or  fissure-like  cavities  are  seen  filled  with  a  ])urulent  fluid.  Chiari 
states  that  some  of  these  supiio.sed  abscesses  are  areas  of  jiost-mortem  .soften- 
ing, or  cysts  lined  with  flatten-d  epithelium  containing  detritus  of  thymus 
cells.    In  one  case  Jacobi  found  a  small  gumma. 


SFXTIOX   IX. 

DISEASES   OF  THE   IvIDXEYS. 


I.   MALFORMATIONS. 


A.  Dis- 


Newinan  classifies  11).  ,nalf..rinati..ns  ..1  tl.o  kulnoy  as  fo  low* 

placomonts   without    .uol.ility-d)   con-nMutal    .Lsplacomont    w.tl.ou      k- 

f    mitv    (2)  conj:..nital  displacnncnt  with  defornnty;    (:})  no(,tnm    .1>.- 

h  "  nu'nt  .    ]?.  ^ialforn.ations  of  th.  kidney.    I.  Variat.ons  ,n  n.nuhor- 

.      ".ennnnenu-y  kidnoy:  (/.)  single  kidney    con,omlal  absence  <^  one 

ddne>'   atrophy  of  one  kidney;  (0  absence  of  both  kidneys      H.  \  an. - 

ons  ;  form  a\>d  si.e-(«)  general  variations  in  1  -rn,  lobulat.on    et  ) 

l.vnertrophy  of  one  kidney;  (r)  fusion  of  two  kulnoys-lu.rseshoe  kul 

sigmoid  kidney,  di.^k-shaped  kidney.     (".  Variations  ,n  pelvis,  ureter.,  and 

'''"  ThTfiii  kidneys  may  form  a  la,-o  mass,  which  is  often  displaced,  being 
either  in  an  iliac  fo^sa  or"in  the  mi.bUe  line  of  the  alub.men,  or  even  in  the 
pelvis  Vnder  these  circumstances  it  may  bo  mistaken  lor  a  new  growth. 
In  Polk's  case  the  organ  was  removed  under  the  belief  that  it  was  a  floating 
kidnoy*  The  patient  lived  eleven  days,  bad  complete  anuria,  and  it  was 
found  j.ost  mortem  that  a  single  unsymmetrical  kidnoy,  as  this  lorm  is 
called,  had  boon  removed. 

II.    MOVABLE    KIDNEY. 

(Floating  Kidney ;  Palpahle  Kidney ;  RenmohiUs;  Nephroptosis). 
The  kidney  is  held  in  position  by  its  fatty  capsule  by  the  peritonfrum 
which  passes  in  front  of  it,  and  by  the  blood-vessels.  Normally  the  k,dno> 
i.  firmly  fixed,  but  under  certain  circumstances  one  or  another  organ,  niore 
rarely  both,  becomes  movable.  In  very  rare  cases  tlie  kidney  is  ^--un|  od 
to  a  greater  or  less  extent,  by  the  peritonirum,  and  is  anchored  at  the  lulus 
V^^  aresonephron.    Some  would  limit  tbo  term  floating  kidney  to  this  con- 

'^'^^Movablo  kidney  is  almost  always  aeqnired.     It   is  more  common  in 


840 


*  New  York  Jledical  Journal,  1883. 


A.  Dis- 
lout  <U'- 
ircd  (lis- 
iinil)t'r — 
L'  of  one 
I.  Viuia- 

ctc;  (/') 
:\  kidney, 
■tors',  and 

!cd,  being 
on  in  the 
\-  growth. 
11  iloating 
nd  it  was 
!5  iorni  is 


)• 

^ritonsrum 
ho  kidney 
•gan,  more 
irrnundcd, 
t  the  hilus 
0  this  con- 

nmmon  in 


MUVAULK   KinXKY. 


647 


women.  Of  the  CCu  cuscs  colheted  in  tlie  hit  rat  lire  Ity  Kiittner,  .'Si  woro 
in  woiiirn  and  oiil^-  K\  in  men.  It  i.s  more  cuiMnion  on  tiio  riglit  than  on 
the  1(  ft  :~idi'.  Of  T','T  cashes  analyze<l  l»y  llii.s  aiitiior,  ii  occurred  on  llie  rigiil 
in  '>.■>;!  casts,  on  the  k'Ct  in  M,  and  on  both  .^^idcs  in  l»;t,  Tiio  greater  frc- 
HUency  of  tiic  condition  in  womvii  may  he  attriliuted  to  coni[)rcs.sion  of  tiio 
hiwor  thoracic  zone  hy  tiglit  hieing,  and,  more  inijiortant  t>till,  to  tiio  relaxa- 
tion of  tlie  alidoiiiiiial  walls  which  follow.^  ri'iiealed  pregnancies.  This  does 
not  account  for  all  thocaj^cs,  a.s  movable  kidney  is  by  no  means  uiicomnion 
in  nuliijiaiic.  Oriiinuioiid  believes  that  in  a  majority  of  the  casi.s  there  is 
a  cniigciiitally  rela.xcd  condition  of  the  lu'ritonoal  attaciiments.  The  condi- 
tion has  been  met  with  in  infants.  Wasting  of  tlie  fat  about  the  kidney 
may  be  a  cause  in  simio  instances.  Trauma  and  the  lifting  of  heavy  weights 
are  occasionally  factors  in  its  production.  Tlu'  kidney  is  t-onietimos  dragged 
down  by  tumors.  The  gri'atcr  frctiucncy  on  tlie  right  side  is  probably  asso- 
liated  with  tlu'  position  of  the  kidney  just  iieiieath  the  liver,  and  the  de- 
jirossion  to  which  the  organ  is  siiiijccteil  witli  each  descent  of  the  diaphragm 
in  inspiration. 

And,  lastly,  movable  ki<lney  is  met  with  in  iiuiiiy  cases  which  present 
that  combination  of  neurusthenia  witii  gastio-intestinal  disturbance  which 
has  liecn  described  by  (Jlenard  as  ciilcniiitosis  (see  p.  oil). 

To  determine  the  presence  of  a  movaiile  kidney  the  patient  shoiihl  1)0 
placed  in  the  dorsal  position,  with  the  head  nio<lerately  low  and  tlie  ab- 
•himinal  walls  relaxed.  The  left  hand  is  placed  in  the  lumbar  region  i)ehind 
the  eleventh  and  twelfth  ribs;  the  right  hand  in  the  hypoehoiKlriac  region, 
in  the  nipple  lino,  just  under  the  edge  of  the  liver.  Himanual  imlpalion 
may  detect  the  ])resoneo  of  a  firm,  rounded  body  just  below  the  edge  of  tho 
libs.  If  nothing  can  he  felt,  the  patient  sluuild  bo  asked  to  draw  a  deep 
breath,  when,  if  the  organ  is  palpalde,  it  is  touched  iiy  the  lingers  of  the 
right  hand.  Various  grades  of  mobility  may  l)0  recognized.  It  may  be 
jiossiblo  barely  to  feel  the  lower  edge  on  deep  palpation — pdlpublc  kiditci/ — 
or  the  organ  may  bo  so  far  displaced  that  on  drawing  the  deepest  breath 
the  fingers  of  tlie  riglit  hand  may  be,  in  a  thin  person,  slipped  above  the 
upper  eiiil  of  the  organ,  which  can  be  readily  held  down,  but  cannot  i)0 
]iuslicd  below  the  level  of  the  navel — vnivaldc  hidnci/.  Jn  a  third  group  of 
eases  the  organ  is  frooly  movable,  and  may  even  be  felt  just  above  rou|)art's 
ligament,  or  may  bo  in  the  middle  line  of  the  al)domen,  or  can  oven  bo 
pushed  over  beyond  this  point.  To  this  the  term  fJcalliuj  Jiidnri/  is  appro- 
priate. 

The  movable  kidney  is  not  painful  on  pressure,  excoiit  when  it  is  graspcu 
very  firmly,  when  there  is  a  dull  pain,  or  sometimes  a  sickening  sensation. 
Examination  of  the  patient  from  behind  may  show  a  distinct  flattening 
in  the  lumbar  region  on  the  side  in  which  the  kidney  is  mobile. 

Symptoms. — Tn  a  large  majority  of  cases  there  are  no  .symptoms,  and 
if  detected  accidentally  it  is  well  not  to  lot  the  patient  know  of  its  presence. 
Far  too  mnch  stress  has  been  laid  npon  the  condition  of  late  years.  In 
other  instances  there  is  pain  in  the  lumbar  region  or  a  sense  of  dragging 
and  discomfort,  or  there  may  be  intercostal  neuralgia.  In  a  large  gronp 
the  symptoms  are  those  of  neurasthenia  with  dyspeptic  disturbance.     In 


g^g  DISKASKS  OV  TIIK   KIDNKYS. 

W(,iiu'M  111.'  l.v>t.  ri.iil  svmi'touis  nmy  l)c  inark.d.  ;iih1  in  iumi  vjirinii^  frrad.'- 
„r  hvpo.lH.n.'hii.si..^.  TIk'  >;M>tnc  .li>tmlmii.'.'  is  iiMully  n  Inrm  nf  ihtvch^j 
dvsiiq.Mii.  Dilatation  of  tlu'  ^^t.llnal■ll  liar-  \nvn  (.I.smv.mI,  uwiii^'.  a>  <n^'-.'>lt'«l 
by  Harli'ls  to  prosiiiv  of  tlio  dislcH'at.'d  kidmy  ni'on  tiic  duodenum.  'I'liw 
view  has  larii  siippoitrd  l.y  t);^  /.  I/in.laii.  and  Kwald.  On  tin'  oIIht  hand. 
Littfii  holds  tliat  tlif  dilatation  of  thf  stomach  is  th-  can-.'  <d'  the  niol.dity 
,,f  tin'  ki.lncy.  ami  he  found  m  Ht  cases  of  dcpivs>i.m  and  dilatatnui  of  the 
stomach  S'.' "inslaiin's  of  <lislo.;ilion  of  tin'  kidney  on  the  rij^ht  snle.  My 
ovn  experieiH'i"  coincides  with  that  of  Kiuniinond,  who  has  very  exeel- 
ti„uallv  fouiul  the  two  cnditions  to  eoexiM.  The  association.  In.wev.r, 
with  n'ilrinrsscl  stomach  is  certainly  not  unc.mmon  in  women.  Con.tipa- 
1i.,n  is  not  infre.pient.  Some  writers  have  desciihed  jMc-nre  upon  the 
gall-dncts,  with  jaundice.  Imt  it  is  not  very  likdy  to  oe.ur  hecid  aciunu- 
hition  and  even  ohstructioii  may  lie  associat.-d  with  the  displaced  or^iaii. 

Dirtl'x  ('iisrs.—\n  tloatin^r  kidney  there  arc  attacks  eharactiri/ed  hy 
severe  ahdomiual  pain,  chills,  nausea,  vomitin-.  fever,  and  ndlai'se.  Scaivdy 
nnv  mention  is  made  of  such  symptoms,  which  were  first  dcserihcd  hy  Dictl 
in^lSCI.  and  a  more  widespread  kn.iwled-c  nf  their  occurrence  in  connec- 
tion with  this  conditi.m  is  desiralde.  My  attention  was  oaUed  to  them  in 
ISSO  hy  J'almcr  Howard  in  the  case  of  a  stout  lady,  who  sulf.'ivd  repeatedly 
with  the  most  .-evcre  attacks  of  ahdominal  pain  and  vouiitin-,  which  con- 
stantly rc(pured  morphia.  A  tumor  was  di>covcred  a  little  to  the  ri-ht  o| 
the  navel,  and  the  dia-nosis  of  pn^halde  ncopkiMu  '.vas  concnrrc.l  m  hy 
Flint  (Sr.)  and  (laillar.l  Thomas.  The  iiatient  lost  wci-ht  rap'dly.  hecame 
emaciated,  ami  in  the  s])rinf,'  of  ISSl  aeaiu  went  to  N.w  ^  ork.  where  she 
saw  Van  r.urcii,  who  dia^niosed  a  lloatin^^  kidney  ami  saul  that  these  parox- 
ysms were  as.sociated  with  it  in  a  jionty  person.  lie  cut  olV  all  stimulants 
'reas-iired  the  lady  that  she  had  no  cancer,  and  from  that  tunc  she  rapidly 
recovered,  and  th'e  attacks  have  been  few  and  far  hetwe.n.  In  this  jiathut 
any  overindulgence  in  eatin-  or  in  drinkiufr  is  still  liahle  to  he  folh.ucd 
h/a  very  severe  attack.  These  attacks  may  also  he  mistaken  for  renal  colic, 
aiid  tlu'oiieration  of  nephrotomy  has  heeii  ])erfornud. 

In  other  instances  the  attacks  nf  pain  may  l)e  thought  to  he  due  to  m- 
tc-^tinal  disease  or  to  recurrinj,'  apiundicitis.  The  cause  of  these  parox- 
ysmal attacks  is  not  (piite  clear.  J»ietl  thou;.dit  they  were  due  to  straii<;n- 
iati(m  of  the  kidney  or  to  twists  or  kinks  in  the  renal  vessels  due  to  the 
extreme  molality.  "Durin-  the  attacks  the  nrine  is  sometimes  hitrh-colored 
and  contains  aii  excess  of  uric  add  or  of  the  oxalates.  It  is  stated,  too, 
that  hlood  or  ].ns  may  he  present.  The  kidney  may  he  tender.  su(dlen. 
and  less  freelv  niovahle. 

Tnln-iiiillnit  JiiiJrdnrphri.fls  is  sometimes  associated  with  niovahle  kulncv. 
Three  cases  are  reported  in  mv  Lectures  on  Abdominal  Tunio.s.  In  two  the 
condition  has  been  completely  ivlieved  by  a  well-adapted  pad  and  belt;  in 
the  third,  attacks  recur  at  lon<;  intervals. 

The  fJi<t<inos!:^  is  rarclv  doubtful,  a-  the  shape  of  the  orpan  is  usnally 
distinctive  and  the  mobility  marked.  Tnmors  of  the  .irall-bladder.  ovariaii 
growths,  and  tumors  of  the  bowels  may  in  rare  instances  bo  confounded 
with  it. 


,■■! 


CIIlCri.ATollV   DlSTriJllANcIX 


849 


Treatment.  -The  kiilmy  lia-  Ihvh  cNlirpatcil  in  many  iii.-'taMccs,  but 
thr  ..|Miaii,,n  i>  not  witlioiil  ri-k.  ami  tlicrc  liavc  limi  -.rvrral  I'atal  (mms. 
Stitcliinj.'  n|'  tilt'  ki(lii(;v~m'|ilirnirlia|.liy— IIS  iviniiiincmlcd  \>\  Halm,  is  the 
mo.-t  siiilaMc  |iri>c.Mliirc.  and  statistics  pnlilisliid  \>\  Keen  show  tliat  ivlicf 
is  atVonlcd  in  many  cases  liy  the  ]ir(pccduiv.     It  duo  nut,  Imwcvcr,  always 

>lll  cccil. 

in  many  instances  the  jrroatcst  iclid'  is  e\|iciicnceil  fnun  a  lianda.i^'e  and 
l''i'l'  I'  >li"iild  he  a|)|ilied  in  tlie  niurniiij:-.  with  the  patient  in  the  iveum- 
iieiit  |M,stiire.  and  she  sliunid  he  taught  huu  tu  \,u-\\  \\\>  the  kidney.  An  air 
pad  may  he  n-ed  if  the  (.r;;an  is  sensiti\i'.  In  ulher  cases  a  hrua'd  handai,'e 
well  jiaddcil  in  the  lower  alxlominal  zune  jinshes  ii|)  the  intestines  and 
makes  them  act  as  a  sniipurt.  In  the  imacks  (d'  severe  culie  murphia  is 
reqnircd.  When  dependent,  as  seems  so.  >  inies  the  case,  npuii  an  excess 
of  nric  acid  or  the  oxalates,  the  diet  must  he  carefidly  ivunhited. 

I'or  an  exhan-tive  coii>ideration  (d'  all  aspects  of  the  snl>ject.  see  Fisclier, 
in  \i>-.  1-.')  of  the  Ccntralhlatt  f.  d.  (irenzjichietu  der  Medicin  iind  Chirur- 
gie.  IMIS. 

III.  CIRCULATORY  DISTURBANCES. 

Normally  the  secretion  (»f  urine  is  aceompli-lied  ])y  the  maintenance 
nf  a  certain  lilood-pressnre  within  the  ejumernli  and  hy  the  activity  of 
the  ivnal  epithelium.  I'.owman's  views  on  this  (piestiun  have  heen  f^oii- 
erally  aceepled.  and  the  watery  elements  are  lu'ld  to  he  liltered  from  the 
frlomernli;  the  amount  dependin<^-  on  the  rapidity  and  the  pressure  of  the 
hlood  current :  the  (|uality,  whether  normal  or  aliiiurmal,  depending'  upon 
the  condition  (d'  the  ca|Mllaiy  and  <:Iumerular  e|iitlielium;  while  the  -jreater 
]iortion  of  the  s(did  in,<:redients  are  excreted  hy  tlie  (  pitiielium  (d"  the  con- 
voluted tuhules.  The  intejjrity  of  the  e]iithelium  eovcrino-  the  capillary 
tufts  within  r.owmauV  capsule  is  essential  to  the  production  (d'  a  normal 
urine.  If  under  any  circumstaiu cs  their  nutrition  fails,  as  when,  for  ex- 
ample, the  rapidity  (d'  the  hlood  current  is  lowered,  so  that  tliey  are  de])rived 
of  the  necosary  amount  of  oxy^'en,  the  material  which  filters  throu^di  i.s 
no  lon^rer  normal  (i.e.,  water),  hut  contains  serum  alhumin.  Colinhciin 
has  shown  that  the  renal  epithelium  is  extremely  sensitive  to  circidatory 
ehan<.'es,  and  that  eomi)ression  of  the  rt'iial  artery  for  oidy  a  few  minutes 
causes  serious  disturbance. 

The  circidation  of  the  kidney  is  remarkably  influenced  l)y  reflex  stimuli 
comin.LT  fr.mi  the  skin.  Kx])osure  to  cold  causes  heightened  l)lood-pressiire 
within  the  kidmys  and  increased  secretion  n(  urine.  Bradford  lias  shown 
that  after  excision  of  jiortions  of  the  kidney,  to  as  much  as  one  third  of 
the  total  weight,  there  is  a  remarkable  increase  in  the  flow  of  urine. 

Congestion  of  the  Kidneys.— (1)  Artirr  C(,i,,ic:ilinn  ;  Ili/iirnnnia.-- 
Acute  congestion  of  the  kidney  is  met  with  in  the  early  stage  of  nephritis, 
whether  due  to  cold  nr  to  the  action  of  ])oisons  and  severe  irritants.  Tnr- 
jientine,  cul)e])s,  cantharides,  and  copaiba  are  all  stated  to  cause  extreme 
liypera-mia  of  the  organ.  The  mo<t  typical  congestion  of  the  kidney  M-liich 
wc  see  post  mortem  is  that  in  the  early  stage  of  acute  r.right's  disease,  when 


■■■I 


gjQ  DISEASES  OF  THE  KIDNEYS. 

the  organ  may  bo  large,  .oft,  of  a  dark  color,  and  on  section  blood  drips 

^'"  rIII  U^n  held  that  in  all  the  aeute  fevers  the  kidneys  are  congested 
,.d     1  Uthis  explained  the  scanty,  high-colored,  and  ol.en  "'>;•";;-- 
m-ne      on  the  .llher  hand,  by  Koy's  oncon>eter,  ^^  alter  Mendelson     .  . 
own  that  the  kidnev  in  acute  fever  is  in  a  state  of  extreme  anaMu.a.  small 
r  an    hi    HlU.ss;  and  that  this  anaemia,  increasing  with  the  pyrex.a  a^>d 
;.  ^  ng\vith  the  nutrition  of  the  glon.erular  epithelnnn,  accounts  i.n- 
he  ica2/dar^  """^  "f  ^^^'^^  ^"^^  "^'^  the  presence  of  albunn 

t^  i^oh.nged  fc™  1'— ;; '^^it^t  s;:2tt;;;L:;^s::^ 

r::;:;dit- !;r;i    ;:;£  -as  •ri:s:!^b:^/by  Menddson.^  on  the  contrary, 

'li  e  k  1   ev  of  fever  is  c  .mmonly  swollen,  the  blood-vessels  are  congested, 

n^l  Vie  cortex      eouently  shows  traces  of  cloudy  swelling.     However    the 

,      o       H^u  b  nces  in  acute  fevers  are  probably  less  ""l-rtjmt    han 

le      if  the  ellects  of  either  the  specific  agents  of  the  disease  or  the  prod- 

^<       :^     d  i^    heir  growth  or  in  the  altered  n>etabolisn>  of  the    issues. 

•n!e  l^"ne^  di.uini.hed  in  amount,  and  may  contain  albunnn  and  tube- 

""%)  Fassirc  Congestion:  Mcrhanhal  //^/.nvrmf^.-This  is  ^^^ ^^^^'^ 
of  clonic  disease  of  the  heart  or  lung,  with  impeded  circulation,  and  a.  a 
<  It  o     .    ssnre  npon  the  renal  veins  by  tumors,  the  pregnant  uterus   o 
'     t^  m,  d     In  the  cardiac  kidney,  as  it  is  called,  the  cyanotic  indura   on 
"ic'iUed  with  chronic  heart-disease,  the  organs  are  enlarged  and  Inn, 
h    cap    10     rips  oiT,  as  a  rule,  readily,  the  cortex  is  of  a  deep  red  co  o  , 
nd  tlil;pyramiL  of  a  purple  red.    The  section  is  ---l;;;;k-|  t^-     ^ 
.tance  is  verv  firm,  and  resists  cutting  and  tearing.       he  inters  itial  aait 
cr  ^i^and    hero  is  a  small-celled  infiltration  betwcm  the  tubule  . 
k"     ml  there  the  Malpighian  tufts  luive  become  sclerosed.     Ihe  blo-u^ 
c.    1    are  usually  thickelu.l.  and  there  may  be  more  or  ess  granular,  fatty, 
:;'i;  aline  changes  in  the  epithelium  of  the  tubules     The  -'^^^  -  ^    > 
,1..ed  1  ditVu^e  nci.hritis.     The  urine  is  nsually  reduced,  i^  ot  lugli  spccu  c 
viK       dion    ins  more  or  less  albumin.    Hyaline  tulie-casts  and    dood- 
r     n   ck     r    n      uncomn^on.    In  uncomplicated  eases  of  the  eyanoti.  m- 
Z^^  nr.mia  is  rare.     On  the  other  hand,  in  the  ^^^^^^^ 
tensive  arterio-sclerosis,  the  kidneys  are  more  involved  and  the  unai  uinc 
tion  is  likely  to  be  disturbed. 


IV.    ANOMALIES   OF   THE   URINARY   SECRETION. 

1.  AxrmA. 

Totil  «nnpression  of  urine  occurs  under  the  following  conditions: 

m  1  aTevent  in  the  intense  congestion  of  acute  nephritis      For  a 

tim    no    Tine  mav  be  formed;  more  often  the  amonnt  is  great  y  reduced 
Tm    0  commonly  complete  anuria  is  seen  in  subjects  of  renal  stone, 

fraimentVof  which  block  both  ureters.    Sir  William  Eoherts  calls  the  con- 


ANOMALIES  OF  THE  URINARY  SECRETION. 


861 


(lition  "liUfiit  ura'niia."  There  may  l^e  very  little  di-eunifort,  and  tlio 
t^yinptoms  are  very  unlike  those  of  ordinary  ur.'emia.  Convulsions  occurred 
in  only  T)  of  -11  eases  (Ilerter);  lieaiiaelie  in  only  (i;  voiiiitin-;  in  only  12. 
Consciousness  is  retained;  tiie  i)ui)iis  are  usually  contracted;  tlie  tempera- 
ture may  he  low;  there  are  t\vitcliinf;s  and  perha]>s  occasional  vomiting. 
Of  41  cases  in  the  literature,  ;?,')  occurred  in  males.  Of  3(j  cases  in  whic'li 
there  was  ahsolute  anuria,  in  11  the  condition  lasted  more  than  four  days, 
in  18  cases  from  seven  to  fourteen  days,  and  in  7  cases  longer  than  four- 
teen days  (Ilerter). 

(3)  Cases  occur  occasionally  in  which  the  suppression  is  ])rerenal.  The 
following  are  among  the  more  important  conditions  with  whidi  this  form 
of  anuria  may  bo  associated  (Ifensley):  Fevers  and  inllammations;  acute 
poisoning  by  ])hosphorus,  lead,  and  turpentine;  in  the  collajise  after  severe 
injuries  or  after  operations,  or,  indeed,  after  the  passing  of  a  catheter;  in 
the  collapse  stage  of  cholera  and  yellow  fever;  and,  lastly,  there  is  an 
hysterical  anuria,  of  which  Charcot  reports  a  case  in  which  the  suj)prcssioa 
lasted  for  eleven  days.  ]5ailey  rejiorts  the  case  of  a  young  girl,  aged  eleven, 
inmate  of  an  orphan  asylum,  who  ])assed  no  urine  from  October  10th  to 
December  Tv>th  (when  8  ounces  were  withdrawn),  and  again  from  this  date  to 
March  1st!    The  question  of  hysterical  deception  was  considered  in  the  case. 

A  paticTit  nuiy  live  for  from  ten  days  to  two  weeks  with  complete  sup- 
pression. In  I'olk's  case,  in  which  the  only  kidney  was  removed,  the  pa- 
tient lived  eleven  days.  It  is  remarkable  that  in  many  instances  there  are 
no  toxic  features.  Adams  reports  a  case  of  recovery  after  nineteen  days  of 
sup])ression. 

In  the  obstructive  cases  surgical  interference  should  be  resorted  to. 
In  the  non-obstructive  cases,  particularly  when  due  to  extreme  con^'cstion 
of  the  kidney,  cu])])ing  over  the  loins,  hot  aitplications,  free  purging,  and 
sweating  with  ])ilocarpine  and  hot  air  are  indicated.  AVhen  the  secretion  is 
once  started  diuretin  often  acts  well.  Large  hot  irrigations,  with  normal 
salt  solution,  with  Keni])'s  doidile-current  rectal  tubes,  should  be  tried,  as 
they  are  stated  to  stimulate  the  activity  of  the  kidneys  in  a  remarkable  way. 

2.  rr.T:MATrniA. 

The  following  division  may  be  made  of  the  causes  of  ha^maturia: 
(1)  General  Dimixes.—Tho  malignant  forms  of  the  acute  specific  fevers. 
Occasionally  in  leuka'mia  ha^naturia  occurs. 

(3)  liennl  Causes. — Acute  congestion  and  inflammation,  as  in  Wright's 
disease,  or  the  effect  of  toxic  agents,  such  as  turpentine,  carbolic  acid,  and 
cantharides.  "When  the  carbolic  s])ray  was  in  use  many  surgeons  sulTercd 
from  ha^maturia  in  consequence  of  this  poison.  Kenal  infarction,  as  in 
ulcerative  endocarditis.  New  growths,  in  which  the  bleeding  is  usually 
profuse.  In  tuberculosis  at  the  onset,  when  the  pajMlhe  are  involved,  there 
may  be  bleeding.  Stone  in  the  kidnev  is  a  frequent  cause.  Parasites:  The 
Filaria  saiigvini.-t  Immiiiis  and  the  BUharzin  cause  a  form  of  haMuatiiria  met 
with  in  the  tropics.  The  echinococcus  is  rarely  associated  with  haemor- 
rhage. 


m^ 


ft 


1= 


852 


DISEASES  OF   TlIK  KIDNEYS. 


siniially  ..r.uis  )n  ^..nnn!i..'U  and  a>  a  u.uu 

'"''r.\  7'  ,/;  u,    -Tniuries  mav  i^-cluro  l.U....lin-  from  any  rnrt  o[  tho 

,,,.„„,  ,„„nc.s  from  injury  n    tlu<  l.la.1.1...   o  ^   »;    "    ;  ^,^,^,,^,,,,    „, 

the  nn.thra  is  Impu.ndy  .In.  to  mjun   hs    tl>o  pa.a... 
eonu-tinu's  to  falls  ..r  Ijlows.  carefuUv  stu.lird  of  lato 

Ana,  laMly,  tluT.  is  a  v.ry  H.terc.tn  g  f^"  '  ;  ':-^;^       -^.^^.^^^^  ,,,  j,,,,,,, 

,oa,.s,  ,av,i.ulavly  i.y  ^'-['"-^j;  ,',;,,  '^^up'f^ases  that  (luirs 
Unions  hay.  luvnluun.l.  ^\_  ''^  ^'^,^  !  ,  ,,  ,^„.,,;,a  IS  o[  those  cases 
"ronal  opistaxis    o.rurs.     llaiiis  lias  ^^'   "    >  .    j^      ^.,,,,„  „f  angio- 

f,.on.  tho  li...ratn,v.  Tho  lirst-nanu-a  avdho,  -'-  '  ^  ^^^^^^^  ^^^,^^ 
^,^,„,,i,  ,,,,„„„,ia.  AnuUorostnigp..  ^tha  mil  1^  ^  ^  ^^^^  ^^_ 
l,v  Harris  uophrotomy  uas  .lone;    of  thoso,  J  ca..i..  l        . 

^Hk  cpooinl  intorost  is  tho  malarial  Inon.atnria  .hioh  ,,rovails  in  n^>'^->^ 

,;.;.;;.t:^:;a  has  aln.a.ly  hoon  oonsl.lor..  in  t^so^.n  .n  ..l.l^-  ^^^^^^^ 

rp,,,  ,,;„,,nosis  of  ha.natnru,  >s  nM.ally   eas^  k  ^^^^^^^_ 

v.vi.s  rr.,n>  a  light  sn>oky  to  a  hr.gh    -<^' J^  L        >>    -  ht  aro  rladily 

rr.dgni/od,  oitlioi   jiiainiy   m  k-  nc  ^hnh.w-      Tn   anni\onia(al   nrino 

""■^ ""  ''r::!; ':::;;;r';,;;'.:'u  .™:  i;';;;:  i. ^  *'*v'  ""'r 

or  urinos  oi  low  siuciiu   ^'a^i.  ,,„,^,,ii,«  for  manv  hours  nnohangod. 

the  diagnosis  in  ohsouro  eases. 

3.   IT.TiMOOLOBIXrRIA. 

This  condition  is  characterized  hy  the  presenee  of  hh.od-vigmont  in 
the^lne^    Thrhlood-eell^  are  either  ahsent  or  in  ins.gn.hoant  nun.bo,.. 


i1 
It 


ANOMALIES  OF  THE  URINAUY  SECKKTION. 


t  of  the 
]w  rup- 
m'y  tho 
111  I'rom 
wU'Y,  iir 

1  of  liUo 
1  known 
lit  (iuUV 
oso  c'a>i'?' 
)[  angio- 
coUoctcd 
oti'ly  I'o- 

n  coi'lain 
siu. 

tho  urine 
vk  porter 
•(J  readily 
hicli  ca^e 
ical  Airine 
Ived  I'roiii 
neliun.Lit'd. 
ical  Diag- 

ic  bladder 
lie  bladder 
)nly  at  the 

tho  blood 
\nd  in  tho 
the  ureter, 
this  organ, 
bleeding  is 
dillleiilt  to 

tho  symp- 
Cystoi^oopic 
may  aid  iu 


•pigment   in 
lit  nvimbers. 


853 


Tlio  eoloring  niatler  is  not  lia'matin,  as  inditatid  hy  IJie  old  nann',  haina- 
liinirid,  nor  iu  reality  always  haanoglohju,  hut  it  is  most  {'reipientlv  nirtJia'- 
moglohin.  'i'lie  urine  has  a  red  or  lirow  iiish-red,  sonielinies  quite  blatk 
color,  and  usually  dejmsits  a  very  heavy  hrowuisli  st'dinient.  When  the 
ha'Mioglol)in  occurs  oidy  in  small  ijiiantities,  it  may  give  a  lake  or  smoky 
color  to  the  urine.  .Microscopical  examination  shows  the  iireseiico  of  granu- 
lar pigment,  .sometimes  fragments  of  blood-disks,  epithelium,  and  very  often 
darkly  pignu'uted  urates.  'I'he  iirino  is  also  alimminous.  Tho  niiiid)er  (d 
red  blood-corpuscles  hears  no  proportion  whatever  to  tho  intensity  of  tho 
color  of  the  urine.  Kxaminod  spectroscoj)iea]ly,  there  are  either  the  two 
absorption  hands  of  oxyluemoglohin,  which  is  rare,  or,  more  commonly, 
there  are  the  three  ahsorjition  hamls  of  metluemoglohln.  of  which  tho  ono 
in  tho  red  near  (J  is  characteristic.  Two  clinical  groups  may  be  distin- 
guished. 

(1)  Toxic  HBBmoglobinuria.— This  is  caused  by  i>oisons  which  ])roduoe 
rapid  dissoluti<in  <d'  the  blood-corpuscles,  such  as  chlorate  of  potash  in  largo 
doses,  ])yrog.illic  acid,  earholio  acid,  -  'liurettod  hydrogen,  carliou  mon- 
oxide, uaphthol,  and  muscarine;  al.-  e  ])oisons  of  scarlet  fever,  vellow 
fever,  typlioid  fever,  malaria,  and  syphi.i...  According  to  J>astianelli,  luemo- 
glohinuria  due  to  the  administration  of  (piinino  never  occin-s  excepting  in 
jiatients  who  are  sulVei'ing  or  who  have  recently  sulVered  from  malarial 
fever.  It  has  also  followed  severe  burns.  Ex|)osuro  to  excessive  cold  and 
violent  muscular  exertion  are  stated  to  ])roduce  ha-moglohiniiria.  A  most 
remarkable  toxic  form  occurs  in  horses,  coming  on  with  great  suddenness 
and  associated  with  ))aresis  of  the  hiiul  legs.  Death  may  occur  in  a  few 
hours  or  a  few  days.  The  animals  are  attacked  oidy  after  being  stalled 
for  some  days  and  then  taken  out  and  driven,  jiartieularly  in  cold  weather. 
The  form  of  ha'inoglobinuria  from  cold  and  exertion  is  extremely  rare,  Xo 
instance  of  it,  even  in  association  with  frost-bites,  camo  under  my  observa- 
tion in  Canada.  lUood  transfused  from  one  mammal  into  another  causes 
dissolution  of  the  corpuscles  with  the  ])rodiiction  of  lurmoglobinuria;  and, 
lastly,  there  is  the  cpidrnnr  lui'maglolniiurin  of  the  new-born,  associated  with 
jaundice,  cyanosis,  and  nervous  symptoms. 

(2)  Paroxysmal  Haemoglobinuria. — This  rare  disease  is  characterized 
by  the  occasional  jiassage  of  bloody  urine,  in  which  the  coloring  matter 
only  is  present.  It  is  more  freijuent  in  males  than  in  females,  and  occurs 
chieily  in  adults.  It  seems  specially  associated  with  cold  and  exertion,  and 
has  often  been  brought  on,  in  a  susce])til)le  jiorson,  by  the  use  of  a  cold 
foot-bath.  Paroxysmal  haemoglobin uria  has  l)een  found,  too,  in  persons 
sid)ject  to  the  various  forms  of  Raynaud's  di.«ease.  Many  n'gard  the  rela- 
tion between  these  two  afTections  as  oxtrenu'ly  close;  some  hold  that  they 
are  manifestations  of  ono  and  tho  same  disorder.  Druitt,  tho  author  of  the 
well-known  Surgical  Vade-mecum,  has  given  a  graphic  description  of  his 
sufferings,  which  lasted  for  many  years,  ami  were  accompanied  Mith  local 
asphyxia  and  local  syncope.  The  connection,  linwever,  is  not  very  common. 
In  only  ono  of  the  oases  of  Raynaud's  disease  -which  I  have  soon  was  ])arox- 
ysmal  Invmoglobinuria  present,  and  in  it  epile])tie  attacks  occurred  at  tho 
same  time.    The  relation  of  tho  disease  to  malaria  is  not  so  close  as  has  been 


DISEASES  OF  THE  KIDNEYS. 
854 

u  ..•  IVi.fniu'lli  asserts  tl.at  it  is  i-raetieally  prove.! 
thought  by  many  ^vntel..  ^^'^^  '^  !  '  .  .  „,  ^^Mwu.  with  the  a'.tivo- 
that  n.alarial  ha.mog  oh.iu.m  "^^  '      ^  ^^^^  ^  j„  ,,,,  ^rst  attaek,  usually 

;r;;^j::tV".-^^  ..a  o^  as  a  .suu 

Theattaeksnuo-c..n>e..uMa.lcnl       't  r      1  ^      ^^^^^^^  ^^^^^^ 

of  mental  or  '-'^'ly^^^'^'^"!  I";,,  '     i^t^L  sublrn.al.     There  n:ay  bo 
pyrexia.  In  other  '-^ane  s    h    t     M     ^  ^^^^^  .^  ,,,,^  .neommon     The 

von.itiu-ana.harrlKea.    1'"    '"     '  ^,,,^„  ,,  ,iay  or  tNvo-sometimes 

,,.,uoglobinuria  rarely  V-;  *  J^^^^-s  in  whieh,  even  in  the  course  of 
indeed,  not  for  a  .lay.     1  u'lc  '^'^  paroxysn>s,  and  in  the  interval. 

,  ,i„,le  day,  there  have  been  ^^^  <^    ^^'^      ^J^  ,  ;,  ,  number  of 

,lear  urine  has  be.^n  parsed.    '''^  ^^  ,nay  alternate  with 

oases.  According  t.>  Kalte,  I-  ^  ^;;^^,  ^Y't.ociated  only  with  the  pas- 
peneral  syn.pio.ns  o  the  san.e  ^^  >■";;'  ^^j  ^^^ea  in  the  urine.  In  sucli 
i,.  of  aUnunin  -j^  "';,-^^r  *^S  wUlver  its  nature,  has  dcstn^cd 
cases  he  supposes  that  ^l^^-  / '^' ;  ";■  ^^.  ^,,    jh,  ,„h,ring  n.att.'r  of  which  i 

t„  torm  a  tl»™T  ""''''■\ri  h      r  -    1  '    opnnk.l  's  a  va^.-molor  JUonl.r. 

i/r.  Chv.)stek's  monograph.  „  .„^:.,  ^,,«t  is  essential.    In  that  pro- 

Treatment.-lu  all   orn>s  ..f  ha^mat^n   ja    -^^^^^^  ^^^  ^,_^,^,^^  ^,^^ 

d„oed  by  renal  calculi  the  -"'"l''     ^        '    ,;"     ,l,n.ld  l>e  tried,  then 
bleeding.     TuVl  doses  of  '^-^^'^^^'^  ^^  •^.j^  V  s\  phuric  acid.     Tlu>  oil  of 

t-l;.i;f^^^^^^^^ 

;=e.f^';ir;r";"^^^^ 

region.  ...       • ,  :,  „ns.i+isfictorv.     Amvl  nitrite  will 

^  The  treatment  of  ha^moglobmuna    s  ^^;^%^^,,^^,  paroxysm 

sometin.es  cut  short  ov  prevent  an  ^^^'^j^^^^^'^^  q, .inine  is  recom- 
the  patient  should  be  kept  warn>  and  gu  n  ^  ^^  ^J  "^"^^^.^^^^.ted-that  the 
memled  in  large  doses,  on  the  .^'JPP-^t  ^"'^  >  ^^^  ,  ,,,,uaitie  hist.>ry, 
disease  is  specially  connected  w.t^^.  i|udaru.  K  ther  ^  J^  ^^.^^^^^^  ^^^^ 
iodide  of  potassium  m  full  d..so.  may  be  tnca. 
attacks  are  nuich  less  frcpient. 

4.  Ai.BVMixrRT.v. 


ANOMALIE.S  OF  THE  URIXARY  SKrRKTlOX. 


855 


proved 

a-'titivo- 

usimlly 

jt  i*.  lia:^ 

a  result 
lills  iind 

ii;ay  bo 
on.  Tho 
motimes, 
c-oiirsc  of 
intervals 
invilter  of 
iiate  with 

I  the  piiii- 
In  sueli 

clesitroyed 

which  is 

i  excreted 

9  difTicult 
0  relation 
r  disorder, 
ood-seruni 
the  color- 

,  l)e  found 

II  that  pro- 
clieck  the 

tried,  then 
Tlie  oil  of 
:  in  Invmii- 
ilso  reeoni- 
the  lunihar 

nitrite  will 

10  paroxysm 
10  is  recom- 
(l_that  the 
itic  history, 
climate  the 


as  indicative 
any  circ^nn- 
ddiiey.    Two 


gronps  of  cases  may  he  recoirnjzed — those  in  whiiji  tlie  kidneys  show  no 
coarse  lesions,  and  those  in  wliieh  there  are  eviih'nt  uMatoinical  chan;^a's. 

Albuminuria  without  Coarse  Renal  Lesions.— («)  Funrilnnal,  si-calh'd 
Plnjsiiilotjinil  Alhiniiiiiurin. — In  a  normal  comlition  of  tlie  kidney  only  the 
water  and  tho  salts  are  allowed  to  pass  from  the  hiood.  When  aihnniinous 
snhstances  Iransnde  there  is  jirohahly  distiirhance  in  tiie  nutrition  of  the 
ei)itheliinn  of  the  capillaries  of  the  tuft,  or  of  the  cells  snrronnding  the 
gloinemlns.  This  statement  is  still,  however,  in  dispute,  and  Senator, 
(Jrainj^'er  Stewart,  and  others  hold  that  there  is  a  ])hysioIoj,neal  alhnininnria 
wliieh  may  follow  museuiar  work,  the  inj,^'stion  of  food  rich  in  allmniin, 
violent  emotions,  cold  liathinjx.  and  dyspepsia.  The  diirerences  of  opinion 
on  this  point  are  strikin<r,  and  observers  of  eipial  thoroii^dmess  and  relia- 
hility  have  arrived  at  directly  ojiposite  conclusions.  'J'lie  jjresence  of  alhu- 
min  in  tlio  urine,  in  any  form  and  under  any  circumstance,  may  he  rejrarded 
as  indicative  f)f  chanj^'e  in  the  renal  or  glomernlar  ejiithelium,  a  (;Iiange, 
however,  which  may  he  transient,  slight,  and  iinimiiortant,  de|ieiidiiij,f  upon 
variations  in  the  circulation  or  upon  the  irritatinjr  eilVets  of  substances 
taken  with  the  food  or  temporarily  ])rosent,  as  in  febrile  states. 

Albiniiinuria  of  adoleseence  and  cyclic  a]l)iiminuria,  in  whicli  the  albu- 
min is  present  only  at  certain  times  durinjr  the  day,  are  interesting  forms. 
A  majority  of  the  eases  occur  in  young  jiersons— boys  more  commonly  than 
girls — and  the  condition  is  oft<>n  discovered  accidentally.  The  urine,  as  a 
rule,  contahis  only  a  very  small  (luantity  of  albumin,  but  in  some  instances 
large  quantities  are  jiresent.  The  most  striking  feature  is  the  variability. 
It  may  be  absent  in  the  morning  and  only  jtrcsent  after  exertion,  or  it  may 
bo  greatly  increased  after  taking  food,  particularly  .  roteids.  'J'he  quan- 
tity of  urine  may  be  but  little,  if  at  all,  increased,  tho  specific  gravity  is 
usually  normal,  and  the  color  may  be  high.  Occasionally  hyaline  casts 
may  bo  found,  and  in  some  instances  there  has  been  transient  glycosuria. 
As  a  rule,  tlie  pulse  is  not  of  high  tension  and  the  second  aortic  sound  is 
not  accentuated. 

N'arioiis  forms  of  this  affection  have  been  recognized  by  writers,  such 
as  neurotic,  dietetic,  cyclic,  intermittent,  and  paroxysmal — names  which 
indicate  the  characters  of  the  diU'erent  varieties.  A  largo  ])ro])ortion  of 
the  cases  get  well  after  tlie  condition  has  jiersisted  for  a  varialile  jieriod. 
Tills  in  itself  is  an  evidence  that  the  changes,  whatever  their  natuiv,  were 
transient  and  slight.  In  these  instances  the  albumin  exists  in  small  (pian- 
tity,  tube-casts  are  rarely  present,  and  the  arteiial  tension  is  not  increa.sod. 
In  a  second  group  the  alinimin  is  more  i>ersistent,  the  amount  is  larger, 
though  it  may  vary  from  day  to  day,  and  tho  pnlse  tension  is  increased. 
In  such  instances  the  ])ersistent  allmmimiria  probal)ly  indicates  actual 
organic  change  in  the  kidney. 

(h)  Febrile  Albuminuria. — Pyrexia,  by  whatever  cause  produced,  ni;iy 
cause  slight  albuminnria.  The  presence  of  the  albumin  is  due  to  slight 
changes  in  the  glomeruli  induced  by  the  fever,  such  as  cloudy  swelling, 
which  cannot  bo  regarded  as  an  organic  lesion.  It  is  extremely  common, 
occurring  in  pneumonia,  diphtheria,  typhoid  fever,  malaria,  and  oven  in 
the  fever  of  acute  tonsillitis.     The  amount  of  albumin  is  slight,  and  it 


li 


!! 


DISEASES  OP  THE  KIDNEYS. 


n..nv  di^n-v.  fron.  the  uvine  .itl>  tho  oossatK.n  c.  ,ho  f.vor.    Hyaline 

mercury,   Kplulis,   leukauua,  :„,,,.,.,iionts   in  tlu-  Llood,  sueh  as 

l.iU-i.iununt  an.l  .u>iar,  may  eaii^e  the  i.a..a„c 

' ^» -"' »' ;'r.;iK:^i«"" "'--  "-';™^ 

chlurcfnrin.  ,,„.*.,;„  -itVections  of  the  nenvii.^  sijsh'iii.    Tins 

(,/)  Alhu.ninuna  cecur.  in  ^'y'*'*''   '      '  ;""',,ii,,,tic  seizure  aud  in  npo- 
.o-called  neurotic  "i;-'-^-'-;;;^"  ^^^^  ji    ^^  1^  l,o  head. 
l,lexv,  tetanus,  exoi-litlialnue  -..itie   au.l  in.)ui.  0rKan8.-('')  (>»- 

^'"a  buminuria  with  Definite  Lesion        «^«  ^nn^^^  ,,  ,!,ad  and 

...stion  of  tl>e  kidney,  either  aetise,  '^"^  .'  /  "  1^,;^  ^ue  to  obstructed 
i  associated  .itU  U.e  -^Jy^^^jf-t:;:;^:  i';:;  ..^^su:;  ;n  tl.  renal  veins 
„utllo\v  in  disease  of  the  htait  oi  mu^  , 

by  tlie  P''^^""'^V'?ronile'Sneys-a..ute  and  cbronic  Brigbt's  disease, 

the  formation  of  i>us.  ,  -,         ,,;,,„  in-ine  sboubl  be 

TestB  for  Albumin.-iwih  '■"■";'\«      '\  ,         '/     t  t..rl.i.l,  tl.c 

i,  present,  a  white  ring  is  h.rn,ed.  j  -  -^\  J  ^^^,,^,  .atisfaetory.  A 
and.  for  the  routine  ehnioal  ^^nA,  is  1"'\''-""         <^  ^^,^.„  .,„t  above 

ailf;,sed  haze,  due  to  muein  O-;"!-'^^^"^;:  ^;  ^^^d^udn  or  after  the 
,,,  white  rin,  ^>f  "^;;;;;;-;;-Vm^'^.  ;;;;::f 'miy  be  due  to  urates  or 
taking  of  balsanue  '^'''^^''l'^''"  ;;  ;;\;.,,„,i,,.     A  colored  ring  at  tbe  ]unc- 

,„„c  l,alf  full  of  nrinc,  am  a.1,1  .  ™  «-;,•,„■    ™  „„j  „,,,,  lo  to  13 


MM 


AXO.MAIJKS  OK   Till-;    riMNAKV  SKCI{I-:TI()N. 


857 


[Tyalino 

k'lul  or 
sociatinl 
^wh  as 
ri  of  al- 

i  hivmic 
ho  ronal 
ether  or 

in.  Tliis 
1  in  apo- 

-(^0  C'on- 
cuUl  and 
hi^triutcd 
nal  VL'iiis 

"s  (lii<oase, 

irg. 

atcnl  with 

should  he 
urhid,  the 
J  nionicnt, 

.ihe  over  a 

iiess  oecnrs 
It"  addition 

io\ired  into 
ently  down 
if  alhnmin 
vustworti\y, 
factory.     A 
I  just  ahove 
ir  after  the 
:o  urates  or 
at  the  jnnc- 
ring  matters 

rdinary  tcst- 
vanido  solu- 
dd  10  to  15 
rying  in  de- 
'his  is  a  very 
alkaline,  but 


does  not  procipitale  iniicin,  pcploncs,  iihosjiliali's,  mates,  vcgclahh'  alkaloids, 
or  the  ])ine  acids. 

Sir  William  Ifohcrts  stnDigly  recommends  the  tti<n;iicsiitui-iiilrir  Irsl. 
One  volume  of  strong  nitiic  acid  is  mixed  wilh  live  volumes  of  the  satu- 
nitcd  solution  of  .-ul|iliate  of  ma^nc.-iiun.  Tliis  is  used  in  the  same  way  as 
the  nitric  acid  in  Heller's  test. 

I'icric  aiid,  introducecl  hy  (ieorge  .lohnson,  is  a  delicate  and  uselid 
test  for  allmmin.  A  saturated  solution  is  used  and  employed  as  in  the 
contact  nicthod.  It  has  licen  urged  against  this  test  that  it  throws  down 
the  mucin,  peptoiu's,  and  certain  vegetal)le  alkaloids,  hut  these  are  dis- 
solve d  hy  heal. 

I"or  minute  traces  of  alhuniin  the  trichlora(;ctic  acid  may  he  used,  or 
MillaidV  lluid,  which  is  extremely  delicate  and  consists  of  glacial  carholic 
acid  (Ko  per  cent),  '2  drachms;  pure  acetic  acid,  7  drachms;  liiiuor  potassa', 
I'  ouiu'cs  (!  drachms. 

A  (piantitative  estimate  of  the  alliumin  can  he  made  hy  means  of  hls- 
haclTs  tnhe,  hut  the  rough  method  of  lieating  and  hoiliiig  a  certain  cpian- 
tity  of  acidulated  nriiu'  in  a  test-tuho  and  allowing  it  to  stand,  is  often 
eiujiloycd.  The  depth  of  deposit  can  then  he  compared  with  the  whole 
amount  of  urine,  and  the  proportion  is  expressed  as  a  mere  trace,  almost 
solid — one  fourth,  one  half,  and  so  on.  'I'liis,  of  course,  does  not  give  an 
accurate  indication  of  the  ]U'o|iortion  of  alluimin  in  the  total  (piantity  oi' 
urine.  Forthe  more  dahoiate  methods  the  reader  is  referred  to  the  W(U'ks 
on  ui'inalysis. 

The  id)ove  tests  refer  entirely  to  serunv  alhuniin.  Other  alhumiiious 
suhstances  occur,  sueh  as  alhumose.  scrum  glohulin,  peptoiu's,  and  hcmi- 
alhumose  or  jiropepton.     They  are  not  of  much  clinical  importance. 

AllnniKisiiri/r. — Traces  of  jwidnurs  (all)unu)ses)  are  found  in  the  iiriiic 
in  many  fehrile  diseases  and  in  chronic  suppuration.  Albunu)siiria  luis  hut 
little  clinical  significance  except  in  one  connection.  In  ISIS  Uencc-.Jones 
descrihed  a  case  of  osteo-malacia  in  which  he  found  a  modilied  form  of 
alhuniin  in  the  urine.  Of  late  years  renewed  interest  has  heen  taken  in 
the  subject  hy  the  discovery  of  the  as.sociation  of  alhumose  with  miiltipli' 
myelomata  of  the  liones.  .\s  Kaliler  called  sjiccial  attention  to  it,  the  Ital- 
ians have  given  the  condition  his  name.  V\\/.  reported  an  instance  at  the 
last  meeting  (ISilS)  of  the  Association  of  American  Physicians,  the  only 
one  recognized,  so  far  as  I  know,  in  this  country.  In  I'lradshawV  case  the 
patient  jnisscd  at  intervals  lor  a  year  a  turhid,  milky  urine,  which  dejiositcd 
a  copious  white  sediment.  On  adding  niti'ii'  acid  to  a  urine  cmilaining 
alhumose  a  white  precipitate  is  formed,  which  is  dissolved  when  the  speci- 
men  is  hoilcd,  l)ut  reappears  on  cooling. 

aiiilitilin  rarely  occurs  in  the  urine  alono,  hut  generally  in  associati(m 
with  serum-alhumin.  The  latter  is  usually  |)rcsent  in  greater  ([uantity,  hut 
in  .'^evero  organic  renal  disease  and  in  diabetes  Maguirc  has  found  that  the 
proportion  of  globulin  to  albumin  is  often  2.5  to  1.  Senator  states  that 
more  ghihnlin  is  ])rescnt  in  lardaceous  kidney  than  in  other  forms  of 
uepliritis.  The  clinical  significance  of  globulin  is  the  same  as  that  of  seruin- 
albumiu. 

.'i3 


ft 

I 


V  » 


gns 


DISEASES  OV  THE  KIPNEYS. 


,ll,„„„„„iia  IS  tnuisicnt    ain     in  a  -^            „,,,  ,.i,i,H.ys  inta-t. 

.^,o..a.ional.nu.M,nninn,un       a           -  j      >^,,^  ^^,^^^,,  ,,,„..  usually 

l.valim.  casts  an.l   w.th   .urn  is^  1   tuM  ,^.  ^^^  ^,  ^,i^,,,  „.„,,nt  .1 

ini.unnninyoun,  UH.MW.h;u.     nn-^^  M-av.  ahva-ly  .-uk-n 


,,,,,,,,,,,Uv  iu  all  cases  the  l..vs..ncc        •     "';         ,        .,^,  „,■  ,,,,i,u  it  is 


C^)  The  fvo(iiH' 
,;.,   onittleovnoi-vactuarnupovtam-o. 


AN'OMAIJKS  OF   THK   rUINAKY   SKCIiKTKiN. 


859 


intiut. 
i  a  IV  w 
usually 
mint  <il 
scrinii-i, 


iaii}-'t'  111' 
icli  il  i^* 

StMUV   of 

n  (iT  iIh' 
lan't'iiUy 

iiria  ami 
•oiiipany, 
[t  is  oven 
tvansii'iit 
vst'uci'  or 
itli  whii-li 
uttcii  al)- 
tlic  I'orti- 
■rics  is  I'ar 

s,   1   (juitc 

lumin  anil 
it's  disease 
osnl. 
ailvaiu'in,^ 

he  alWumi- 

rovcil.  it  ii^ 
nrly  jiTiinn- 
riy  year^  of 


;  of  till"  Idd- 

r  even  weeks 
viiria  is  usu- 
is  a  rule.  Ilie 
.  early  stages 
IS  not  in  any 
T  cystitis  the 


iirinp  is  nsnally  alkaline,  ami  eoniains  more  niiieus;  niiit  uriliim  is  usually 
more  freijUt  111.  ami  llie  liisluiy  poiMts  to  a  |ii'evii)us  hlailder  aU'eeliou. 

(■-')  ('iislilis. — 'I'jie  urine  is  alkaline,  often  IVtiil.  the  |ius  ro|>y.  ami  iMe 
anmunt  of  urine  <:reatly  increaseil.  The  rnpy,  thirk  mmus  u>nally  eunu'.- 
uilli  the  la.-l  iiiirtinns  oi  tlie  uriiu'.  '"riple  |ihn>|ihate  iiy>tals  may  lie  ]ue>- 
ent  in  the  frohly  passed  urine. 

(;>)  I'nllirilis,  partieularly  ^'onorrhiea.  The  \)U>  ap|iear.-  fn>t,  is  in 
small  ipiaiitities,  and  tlu're  are  sii;iis  of  loeal  inllammatiou. 

(I)  In  liiifiirrlmi!  the  ipiantity  of  pus  is  usually  small,  and  lai';;'e  llake- 
(d'  va^^iiuil  epithelium  are  nunu'i'mis.  In  doulitfid  eases,  when  leueoirhiea 
is  present,  the  urine  should  he  withdraw  throu;^h  a  eatheter. 

(."))  Uujilurc  (if  Ahficcssfs  iiilti  tin-  rriiiiiri/  J'ttssai/rs. — In  siii'h  eases  as 
pelvic  or  perityphlitie  ahseess  there  have  hei'ii  previous  symptoms  of  |iu,- 
formation.  A  lar^e  amount  is  passed  within  a  short  time,  then  the  dis- 
charj^e  stops  alirnptly  or  rapidly  diminishes  within  a  few  days. 

J'us  jiives  to  the  urine  a  white  or  yellowish-white  appearaiu-e.  Oii  set- 
tlinij;  there  i.»  a  heavy  niayi^h  sediment,  and  the  snpermitant  lluid  is  usually 
turhid.  The  sediment  is  often  tenaeious  and  roiiv.  The  reaction  is  iicn- 
erally  alkaliiu',  ami  the  odor  may  he  amnioniaeal  even  when  ]i,issed.  K.\- 
aminatioii  with  the  micrnscope  ii'veals  the  presence  of  a  lar^c  nundier  of 
pus-corpuscles,  which  jire  u.-ually,  when  the  pus  conu's  fi'iun  the  hladder, 
well  formed;  the  protoplasm  is  ^ranulai',  ami  often  .-hows  many  traii>luct'nt 
jirin'csses. 

The  oidy  sediment  likely  to  be  eonfoumled  with  pus  is  that  of  the 
phosphates;  hut  it  is  whiti'r  and  less  dense,  ami  is  distinguished  immedi- 
ately hy  mierosco)iical  examination. 

With  the  pus  there  is  always  more  or  less  oiiithelium  from  the  hladdi'r 
ami  pelves  of  the  kidneys,  l)ut  since  in  these  situations  the  forms  of  cells 
are  praetieally  identical,  they  ail'ord  lu)  infornuition  as  to  the  locality  from 
which  the  ju     has  eome. 

The  trt'atment  of  jms  in  the  urine  is  considered  under  the  conditions 
in  which  it  occurs. 

0.  (' It  VI. fin  A — X()^■-I•Al^\slTI^. 

This  is  a  rare  alVection,  oceurrinj:  in  temperate  reixions  aiul  unassoei- 
ntcd  with  the  Filnrin  liancrofti.  The  urine  is  of  an  opaque  white  color; 
it  resenddes  milk  closely,  is  occasionally  nuxed  with  hlood  (ha'inatochy- 
hiria),  and  sometimes  coagulates  into  a  firm,  jelly-like  mass.  In  other 
instanoes  there  is  at  the  liottom  of  the  vessel  a  loose  clot  which  nuiy  he 
distinctly  l)!ood-tin<red.  Under  the  microscope  the  turhidity  seems  to  he 
caused  hy  nunu'rous  nunnte  ,<rranules — more  rarely  oil  droplets  similar  to 
those  of  nnlk.  In  ^lontreal  I  made  the  dissection  of  a  case  of  thirteen  years' 
duration  and  could  find  no  trace  of  jiarasites. 

7.  T,iTirt"i!iA   (Lilluimla ;  LUhic-arld  Dialliexis). 

The  ixeneral  relations  of  uric  acid  have  already  been  considered  in  speak- 
ing of  gout. 


(T 


w 


V 


i 


DISH  ASKS  OF  TUK   KIKNKYS. 

SCO 

.       ,      ;•   •  Tl,,.  nric  iiciil  occurs  ill  cdiiiUiniit ion  cliicllV 

Ornmrwr  m  the  I  wn'.-\h.  ...u        -l 

,vith  a.nnu.nuun  and  so.hnn,,  luVMUU,  ';;" ■•,-,.,  ..ic  acid\nay 

be  seimratcl   lnm>  it.  base,    ind     ^^^  ''     -^  ,,;^„i„i       .,f  th,  urinary  i^i^- 
„ve  usnaliv  nl'  a  .Ice,,  rnl  .ul.r,  ""';/,,,  ^         .,r  ,,ystaU  lo.-... 

liU,  grains  ..1  (  aycinic  pc    u   .     1  ^^^  ^^^^__^^  ^,^^^^^  ^,,^^.,,^  j,^  ,   , 

poHit  of  uric  aci.l  l-r  an  cxcc-s.     1  lu    h  .  .  ^^^^^^  ^^^  ^,,^,^,,,. 

l„,,e  uiihin  a  few  lu-urs  ="  ^  l-;;^^^;  ;  l.;....  in  the  nuantity. 

;:;;:j;;:^X^  -"^-"- 

t^is  prnlml.ly  tho  most  inq.nrtai.t  clcnu.i  .  ^,^^,.  ^ 

•  lJhcal.i>  the  ucight  or  -••V''t:on;i  1  in  Xolracn,  the  average 
t„  tUe  ucight  or  uvea  olnnmalc  ;  '  ^'  ^J.^i^,,  ,  ,f  „,ic  acid  to  the 
ratio  is  1  to  5..  .hilo  c  :-;  ^'  :  '.f;  ;  „,  In  several  of  the  oases 
total  nitro^'en  chn.inatcl  in  tin    "'        '  ,^  ,,,,t,,,,,,„  ,1,,.  acute 

of  gout  in  my  Nvanls  Futchcr    omul  tha         ^^^^    '  .  ^^,,,,,  than 

arthritic  attacl<s  the  uric  a.nl  xvas  rcluc-e.!  ;>  '  .'  J^,,^  ,,,;,,i  between 
the  urea,  so  that  the  ratio  o  the  ^i;--^^^  :;:;;';;;;  ,„„,,al  pn.-or- 
1  to  m)  up  to  (111  one  case)  1  to  l,.)(tu,  a  rcuiin 

ti,nis  occurring  (luring  the  acute  attacks  Un-mm-  the 

More  ..oiini.on  is  tlie  prccipita  ion  M  m     ■  pho        .,  ^^^^^^ 

,..ealh.l  hrick-iust  or  latentious  ^Jl"'^  '  .^'^  ,  \  ,h1v  of  the  aci.l 

,„  uu.  presen..e  of  urinary  lugnie        ^ ^^^     ^,,.,,^  ^.^  ,;  j.j^u  specili.- 

gravity.     As  tlie  uiatc>  ai(  n  t,,,  aep..siti.m  does  u.>t  u.H.c^sarih. 

s;:a:;:u;xx::;:"J'--^^^^ 
-"^:;;;;::^nra:;:t;!;;rr  .hat  lu.  a.eady  h.n  ..a.,..;; ..;,  ^o 

„„v  ,.,nsi.l..r  here  the  hypotheli.al  7''''\^'7; J^     ^  \ ;  .  !  .;,  ato  certain 

„Hc-aci.l  diathesis,     ^^--'''-^'f  "^^IJl^'V^^t X^  ''"' 

svn.ptonis  due,  as  he  supposed  to  ""["^^^  often  tho  case  .hen 
only  have  his  views  been  wid.. ly  ^'I'M'^'  ;  >'  '  '^  '  ;  .  ^^.^^^i^.a  inani- 
,vo  give  the  rein  t.>  theoretical  ^''^"';'  '\\''";  ''''■;  \;^,,,,,,  ,,t,,ib„te  to 
fostiitions  of  this  state  have  so  -"'^'1-^';;  ^^j  ,;  ^  '^l  i:,  the  various 
this  cause  a  coTisiderahle  proportion  of  the  ^^^^J^'^^^;^^,,,,,  thirtv- 
svsten..  of  the  l.ody.  Thus  o.e  --^^ /l?"  f  i,!^^;  V"v,on.  our  hu.k 
nine  separate  uu.rbid  oon<ht,..ns  associated  ^^         ™  ,,id  it  is 

.,  Unolledge  of  the  nr.ulo  of  f-'-f-^-^.;  ^'^^    *  t..;  civ  oxtended 
v.rv  evident  that  the  physi.dogy  of  ^Ih'  ^uh.,ce    n vu.  t  ^^^^ 

b.^.re  wo  are  in  a  po.iti.>n  to  draw  -f  ^^^  ^^  ■,,^  '  J  ,,  ,  fnnc- 
,„,ans  sure  that,  as  Murch.son  l^^'l'l--"!'  '  ■  ^^  ^''.^^  ^^^  albuminous 
tional  disorder  of  the  liver,  ^'^l"''  ^"J  ^  ^  J  ^'^nd  n.  substance  is  ur^c 
ingredients,  nor  is  it  atall  certain  n^  ^^^l^^  -,  ;,  i^^ossihle  with 
acid.     In  the  present  imperfect  state  ol  kn.nMtd^e  i 


AXoMAIJKS  OF  TIIH   I'lMNAliY   SKCliKTloN. 


SOI 


'  (juan- 
i(l  uitiy 
whiili 
ry  I'ij,'- 
ils  luo''. 

-  ill  till' 
)  ((iiiili- 
iiaiility. 
■ts  -rivrs 
(:>)  InW 
ot  aciil- 

lut  ratio 
•  avi'vaiif 

1(1    to   tlK- 

llu>  cases 
;1r'  ai'UU' 
cut  than 
bctwioii 
1  proi'or- 

iniii.u'  tlio 
•olor,  (Uu' 
the  aciil 
^h  siK'filic 
,'ix'(liK'iitly 
i>ccssarily. 
istc'iu'i'  o{ 

r  gout,  wo 
lia.  or  tlie 
itc  ocM'taiu 
liver.    Xot 
case  when 
illed  niani- 
ttril)ute  to 
lu?  various 
ban  thirty- 
111  o\n'  laek 
c  acid  it  is 
y  extended 
it  is  liy  no 
;  in  a  fmie- 
alhuniinons 
iinee  is  nr'c 
ossihk'  with 


any  eleariie-s  to  diliiie  the  iiiithol(.;:y  of  tiie  so-called  iivie-aeid  diatliesis. 
We  ni;iy  say  tliat  certain  syiiiiitoins  arise  in  eoiiiieclion  wilii  defective  food 
or  tissue  iiietaliolisiii,  nioie  |iiirticnlarly  of  tiie  niti'oLii'iious  elements.  l)e- 
licieiit  oxidation  is  jirolialily  the  ino>t  essential  factor  in  the  |ir(ice-s,  witii 
the  re^uh  of  tiie  forMiatioii  of  h'ss  ivadily  sohiiile  and  K'>s  readily  eliniiiiatiMl 
products  of  retro^'rade  inelanioiiiliosis.  This  faulty  nietalioli-.ui  if  Ioiil; 
continued  may  lead  to  ^out,  with  iiratic  deposits  in  the  joints,  acute  in- 
tlamniations,  and  arterial  and  renal  disease.  In  a  la.-e  ;,'roup  of  cases  the 
distiirhed  metaholism  produces  hifili  tension  in  the  arteries  (prohahly  as  a 
direct  secpience  of  interlVronco  with  the  ca|>ilhiry  circulation)  and  iilti- 
niately  de<,a'nerations  in  various  tissues,  particularly  the  scleroses. 

Overeatinjr  and  overdrinkinjr,  when  comiiined  with  deiieii'iil  muscular 
I'xercise,  lie  at  the  hasis  of  this  nutritional  dist'urhaiice.  The  symptoms 
whii  h  are  helieved  to  characterize  the  uric-acid  diathesis  have  already  heen 
hrii'ily  treated  of  under  the  section  on  irrejruhir  gout,  and  the  (piestion  of 
diet  and  exercise  has  also  heeu  there  considered. 

<S.    OXAI.IIilA. 

Oxalic  acid  occurs  in  the  urine,  in  eomhinatioii  with  lime,  forming  an 
oxalate  which  is  held  in  solution  hy  the  acid  phosjihate  of  soda.  Ahout 
.01  to  .ivi  gramme  is  excreted  in  the  day.  It  never  forms  a  heavy  deposit, 
but  the  crystals — usually  octahedral,  rarely  dundj-l)ell-slui[)ed — collect  in  tlie 
mucus-cloud  and  on  the  sides  of  the  vessel.  The  amount  varies  extremely 
with  the  diet,  and  it  is  increased  largely  wlien  such  fruits  and  vegetables 
as  tomatoes  and  rhul)arl)  are  taken.  It  is  also  a  jiroduct  of  incomidete  oxi- 
dation of  the  organic  substances  in  the  ])ody,  and  in  conditions  of  increased 
metaliolism  the  amount  in  the  urine  becomes  larger.  It  is  stated  also  to 
result  from  the  acid  fermentation  of  the  mucus  in  the  urinary  passages, 
and  the  crystals  are  usually  almndant  in  spermatorrluea. 

\\hen  in  e\c(>ss  and  ])ri'sent  for  any  considerable  time,  the  condition  is 
known  as  oxaluria,  the  chief  interest  of  which  is  in  the  fact  that  the  crys- 
tals may  be  deposited  l)efore  the  urine  is  voided,  and  form  a  calculus.  It 
is  held  bv  many  that  there  is  a  s])ecial  diatliesis  associated  with  this  state 
and  manifested'clinically  by  dyspepsia,  particularly  the  nervous  form,  irri- 
tal)ility,  dein-ession  of  spirits,  lassitude,  and  sometimes  marked  hypochon- 
driasis. There  may  l)e  in  addition  neuralgic  i)ains  and  the  general  symp- 
toms of  neurasthenia.  The  local  and  general  synijitonis  are  ])rol)al)ly  dc- 
])cndent  upon  some  disturbance  of  metabolism  of  which  the  oxaluria  is  one 
of  the  manifestations.  It  is  a  feature  also  in  many  gouty  jiersons,  and  in 
the  condition  called  litluvniia. 

9.    f'YSTIXriilA. 

Stadthogcn  claims  that  normal  urine  docs  not  cmitain  cystin,  tliough 
r>aumann  and  Goldmann  succeeded  in  separating  it  in  very  small  ipian- 
tities  from  healthy  urine  as  a  l)enzoyl  ccnnpound.  It  is  associated  with 
elimination  of  diamines  both  in  the  fieces  and  urine.    It  is  very  rarely  met 


mi^ 


hG2 


I>1SKAM:s  uF   TllF,   KIDNEYS. 


j 


Hi 


:;::i;'Si;:       .;;;-. :>;::^:::;:;r;::;-;;,'L 

10.     rilllSl'llAII   UIA. 

.  ,   •  <    1    I'rMi,,   til.'  ImmIv   in   ((imliiniition   willi 

li„H' :uia  mn-ncsia.     1 1  c  .mininn  .  '    .  „,       i„,tvv.vn    1    and    •• 

tw..nty-ruur  hunvs  varu.,  -•:-';,,'"',;,,;„,  ,„ainly  Ivun,  .1." 

uci  fn.u.  nn.l.'in.  im.ta-  n.  and  "       '  .,l,un.lant.     Tlu«  alkaline  phns- 

.^^  nnul.inat.on  xvith  sndunn  aiv    '",',;,„  ,,,,..,,1.:,,.. 

1''-'-  "'■  ""■  "••'•^"  r  '77:':;;;;  i  V      i.undan,!  ..f  n^a^ncsmm 

„,  „      r.rllni  //-;/  ^''^  jj         ,      J   '  Ln.onia.al  iVrnu.nta.ion,  .i.luT 

^,u,ty.     In  urnu.  wn.l   \u>  '  "'    -    '  ,,,.,^i„„  j,,,  annn.nun-nui.^nrsnnn 

i„si,l..  or  oulsi.lo  the  luHly,  tluM..  '^  >'    '  ,.^,„,  .,,  j,,   ,Vatl,ovy  or 

.,r  IripU.  vl'-l'""^"-  -1-"  r"'"  i     n    :  ^        o  m  of  stellar  phosphates, 
st.llate  erystals;  hene..  the  tern.  ^'\  ",    ^,,^,  „,i,„  ,,,„  the  alka- 

,',,0  earthy  phosphates  oj^ur  - ;    -    ^    ^^^^'^  ,i,.c.un,stan<.es  the  deposit 
Unity  is  dne  to  a  fixed  a  kal     •  '   ""'  ,      nhosi-hates  are   pa^.ed 

,„,,,v-take  plaee  willun  the  '•''';' l^^      id   uli       is  popnlarly  oonfonnde.l 

,,  the  end  of  •";'-''^;!;,:;:;,:^     ^^        1 1;;':..  iJ  ileeipitated  hy  heat 
with  spennatorrlnea.      1  he  ( .  1  nun  ,„.,,,,,,,  f,,,.  all.uniin.  hnt  is  at 

-^<'  v'-'-'"  ''  '•''•"'•'"'T."'"  ;.';;  hJ"  -.ondition  is  v..ry  fre- 

•--'  •^'^^"'^■'■'  "'""\;'t:"'rm  d  p  p  or  Troru  dehility  of  any  kind. 
,,uont  :.  persons  ^"'  ^•>'  f  j  \^;!.  \,i,i„.  in  the  twenty-four  hours  to 
The  Pi.o^pl.atesniay  he  up  ^  -^  ^^-^  thcTnormal  an.ount  is  not  n.ore 
,„„,  ;  to  .  J^—-    ,1-^^;'       :  ;;;.sphates  n,ay  he  deposited  in  nr,no 

;;.;:;;,,rhr=;;on;^  d!;  L,.^ 

ft'rment.  .  i,h(wnhates.  to  which  the  term 

TlKMdiniealsi^niineanec.cif  anexees.of  l-       P    11^  ^^^^,_^^_ 

phosphatnria  is  applied,  has  been  "'"^'l;'^  ^  "'  'l^;^  ,'  ,;:.  ,„  .letcrnnno 

Led  that  a  'l^l-^'^^-^'V^iniui^l      "  ^  m^^ 
,,Uiehaearofnlanays,so     he    wen     --n  .    ^  ^^^   ^^^^^^  ^,^^,  ^^^.^,^^  ,,f 

It  has  Ion,  heen  ^''"''j;  I*,,  ;;y^  "^  ^^  •'  aeid;  hu,  the  .question  ean- 
the  nerve-t.ssnes  and  ^1'  "  *r[,  ' .  ,,  „t  is  increased  in  wasting  diseases, 
not  yet  l.e  oonsulered  settl  d.  ^  >  '  \':^';;  ^^^  i;,,,.  i.,„k:enda.  r.nd  severe 
sueh  as  phthisis,  aente  yollms   atrophy   "^     '  ^  .     ,     ,,,„,„ncy. 

ana.nia.\vhe.as  it  is  '^i--;^^':^,  ^  ^^^l^l^^^^nd^'rUrs.  phl^l^iatic  dia- 
In  a  condition  termed    •>   ^  ^    "'•,;.'-' .„,,-,  ,  .,,,,it   increase  in  the 
botes  tliore  are  polynria.  thirst,  en.aciation.  and  a  ,.c 


-^ 


ANOMAMKS  OF  THK   rRlXAUY  SWMIKTION. 


803 


ciiUu- 
tu-rs  1)1' 
I'ditiuy. 

of  tlu' 


cxcrctidti  of  |ili(is|iliiitcs,  \\lii(  li  iiiiiy  Im'  us  tiiiicli  as  Trorn  I  to  !•  jiniimiics  in 
tlu'  liny.  Tlic  iiriiii'  is  ii.-iially  iiciil  and  lice  Ironi  snj,'af;  tlu'  patients  arc 
ncrvdUs;  in  sonit'  instances  sn;:ar  lias  lieeii  |ii'escnl  in  tlie  mine,  and  in 
otliers  it  (<nlise(iiiently  makes  its  apin'aranee. 


m  willi 
lie  alka- 
hates  of 
(1  in  tlio 
and  ■"> 
nmi  tiie 
(in  jn'od- 
cs,  tlxi^e 

1H>    phiiS- 

ifTiK'sinm 
)n,  eitliiT 
a.Linesiiini 

iUlievy  "f 
losjihiites. 
the  alka- 
\e  deposit 
re  passed 
)nfonn<leil 
d  liy  iK'at 
Init  is  at 
very  Uv- 
any  l<iii<l- 
r  hours  to 
not   more 
•d  in  urine 
I'  ammonia 
:  the  triple 
a  baeterial 

1,  the  term 
lie  remem- 
I  determine 
Id  lie  made, 
activity  of 
iicstion  ean- 
jnir  diseases, 
,  rnd  severe 
ircu'naney. 
ispliatie  dia- 
rease  in  Uk- 


11.     ImiH' AMUI.V. 

The  sMh>tance  in  tiie  nrine  wliicli  has  received  tiiis  niiiiiL'  is  the  indoxyl- 
sulpliate  of  potassiiun.  in  which  form  it  appears  in  the  nrine  and  is  e(dor- 
le>s.  When  concentrated  acids  or  stronj,'  oxidizing,'  agents  are  added  t(t 
the  ui'iiie.  tliis  snhslance  is  decdinposed  and  tiie  indiffo  yet  free.  It  is  pres- 
ent only  in  ,-mall  ipiantities  in  hi'altliy  nrine.  It  is  derived  from  the  indol, 
a  product  formed  in  the  intestine  hy  the  decomposition  of  the  ailnimin 
under  the  inlliience  of  hacteria.  When  ahsorhed,  this  is  oxidi/ed  in  the 
tissues  to  indoxyl,  which  coinhiiics  with  the  potassium  sulphate,  formini,' 
the  ahove-nanied  suhstance. 

The  (|Uantity  id'  indiean  is  diminisiied  on  a  milk  (and  a  Kelir)  diet. 
It  is  increased  in  all  wasting  diseaes,  as  carcinonni,  and  whenever  any 
large  ((uantities  of  albuminous  snhstaiwes  are  undergoing  rapid  decompo- 
sition, as  in  the  severer  forms  of  peritonitis  and  empyema.  It  is  not  usuallv 
increased  in  constipation,  hut  is  met  with  in  ileus,  partieidarly  in  ohstruc- 
tion  id'  the  snudl  intestine.  Indiean  has  occasionally  been  found  in  calculi. 
Though,  as  a  rule,  the  urine  is  colorless  when  passed,  there  are  instances 
in  which  the  decomposilinn  has  taken  place  within  the  body,  and  a  blue 
color  has  been  noticed  imnu'diately  after  the  urine  was  voided.  Sometimes, 
too,  in  alkaline  urine  on  exposure  there  is  a  bluish  lilm  on  the  surbu'C. 

To  test  for  iniliciin,  place  I  or  .">  cc.  of  nitric  or  hydroehlorie  acid  in  a 
test-tube;  boil,  and  add  an  cipial  quantity  of  urine.  A  bluish  ring  develops 
at  the  point  of  contact.  Add  f  or  ;i  cc.  of  chlond'orm  and  shake  the  test- 
tube;  on  separation  the  chloroform  ha.s  a  violet  or  bluish  color  due  to  the 
presence  of  indiean. 

}'2.    Mlir.AN'I'KIA. 

In  melanotic  cancer  the  iiriiu',  either  at  the  time  of  voiding  or  after 
oxposnre  to  tlu'  air,  may  present  a  dark  color.  This  jiigment  is  known  as 
melanin,  and  it  may  occur  in  solution  or  in  the  I'oim  of  small  granules. 
The  ui'ine  may  be  \<>ided  clear,  aiul  subseipiently,  on  exposure  to  the  air 
or  nn  the  addition  of  oxidizing  substances,  becomes  dark.  In  these  eases 
it  contains  a  clii'omogen  called  melanogeti,  which  turns  dark  by  oxidation. 
\'on  .laksch  has  found  that  "  in  nrine  containing  melanin  or  its  precursor, 
melanogcn,  I'liissian  blue  is  formed  by  adding  a  nitroprnssiile,  aipieous 
potash,  and  an  acid.  This  reaction,  however,  does  not  seem  to  depend  on 
the  presence  of  mcliinin.  as  it  is  not  given  by  that  suhstance  when  se|!- 
arated  from  the  nrine,  but  apparently  by  some  other  at  present  unknown 
substance,  which  is  ]iresent  in  traces  in  normal  urino  and  is  increased  in 
cases  of  melanuria,  and  also  in  those  conditions  where  excess  of  indigo 
Occurs  in  the  urine '''  (Ifalliburton). 


804 


DISEASES  OF  THE   KIDNEYS. 
K?.    rxiUMATriUA. 


Ill 


,     ,:■       ,     ',,, „,,,..,li„i,      (llvi-"'"na  '■»«  '■«"  I"''*"'  '"  "  '"•')'"">  "' 

Tz::  "It ;!.:;;'::;..  ,iL  ™i„„  u..m.>.  ..^  11.0  i«.cm,«  a.,,.go„os 

capsulatiis  havo  boeu  found. 

•I    111  P'im>^  of  vesico-i'nU'i'ic  fistula.  , 

:'::'  h, "  baU,  ,.r  1.,  ,.h...gi..g  .he  cul  ol  11,0  «.l...c.  u„Ja-  .UU.. 

11.    OtIIKU   SuiiSTAXJKS. 

V.t  in  the  uvino,  or  lipuria,  occurs,  according  to  lIallil>urton  first,  ^vill.- 

lUiigiil 

.hich  fat  casts  are  sometimes  present,  and,  --'^""^,^^' ^:f' ;^^,^\     ,  ^ 
1       •  .  „,„!    fl.ivdlv    in  the  al  ection  known  as  chjluiia.      inc   umn- 

tlKT.  arc  volatile  fatty  adJs  in  tl.c-  urme,  .acl,  as  acct,c,  butjnc,  (..nine. 

""^S;«S.-V.„  JaK.ch  ,li.ti,„aisl„.  tl,o  f„llowi„R  fon,»  .f  ,.a«.o- 
U,,.i«l  a  "onuria:  The  febrile,  tl,e  cliahetic,  the  aeetemina  »,th  can 
f  ™rJ  cw  r  the  fen,,  assoeiate.l  with  i..a..ition,  aeetom.na  ...  i»ych  .,e^, 

::;,;» ::r,;,il;:  .hiei,  re»„it,  ..„„.  auto.i,.,«i™.io..  t ,»»..., 
iXhr;  ""!;s.:"xi;::mX  s?  i;t:,r:;^iic;;l::;;  ih^ 

:  ■;,  t  'the  ■,,.e.,-h..tyrie  aei.,.     The  ,..,,.  „f  j;- -';";;-;';;;:  ''If;: 
in  the  breath  and  evident  ni  the  urine.     Ihe  tests  ha\e 

'-'ZZ''tS^:.  prr,hahl,  ..ever  pre.;,.t  i„  ,..e  ..w  i;  ^f^^^^ 

::--?;.;i:!,;;::t:i:rtiS^ 

insoluble  in  ether. 


M 


UR.EIMIA. 


805 


•  cysto- 

uhctLT- 
iriiy  i>t' 


'  a  miUl 
iL'!f  with 
tit'iit  to 
jr. 


st,  witli- 
}  adiiiin- 
s,  in  the 
iUioii.  as 
Lily,  with 
isoai^c,  in 

he  urine 
itals  liave 

in  which 
:•,  I'ornilc, 

of  patho- 
h  certain 
psychoi^L's, 
(lo>il)tl'ul, 
etonc.  It 
10  (liacotic 
)o  marked 
a>n  in  the 

th.  ^Vith 
similar  re- 
be  present 
il  the  sali- 
prescnco  of 
h  a  second 
he  ethereal 
be  present, 
:ic  acid  are 


/3-oxy-l)ntyrie  acid  is  helieved  l>y  Sladelmann,  Kiilz.  and  Minkowski  t(v 
be  the  cansc  "of  diabetic  coma.  Jt  is  a  prodnut  of  the  decomposition  of  the 
tissne  all)nmins,  and  from  it  diacetic  acid  is  readily  formed  hy  oxidation, 
its  tests  have  already  been  given. 

Ah-aidonuria. — Aromatic  eomjionnds  occur  alter  the  administration  of 
earlxdic  acid  or  ji:allic  acid,  and  the  urine  on  exposure  to  air  becomes  dark. 
In  carboUiria  the  substance  causing  the  l)lack  color  is  known  as  hydro- 
chinon.  .Abuiy  years  ago  Boedekor  met  with  casi-s  in  wiiicdi  the  urine  be- 
came dark,  owing  to  the  presence  of  an  aromatic  eompound  which  he  called 
alcapton.  The  lu'ine  is  clear  on  ])assing,  and  then  darkens  on  exposure  to 
the  air,  or  on  the  addition  of  liquor  potassa\  Jiaunninn  isolated  a  sid)stanrc 
from  the  urine  of  a  case  of  alcajitonuria,  to  which  he  gave  the  name  of 
homoueiitisinic  acid.  Later  observers  have  i.solated  this  substance  in  other 
cases.  Kirk  believed  the  reaction  in  his  case  was  due  to  nroleucinic  acid. 
]n  several  instances  more  than  one  mendjer  of  a  family  has  shown  this 
nrinarv  change.  The  substance  is  apparently  without  clinical  significance 
excei)t"iu  so  far  as  it  is  capal)le  of  reducing  the  Fehling  solution,  and  may 
be  mistaken  for  sugar.  Alca])ton  nrine  may  be  distinguished  from  diabetic 
urii\e  from  the  fact  that  it  does  not  ferment  nor  reduce  alkaUne  bisnuith 
solutions,  and  becatise  it  is  optically  inactive  (see  xVlcaptonuria,  by  T.  15. 
Futcher,  New  York  Med.  Jonr.,  IS!)?,  ii). 

t'holnria  and  glycosuria  have  already  been  considered  under  jaundice 

and  diabetes. 

llamalnporpluirin  occasicmally  occurs  in  the  nrine.  It  was  first  recog- 
nized by  nopi)e-Soyler.  Nencki  and  Sieler  determined  its  exact  formula, 
and  the  former  demonstrated  that  the  only  chemical  dilVerence  between 
luvmatin  and  luematoi)orphyrin  is  that  the  latter  is  simply  ha'matin  f.ce 
from  iron.  It  has  been  found  in  the  nrine  in  ])nlmonary  tuberculosis, 
pleurisy  with  elVusion,  acute  rheumatism,  lead  poisoning,  and  intestinal 
luvmorrhages.  This  ])igment  has  been  found  very  frequently  after  the  ad- 
ministration of  snlphonal,  and  sometimes  imparts  a  very  dark  color  to  the 
nrine. 

V.    UR>EMIA. 

Definition.— A  toxamda  developing  in  the  course  of  nephritis  or  in 
conditions  associated  with  annria.  The  nature  of  the  poison  or  poisons  is 
as  yet  unknown,  whether  they  are  the  retained  normal  products  or  the 
products  of  an  abnormal  metabolism. 

Theories  of  Urgemia.— The  view  most  widely  held  is  tha^t  nrannia 
is  due  to  the  accumulation  in  the  blood  of  excrementitions  material— l)ody 
poisons— which  should  be  thrown  off  by  the  kidneys.  "If,  however,  from 
any  cause,  these  organs  make  defaidt,  or  if  there  l)e  any  prolonged  ol)struc- 
ti(Hi  to  the  ontllow  of  urine,  accumulation  of  some  or  of  all  tlie  i)oisons 
takes  iilace,  and  the  characteristic  symjitoms  are  manifested,  but  the  ac- 
cumulation may  be  very  slow  and  the  earlier  sym])toms,  corresponding  to 
the  comparatively  small"  dose  of  itoison.  may  be  very  slight:  yet  they  are  in 
kind,  though  not  hi  degree,  as  indicative  of  nrtemia  as  are  the  more  alarm- 


^^k 


1 


y 


\x 


DISEASES  OF  THE  KIDNEYS. 


8G0  .     . 

1  'lu.  ..n,l  'iiKl  to  whicli  alone  the  nniw  uraMnin  i;^ 
i,,.,  ^vl.i.h  Mpi-ar  lowan  >h  .  "  ;  j'  ,^  ,^.^,  ^,,.,,„  t,,„  ,1,,  toxicity  ot 
„,Ieu  given -(nntev).     "-■»-      '     '^  v    ',1.     'Plu.  part  ,laye.l  l.y  utva 

;::,r';;;\;n;;:;\::ri:r.-^-:.; s ..........  n.. ......  ..,.- 

•'-t.Uu.,-  vie.  is  iln.t  nnejnia  ae,...  on  tl.  P.^ 

-'•^"''">-"-      '^••':^^  ■-''T;;;:  t  "f :    't      '  .'  ;n.;.nna  >u.e  due  to  i..  d.- 
s.,.retion,  an.l  it  .s  .n-ed  ti.at  t  u   •       l^  ,,„  i,„u„„,e  lu.,- 

,,„,„,  uu.  n.eta.u,l,s,n  j;  .    ^^'^  ,  tdne/^Wl.t  i.  -en.ove.l,  ti.ere 

.•les.     If  n.ore  tl.an  one  t^'"  ;,,,„^.,.,„„  „,.\„,,a  and  of  tl.e  n.tro^n.nu..s 

i.anextraordina,.y  .nerea.e  "  /''    i;  ;^'     j!^  ^.^,,,  ,,,t  ,.k..owlc.d^es  ti.at  we 
l,,aies  ..r  tl.e  eveat.n  class     ^^^    ''  ..^      k,„„  „  earetul  st.xly  of  tl.e 

a,.o  still  igno,ant  of  the  nature    1  "  ,  ,    ,.,,.„,  ,,„  ,„  ailu.u.inous 

^-srt:^:.i;r;;;:.;  ti!;:;;::;;;: :: '^^^  - 

and  c;;;.vn,sio,.s.  ....e  due  to  l.'-i-    ;;;;;-     ^i^^ui.  a,.d  ehn-nie 
SymptomS.-('l.n.c.ally.  ^  •■  •"' >  '^     ;-"    „„„ie,-ea  nnder  tl.e  section 

fov,.,f  of  n,.a.,..ia.     Tl.e  ^^^l:;2ZX^'^^-  '>^  -l'^'"^""      ^^    '^ 
""  an..ria.     Acute  --"-;  '  ^        ^  "  ,„,,u.„.a  thinks  that  it  is  s,m.- 

,n..ve  common  ...  the  i.ost-teh.U  ^  '  '        ,  ^j,^,,    .  ;,,  ,,,„„-  suhjects. 

eially  associated  with  a  form  ^>^  ^  f '^,^^,^   '*  ,\,e  arterio-selen.tie  and 
Chronic  forn.s  of  ...•a.,..,a  "'^^^''^  ^^^  "     '     ...s  .d'  ..ra....ia  ...ay  be  de- 
,va..nlar  kidney.     Vor  --;;;;;;;  '':,^;,       1  Itlstinal  ...anifestations. 
,c-rilied  nnder  cerel.ral   <l^^l'"'"'*  "'"  '  ,^     •,  ^,„,.  h,.  descrihed: 

Among  the  cnrhral  ^vnM'to.ns  o    u,.    n.    n-^     ^        ^^^^.^.^^^^^^^  ^^^^^^  ^^^^^ 

(.)  Mania.-'V\n^  ,„ay  con.e  on  ■    "  i'     J^  ^  ,,.,,„  ,,,,,  „ot  bo 

,„:,,  .o   ,H-evio..s  indic.t.ons  "^  -'  ^  ,^^         h.  ^^f  U.is  kind  which 

'-"^^"  ^'^  ^■"*'  'V'^'   V'rrm     m  -uddcly  n.aniacal  a..d  died 

,a,ne  nnder  n.y  observat.on    ^J^'    f ^ ^      ^^^    ^^  j^,,,  ,i,,;.„t,  but  tl.e  patic.t 
in  -ix  davs.     More  comn.only  the  d  lii.nm 

is  noisv.  t.lkstlve.  restless,  a..d  ^^^'V^^'',  ,         ,,,,.  ^,,.  „„  n.eans  un- 

,,)  ,>,.l„si,.nnl  lnsa,ul,,il;ol,e  /"''^  "    ^l^  ,     l^i    „o<ro..  tbe  s..l..ie.t 

eomn..m,  and  excllent   ^■•'"'7/^1;  ,nt^.'.  1^-1  -'Iv  bv  U,.eme,-,  Chris- 

z^t::::::Z^:;^^^^^-^'^^^""^''' •--"' - 

I'rofonnd  melancholia  n.ay  also  ^>'1"''^<''>^'-  ^^   ^^,     ,„.  ,,,     ,,,,,,ied  by 

(.)  r.«r./M'./<..-These  n.ay  en,,  e  '"    ^^^^  ^  '         '^,^^,  .,,,„„,,  „„,  idc.,- 

,,ai,;  i..  the  head  and  -*!--'-•,,,    '';,'r,;rnHi^.l  «-  -^^  ""*  "^ 
.,,,,   ,,i„,   n.ose  of  .u.d.na..y  e,.,le,  ^      t       -  ^^^^    ^^^^,     ^^^j.^,,,^    ^^ 


r  R.EM  I  A. 


8(;< 


v'lnia  IS 
icily  of 
liy  mva 
11  dctcr- 

bnonniU 
internal 
1  iis  dit-- 
nce  pro- 

lu!   n\U:^- 

■(1,  tlieri' 
ro^onuus 
;  tliat  wi- 
ly of  tlio 
luniinniis 
rd's  «iul- 
tidU. 
llu'  coniii 

(1  clironic 
10  section 
lis.  It  is 
it  is  spc- 
f  sultjects. 
Totic  anil 
iiy  1)0  de- 
tions. 

1  who  has 
ay  not  he 
ind  whieU 
il  and  died 
he  patient 

means  nn- 
ho  snhject 
mer,  Chris- 
n.     Oiu'  of 

0  condition 
ry  c'ai)aeity. 

(receded  hy 

1  and  ideii- 
iiiay  not  he 
0  patient  is 
I.  hut  more 
aek.     T.ocal 

in  urannia. 


A  reniarkahle  se.ineiice  of  t!ie  cnnvul.-icns  is  lilindness— ((n//«/V  (uiiniirosn 
— whieh  may  persist  fur  several  days,  'i'liis,  however,  may  occur  ainirl  from 
the  convnl>ions.  It  usually  passes  oil'  in  a  day  or  two.  There  are,  as  a  rule, 
no  opiithalmoscopie  ehanjies.  Sometimes  ura'inie  deafnos  suitervenes,  and 
is  prohai.ly  also  a  eorohral  manifestation.  It  may  also  occur  in  conneotion 
with  jtersisteut  headache,  nausea,  and  otlier  pistric  symptmns. 

(,/)  Coiiiii. — rneonseionsnoss  invariahly  aeeomi>anieri  the  general  con- 
vulsions, hut  a  coma  may  doveloj)  trra.lnally  witliout  any  convulsive  seizures. 
Freipien'tly  it  is  preceded  liy  headache,  and  the  patient  gra.lually  heeomes 
dull  and  ajialhetie.  In  these  cases  there  may  have  heen  no  previous  indi- 
cations (d'  renal  disease,  and  unless  the  urine  is  examined  the  mituro  «d'  tlu! 
ease  may  lie  overlooked.  Twitehings  of  the  muscles  occur,  particularly  in 
the  face  and  hands,  hut  there  are  many  cases  of  ciuua  in  which  the  muscles 
are  not  involved.  In  some  of  these  <ases  a  condition  (d'  torpor  persists  for 
weeks  or  even  months.     The  tongue  is  usually  furred  and  the  hreath  very 

foul  and  heavy. 

(r)  Jjinil  A(/.s/cs'.— In  t!u'  e(nirs<'  of  clinuiic  r.righfs  <!isease  hemiiilegiii 
ov  monoplegia  may  c<uiie  on  spontaneously  or  follow  a  convulsion,  and  post 
mortem  no'^ixross  lesions  of  the  hrain  lie  found,  hut  only  a  loealix.e<l  or  dif- 
fused (edema.  These  cases,  which  are  not  very  uncommon,  may  simulate 
almost  every  form  of  organic  paralysis  (d'  eerehral  origin. 

(/■)  Of  otiier  eerehral  symittoms,  headache  is  imitortant.  It  is  most 
often  occipital  and  extends"  to  the  neck.  It  may  l)e  an  early  feature  and 
associated 


with  giddiness.  Other  nervous  symptoms  of  ura-mia  are  intense 
itching  (d'  the  skin,  niimhiu'ss  and  tingling  in  the  lingers,  and  cramps  in 
the  m'liscles  of  the  calves,   particularly  at   night.     An   erythema   may  ho 

^'^  Cnriinr  di/spmra  is  classified  hy  Palm.'r  Howard  as  follows:  (1)  Con- 
tinuous dv>p]i.ea;  (■-')  ]uiroxysmal  dyspniea;  (:'.)  hoth  types  alternating;  and 
( 1)  Chevne-Sfokes  hreathing.  The  attacks  of  dyspiuea  are  most  commonly 
nocturnal;  the  patient  mav  sit  uj).  gasp  for  hreath.  aiul  evince  as  much 
distress  as  in  true  asthma.  Occasionally  the  hreathing  is  noisy  and  stridu- 
lous.  The  Cheyne-Stokes  type  may  persist  f(M'  weeks,  and  is  not  necessarily 
associated  with  (imia.  1  have  seen  it  in  a  man  who  travelled  over  a  hun- 
dred miles  to  consult  a  physician.  In  another  instance  a  pati.'iit.  up  and 
ahout.  could  only  when  at  meals  feed  himself  in  the  apmea  period,  'i'hough 
usually  of  serious  omen  and  occurring  with  c(mia  and  other  symptoms,  re- 
covery may  follow  even  after  persistence  for  weeks  or  even  months. 

'V'hv  nastni-iiilesliiinl  manifestations  of  niwmia  often  set  in  with  a1)rupt- 
ness.  I'ncontndlahle  vomiting  may  come  on  and  its  cause  he  (piite  un- 
rccognizahle.  A  young  married  woman  was  a.lmitted  to  my  wards  in  the 
:\roirtreal  tleneral  Hospital  with  iiersisteiit  vomiting  <d'  four  or  five  <lays" 
duration.  The  urine  was  slightly  allmmin.nis,  hut  she  had  none  of  the 
u-'ual  signs  of  ura'inia,  and  the  case  was  not  regarded  as  one  of  P.righfs 
disease  ^  The  vimiiting  persisted  and  caused  death.  The  i>ost  mortem 
showed  extensive  sclerosis  of  hoth  kidneys.  Tiie  attacks  may  he  ])receded 
hy  nausea  and  mav  be  associated  with  diarrli.ea.  Tn  some  instances  the 
d'iarrh.ea  mav  come  on  without  the  vomiting;  sometimes  it  is  profuse  and 


«■* 


a 


DISEASES  OF  THE   KIDNEYS, 
boo 

„..,..i„U..l  .ill.  m,  in..,..  .,,U.nlK,l  or  .■»•,.  .li,.l..iH'">i.-  i""--,.,,!.,.  of 

nephritis.  Mith  tlR-  c<.ini'l'«itmns,  i.ml  u^  .i  luaniH.i.iu 

i,..lf  (Stengel).  ,^,^,,^^,,  ,,,  ^,,,,^  1  i„ve  ealle.l 

,,,,.:3:;v-.!::;-:::.:;:n--i^.i--"'"-' - "'"-■■" 

etidoearditis.  ,      vilne  of  the  dinieal  deter- 

,,  tl>e  urine  is  concerned,  tl>e  vo  mac  a^ul  .poe,  ^  -  J^;;  \J,  „,,,, 
.olid.,  and  the  deternun.U.>n  .t  he  ^^  J  ^  ,  ^^  ^  :i;;nded  .Uh: 
tion  of  the  cii>ant.ty  m  tlu  >lu..d  I  ''te\^^,„i„ „.;,;,.  „,  ,ven  tumor. 
(,)  Cerebral  lesions,  such  as  l-^;  ''^^f  ^^^^^^  r'  ia„ov  disease  and 
In  apoplexy,  which  is  so  ^•'^■'""•'"1>  ."^^"^'''^^  ,,;,,,!,,  if  ,vith  eonvul- 
,titV  ar/eries,  the  sudden  loss  '"^ ---;;;;';;-,  ^1^ J;  Ll  the  existence 
,,,.,  nu^  sinudate  a  --;-,f  V,,!  ^  ,!,;,,  ,,  the  oyos,  suggest 
of  complete   henuplegui,  \\ith   unjivaie  .,.,.,,„iie  hemiplegia  or 

huMnorrhage.     As  already  noted,  tin-  a      c  s  >        u  a mK  .^.  ^^^^ 

„,.,noplegia  which  cannot  be  separa  ed  f^"  '  1^  ^  -^^.^^j^^^  j  know 
,,,i,,:  post  mortem  show  m,  trace  ot  ^-'r^,  '"^  u  o  tty  of  opera- 
of  an  instance  "7;-''\ ---;  ^;:;™  t' dTto    ul^dllnU  hiMuordu.ge 

:;;-h^:tm:r;^.;:^^£^ 

furred  tongue,  and  without  localizing  symptoms.  ma>  uadilN 

with  ura-mia.  Vm.i.ii.i   iiviv  uer^ist   for  weeks 

.rim,™.,,  .^i.h  ■>  hoav,  >■  -;,';•,;:;     "I';,       ;;■-;  "n„>»U,rany  suggests 

lor  miliary  tuberculosis.  .        i  ..i   ^-ith    noi«onin>r  bv   alcohol   or 

(,)   l-nvmic  ccnua   niay  h..-'^-^o.M  "^^  ^^!''^^-,^,,^^,^,  they 

"I-™-    ^"  "•^'""^^'"lu;;;:?  t  Z  da    H      a     tl'constant;  they  may 
arc  more  commonly  dilated.     In  ^z' ""'^J''  "Vp,  ^  nv,,iunatlon  of  the  eve- 

breath  sometimes  gives  an  important  hint. 


1 


ACUTE   HUIGHT'S   PISEASK. 


800 


tii>n  (if 

ich  tlu- 
s.  Tlu- 
ill  iiiiis- 
1,1  letid. 

111.'  acute' 
lira' mi  11 

ve  callod 
ij^^ilis,  or 

ill  ik'ttT- 
jic  cent'i- 
.    So  far 
the  total 
lu  iiuVua- 
witlr. 
11  tumor, 
icase  and 
h  c'ouvul- 
oxislencc 
;,   suo-gest 
ipk'gid  or 
osiou  and 
.    I  know 
,•  oi'  opera- 
L'luorrhaiio 
these  cases 
.     So,  too, 
i<,dit  fever, 
Dlifonnded 

f(n'  weeks 
•en  uneon- 
twitehings, 
ly  suggests 
nd  are  not 
1  fever  and 

aleohol  or 
liolisni  they 
;;  they  may 

of  the  eye- 
nlhuminiiric 
odor  of  the 


Tlie  condition  of  the  lu'art  and  arteries  slionld  also  lie  taken  into  ac- 
count. SikMcu  iira'niic  coma  is  more  comnioii  in  tlie  chronic  interstitial 
ncpliritis.  The  character  of  the  delirium  in  alcoholism  is  scnnetimes  ini- 
|i(irtant,  and  the  coma  is  not  so  (h'e[i  as  in  uriemia  or  opium  poisoning. 
It  mav  for  a  time  lie  impnssiiih'  to  determine  whether  the  condition  is 
due  to  uru'inia,  iirofouml  alcoholism,  or  Inemorrhage  into  the  jions  Varolii. 

And  lastly,  in  connection  with  suddi'ii  coma,  it  is  to  lie  rememlH'ri'd 
that  insensibility  may  occur  after  jiroloiiged  muscular  exertion,  as  after 
running  a  ten-mile  race.  In  some  instinces  iincdiiseioiisness  has  come  on 
rapidly  with  stertorous  lireathing  and  dilated  juipils.  Cases  have  occurred 
under' conditions  in  which  sun-stroke  could  he  excluded;  and  I'oore,  who 
re[iorts  a  ease  in  the  Lancet  (ly.M),  considers  that  tlu'  condition  is  due  to 
the  too  rapid  accumulation  of  waste  products  in  the  blood,  and  to  hyper- 
pyrexia froTii  sus|H'nsion  of  sweating. 

The  treatment  will  be  considered  under  Chronic  I'riglil's  Disease. 


VI.    ACUTE    BRIGHT'S    DISEASE. 

Definition. — Acute  dilVuse  nephritis,  due  to  the  action  of  cohl  nr  of 
toxic  agents  upon  the  kidiU'ys. 

In  all  instances  changes  exist  in  the  ejiithelial,  vascular,  and  inter- 
tuliular  tissues,  which  vary  in  intensity  in  dilVereiit  forms;  hence  writers 
liave  described  a  tubular,  a  glomerular,  and  an  acuti'  interstitial  nephritis. 
Delaiield  recognizes  anilr  c.nnhittvf  and  acuh'  jfrndurliir  birnis,  the  latter 
characterized  by  ])rolifi'ration  of  the  connective-ti.~siie  stroma  and  of  the 
cells  of  the  ^Malpighian  tufts. 

Etiology. — The  following  are  the  jirincipal  causes  of  acute  nephritis: 

(1)  Cold.  Exposure  to  cold  and  wet  is  oiu'  of  the  most  common  causes. 
It  is  particularly  jirone  to  follow  exposure  after  a  drinking-bout. 

(V')  The  poisons  of  the  siiecitic  fevers,  particularly  scarlet  fever,  less 
conimonly  typhoid  fever,  measles,  diphtheria,  small-pox,  chicken-pox,  ma- 
laria, cholera,  yellow  fever,  meningitis,  and,  very  rarely,  dysentery.  As 
already  mentioned,  acute  nephritis  may  be  associated  with  syphilis.  In 
acute  "tuberculosis  nephritis  is  not  uncommon.  It  may  also  occur  in  seji- 
ticaMiiia.  The  frcipiency  of  acute  nephritis  in  malaria  has  been  emithasized 
hy  Tliaver  in  a  recent  analysis  of  the  cases  at  the  Johns  Hopkins  Ho,-iiilal. 
Among  'i.f'.Vi  cases  there  were  'iCt  of  uephritis. 

(3)  Toxic  agents,  such  as  turpentine,  cantharidcs.  chlorate  of  potash, 
ami  carbolic  acid  may  cause  an  acute  congestion  which  sfunetimes  terminates 
in  ncjihritis.     Aleohol  probably  never  excites  an  acute  nephritis. 

(4)  Pregnancy,  in  which  the  eomlition  is  thought  by  soiiu'  to  result 
from  eonipression  of  the  renal  veins,  although  this  is  not  yet  dually  settled. 
The  condition  may  in  reality  be  due  to  toxic  products  as  yet  undetermined. 

(5)  Acute  uephritis  occurs  occasionally  in  c<mnectiou  with  extensive 
lesions  of  the  skin,  as  in  burns  or  in  chronic  skin-diseases. 

Morbid  Anatomy.— The  kidneys  may  lu-eseut  to  the  naked  eye  in 
mild  t'ases  no  evident  alterations.     When  seen  early  in  more  severe  forms 


^^b 


A\ 


DISEASES  OF  THE   KIDNEYS. 

it-rzla"r;:;.r-:%i'':""U ,a  .,„.,m;  .  .„.. 

The  l.isl.aooy  nuiy  ''^'/''"V  u   t..  tox  c  n-cnts  ^vlm•ll  vouch  the 

kid.u.y  through  Iho  '''"'t^^'^';  ;:;,1^\  "    j;  ,,  the  cai-iHari..  become  lllle. 
an  acute  intracavillavy  ,loiuc>u    t  ^   --  lj.^_^_^  ^^^  ^,,^.  ^.f,  ,„. 

-tl>  -'nsanathron,!.    or  n,  nu'.     n         th      ,^^^.^^     ^^^^^^^^^^.^^,^  ^^,^^,        , 

,.,.   i.„,,„„r.  cap^uU.,  the  -'^ '  /^"   ;  ^1,,  ,,,>tent.  a.vl  of  the  walU 

hh.oa-cov,u.cles.       lynluK  ^^•^^■'     ■'  ^  1^    ',,;  ,,„„„„„  evenv.     The.e  yro- 

s;s;;it:ir:x;H;"S"'"" ■•■- ■ ""^ 

,tvuelui-es  iK'yon.l  them.  ,,,itlu.liuiu  c.nsist  in  eh.iuly  svvellin-. 

(,,)  The  alteration,  .nthetnl.nl  tin  ^,^^.„,„t,a  t^hnle.,  the 

fatty  change,  and  hyaljne  ;^^--        ;,^.,^     l,,  hloo.Vconn.cU.s  causes 
accumulation  of  altered  cell.  ^^ ^ ^^   ^       '  f   ,,,i,^.      niu-lial  cells  lo.e  the.r 

'•-l:^-nterstitial  changes      in  the  mild.  ...s  .^;i;^^ 
oxudate-sevun>  uuxed   .uh   leucoc>    ^  and^J.  I    ^_^^^^,,_^,^„^„^   .,,,iu,ation 
between  the  tuhules.      In   J^™  ,^,  ;\,,,  ;,„„,:„u>tea  tnhes.    Those  changes 

r^^':il^;^litrum^         -  --  -  --  '^^'- 

'•.-...  -  .  •  .  .    i.;..n 


,,.  certain  regions.  julcrslilial  nephrili.^  occurring  chictly 

,ic.,l  to  the  kidneys  in  the  l.lood  current  ^^^^^  ^^^^^  ^^^,j,,^,.ti, 

Symptoms.-The  onset  ,s  ^^"•'  .;';;., ,,bours.  After  fevers 
UaJ.  cold,  dropsy  ,  y  he  -'^'-^^^^^  ^  ^^  becomes  pale  and  a  nuHi- 
,,„  „,,,t  i.  less  ahrup,  hut  ^  -  F  k^  P  '  ^^^.^^,_  j^  ,,,ndren  then> 
ncss  of  the  face  or  swell.ng  ot  the  '^'''^,  '  .^  ,^^.  ^.„^,,  i,,itiate  the  attack 
„ay  at  the  outsc^  he  -nvds.^s  >  -  ^;^  ,^^^;,,^,.  ,,,  ,,,„i,ing  n.ay 
i„  ,  ii,„ited  uuiuher  of  oase^.    T.  m  in  t m  ^^^^^^^^  ^^^^^  ^^^^  ^,^^^.  ,,^ 

,,,  present.     The  fever  -,-^;^^^^.,j^'       ,,     ,;,  f,..nn  cold  or  scarlet  fever 
tcnperature.     In  youug  ^■'";'^'^'  \    '^^     ,   '    ,„,  ^.r  to  KK^. 
the  len>l.orature  )uay.  for  a  few  '^>-'*";^\  ;;,;„,,,,  changes.    There  mnv 
.Pln'most  characteristic  ^.V'-H't-Hns  au  the  u    ,     >  ^.,,,„^^„^ 

at  iirst  he  sn,.pvossion;  more  ">7;";  ^^^^  /"Th^'.^antity  is  reduced  ami 
a„d  contains  hlood,  alhumm,  and  f^'^^J'U  hours;  the  spociiic 
^„ly  4  or  5  ounces  may  he  passed  m  the  lutnij 


ACl'TK   liKlCIlTS   DISKASH. 


871 


p  lilooil. 

trips  (itV 
)!•,  wliiK' 
SiiUU'    iii- 

iu  ulh'T 

iK(..<.     In 
reach  tiu- 

iri  oitlu'V 
)nie  I'llU'il 

ti\t'l  aiul 

and    n'll 

tlio  WiiU-^ 
."hose  pn>- 

0  may  he 
■  with  the 
Ik'  tul)ul;-.r 

V  swell in;j;. 
"iliuU's,  tlu' 
cU's  causrs 
s  lose  tlu'ir 
aciuimilate 

tlaininattiry 
:ck'S— exists 
inliltmtion 
loso  changes 
lore  intense 

rring  ehietly 
Is  similiir  tn 
ese  cells  are 
and  are  ear- 
he  nephritis 
After  fevers 

1  and  a  nniri- 
liildren  there 
te  the  attaek 
koniitin,^  may 
ive  no  rise  in 
•  t^earlel  I'ever 

;.  There  niav 
liohly  colored. 
is  rednced  and 
■s;  the  specific 


gravity  is  liigli — \.()2'k  or  ev(  n  nmic;  the  color  varies  i'nini  a  smoky  to  a 
(iei'p  iiortcr  color,  1ml  is  seliloni  hriglit  red.  (Mi  standing  there  is  a  heavy 
deposit;  microscopically  there  are  hlood-corpnscles,  epithelinm  from  the 
nriiiary  i)a>sages,  and  hyaline,  hlood,  and  epithelial  tnhe-ca>ts.  The  alhu- 
min  is  ahiindant.  fonning  a  curdy,  thick  precipitate.  The  total  i',\cr(  lion 
of  urea  is  reduced,  thoujih  the  percentage  i.-  high. 

Ana'una  is  an  early  and  marked  syinptoni.  in  cases  of  exten-ivi'  drop  y, 
ell'usioii  may  take  place  into  the  pleura'  and  peritoiucum.  'I'here  are  ca.-es 
of  scarlatinal  nephritis  in  which  the  di'opsy  of  the  (Wticmities  is  trivial  and 
clfusiou  into  the  pleura'  I'.xtcnsive.  The  lungs  may  heeome  (edematou>.  In 
rare  cases  there  is  (edema  of  the  glottis,  l-lpistaxis  may  ot'cur  or  cutaneous 
ecchymoses  may  devcloj)  in  the  course  of  the  disease. 

The  lailse  may  he  hard,  the  tension  increased,  and  the  second  souiul 
in  the  aortic  area  accentuated.  Occasionally  dilatation  of  the  heart  coiiu'S 
on  rajudly  and  nuiy  cause  sndih'ii  death  (iioodhart ).  'i"he  skin  is  dry  and 
it  may  lie  dillicult  to  induce  sweating. 

I'ra'mic  symptoms  develop  in  a  limited  numher  of  cases.  They  may 
occur  at  the  onset  with  suppression,  more  cominoidy  later  in  the  disease. 
Ocular  changes  are  imt  so  coninmn  in  acute  as  in  chronic  Uright's  disease, 
hut  luemorrhagic  retinitis  may  occur  ami  occasionally  pajiillilis. 

The  course  of  acute  liri.uht's  disease  varies  considerahly.  The  descri])- 
tion  just  given  is  of  the  fomi  which  most  conimoidy  follows  cold  or  st'arlet 
fi'ver.  In  many  of  the  fehrile  cases  diojisy  is  not  a  prominent  symptom, 
and  the  diagnosis  rests  rather  with  the  examination  of  the  in'inc.  More- 
over, the  condition  may  he  transient  and  less  seri(ms.  In  other  cases,  as 
in  the  acute  nephritis  nf  typhoid  fever,  there  may  he  haanaturia  and  ])ro- 
nounced  signs  of  interference  with  the  renal  function.  The  most  inten,-e 
acnle  ne])hritis  may  exist  without  anasarca. 

In  scarlatinal  ne|)hritis,  in  which  the  o;lomeruli  are  most  sei'iously  af- 
fected, su])i)ression  of  the  urine  may  he  an  early  symptom,  the  dropsy  is 
apt  to  he  extreme,  and  nra-nhc  manifestations  are  common.  Acute  liright's 
disease  in  children,  however,  may  set  in  very  insidiously  and  he  a-^sociated 
with  transient  or  slight  redema,  and  the  symptoms  may  i»oint  rather  to 
all'ection  of  the  digestive  system  or  to  hrain-disease. 

Diagnosis. — Tt  is  very  important  to  liear  in  mind  that  the  most  seri- 
ous involvement  of  the  kidneys  may  he  manifested  only  hy  slight  fcdemii 
of  the  feet  or  imfriness  of  the  eyelids,  without  imi)airment  of  the  general 
health.  The  first  indication  of  tniuhle  may  lie  a  nra-mic  ccmvulsion.  This 
is  particularly  the  case  in  the  acute  nephritis  of  jiregnancy,  and  it  is  a  good 
rule  for  the  practitioner,  when  engaged  to  attend  a  case,  invariahly  to  ask 
that  during  tlie  seventh  and  eighth  months  the  urine  should  occasionally 
he  sent  for  examination. 

Tn  nephritis  from  cold  and  in  scarlet  fever  the  symjifoms  are  nsiudly 
marked  and  tlie  diagnosis  is  rarely  in  doulit.  As  already  mentioned,  every 
case  in  which  alhnmin  is  present  must  not  he  called  acute  llright's  disease, 
not  even  if  tuhc-easts  he  present.  Thus  the  common  fehrile  nlhnminuria. 
although  it  re])res(>nts  the  first  link  in  tln^  chain  of  events  leading  to  acute 
r.rirrht's  disease,  should  not  he  i)laced  in  the  same  category. 


^■^ 


DISEASES  OF  THE  KIDNEYS. 

«''^^"'^"'t;:::;  ;r;:  -:i"v';-;;,:;i. ?  >■ -;» •■'  ^" ^ 

,.,,niluu)ii.      lul.t-ia.i.   ->>  ,.,.,:.  i„,  ivaueed  in  amount. 

.•an.ly  Frnuuu..>t.    ''--;';;;  '^j^  ,\r  in  the  diagnosi.  of  tl>o  lonn  o 

liright's  .li..as.,  Uut  ^can.  >   '•  1^     j^^ '.„„„,,„  to  all  variotios.     The 

T,u.,  the  i'y:^;-'.,-;  ,j;r'     ;    c     arlv  th..e  nuulc  up  o^  leucocyte,  are 
bl.M.d  and  eintlu'lial  ca>  ..  Imu 

luo.t  eonunon  in  tlie  acute  |''^;;^;  ,„„„,,,h;U  witli  the  cause  of  the  dis- 

PrognOSis.-ri.e  outlook  ;^'\:;  ";„,,,,  t.,  e.dd  are  niuch  more 

i-4U-t  than  aner  ^^^^^f^^^'^;^';,  ^L  ^.^^.  Serious  .ynn>l...- 
i,  high,  a.nounling  to  at  -^^^  .^  ,  .'^'.^  ,,,,,„ia,  and  elVusiou  into  the 
„,,  U  arterial  t-'-'"'  ^'>^V  u  drop.'  alter  the  iir.t  n>onth,  mten.e 
,.vous  sacs.  The  l-''^'^^^^'^','-!  plicate  the  possihilitv  ot  the  d,s- 
and  a  large  —j^^f ;:,;;,  ,rt.r  the  disappearance  oi  the 
,,sc  hccoming  chrome.  1  '"  '>^  ;  ^„„i  ,  f,nv  tube-casts, 
aropsy  there  may  he  t-ces  ot     1  urn      ^  .^^  .^  ^^^^  , 

In  a  week  or  ten  da>^,  m  ;^    '^^     ;;,,.„^  .^,,,^,,,,  the  alhunnn  lessens, 
i.  fav..ralde,  the  dropsy  dumn.^.esun  ,^,,j  ^,„,,  ^,„  ,„,,ne  is 

,,a  hy  the  end  ol  a  -'-"^ /,  ^^.^  ^^f^.^eou  le  niy  he  rapid,  and  I  have 
„,arlv  free.     In  very  .V';'i>.^/'"'*1  ,  i„  ,,,,  f.,,;,.th  week.     Other  cases 

^nown  the  urine  to  he  free  i7";\^  ;.',,,  disappear,  the  alhuniin  per- 
a  ;  „H>re  insidious,  and  ^1>-'?'^,    '  ^  ^    ,  '  Ke  condition  hecomes  chrome, 

^^^T;^:Snent.-The  ptient  ..^^^^^^^^ 

,11  traces  of  the  disease  have  '  -    '       ^'^    ^^^j,,,,  ,,  ..custom  the  patient 
portant  part  in  the  treatment     t       v     hi  ^^^^^^^^^.^ 

o  hlankets.    He  shmdd  ^^^^    ^  "  Zter-milk,  gruels  made  of  arrcnv- 
Tho  diet  should  consis    ot   ^\^l^^^^^^,, ^  ,,,,f  tea  and  chicken  hroth. 

begmdual.  ,,1-1    .,,        of  alkaline  mineral  waters,  ordinary 

The  patient  should  '1'''"1^/Y  o  1  h  nev-  Hushed  and  wash  out  the 

,vatl  oAemonade.    The  ^^^Z^t^tn^.l  of  cream  of  tartar  in  a 

^jfj,.i,  from  the  tubes.    A  ^  ,  "    '  .'      ^ided     le  iuico  of  half  a  lemon  and 

a  little  sugar,     iakenwncu 

(hilt  the  iintm-al  |.roocp.(;>  m.i>   "^    >' 
the  8jml<t»"«  "^  "'"J  "'"'■ 


ACITK   nillGIlTS   DISl'lASE. 


87:? 


IC'il.    Ill 

ii  liue 

nniu  is 

I'onn  of 

sUUod. 

s.     The 

:toH,  are 

tlio  (lis- 
(.:li  more 
uortality 
viuptoms 
into  the 
,  intense 
:  the  dis- 
co of  the 

;  progress 
n\  lessens, 
e  urine  is 
nd  I  liavc 
ithcr  cases 
inniin  per- 
L'ri  chronic, 
:e  recovi'ry 

main  until 
II ch  an  im- 
the  patient 

0  of  arrow- 
ckcn  broth, 
k  diet.     As 

rcss,  grapes, 
diet  should 

rs,  ordinary 
vash  out  the 
f  tartar  in  a 
a  lemon  and 
?tory  diluent 

OS  whieli  are 
[he  excretory 
s,  in  the  hope 
;  (2)  to  meet 


111  a  ciisc  of  scarlet  fever  it  may  occasiimally  lie  possihle  to  avert  an 
attack,  the  preiiKinitory  symptoms  of  whieii  are  marked  increase  in  the 
tiiterial  teii.-ion  and  tlie  presence  of  lilood  coloring  matter  in  the  nrine 
(Mahomi'd;.  An  active  saline  cathartic  may  com|iletely  relieve  this  con- 
dition. 

At  the  onset,  when  there  is  pain  in  the  hack  or  ha'inatnria.  the  ra(|iielin 
cauterv  or  the  dry  or  wet  cups  give  relief.  The  last  should  not  he  ii>ed 
111  childrcii.  Warm  |iniil(ices  are  often  grateful.  In  cases  which  set  in 
with  sii|p|iiession  (d'  urine,  these  iiuMsui'es  should  he  adopted,  and  in  addi- 
tion the  iiot  hath  with  siiliseipiciit  pack,  copious  diluents,  and  a  free  [lurge. 
The  dropsy  is  hest  treated  liy  hydrotherapy — cither  the  hot  hath,  the  wet 
pack,  or  tlie  hot-air  hath,  in  children  the  wet  pack  is  usually  satisfactiu'y. 
it  is  applied  hy  wringing  a  hlanket  out  of  hot  wat(.'r,  wrapping  the  child 
in  it,  covering  "this  with  a  dry  hlanket,  and  then  with  a  ruhhcr  cloth.  In 
this  the  child  may  remain  for  an  hour.  It  may  he  n-peated  daily.  In  the 
case  of  adults,  the  hot-air  hath  or  the  vajior  hath  may  he  conveniently  given 
l,y  allowing  the  vapor  or  air  to  jmss  from  a  funnel  heiicath  the  hed-clothes, 
w'hich  are  raised  on  a  h<\v  cradle.  IMore  ellicicnt,  as  a  rule,  is  a  hot  hath  of 
from  (iftcen  or  twt'uty  minutes,  after  which  the  patient  is  \vra})ped  in 
hlankcts.  'i'he  sweating  produced  hy  tliese  measures  is  usually  profuse, 
rarely  exhausting,  and  in  a  majority  of  cases  the  dropsy  can  in  this  way  he 
relieved,  'i'here  are  some  cases,  however,  in  which  the  skin  does  not  re- 
s])oud  to  the  hatlis,  and  if  the  symptoms  are  serious,  jiarlicularly  if  ura'Uiia 
supervenes,  jahoranili  or  its  active  principle,  pilocarpine,  may  be  used. 
The  latter  may  he  given  hypodermically,  in  doses  of  from  a  sixth  to  an 
eighth  of  a  grain  in  adults,  and  from  a  twentieth  to  a  twelfth  of  a  graiti  in 
children  from  two  to  ten  years. 

The  bowels  should  he  kejit  open  by  a  morning  saline  purge;  in  children 
the  fluid  magnesia  is  readily  taken;  in  adults  the  sul[)hate  of  magnesia  may 
be  given  by  Hay's  method,  .u  concentrated  form,  in  the  morning,  before 
anything  is  taken  into  the  stomach.  In  ISright's  disease  it  not  infre(|uently 
causes  vomiting.  The  comixmnd  powder  of  jalap,  in  half-drachm  doses, 
or,  if  necessary,  elatcrium  may  bo  used.  If  the  dropsy  is  not  extreme,  the 
urine  not  very  concentrated,  and  ura'inic  symptoms  are  not  present,  the 
bowels  should  be  kejit  loose  without  active  })urgation.  If  these  measures 
fiil  to  reduce  the  dropsy  and  it  has  become  extreme,  the  skin  may  he  punc- 
tured with  a  lancet  or  drained  by  a  small  silver  canuhi  (Southey's  tube), 
which  is  inserted  beneath  it.  A  fiiu)  asjiirator  needle  may  be  used,  and  the 
fluid  allowed  to  drain  through  a  i)iece  of  long,  narrow  ruhhcr  tubing  into 
a  vessel  lienenth  the  bed.  If  the  (lys|)no>a  is  marked,  owing  to  ]iressur(>  of 
fluid  in  the  iileura\  asjjiration  should  be  performed.  In  rare  instaiu'cs  the 
nscitcs  is  extreme  and  may  reipiiie  paracentesis,  or  a  Southey's  tube  may 
be  inserted  and  the  fluid  gradually  withdrawn.  If  ura'tnic  convulsions 
occur,  the  intensity  of  the  paroxysms  may  be  limited  by  the  use  of  chloro- 
bu'in;  to  an  adult  a  pilot^ariiiiie  inj(>ctii)n  should  he  at  once  given,  and 
from  a  robust,  strong  man  '-.'O  ounces  (d'  blood  may  he  withdrawn.  In  chil- 
dren the  loins  may  be  dry  cupped,  the  Avet  pack  used,  and  a  brisk  imrgativc 
given.  Bromide  of  potassium  and  chloral  sometimes  jirove  n.seful. 
54 


DISEASKS  OF  THH   KIDN'KYS. 

l,,r  tl.o  persistent  f  •"">;';'";, ':",,,,.  Nothi.,^^  in.li.at.s  ,no,v 
U,at  ^ve  l.avo  no  rcMnedy  ol  ^l/^^ '^r^^^: ',,,,, .olisn.  than  inal,ility  to 
,,,,rly  our  helpless,.oss  .n  ^•'''>'^"  '^^';'  "  j^alies,  nit.'o,ly.c.,in.  and  n...- 
„„,,t  tl.is  con.nion  symptom.    Astiin^.  nt. , 

eury  Lave  been  ""•"'"">';":  ^';.,^^.„i  ,,;„,  ,,,„.  Unj^ht's  .lisease  iron  sl,o..l.l 
For  the  amemia  always  asMHiat.d  \Min  ^vmntoms  have  suh- 

he  e...ploye.i.     It  shouUl  ->*  he  ,.ve,.  un  ->->     1_.^.,^,,,^.,^  ,    • 

,Ule.l.    in  the  mlnlt  .t  n.ay  he  ''>        ;  ^^'^   '  ,,  ^.,,i,.,,,,,.  t,,,  syrnp  of  the 

creasing  doses,  '^V""'     "Tllu-  H  phate  of  ii'o..  a.-e  better  preparat.ons 

iodide  ..n.-on  or  the  syrnp  ol  tlu     h  p..  ^_^^_  ^^^.  .^.^^^^  ^^^  ,^„^„^.y 

Tyson  has  recently  ..r,e     e,u.  .o     >       h    io  ^^  .^^^  ^,^^^^^  ^^,„^^,,^„^. 

diVease.    The  ddatation  ol  the  iuail  .s 

thus,  and  stryehnia.  .     ^i^,.,„,.^  ,,,,,.  should  be  taken 

In  the  (.o..valeseeneo  f  ron.  a    .b  I,-        ^^^^^^^^^^  ^^.,j  ^„„,^i,t  ,,,  ,ny  of 

to  .n.ard  the  patient  aga.ns    e ol d .  ^^^^^^^^_^^^      ^^  ^.j,,,,^.,,  ,^  ,„•  ^s 

Vll.    CHRONIC    BRIGHT'S    DISEASE. 

1    ,1   with  a  dilTuse  proeess.  involving  epi- 

Uoro,  too,  in  all  lorms  -  ;^^>^  ^^  "(,i„i.allv  two  groups  are  reeo,- 

„,,liM.  inte..litiaU  a..d  ^'^^"^      i^ ,    ,,  ^  n^^hvitis,  whieh  follows  the  aeute 

ni,ed-(rO  the  .•hron.e  y^'^^'^'^^^^JJ^.a  by  marked  dn.psy,  a..d  y^i 

..itack  or  oon.es  on  i"'^>'l'<'^"^'>' ""''''',.   i.tei-ta-^es  of  this  proeess  the 

1  .ton,  by  the  lar.e  vMe  ^''''^J^^^^t\\^ sn,all  vlul^'  ^-""7/:  (") 

,i,„,v  ...ay  be  --''l^Vr' in  1.  W^^  ""^  — ""  ^"'  '''  ^t' 

,,„,,„•,  interstitial  ,.ephrd,s,,nwhul...  .^^^  ,  ,i,,on.c  d.ll..se 

vas..,lar  ehanges  -'Vl'-^^*;;;;7  i,,^    ''     ,  ...live  diffuse  nepimtis  w.tl. 
n,phritis  with  ex..dat.o..  a.,d  ^^  ^^^^.^  eontraeted  kidney  of  a..tl.ors. 

ouoxudation,  the  latter  oor..esnd,gto^^  ^^^  .^^.^,^,^,^,,. 

of  nephritis. 


CIIUuNlC   Bi.I(.ilIT-.S  DlaKAbK. 


875 


1'  fuiul. 

•  dilulf 

not  yt't 
1  irci'ly 

lu'ltl    t'» 

isily  t'x- 
ics,  and 
the  cur- 
ls I'roni 

isiMistcin 
l(S  nimv 
ihility  to 

iUul    llli'l'- 

)ii  climild 
luivo  sid>- 
ide  in  in- 
ip  of  the 
jiarations. 
in  kidnoy 
gtroplian- 

l  111'  taken 
chiotly  t)l' 
0  of  ail'  ii^ 
late. 


olving  opi- 
s  art'  rt'coo;- 
s  the  acute 
^y,  and  ]Hi>t 
process  the 
l-idiinj:  (h) 
1  thocardio- 
•onic  dilVusc 
|)hritis  with- 
V  of  authors. 
'r,ri<.dit"s  di>- 
nv  any  form 


CiiitoNic  I'AiiKM  iivM  \rors  N'lM'iim  ris 

(Chriinic  Dcsijiinmiilin:  ami  Chniuic  'J'hIkiI  Xrp/irili^;  Chninic  Diijiim'  Xi iihrilin  irilU 

K.iH(lnliiiii). 

Etiology. —  In  many  cases  tlic  di-rasc  fullnus  the  miite  nephritis  of 
(lild,  scarli'l  lever,  or  iin^naney.  !More  lre(|ueiilly  than  is  ii-iiaily  slated 
llie  disease  lias  an  iii>idioiis  onset  ami  occurs  iiideiicmlciitiy  of  any  acute 
attack.  The  levers  may  play  an  im|)ortaiit  ridi'  in  certain  of  these  cases. 
IJosenstciu,  llartels.  and,  in  this  country.  1.  \\.  .Vlkinnm  and  ThaNcr  have 
hud  t^pecial  stress  iiiioii  malaria  as  a  caii;-e.  lieer  ami  alcohol  are  helieved 
to  load  to  this  form  of  nephritis,  in  chroiue  suppuration.  >yiiliilis,  and 
tul)ercnk)sis  the  (liU'u.-e  parenchymatim.^  nephritis  i-  not  uiiiummon,  and  is 
usually  associated  with  amyloid  diseasi'.  .Males  are  rather  more  .-uiijeet  to 
the  alfection  than  I'einales.  it  is  met  with  mo>i  ccnnmonly  in  younu  adults, 
and  is  hy  no  means  inrreipient  in  children  as  a  siMpieiice  (d'  scarlatinal 
neiihrilis. 

Morbid  Anatomy. — Several  varieties  ui'  this  I'orni  have  heeii  reco;^- 
ni/.ed.  The  most  common  is  the  htnjr  irliilv  Icldnci/  id'  Wilk>.  in  which  the 
or^iiin  is  enlarj^ed.  the  capside  is  thin,  and  the  surface  white  with  the  stellate 
veins  injected.  On  section  the  cortex  is  swollen  and  yellowish  white 
in  ciilor,  and  often  presi'iits  opacpie  areas.  Tln'  pyramids  may  he  deeply 
congested.  On  microscopical  examination  it  is  seen  that  the  epithelium 
is  yranidar  aiul  hitty,  and  the  tuhules  of  the  cortex  -.wv  disteniled,  and  con- 
tain tuhe-casts.  Hyaline  ehanj:es  are  also  present  in  the  epithelial  cells, 
'i'lio  glomernli  are  large,  the  capsules  thickened,  the  capillaries  show  hyaline 
changes,  and  the  e|iitlieliinn  of  the  tuft  and  of  the  caii>ule  is  exlt'nsively 
altered.  The  interslitial  tissue  i:?  everywhere  increased,  though  not  to  an 
extreme  degree. 

"■J'he  second  variety  of  this  form  residts  from  the  gradual  increase  in 
the  connective  tissue  and  the  snhsecpient  shrinkage,  forming  what  is  called 
the  small  white  Indiici/  or  the  pale  granular  kidney.  It  is  douhtful  wlu'thcr 
this  is  always  preceded  hy  the  large  white  kidney.  Some  ohservers  hold 
that  it  may  he  a  primary  independent  form.  The  capsule  is  thickened  and 
the  surface  is  rough  and  granular.  On  section  the  rosi.stance  is  greatly 
increased,  the  cortex  is  reduced  and  presents  nmnerous  opaipie  white  nv 
whitish-yellow  foci,  consisting  of  accumulations  of  fatty  epithelium  in  the 
convoluted  tuhules.  This  eondiination  of  contracted  kidney  with  the  areas 
of  marked  fatty  degeneration  has  given  the  name  of  small  granular,  fatty 
kidney  to  this  form.  The  interstitial  changes  are  marked,  many  of  the 
glomeruli  are  destroyed,  the  degeneration  (d'  epithelium  in  the  convoluted 
tuhules  is  widespread,  ami  the  arteries  are  greatly  thickened. 

I'lelonging  to  this  ■hronic  tuhal  neiihritis  is  a  variety  known  as  the 
rhrmtic  lu(in(irrlm<i\c  urjihrHix,  in  which  the  organs  are  eidarged,  yellowish 
white  in  color,  and  in  the  cortex  are  many  hrowiush-reil  areas,  due  to  luemor- 
rhage  into  and  ahout  the  tuhes.  In  other  ri'spects  the  changes  are  identical 
with  those  in  the  large  white  kidney. 

Of  changes  in  the  other  organs  the  most  marked  are  thickening  of  the 
lilood-vessels  and  hypertro]ihy  of  the  left  heart.     ' 


daA 


DISKASHS  OF  TIIH   KIDNKYS. 

in  a  .nu.l,lir,l  u..>.  tlu.  sv,ui4u..>>        th  ^^  ^^_  ^  ^^^,  ^,^.,.       ,^^,^_„j, 

in  in.uliously,  and  alter  an  atta rk  of        l-       '  ^  ^^  ^  j.  ^,^^,       ,j;,,^ 

„„,llo.sot'.triM,-tl.  tlu.  patu'nt  l.rmm;.-.  l-aU  .  a.ul   i 

,„„„i,y,'on;.n  scanty.  It  !>-  a  "^»^-;;;''  ;„:',„,,  ,;,,i„,..Mt  falls 
il  ,url.ia  frn,n  th.  ,n.s..n.c  ''^  ;>;;;  ';:;^,  '  ^^  ^  ^  .i  ,,.s  an.l  .iz.s,  hyalino. 
i,,  ^vhi(•h  a.T  l'..nn(i  min.rn.us  tnla-c^t      1         '  l,.,u.,H.yt..^  arc 

,„,U  lar,.  a.nl  s.nall,  ^^MM,  ^-";;'''  '      ^^         \  ;  ,,  ,„.,  .,.iUu.lium 

"'•"-1-'^  -'  '•^•""V""'ir"'"'n:a  Xnnlan,  and  n,ay  amount 

r,nm  tin.  kidm-ys  and  i-rUc..      I  In   ""  '"      ,      ,     ;,  ,„„,,  ,,l,„ndant  in  tlu' 
to  on.  hair  or  on.  third  ol  llu;  urnu.        '     ;       .       J  ',,  ,  •  ,,  „  ,„.  early 

.,,,..,.Lfv„,u  1.0-iO  to  l.(fj:.-lh"uj;h  in  tlu  lat^r  .la, 
,„,^i  is  always  r.duml  in  .inantity.  „,.  „,•,,  ,•„,„,  ol'  r.ri-hfs 

,„,,,.v  is  a   .narkod  and  ol.tn  at.  ^>  "     ^  ;^,,,     V,,,,  ,,,,  ,v..lids  ar. 

..,.U,„at..ns.    Th.  a,>asarca  is  f^^"""'' ';  -^  '  ,        ,,,;,.,  Uidn.y  th.ro 

U„.  fr.<in.nt  than  in  th.  int.rstitnd  ";;i^';;  '■•    ^^.,^.  „„.  ,.„„,,,  „llimat.ly 

Th.  tension  of  th.  ruls.   .s  ->'^   >    '"^   ; ,    ^       ,,,,  „•.  instan..s  of 

,H.con.o  stiff  and  th.  ''--^  '>yp.rtro,  u  d     H.  tl  ,  ^^^^,.^.^.  ^^,.,,„.^ 

sound  is  a.c.ntuat.d.     K.  inal  .  nan  /]     ^  ^    ,unnh.r  of  .as.s. 

ehnnue  int.rstitial  -^In'^-s    -u^ur  n       c     m  UtM_,^^^^  .^  ^^^^^^^^^^^^^   ^ 

CJastro-int.st,nal  synii-t.-n'^  .'''';',,.,, ^,,,  ,„,,.  ,,.  profu...     n..ra- 
,listr.ssin,r  and  sc.rions  synn-t-mu  '^'^  \;>:;      '^' "        ^ 

tion  of  th.  .ohm  n,ay  •"-"[;"•;    ';;:;;,^,:  evo.i  l«v  the  n..st  careful  ox- 
It  is  sometimes  imposs,  de  to  f' '  ^   I''    '  ',,.,^„,t;,n.,  xvh.lh.r  the  eon- 
,,,,UvMon  of  the  ^^^^' ^  ^^y  ^^^''^    Avhite  or  of  the  snrall  ^vhite  form, 
.lilion  of  th.  kidney  is  that  ot  tnc  ^^^^^^  ^^^^^^^^  ^^..^^^  ^,^^,  ,,v<^>iressiv.> 

In  cases,  however,  \vhieh  liayo  la^  ^^^^  ^^^^_  eardio-vas.nlar  chan-es,  the 

increase  in  the  renal  connect  •       ,e<nocts,  that  of  the  contra.t.'d 

,li„ic.al  vi''tin-e  may  appr.  .,,  ^^  .''     ..ific  <rravilv.    It  is  often  tnrhid. 

,,i,1,,,v.    The  urnte  ,s  ,ncM-eu         "j    ^^     ^  ,^,^  ^„;  „„i,.,,.,.  and   of  every 

-  ;;:r;:rr  d  i:t;;h;::^^^^^^^ 

;esent,thou,hnotsoc.tensKoas^n.th     ab^a^^^         ^_^^^ 

The  rmjnns,^  is  extrenielv  ^™;  ,    /  ,  ■,,,,„,  ;,  caused  either  hy 

,,ore  than  a  year  rcnnery  ^^;f\'^^;'^,.,,,^,,  or  hv  secondary  inilam- 
,,.e,.t  efTusion  with  -'^--^^^  ^^  ^"^f;,X-n  children,  even  .hen  the 
;;-;,;:  t';:::ZZt:^^^r:X  ^y-n^toms  disappear  and  recovcrv 
t;^,kcs  i^lacc. 


(.IIUONIC    UKKIHT-S   DISKASK. 


877 


Sl'I*    it    SL't> 

in^'  liciillh 
111.'  I'yi-'li'l- 

inishcd  in 
col'iv,  niiil 
iiK'Ml  riiU-. 
s,  liyiiliiK', 
cdcytts  i\i\ 
(.pillu'limn 
my  iiuioiilit 
hint  in  the 
11  iho  oarly 

(iWiT.      'I'llt' 

,,!■  r.ri.iihl's 
cy dills  iiri" 
iiiciil  of  tlu" 
viiliH'y  tln'io 
s  imsty,  tlu' 
is  ]u'ciiliiuly 
art'  iicrliiii'- 

<  iiUimatcly 
iustaiu'i's  (if 
iiortic  socDinl 
than  in  thi- 
(»r  cases, 
i'rciiurntly  a 
,,,('.     riccra- 

st  careful  ox- 
tluT  the  cnn- 
,1  wliite  form, 
lie  i)ro,!iressivt^ 
r  I'lianp's.  llie 
lu'  eontraeleil 
s  ofien  tnrUitl. 
iuitl  of  every 
)psy  is  usuany 

s  iiersistod  for 
used  either  l>y 
ondary  iiiflam- 
oven  when  the 
r  and  recovery 


,  suue  tivatnieiil  sliould  ho  earned  ou    a. 

>te  i;n,difs  diM.a.e.     Mi  k  o         t  ,,^.,,.,„,.,,„,,.     l,„i,  i.vi- 

,  of  f I     'H'"  'I'-l-.V  ^'""1''  ''!   *""      \  .  ,,,;, „i,,       I,  i.  lo  he  reiiu'in- 

,     -rv.,u  Hunks  thai  th     ...     -    ;'  ^^^.^^^^  „„,  ,,,„,vtn. 


in  aen 
arlieli 
aratio 

ll'„';l  T;>....  timiks  iiu,.  \";  ;':;;,;;,:;;;:';,r,,,,,,,,i,.  .ii.„.,iis.  ,„.i  .li...",,. 

!;::::l;:-;;;,,';;::.;:u-w:':n,n,,...  ..^ ■.,..„...■.....,...... 

„,■  water  N^Ul  he  found  heueheiah 


{C'Oilnutid   Ki'lm-u , 


^HKONH'    INT1:1!ST1T1A1,    XKl'lllMTrS 

anuud.r   lud,.y:   CirrhoxU  of  II.   Kuln.i;. 
Jic):«l  SdiroaiK). 


(luiilij   h'iilni-ij ; 


s,w„,s.  ,.n,„.  .<..in..v  i. -t  »i.i,  w :-. -'i-r-'- -  !^- 1:'?;:::;!::!'' 


-m   many   re>iiea> 


,i.,,l„rly  h.  .■unjmutum  »  '  ."  ".'   ,„„,  ,„„„„,„„,  .„„l  i      " 

,„.  „.„„„■,■  .hn...  i;;;^^  ;,,;„,„ ,,,;„,,.„., i„ „.c„i,..i, ^ s..-  .. 


leheve. 
1k- 

OUt 


rials  i 

irritate  the  kidneys  (.o,nn,on  can^e  of  interstitial  ne- 

Aetual  ^-ut,  wlueh  ^n  Knula.  n  ^^^^^  ^^^^^^^^^  ^^^^^ 

,.l„.itis,  is  n..t  an  inn-rtan    1-  -  '> ;    ;  ^^  ^  „,,„,  ,uher  .ith  or  without 

i,„„l  disorder  known  as    ''•■'■";    '^^.^'-^J^eo  renal  sclerosis,  hut  d  >s  a 

.1vspe,.^ia.     L(-ad.  as  >s  well  kno    n,      ay  P    m,  ^_^^^^_^^^^^^^  .^  ^^.^^^^^^^^ 

^••-'-  ^'!^'7  ;;:;^Z;rr::;  :  t:^:::^^^  regions  of  tm.  X.,rtheast- 

'::  ^;it;:'ar  ;::iau;to.dde  to  ^^;' ji^;-^,^.,^,,,, .,  ,„..ie  .ri^ht. 

other  factors  which  -^^y  !^^^;T\^^,^^  ^^  ^  ,e  the  intense  worry  and 
.,i,,...  in  the  hetter  ^•l;':-VVt;v"f^  arc  with  hahit.  of  lu.rried  and 
;^ii;:S:^.ntkV;;o;erl^^^         ^alcs  are  .ore  connnon, 


-    - 


M^y 


i^\' 


:  '    1  . 

ill 

!  'i 


878 


DISEASES  UF  THE   KIDNEYS. 


an.l  sixty  it  is  uonnnon.  j,    .,,^,1  t  ^.^.tlRT 

Morbid  Anatomy.- llu'  '^'''"'  V     ,  ''';,;,  ,,,,.,,.  is  tl.i.k  an.l 


""'.;' '':l;^,,;^:;:,:'*r,'^l";^:r^;^:;;l.,... ,..,,,. 

::  jii:'i::  ::;;;:';;i:;::^>;u';u;:;:i  ».H.;ol-.  ...^ --' - 

^"^T.^  Tin-  trln,l..<  ^lunv  <ha,>-os  in  tlio  opithcliuni,  w1uoh  vary  a  good 
(,0  TlK-  nvlcics  .!,.»•  »n  a.l  .  m   'I  _    '  ,  ;„  t|,e  ,„o,lia,  con- 

;;:;;:  ;:,;;"iX^:;':*ro;;.«  ..nn^  -:;- --t.  „.,„„, 


CHRONIC   lUllGIITS   DISHASR 


870 


ck  111 


-t:-    iU'O 


.I'il- 


tlie  loiincctivi'-tifsiu'  ovcrgniwili  is  sccoiulary  tn  this.  (Ircciifu'ld  liolds  lliat 
the  i)riiiiiiry  ohaiijiv  is  in  iimst  instances  in  the  ^Idiin'iiiii,  to  wliicli  l)i)tli  the 
cic'-vntTalinn  in  tlu'  cpitlicliuni  ol'  the  (•oiiVDluti'd  tnl)iilcs  and  the  incivasc 
in  till'  intnlidnilar  cunncctivc  tissue  are  secondary. 

Associated  Willi  contracted  kidney  are  i^eneral  arterio-selerosis  and  iiyiier- 
trophy  oi'  ti'.c  heart.  Tiie  clian,u;cs  in  tlic  arteries  have  already  ht'cn  de- 
scrihed  in  the  section  on  arterio-sclerosis.  The  hypertrophy  oT  the  heart  is 
constant,  and  the  eiilar^^enieiit  may  reach  an  extreme  grade.  Variations 
depend,  no  douhl,  in  Jiart  upon  the  extent  oi'  the  dilVuse  arterial  degenera- 
tion, hut  there  are  instances  in  which  the  term  cur  horuiiiiii  may  l)e  ajiplied 
to  the  I'ldarged  organ.  In  such  cases  the  liyi)ertrophy  is  not  conlined  to 
the  left  venrricle,  hut  involves  the  entire  heart.  The  explanation  of  this 
hyiiertrophy  has  heen  iniicli  discussed.  It  was  at  first  lield  to  lie  d\w  to 
the  increased  work  thrown  111)011  the  (U'gan  in  ilriving  the  impure  hlo.id 
through  the  capillary  system.  I'.asing  his  opinion  iii>oii  the  supposed  mus- 
cular'ii, crease  in  the  smaller  arteries, -lohnson  regarded  tlu'  hypertrophy  as 
an  ell'ort  to  overcome  a  sort  of  stop-cock  action  of  these  vessi^ls.  which,  under 
the  inlluence  of  the  irritating  ingredient  in  the  hlood,  contracted  and  in- 
creased greatly  the  iieripheral  resi>tance.  Trauhe  helieved  that  the  ohlitera- 
tioii  of  a  large  numher  of  capillary  territories  in  the  kidney  materially  raised 
the  arterial  pressure,  and  in  this  way  led  to  the  hy|ierlrophy  of  the  heart; 
an  additiimal  factor,  he  thought,  was  the  diminished  excretion  of  water, 
which  also  lieiglitoned  tlio  jiressnre  within  the  iilood-vessels. 

With  our  ])resent  knowledge  the  most  satishictory  explanation  is  that 
given  hy  Colinheim,  which  is  thus  clearly  and  succinctly  put  hy  Fagge: 
•'  He  gives  reasons  for  thinking  that  the  activity  of  the  eiroulation  tlirougli 
the  kidneys  at  a.ny  moment — in  other  words,  the  state  of  the  s^maller  renal 
arteries  as  regards  contraction  or  dilatation — depends  not  (as  in  the  case 
of  the  tissues  generally)  npon  the  need  of  those  organs  for  blood,  hut 
solely  upon  the  amount  of  material  for  the  urinary  secretion  that  the  cir- 
culatory fluid  hapjiens  then  to  contain.  This  suggestion  has  hearings  .  .  . 
upon  the  develojinient  of  hypertrophy  in  one  kidney  when  the  other  has 
heen  entirely  destroyed.  But  another  consequence  dedueihle  from  it  is 
that  when  parts  of  both  kidneys  have  undergone  atrophy,  the  hlood-llmv 
to  the  ])arts  that  remain  must,  ctrtcris  pnrihiix,  he  as  great  as  it  wouM  have 
lieen  to  the  whole  of  the  organs  if  they  had  heen  intact.  Rut  in  order  that 
such  a  quantity  of  blood  should  ])ass  through  the  restricted  capillary  area 
now  o]ien  to  it,  an  excessive  pressure  must  obviously  be  necessary.  This 
can  be  brought  to  bear  only  by  the  exertion  of  more  than  the  normal  degree 
of  force  on  the  part  of  tlu'  left  ventricle,  combined  with  the  maintenance 
of  a  corresponding  resistance  in  all  other  districts  of  the  arterial  system. 
.\nd  so  one  can  account  at  once  for  the  high  arterial  pressure  and  for  the 
cardio-vascnlar  changes  that  arc  secondary  to  it." 

Symptoms. — i'erliai)S  a  majority  of  the  cases  are  latent,  and  are  not 
recognized  until  the  occurrence  of  one  of  the  serious  or  fatal  complications. 
Even  an  advanced  grade  of  contracted  kidney  may  be  compatible  with  great 
mental  and  bodily  activity.  There  may  have  been  no  symptoms  whatever 
to  suggest  to  the  patient  the  existence  of  a  serious  malady.     Tn  other  cases 


^^ 


U  i ) 


DISKASKS  OF  TllK   KIDNEYS. 

'•■t;';:;;;:ff;^;:j-;-:;;:-^ 

that  it  w.U  be  iH'st  u>  c  hm.U  .  <      '    !'  j    ^,^„^^n     iiH^roa.cd,  and  I'n.m 

,,,„,,,  ^F'-'--'l':;;  ;---  ,^  ,  "'  J^;tionU>as  to  get  up  t.o  or 
,  t„  -I  hires  H,ay  '-  P;-  ,  ^  ;,^lu.  l.lLl.ler,  and  tl^ero  is  incr.a.cd 
tlHvc  times  (lunn-  the  uioht  to  ^"M".  tint  relief  is  sou-ht.     It  is 

,\  ■    i      If  i^  for  tiic'^c  sviiiptoins  oefasioiiall}  uiai  uuti  ^ 

tlurst.     It  1^  toi     IK,(   .N  fivnunit   mieturition  at  ni-ht   may  be 

only  with  the  more  dclKate  t  >^t>.     ^    !  '^  ;,  ^^j.  t^;,„,ia  ...nstitucMUs 

,,Uino  or  gra.nUar  easts  a-  lound        •-      ;    '  ,,  ^,  j„^,„,,,,  „„  ,,,, 

,,  ,,,„  „,i„o  is,  as  a  rule,  ^';;;;  "'^^f ;,  '  :^:  ,/  ....psia  or  bronchitis,  or 
„,,v  bo  exm-ted  m  lull  '";;">"^;„,.  '  ,[  ''\  ,,  '  ..t  t  ot  albu.nin  n,ay  be 
in  the  later  stages  whon  the  '"''>'*  .'■".':  '  ^  ),,,:i„„ally  blood  occurs 
greatly  increased  and  the  ^^^^^  ^''^;^;^  ;^;,,  "^^^^ 

'"■  "I'"'" '""","""  ;:'■?::?,;■"    i-  «-i>™--  »"8'"'^  ''i^^"" " " 

tension  mav  be  plus  in  a  noimai  vcci, 

„^,,,,  ,,,,,,;,,  tenure  incn^asedtens^n^  ,,  .,  ,„,, 

A  pnlse  of  increased  teiiMon  1  as    M  i  „^.^,,,,^,„,  jf,  it  is  per- 

and  incom,n-essible,  requiring  a  good  J  ll^f^/,  /  ;,,,i  f,,i,  f,ll  and  can 
sistent,  and  in  the  intervals  be  ween  ^^^      ^^^1;;' ;,;;,, ^.     ,,,ent  in  a  ves..l 
be  rolled  beneath  the  finger.  .  ^ 'f  ^  ?    ,'    ^  ^  /\i     i^^ss.     To  estimate 
ti,,  walls  of  which  are  litt C  ,    .it  "^  ■    "^^  '^,  '  j^'^  ,iial.  and  the  vessel 
„„  latter  the  pnlse  wave  should  be  "'''l     ^'f ^J^^^^     ;,,t,,ial  coats.  nnd..r 
,,„  tV.lt  beyond  it.     In  a  P-'"  .  j;,-^  ^^^^^^  t  .;   nrronnding  tissue; 
tl,ose  circumstances,  cannot  be  '^;"*'''''\*'''*^'  /'™'  ,'    ^li  the  tin-er.     Per- 
.,,..as.  if  thicUened.  ^1- J-     -  ^  ^  ^;:;^  ^.^^^^^^^^^ 
,.,.„„  ,i,„  tensum  IS  -^  ,^    ^^  ^^^.^^  1,,  ,,,ai;  important,  tl.ongh 
interstitial  nephritis.      1  he  cauiiac   u  .  1-^^^  oep^i^s  to  overcome 

often  less  obvions.  hypertrophy  of  ^^^:^^^l^^^^^,  ^^  ^^,  ,,,,rt  nlli- 
tl-  vesistance  oiTered  m  tl-  -'terie.  h  ^^^^  ^^^^^^^^,  ,„,  to  the 
niatelv  becomes  more  general.    1  he  npc  .x         -  ^^.^^^ 

left;  the  impulse  is  fcnvilde  and  may  be  lieaMUg.  }   1 


ems. 
.1(1  I'roiu 
)  t\vo  or 
iH- reused 
t.     It  is 

limy  1>L' 
,h  super- 

inai'ked, 

the  spe- 
:;  gravity 
.  TriUM's 
tiie  early 

apiiiireiit 
1  it  a  lew 
u^titueiits 

the  urea 
ichitis,  or 
n  may  lie 
od  oeeurs 
it  leaka.s^e, 
^seiit  early 
ly  lie,  par- 

d,  and  the 
L'tion  must 
wall.  The 
lisease  It  is 

It  is  haul 
1;  it  is  jter- 
iiU  and  can 

in  a  vessel 
ro  estimate 
d  the  vessel 
•(lats,  under 
ding  tissue; 
nger.     Vor- 
ymjitonis  ni" 
ant,  tliou-h 
to  overcome 
e  heart  nlti- 
d  and  to  tlie 
persons  with 


CllUONIC  BRIGIITS   DISEASE. 


^Sl 


einiiliysemn,  the  (li.-iila( cinent  of  the  ;ipe\  mny  iiut  Im^  e\  Ident.  The  first 
toiinil  at  the  apex  may  lie  duplieated;  iiKirc  cnmiiKinly  tin-  second  sniind 
at  the  aortic  carliiiige  is  acccntuateil,  a  very  charaeteristie  sign  of  iiicreasuj 
tension.  Tlie  sound  in  exticme  ca>es  may  have  a  hell-like  quality.  In  many 
easi's  a  systolie  muiinnr  develops  at  the  apex,  prohahly  as  a  result  n\'  relative 
insiitlieieiicy.  It  may  he  loud  and  tran>initted  to  the  axilla.  I-'inallv  the 
hyperlro[ihy  fails,  the  heart  heeomes  dilated,  galloji  rhylhm  is  pic-ent,  and 
the  general  condition  is  that  of  a  ehronic  heai't-lesion. 

H(!<pir(ihirij  Si/slnii. — Sudden  ledema  of  the  glottis  may  occur.  V.Wu- 
sioii  into  the  iilcuru'  or  sudden  (edema  of  the  lung>  may  pi'ove  fatal.  Acute 
jileuri.-^y  and  piieunKuiia  are  not  uncommon.  I'.ronchitis  is  a  fre([iient  ac- 
companiment, particularly  in  the  winter.  Sudden  attacks  of  oppressed 
hreathing.  particularly  at  night,  are  not  infre(|iient.  This  is  ofti'ii  a  iira'inic 
symptom,  hut  is  sometimes  cardiac.  'Jlie  ]iatient  may  sit  up  in  hed  and 
gasp  for  hreath,  as  in  true  a>thnia.  Cheyne-Stokes  hreathing  mav  he  pres- 
ent, most  commonly  toward  the  close,  hut  the  patient  may  he  walking  ahoiit 
and  even  attending  to  his  occupation. 

DiijcMirc  Si/slrin. — l)yspepsia  and  loss  (d'  appetit(;  are  common.  Severe 
and  nneonlrollahle  vomiting  may  he  the  first  symptom.  'J'his  is  usually 
regarded  as  a  manifestation  of  nra'nua,  hut  it  may  lie  present  without  any 
oilier  indications,  and  1  have  known  it  to  jirove  fatal  without  any  suspicion 
that  chronic  Ih'ight's  disease  was  jiresent.  Severe  and  even  fatal  diar- 
rluea  may  develop.  The  tongue  may  he  coaled  and  the  hreath  heavv  and 
urinous. 

Xrn-dus  Si/slnn.—\;mum  cerehral  manifestations  have  already  heeii 
mentioned  under  ura'una.  Headache,  sometimes  of  the  migraine  tyjie.  may 
be  an  early  and  iiersistent  feature  of  chronic  T>rightV  disease.  Cerehral 
ajioplcxy  is  closely  related  to  interstitial  ne|)liritis.  The  luvmorrhage  may 
take  idace  into  the  meninges  or  the  cerehrum.  It  is  usually  associated  with 
marked  changes  in  the  vessels.  Neuralgias,  in  various  regions,  are  not  un- 
common. 

Spcrial  Senses. — Tronhles  in  vision  nny  ho  the  first  symiitom  of  the 
disease.  It  is  reniarkahle  in  how  many  cases  of  interstitial  nei)hritis  the 
condition  is  diagnosed  first  liy  the  ophthalmie  surgeon.  The  llame-shaited 
retinal  lui'morrhages  are  the  most  common.  Less  fre(pient  is  dilfuse  retinitis 
or  ]mpillitis.  Sudden  hiindness  may  sn|)ervene  wiUiout  retinal  changes — 
uru'inic  amaurosis.  I)iplo]iia  is  a  rare  event.  T  have  seen  hut  one  case. 
Knies  says  that  it  is  frecpient.  Anditory  tronhles  are  by  no  means  infre- 
(pient  in  chronic  I'.right's  disease.  Ifinging  in  the  ears,  with  diz;dness,  is 
not  uncommon.    Various  forms  of  dc^ifness  may  occur. 

Sliin. — (Kdema  is  not  common  in  interstitial  nephritis.  Slight  jmtliness 
of  the  ankles  may  he  iiresi^it,  hnt  in  a  majority  of  the  eases  dro[)sy  does 
not  suiiervene.  AVhen  extensive,  it  is  almost  always  the  resnlt  of  gradual 
failure  of  the  hyi)erlro])hied  heart.  The  skin  is  (d'ten  dry  and  ]iale,  and 
sweats  arc  not  common.  In  some  instances  the  sweat  may  de])osit  a  white 
frost  of  urea  on  the  surface  of  the  skin.  Kezeina  is  a  common  accomjiani- 
nient  of  chronic  interstitial  nephritis.  Tingling  of  the  fingers  or  numh- 
ness  and  pallor — the  dead  fiiiger.s — are  not,  as  some  suppose,  in  any  way 


882 


DISEASES  OF  THE  KIDNEYS. 


prculim-  io  r.ridit's  discMso.    IntnlvraM.'  itcliiii-'  ol'  tlu^  skin  inny  ]n-  pri^mt, 
iiiid  (Taiiips  ill  till'  iiiu^iloiin'  liy  ii"  iiicaiis  ran'. 

IhviiKurliap's  aiv  ii<>t  inricciuciit ;  thus,  cpistaxis  may  occur  and  prusu 
serious.  I'lirpura  may  develop.  I'.roiKlio-pulmoiiary  liicmorrhatres  are  said, 
liv  si.iiie  Freiieh  writers,  to  lie  eoiiimoii,  Init  no  instance  of  it  has  come 
iin(h'r  my  ol>seivation.     Aseites  is  rare  except  in  association  with  cirrhosis 

oi  the  liver. 

Diagnosis.— The  autopsy  ofien  discloses  the  true  nature  ol  Hie  dis- 
ease, one  ol'  the  many  iiitereiirv.'Ut   alVectioiis  ot  which   may  have  [iroved 
latai.     The  early  stajivs  of  intcistitial  nephritis  are  not  rocogiii/cahle.     In 
a   patient   with  "increased   pulse  tension  (partieiilarly  ii'  the  vessel  wall  is 
sclerotic),  with  the  apex  l»eat  ol!  the  heart  dislocated  to  the  left,  the  sec<uid 
aortic  .-^ound  ringing  and  accentuated,  the  urine  aiuiudant  and  of  low  spe- 
cilic  <:ravity,  with  a  trace  of  albumin  and  an  occasional  hyaline  or  granular 
cast, "the  diagnosis  of  interstitial  nephritis  may  he  safely  made.     Of  all  the 
in.lications,  that  olVered  l.y  the  pulse  is  the  most  important,     rersislent 
lii-h  tension  with  thickening  of  the  arterial  wall  in  a  man  under  iifly  means 
that  seri.ius  mischief  has  already  taken  place,  that  cardio-vascular  changes 
are  certainly,  and  renal  most  proljaljly,  present.    It  is  important  in  the  diag- 
no>is  of  this  condition  not  to  rest  content  with  a  single  examination  of  the 
urine.      I'.oth   the  evening  and  the  morning  secretion  should  be  studied. 
The  sediment  should  be  collected   in  a  ccmical  glass,  and   in  looking  for 
tube-casts  a  larue  surface  should  be  examined  with  a  tolerably  low  power 
and  little  li-ht.     The  artcrio-sclerotic  kidney   may  exist   for  a  long  time 
without  the  Occurrence  of  albumin,  or  the  albumin  may  be  in  very  small 
(inantities.    In  manv  cases  it  is  imiiossible  to  dill'erentiate  the  primary  inter- 
stitial nei>hritis  from  an  arterio-sclerotic  kidney,  nor  clinically  is  it  of  any 
special  vahie  so  to  do.     In  persons  under  forty,  with  very  high  tension, 
<rreat  thickening  of  the  superficial  arteries,  and  marked  hypertrophy  of  the 
Fieart,  the  renal  are  more  likely  to  be  secondary  to  the  arterial  changes. 

Prognosis.— Chronic  r.righfs  disease  is  an  incurable  alfi'ction,  and 
11,e  anatomical  conditions  on  which  it  depends  are  (piite  as  much  beyond 
the  reach  of  medicines  as  wrinkled  skin  or  gray  hair.  Interstitial  nephritis, 
however,  is  compatible  with  the  enjoyment  of  life  for  many  years,  and  it  is 
now  universally  recoauizcd  that  increased  tension,  thickening  of  the  arterial 
walls,  atid  i.olvuria  with  a  small  (piantity  of  albumin,  neither  doom  a  man 
to  death  within  a  short  time  nor  necessarily  interfere  with  the  pursuits  ol 
an  active  life  so  long  as  proper  care  be  taken.  I  know  patients  who  have 
had  hi'di  tensi.m  and  a  little  albumin  in  the  nrine  with  hyaline  casts  for 
ten  twelve,  and,  in  one  instance,  fifteen  years.  Serious  indications  are  the 
development  of  nnvmic  symptoms,  dilatation  of  the  heart,  the  onset  o 
.serous  effusions,  the  development  of  I'heyne-Stokcs  breathing,  persistent 

vomiting,  and  diarrluea. 

Treatment.— Pat ients  without  local  indications  or  m  whom  the  con- 
dition has  been  accidentally  discovered  should  so  regulate  their  lives  as  to 
throw  the  least  possible  strain  upon  heart,  arteries,  and  kidneys.  A  quiet 
life  without  mental  worrv,  with  gentle  but  not  excessive  exercise,  and  resi- 
dence in  an  equable  climate,  should  be  recommended.     In  addition  they 


C'lIIlONIC  BUKillTS   IHSEASK. 


8  So 


lul    [II'ONU 

;  arc  siiil, 

has  fdiiio 

ciri'luisis 

£  the  ilis- 
\'o  provctl 
calih'.  Ill 
c'l   wall   is 

lie  rL'L-dllll 
1'    low    S[)L'- 

r  granular 
Ol"  all  the 
IVr^isU'iit 
il'ly  means 
ir  eliaiiii'es 
1  the  (liag- 
iiin  ul'  the 
le  stiulieil. 
)()king  i'or 
low  i)ower 
long  time 
very  small 
nary  inter- 
■;  it  ol'  any 
;h  tension, 
phy  ol'  the 
hanges. 
'ction,  an<l 
leh  heyond 
1  nephritis, 
■s,  and  it  is 
the  arterial 
3om  a  man 
pursuits  of 
s  who  have 
\e  casts  i'or 
ons  are  the 
le  onset  of 
,   persistent 

in  the  eon- 
•  lives  as  tn 
s.  A  quiet 
:e.  and  resi- 
dition  thev 


.-liould  lie  told  to  l<eep  the  howcls  regular,  the  .-kin  active  liv  a  diiilv  tcjiid 
liath  with  friction,  and  the  urinary  f-ecrclion  Tree  ijy  drinking  ilaiiy  a  drli- 
nile  amount  of  cither  distilled  water  or  some  plca>anl  mineral  water.  Alco- 
hol >liould  lie  strictly  pi'ohihited.     Tea  and  colfcc  are  allowalile. 

The  diet  should  he  ligiit  ami  nourishing,  and  the  })atieut  should  lie 
warned  not  to  eat  exeissivcly.  and  not  to  take  uu'at  more  than  once  a  day. 
Care  in  food  and  driidc  is  prolialily  the  most  iniiiorlant  element  in  the  trcal- 
nu'iit  of  these  early  cases. 

A  patient  in  good  circumstances  may  he  urged  to  go  away  during  the 
winter  months,  or,  if  necessary,  to  move  altogether  to  a  warm  equilile  cli- 
mate, like  that  of  Southern  Califoi'uia.  'i'lu're  is  no  douht  of  the  value  in 
the^e  ea.-cs  of  removal  from  the  changeahle,  irregular  weather  which  pre- 
vails in  the  temperate  regions  from  Xovi'iuher  until  April. 

At  this  period  medicines  are  not  re([uircd  unlos  i'or  certain  spt'iial 
sympt(Uiis.  I'aticnts  derive  much  hciu'lit  from  an  annual  visit  to  ci-rtain 
nnneral  springs,  such  as  Polaml,  iJedford,  Saratoga,  in  this  (-(Uintry,  ami 
\'icliy  and  others  in  Europe.  Mineral  waters  have  no  curative  inlluence 
u|ion  chronic  I'.righl's  disca.-e;  they  >im]ily  hel[)  the  interstitial  circulation 
and  keep  the  drains  lluslud.  In  this  early  stage,  when  the  ])iitieut"s  con- 
dition is  good,  the  tension  not  high,  ami  the  (pianlity  of  alhumin  small, 
medicines  are  not  indicated,  since  lU)  remedies  are  known  to  have  the  slight- 
est inlluence  upon  the  progress  of  the  disease.  SooiU'r  or  later  svmplom< 
arise  which  demand  treatment.  Of  these  the  following  are  tlu,'  most  im- 
jiortant: 

{(i)  Grfialhj  Incirdscd  AiirrlnJ  'I'l'iisimi. — It  is  to  he  rememhered  that 
a  certain  increase  of  tension  is  not  oidy  necessary  hut  unavoi(hdile  in  chi'onic 
Uright's  di.-iease,  and  ])roliahly  the  most  serious  danger  is  too  great  lowering 
of  the  blood  tension.  The  liajipy  medium  must  he  sought  hetween  sucli 
lieightened  tension  as  throws  a  serious  strain  upon  the  heart  and  risks  rup- 
ture of  the  vessels  and  the  low  tension  which,  niuha-  these  cireunistaiu-cs, 
is  specially  liahle  to  he  associated  with  serous  cll'usions.  In  cases  with  per- 
sisteid  high  tension  the  diet  should  he  light,  an  occasional  saline  juirge 
should  he  given,  and  sweating  pi'<Mnotcd  hy  means  of  hot  air  or  the  hot 
liath.  Tf  these  measures  do  not  sulhce,  nitroglycerin  may  he  tried,  begin- 
ning with  1  minim  of  the  l-jier-cent  solution  tliree  tinu's  a  ,y,  and  grad- 
ually increasing  the  dose  if  necessary.  Patients  vary  so  much  in  suscepti- 
bility to  this  drug  that  in  each  case  it  nnist  lie  tested,  the  limit  of  dosag(> 
being  that  at  which  the  patient  o.xjierienees  the  physiological  eirect.  .\s 
nmch  as  10  nnnims  of  the  l-jier-cent  solution  may  be  given  three  times  a 
day.  Tn  numy  case  I  liavo  given  it  in  nnieh  larger  doses  for  weeks  at  a 
time.  I  have  never  seen  any  ill  efTcets  from  it.  Tf  the  dose  is  excessive  the 
])atients  com]ilain  at  onee  of  flushing  or  headache.  Tts  use  may  be  kept  up 
for  six  or  sevcui  weeks,  then  stopped  for  a  week  and  resunu'd.  Tts  value 
is  seen  not  only  in  the  reduction  of  the  tension,  but  also  in  the  striking 
manner  in  which  it  relieves  the  headache,  dixziness,  and  dyspmea. 

(h)  More  or  less  unanuia  is  ]iresent  in  advanced  cases,  and  is  lie<t  m^'t 
by  the  nse  of  iron.  Weir  ^fitcliell,  who  has  had  a  uni(pie  experience  in 
ct'rtain  forms  of  chronic  Bright's  disease,  gives  the  tincture  of  the  per- 


^^ 


gg^  DISK  ASKS  OF  TllH   KIDNHYS. 

,,,,.„,,,„  „f  i,,„  in  larp.  .lo^.-IToin  half  n  dra^lnu  to  ,,  .Ira.lnn  ^^ ^^^ 
,  .!,v  11..  ihinks  thai  it  not  only  hcndits  tlu'  lUiaMuia,  l.ul  thai  it  al.o  i> 
;,„  n'm^ortant  n.vans  of  mliirin-  tlu'  arte-rial  tension 

„.  Manv  ,.ati..nt>  with  Brigl.fs  .li..a>o  present  thnnsrlvo.  f^-r  um  - 
„H  ,1  with  MoL  of  ranliac.  dilatation;  tluT.  is  a  Kallo,,  rhytlnn  or  tl...  lu.n 
"nuls  hav.'^a  lo^al  •■haract.r,  th.  htva.h  is  short,  th.  urm.  sc-anty  a  .1 
hi„i.lv  ali.untinons,  an.t  tlu.v  arc  si^ns  of  lo.al  .Iropsv.  In  h.so  cases  Ik 
tr:atn.ent  mnst  be  direete.l  to  the  heart.  A  nn.rnu,,-  dose  ol  salts  or  ealo- 
n  e  nu.y  l.e  ,Mven,  and  digitalis  in  l.i-nunin.  -loses,  three  or  iour  t.nu.  a 
dw.  S  rvehllia  niay  be  used  with  benellt  in  this  eond,t,on.  n  sou.e  ■  - 
Itaneos  other  eardia^  tonies  ,nay  be  neeessary,  lait  as  a  rule  the  digital,,  aet. 

iiroinntlv  ami  well.  . ,         .  , 

^  (,  )  i-raudr  .S//my./,....-l':ve,>  before  .narked  nunule.tafons  are  y resent 
th.re  nu,v  l^e  extmue  restlessness,  mental  wander.nj.,  a  heavy,  ioul  br  ath, 
,n^   a  eoated  ton.ue.     Headache  is  not  often  eon.ida.ned  ol,    hou.h  t.tten.e 

ontal  headaeh;n,ay  l,e  an  early  symptom  of  rtnenua.     In  tln<  c-ond.,, 

t,.o,  the  patient  n,av  eon.plain  of  pali.itat.on,  leel.nj:s  ol   ju,n,bne».     n  I 

otneti.nel  n,.etnrnal  eran,ps.      Ko-'  these  ^.npto.ns  the  --M-';^       - 

.honld  be  ordc.red.  and  bof  baths,  so  as  to  .nduee  copious  ^^^^"=  <"'.-•  ;■•'"• 

ates  that  irrioation  of  the  bowel  with  water  at  a  temperature  Iron,  10 

to    no'      n  ost^iseful.     N>tr..,lyeerin  also  may  be  freely  nsed  t.>  reduce  the 

en<ion.     For  the  uraMnic.  convnlsions.  if  severe,  inl-lf''-  <;'/■';,  ;-;;  "' 

,  V  be  use<l.     If  the  patient  is  robnst  and  full-blooded,  Iron.  U  to  ■.•  0  ounce, 

Uo  d  shonld  be  .•e.noved.     'Fhe  patient  should  be  freely  sweated,  and 
,,    onv.,lsio,.s  ten.l  to  recur  chlo,.al  ...ay  be  ,.iven.  e.ther  by  the  mouth  o 
.;,,„„„,  ,,,  1,.,,,,.,.  still,  n.orphia.      r.'a....ic  coma  n.nst  be  treated  b 
iv     ,.    gition.  a,.d  sweatin,  should  be  pnunoted  by  the  use  of  p.locju- 
;^\l  tl.;  hot  bath.     Tor  the  .cstlessness  and  deliriu.n  -•••p'-,  -  ^'l- 
,en-.ble      Since  its  reco..,n.endatio..  in  n.a.nic  states  some  \.'a.s  auo.  ^'} 
S  c,^  '  "m     Ken.ie.  1  have  nsed  this  rc.edy  extcsively  and  -Yl-f-' 
\      L    .  t  value  in  these  cases.     1  have  never  see.,  ill  elVects  <„•  a..y  tei^e  c> 
;!,  cdn.a  follow.     It  is  of  special  value  in  the  dysp.,o.a  and  Cheyne-btoke^ 
breathiu-  of  adva..eed  a.'terio-s<'ler(,sis  with  cb.'on.e  uramua. 


VIM.    AMYLOID    DISEASE. 

\n,vloid  (lardaeeous  or  waxy)  d.-cneration  of  the  kidneys  is  simply  an 
,vem         tl-  process  of  chnu.ic   nri.hfs  disease,  most  con..no,.  y  .,.     he 
,      ,1     paven!.hv...atous  nephritis  following  fevers    or  o    --l'-^^-^    ;• 
11       no  clai.n'to  be  .•euarded  as  one  of  the  var.et.es  of  Br.ght  s  d.scase. 
The  ai  "t    n  of  the  l<id..eys  is  ,e..e..ally  a  part  of  a  w,desp.-ea.l  a.nylo.d 
.     ;„     .  tion  occnrri...  i.,  ,u'olon,ed  suppu-.tion.  as  m  d.sc.tso  of  the  bo,  e^ 
i^^l^^iillis.  tubeivuhisis,  a.,d  o..<.asio,.ally  lenbvm  a.  lead  poisoning,  and 
.r„„t     It  varies  ei.riouslv  in  frecp.en.y  in  different  local,  .es. 
^      Anat^unieally  the  anlyloid  kid,.ev  is  L.rge  and  pde,  ^lu-ur  ace  smo,  U 
and  the  vcMia^  stellata>  well  n.arked.     On  seet.on  the  cortex  .s  la  ?.    a 
l^vlhow  a  peculiar  glistening,  infiltrated  appearance,  and  the  glo,..e,uli 


A:MYLOir)  DISKASE. 


s.sr> 


iroo  timo.-; 
it  iiUii  is 

for  ti'i'iit- 
tlic  licaii 
ciiiity  ami 
;  fiifL'S  ".he 
ts  or  Ciilo- 
iir  tiiiu'r-  a 
1  soint'  in- 
gitalis  iU'ls 

ire  jilTScllt 
)ul  liivatli, 
lo-li  inlciiHr 

coiiilitioii, 
hiicss.  iiml 

])iir,i:ativ(s 
;.     (iraiidin 

from  1-.'U' 

rciliu'c  tlu' 
chlororonn 

I)  ■.'()  OUlU'Cri 

iti'd,  iiiul  if 
V  inoiilh  or 
troatril  liy 
of  piloear- 
lia  is  mV\<- 
■ars  apt.  I'V 
an  speak  of 
ly  tcnilt'iu-y 
I'vnc-Sti.ike- 


is  siiiijily  an 
loiily  in  tiu' 
u'clic  stati's. 
rht's  (liseaso. 
•ead  amyloid 
of  tlie  l)oiu', 
isoninjr,  and 

•faro  sniontli. 
is  lar,<i<'  and 
lie  trlomernli 


arc  very  di>linct.  Tlic  pyramid,-,  in  strikiiii:'  lontrast  to  ihc  covtrv.  arc  id' 
a  drcp  red  cidor.  A  M'clioii  >oakrd  in  iliiiilc  tiiicliirc  of  iodine  >ho\\s  -[lot.-? 
of  11  walnut  or  nialiouaiiy  lu'owii  color.  'I'lic  Malpi;:iiian  lulls  and  the 
straiiriit  vessels  may  lie  most  all'eeted.  In  lardaeeoiis  dixNise  o|'  the  kidney- 
tlie  orj,^ans  are  not  always  eidarired.  They  may  he  normal  in  size  or  small, 
pale,  and  j;rannlar.  The  amyloid  ehaiiue  i-  lirsl  seen  in  the  .Malpi,i:hian 
liilts,  and  then  involves  the  aU'ereiit  and  elVereiit  ves.-els  and  the  strai;;ht 
vessels.  It  may  he  eonlined  entirely  to  them,  in  later  sla.ucs  of  the  dis- 
ease the  tnhnles  are  all'irted,  ehielly  the  mendirane,  rarely,  if  evei',  the  cells 
lhem>elves,  in  addition,  the  kidneys  always  show  siuiis  of  dilVuse  nephritis. 
The  I'lowman's  eapsnies  are  thickened,  there  may  he  glomerulitis,  and  the 
tuhal  epithelium  is  swollen,  pranular,  and  fatty. 

Symptoms. — The  wmx]  l\'atures  alone  may  not  indicate  the  ]iresence 
of  this  (le;;eiieration,  I'siially  the  associate<|  condition  ;.Mves  a  hint  of  the 
nature  of  the  process.  The  niiiU',  as  a  rule,  shows  ini|iortant  chan;^!''^; 
the  (luantity  is  increased,  and  it  is  pale,  (dear,  and  of  low  specilic  ^M'avity. 
The  alhumin  is  usually  ahiindant.  hut  it  may  he  scanty,  and  in  rare  in- 
stances alisent.  I'ossihiy  the  \aiiations  in  the  situation  of  the  amyloid 
chanjics  may  account  for  this,  since  alhumin  is  less  likely  to  he  |n-escnt 
when  the  (duin,ire  is  ('(uilined  to  the  vasa  recta.  In  addition  to  ordinary 
alhumin  ,>jloiiulin  may  he  present.  The  tnhe-casts  are  variahic,  usually 
hyaline,  often  fatty  or  finely  jiranular.  Occasionally  tin;  amyloid  reactimi 
can  he  detected  in  the  hyaline  casts.  I)rop.<y  is  ])resent  in  many  instances, 
])articnlarly  when  there  is  much  a  mem  la  or  profound  cachexia.  It  is  not, 
however,  an  invariahle  symptom,  and  there  are  cases  in  which  it  does  not 
dcvtdop.    Diarrluea  is  a  O(uiunon  accompaniment. 

lm'reas(>d  arterial  tension  and  cardiae  hypertrojihy  are  not  usually  ])res- 
ent,  except  in  those  eases  in  whi(di  amyloid  de,ueneration  occurs  in  the 
secondary  contracted  kidney;  umler  whicdi  circumstances  thei'e  may  he 
lUiemia  and  retinal  chant's,  which,  as  a  rule,  are  mjt  Juet  with  in  other 
forms. 

Diagnosis.- — I'y  ih(>  condition  of  the  nrine  alone  it  is  not  possihle  to 
recofrnize  amyloid  ehan.u't's  in  the  kidney.  I'sually,  however,  there  is  no 
dillii  'ty,  since  the  llrijiht's  disease  comes  on  in  association  with  syphilis, 
prfdouii'ed  sup]iuration,  disease  of  the  hone,  or  f uherculosis,  and  there  is 
evidence  of  eidarjrement  of  the  liver  and  spleen.  A  sus|n'cious  circmu- 
stanoe  is  the  existence  of  polyuria  with  a  laru'c  anuiunt  cd'  allmmin  in  the 
urii;",  or  when,  in  these  ennstitutional  atVections,  a  large  ipiantity  of  clear, 
pale  urine  is  passed,  even  without  the  presence  of  alhumin. 

The  prognosis  depends  rather  on  the  condition  with  which  the  m^phritis 
is  associated.     As  a  rule  it  is  grave. 

The  treatment  of  the  eondition  is  that  of  chronic  Criglifs  disease. 


^^ 


sso 


DISEASES  OF   THE  KIDNEYS. 


IX.    PYELITIS 

{Consecutive  Nephritis;  Pyelonephritis;  Pyonephrnsis). 

Definition.-! iillaiuiuatiuii  ..f  the  i-flvis  ..f  llu'  kidnry  ana  Uw  con- 

.lilioiis  wiiiih  ivsult  In-m  it. 

Etiology.— ly lit i^   is   in.huc.l    1>.V   iminy   .'Miisrs,   aiimn-   whuh    tla 
r.,ll„wi>,-  aiv  tlK'  HH.sl   uu\nn-Um\:   («)   'V\n'   irritation   ..I'  calcu  i-^i    very 
r,,,nurnt  caus..     (h)  'VuWn-W.     (r)  'Vhv  inlrrtious  i-vchtis  winch  .li'V.L.l.s 
in  IVvcrs.  ill  wl.id.  an  acute  inllamn.ation  of  the  pelvis  ot  the  ku  ney  may 
.urur   soniclinics  haMuorrha-ic  in  character,  more  ircnuMitly  .lii.htheritic. 
(,/)  Tlie  invKMice  of  deonipo.sin-  urine,  lollowin-  proMire  upon  the  urder 
l,v  tumors  or  i,la.l.ler-.lisease.     By  far  the  most  frequent  form  ol  pyelius  is 
that  which  is  c.,ns.rutive  to  cystitis,  from  whatever  cause.       n  these  cases 
the  inflammation  u.av  not  he  coniine.l  to  the  pelvis,  hut  pass  to  the  kulnev, 
inducing  pvelonephritis.     (.')  Occash.nal  causes  are  cam^er,  I'V'lati^ls,  the 
ova  of  certain  parasites,  and,  according,'  t..  somc.tho  irritation  o    the  sac- 
charine  urine  of  diahetes,  and  the  irritation  of  turpentine  or  cuhel.s.      /) 
A  primary  pv.ditis  or  pyelonephritis  has  heen  descrihed  as  oonung  on  after 
cold  ..r  ..'veivxertion,  hut  such  cas..s  are  extremely  rare.     Hie  o.nd.  ion  ,. 
met  with  in  children  (lloll),  and  in  one  case  which  I  saw  with  llolim-.s, 
of  Chatham,  the  pus  and  the  chills,  after  recurrinj,^  at  intervals  for  many 
nionths,  disappeared  after  circunuMsin,^  the  hoy    who  had  a  very  nariou 
prepuce.     (,/)  Following  attacks  <.f  DietFs  crises  m  movahle  kidney  pxel.ti, 

"'"  Mbrbid  'Anatomy.-In  the  early  stages  of  pyelitis  the  mucous  nieni- 
In-ane  is  turhi.l,  somewhat  swollen,  and  may  show  ecchymoses  or  a  grayiih 
pseudo-momhrane.  The  urine  in  the  pelvis  is  cloudy,  and,  on  oxamma- 
ti.in,  numhers  of  ei)itlielial  cells  are  seen. 

I„  the  calcul.n.s  pyelitis  there  may  he  only  slight  turhidity  ot  the  niem- 
l.vane  which  has  l,een  called  hy  some  catarrhal  inelitis.  More  commonly 
1  mucosa  is  roughened,  grayish  in  color,  and  thick.  Under  these  creum- 
staiu.es  there  is  almost  always  more  or  less  dilatation  ot  the  calyces  and 
flattening  .)f  the  i.a,.illa..  Following  this  condition  there  may  he  (a)  ex- 
ension  of  the  suppurative  process  t<,  the  kidney  itse  f,  i--"";^;  Ij^.^ - 
nei.hritis-  (h)  a  gradual  dilatation  of  the  calyces  with  atrophy  of  the  kulnev 
suhstance,  and  finally  the  production  of  the  condition  ot  pyoiiephiv.sis  in 
which  the  entire  organ  is  represented  hy  a  sac  ot  pus  with  or  ^Ythmlt  a 
thin  shell  of  renal  tissue,  (c)  After  the  kidney  structure  has  heen  des  ro  ed 
hv  supi-nration,  if  the  ohstruction  at  the  orifice  of  he  pelvis  persists 
llni.l  '  ortions  may  he  ahsorhed  and  the  pus  hecomo  inspissated   so  that  the 


organ  is  represented  by  a  series  of  sacculi  containing  grayi.-h 
asses,  which  may  liecome  impregnated  with  lime  salts. 


,  putty-like 


ma 


Tuberculous  ,,yelilis,  as  already  descrihed,  visually  starts  iipon  Hum  pic  -, 
of  the  pyramids,  and  may  at  first  he  limited  in  ex  cut.  ^  .  ^^^^'^.^J^; 
,,„„.liti,;,;  produced  may  he  similar  to  that  of  calculous  pyelitis.  Pjone- 
phrosis  is  quite  as  frequent  a  sequence,  while  the  final  transformation  of 


tliL'  con- 

hii'li    the 
i-:i   very 

iliK'v  iiiiiy 
)litlu'ritic. 
I  ho  un'tor 
liyclili^  is 
hoi^o  case;- 
ic  kidiu'v, 
111  ills,  the 
if  tho  Siic- 
i1h,.1)S.  (/■) 
tr  I'll  i 


afUT 


inditioii  is 
h  llolincs, 
i'or  many 
Ty  narrinv 
i>y  ]>yelitis 

cDUs  nii'iu- 
:  a  grayish 
1  oxainina- 

l  tho  nioiu- 

eoniinonly 
;.'so  cirtiim- 
;alycos  and 

be  (a)  ox- 
ig  a  pyolo- 

thc  kidney 
'phnisis.  in 
•  without  a 
n  dostroyod 
lorsists,  the 

so  that  tho 
,  putty-liko 

n  tlio  apices 
inuitely  the 
lis.  ryonc- 
ormation  of 


I'YKLITIS. 


887 


tiie  pus  into  a  imtty-liko  Miatcri;!!  iin]ircgiintc(l  with  salts,  jniining  t||,.  sk- 
called  siTol'iiloii.-i  kidney,  is  e\rn  ((iiiinmiui'. 

The  pyelitis  consoeutive  to  eystilis  i>  ii-nally  liilateial,  and  the  kidney 
is  a|pt  to  lie  involved,  I'oiining  the  sd-cnllcd  sinyiinl  kiilmii — aeiite  siip- 
|Miralive  iiephfitis.  'I'hero  are  lines  oj'  >ii|)|Miratiiin  extending  alnng  the 
pyramids,  or  small  ahsee.-ses  in  the  cortex,  ojteii  just  lieiieath  the  eapside; 
ni'  there  may  he  wedgo-shape(l  aliscesscs.  'I'lio  pus  organisms  I'ither  jiass 
\ip  the  tuliuli'S  or,  as  Steven  has  shown,  through  the  lymphatics. 

Symptoms. — 'I'he  I'orms  associated  with  tho  I'cvers  rarely  cause  any 
symptoms,  even  when  tho  process  is  extensive.  In  mild  grades  there  is 
pain  in  the  hack  or  there  may  he  tenderness  on  ilecp  pressure  on  the  at'- 
I'ected  side.  'l"he  urine  is  turhiil,  contains  a  few  mucous  and  pus  cells,  and 
occiisionally  hlood-corpuscles.  Tlu'  nriiu'  is  acid,  and  there  may  he  a  trace 
of  alliumin. 

JJefore  the  condition  of  ])yuria  is  estahlished  there  may  he  attacks  of 
])ain  on  the  all'ectod  side  (not  amounting  to  the  severe  agony  of  renal  cidic), 
rigors,  high  fever,  and  sweats.  I'lider  these  circumstances  the  urine,  which 
may  have  heen  clear,  hecomes  turhid  or  smoky  Troni  tho  presence  of  hload, 
and  may  contain  large  numliers  of  mucus  cells  and  transitional  epithelium. 
These  cases  are  not  common,  hut  I  have  twice  had  oppi-rtunity  of  studying 
stich  attacks  for  a  jirolongcd  peiiod.  In  one  jiatieiit  the  occurrence  of  tho 
rigor  and  fever  coidd  sometimes  he  jiri'dicteil  from  tho  change  in  the  con- 
dition of  the  urine.  Such  cases  occur,  1  helioNc,  in  association  with  calculi 
in  tho  pelvis. 

The  statement  is  not  infroiiuenfly  made  that  the  eititholium  in  the 
nrine  in  i>yelitis  is  distinctive  and  characteristic,  'i'his  is  erroneous,  as 
may  he  readily  demonstrated  hy  comparing  scrapings  of  the  mucosa  of  the 
renal  pelvis  and  of  tho  hladdor.  ]n  hoth  tho  epithelium  holoiigs  to  what  is 
called  tho  transitiomil  variety,  and  in  hoth  regions  the  same  conical,  fusi- 
form and  irregular  colls  with  long  tails  are  I'ouml. 

AVlion  the  jiyolitis,  whether  ealciiloiis  or  tuliercnhuis,  has  hecome  chronio 
and  discharges,  tho  symptoms  are: 

(!)  J'liiirin. — Tho  ]ius  is  in  variahlo  amount,  and  may  ho  intermittent. 
Thus,  as  is  (d'ton  the  case  wdien  oidy  one  kidney  is  involved,  the  ureter 
may  he  temporarily  hlockod,  and  normal  urine  is  passed  for  a  time;  then 
there  is  a  sudden  oiitllow  of  the  ])ent-U]i  ]ius  and  the  nrine  hocomes  ))urn- 
lent.  Coincideid  with  this  retention,  a  tumor  mass  may  l>e  felt  on  the 
side  all'ectod.  The  ]uis  has  the  ordinary  characters,  hut  the  transitional 
epithelium  is  not  so  ahundant  at  this  stage  and  comes  from  the  hladdor  or 
from  tho  ]ie!vis  of  the  healthy  side.  Occasionally  in  rajiidly  advancing 
]iyolone|)hritis.  ixn'tious  of  the  kidney  tissue,  jiarticidarly  (d'  tho  apices  of 
the  ])yramids,  may  slmigh  away  and  a|>poar  in  the  urine;  or,  as  in  a  ro- 
markahlo  spocimon  shown  to  me  hy  Tyson,  solid  cheesy  moulds  of  the 
calyces  are  passed.  Casts  from  tho  kidney  tulmles  are  sometimes  present. 
The  reaction  of  tho  urino  is  at  first  acid,  and  may  remain  so  even  when 
the  ]ms  is  passed  in  largo  (pianlities.  If  it  remains  any  time  in  the  hlad- 
dor or  if  cystitis  exists  it  hocomes  ammouiacal.  ]\Iicturition  may  he  very 
frequent  and  irritalnlity  of  the  hladdor  may  bo  jiresent. 


^m^ 


8oS 


DISHASKS  UF  TllH   KlDNHV.l. 


;^i;;;r;::;i;.:;r:;;;r;r,i;n;:.::!^^^^ 

■"™',;''.'i!v:i!:i  :'L;,Si...  i..  .i.---  i^y^"-  -»"^  --*  "i"t:";: 

,„      ,.   ,  wi,,l  .i,l..  nr  a  .l,.r„,il.  .-■Hint'.  »l.i.l.  i":'?   ■■■'">■  """1'   '"  " 

*"ti't;;:;:is;7:':;;;::-.^., ...i,,,., '-:7':;;;:?„-|; 

cluivacttT  of  tlio  ini?  in  inai\\  m^taiici.. ,  iiu  i 


Ill    CilSL'.i 

kills,    iiiul 

■lUimi  t" 
f  I'caturi- 
•  assuiius 

|iruloii;j:L'il 
rofivusMvi' 
ill  piclun' 
ihcrculoiis 
'Vlwvv  lire 
it  iuipuir- 

Iciiilcriu'ss 
ell  ill  si/.i' 
luiriUDiisly 

atctl  with 
iiilikc  Ihiit 
ho  (Irciiin- 

1.      A    I'llMll 

u'uritis  has 

ih,  the  pa- 
I'gular,  aiul 
).-•  in  whii-li 

-   fonns   (if 
hy  the  (1e- 
oiili  should 
n  test  may 
is  is  (listin- 
nri'  of  u'de- 
all,  the  liis- 
le  free  from 
1  to  make  a 
had  eystilis 
M'al  months, 
iiliar  region. 
n\,  to  (letcr- 
eve  had  been 

led.  T  liiive 
(ciformed  en 
(>  two  condi- 
Di'v,  tlie  arid 
•renco  of  am- 


IIYDUON'KIMIIKISIS, 


8M) 


moniarnl  derom]insi1ion,  the  loral  siLMis  in  one  linnitar  r(\<;ion,  ami  the 
aliM'iice  iif  |i;iiii  ill  thr  liladdiT  >hoiil(l  he  suHieieiil  to  d illVrciii lalc  the  af- 
J'eetioiis.  In  woiiicii.  hy  cat helcrization  of  the  iiiclcrs,  it  niav  ho  ddinilrlv 
(h'teniiiiictl  whether  llic  pus  (■(uncs  fi'inn  the  l<idni'y>  or  fi'din  the  Maddrr, 
Tile  eystoscope  may  he  used  for  this  |iur|)ose. 

Prognosis. — (a.-es  coining:  on  duriiij:  the  fevers  ii-iially  recover.  'I'u- 
ln>reuKiii>  iiyehtis  may  teiininate  favoralily  l»y  iiispissatioii  of  the  piis  and 
(■(tiiversiuii  into  a  ]iiilty-lil\e  siilistaiiee  witli  depositidn  of  Ijnie  salts.  Wiieii 
pyonephrosis  develojis  the  (hiii^rers  aiv  increased.  I'erforation  may  oceiir, 
the  patient  may  lie  worn  out  hy  the  hectic  fever,  or  anivloid  di-ease  niav 
develop. 

Treatment.  — In  mild  eases  lliiids  should  he  taken  fi'ccly,  particularly 
the  alkaline  mineral  waters,  to  whiih  the  citrate  of  pota>li  niav  lie  adiled. 

The  treatment  of  the  calenloiis  forin  will  he  coiisideicd  later.  Practi- 
cally there  are  no  remedies  which  have  much  inllueiue  iijion  the  pvuria. 
Astriii,i:-eiit,~  in  no  way  control  the  (li>cliai;:-e.  nor  have  I  seen  the  >liulite-t 
lieiK'lit  from  liiichn,  copaiiia,  sandal-wood  oil,  or  iiva  iirsi.  Tonics  should 
lie  ^dveii,  a  nouri.-liin^''  diet,  and  milk  and  Initter-milk  may  he  taken  freelv. 
When  the  tumor  has  formed  or  even  liefore  it  is  perccptihle.  if  the  sviiip- 
toms  are  serious  and  severe,  the  kidney  should  he  e\[i|orcd,  and,  if  iieces- 
sury,  nephrotomy  should  he  [leriornied. 


X.     HYDRONEPHROSIS. 

Definition. — T^ilatation  of  the  pelvis  and  calyces  of  the  kidney  with 
atidjihy  of  its  siihstance,  caused  hy  the  aecnmiilation  of  iion-punileiit  tliiids, 
the  result  of  obstruction. 

Etiology. — 'IMie  condition  may  bo  oon^ienital,  owin.^  to  some  abnor- 
uiality  in  the  ureter  or  urethra.  The  tumor  produced  may  he  laruc  eiiouirh 
to  retard  labor.  Sometimes  it  is  associated  with  other  mall'orinations.  There 
is  a  condition  of  moderate  dilatation,  aiipr.rently  eonjronital,  which  is  not 
connected  with  any  obstruction  in  the  ducts.  A  case  of  the  kind  was  ^liown 
at  the  riiiladelphia  ratliolo^dcal  Society  by  Daland. 

In  .some  instances  there  lias  been  contraction  or  twistinj:  of  the  ureter, 
or  it  has  lieon  inserted  into  the  kidney  at  an  acute  an,i:ie  or  at  a  lii.irh  level. 
In  adult  life  the  conditi<in  may  be  due  to  lodgment  of  a  calenlus^  or  to  a 
cicatricial  stricture  folloM-ing  ulcer. 

New  growths,  such  as  tubercle  or  cancer,  occasionally  induce  hydro- 
nephrosis: more  commonly,  jiressnre  upon  the  ureter  fr(mi  without,  jiar- 
ticularly  tumors  of  the  ovaries  and  uterus.  Occasionally  cicatricial  bands 
comjiress  the  ureter.  Obstnietion  within  the  bladder  may  result  from  can- 
cer, from  hypertrojihy  of  the  prostate  with  cystitis,  and  in  the  urethra  from 
stricture.  It  is  stated  that  .slight  grades  of  hydronephrosis  have  been  found 
in  jiatients  with  excessive  polyuria. 

In  whatever  way  jn'oduced,  when  tlm  ureter  is  blocked  the  secretion  ac- 
cnmnlatos  in  the  pelvis  and  infundihiihi.     Sometimes  aciito  intlanimation 
follows,  but  more  commonly  the  slow,  gradual  pressure  causes  atrophy  of 
55 


i 


^^k 


b'JO 


I.ISKASES  l)F  Tllfc:  Kll>NKYS. 


'. --■-•^r^::l;i;t;;';;;:;;;;t::t;:^:L:^':rL;':."::ii;v 

sac  may  l)o  eiioniioii^,  an  i  (uii.i  .>  rniar.r,.i,i.'m  of  tlic 

*;','    1 ;  ,1,     ;.      .11'.. ■".■.!.;„ ;» «..iii.™i; »  ck-,,,,:.,..! -.".■.-■« 

;:'r;,r.h';.  ;;;'ivi.  ii'...- ..( "-  --  »-■ "- «""'™  -'  "'"""'"■''  -"" 
„  ot  .1.0  ,n;HM;;";;;-  »;;:•„,';;;;;:: :» *:  .,...• .......o  .h...-....,. 

in  early  life.     A^]) nation  aion  hvdi-onci.lirotic  sac  is  fre<iuently 

hvdron.i.l.r.^si.  and  tumor.      1    •  l'^;.^,^;    '''•';  i,,,,,    ,,,,,,,  ,„ol.i  c,  a.ul 
,;i.talu.n  for  ovarian  tun,,.r      ^ -J^*^-,^^^,.;";,^:' .;  l,on,hly.     Tho 

,  i„  cii  •  <lu>  (l('Pi)or  Dortion  oi  tlic  ii'.nio.n   n^i""  »-    • 

rarolv  nils  tin   (uli'i^i   jmih  ,      ,..;,,,,  ,.vi.i-  ilio  renal  tumor,  ami 

.„..„;.ii„,  .,,.„.,  ..,m  ofu.,  ';«;;;;;^'';X"     ,.   ii  Vivo  .,„,...■.»..« 

*»>''*l''^'";:;;;'lj,  :''      ,  l.ll  ...  'l.«™ctor;  the  specific  gravity 

])rej;cncc  ol  cell  elemeni.,  uuy^  ^.^uallv  iire>ont;  ami 

is  low;  albumin  and  traces  ot  ^^'^  !^^  ^' ^^Zn^ I  V^^^^^  ^^  ^^^ 
the  epithelial  elements  in  it  "-y  ^^  ^^^^  ;  n^e  d^acleristie,  since  the 
!;;S  s^r:?i:;;"^^:^rii:r t::Leveral  year,  duration  o.alato 
of  lime  md  »rca  Merc  (.niml.  TO„,liti«n  .if  hyilro- 

rcAaps  tl,e  f-»  ':f;''J"-\  ;:":',,„"; „f  su.Wen  disappear- 

nephrosis  iu  a  movable  kidney,     iiert,  mc  j 


4 


NKPIFROI^ITIMASIS. 


891 


no(iiiii'o(l 

tliL'  ki'l- 
il>  iiu'.'T 
mill  <'i>i>- 
liii.    'I'lii' 

I  iniiy  lit' 
)ritriiftiiiii 
low.  Tlu" 
riic.-t  size, 
lit  1)1'  tlic 
r  li-ll  ^l(lo 

L'ongonital 
miilati'iiil, 
)i,nvs!-ivi'ly 
iuliilt  lil'o 
the  iitonirf 

s  in  wliitli 
jiiaiitity  "l" 
■  jii'iiti'tl  t'oi" 
il  >tri(tui'o 
the  uiiper 
lialed  with 

•(iii('iilir<)si>J, 
t  is  readily 
\n  or  other 

the  kiiliiey 
linal  tumor 
ite  hetweeii 
i  frc(iiiontly 
niohile,  ami 
lohly.     Tho 

tumor,  and 
0  important 
■as^es  the  sac 
:)i(l  from  the 
■t'ific  gravity 
present;  and 

pelvis  of  the 
tie,  since  the 
ition  oxalate 

in  of  liydro- 
■n  disappear- 


iiiicc  of  the  tiinior  with  the  passage  of  a  iar;.'e  (|iiaiitity  of  clenr  fluid  would 
lie  n  jioint  of  great  impoilance  in  the  iliagiio»i-.  in  those  rare  instances 
of  an  enormous  sac  lilling  the  entire  alxlonieii.  iiiid  MHiietinies  mistaken 
for  ascites,  the  character  of  the  (liiid  might  he  the  only  point  of  dilVerencu. 
Tile  tiMiior  of  pyoiiephro>is  may  he  practically  the  same  in  physical  char- 
acteristics. Fever  is  iisiially  jireseiit.  and  pus  is  often  found  in  the  urine. 
In  these  cases,  when  in  douht,  exploratory  puncture  slioiiid  he  maiK'. 

The  outlook  ill  hydnuiephid^is  (le]ieiid«  much  upon  the  ciuise.  When 
single,  the  coiidilioii  may  never  proiliiee  serious  trouhle.  and  tlie  interniit- 
tciit  case-  iiiav  persist  f<M'  years  aid  lliially  disfippear.  OecasioiKilly  the  cyst 
rupture-  into  the  periliuiaiiiii,  more  rarely  through  the  (lia|ilii'agm  into  the 
liimr.  A  reiiiarkahle  ca>e  of  tlii-  kind  was  under  the  care  of  my  colleague, 
Jialsted.  A  man.  aged  twenty-(Uie,  IkhI.  from  his  second  year,  attacks  of 
nhdouiinal  pain  in  which  a  swelling  W(uild  appear  helwecii  the  hip  and 
costal  margin  ami  siiliside  with  the  passage  of  a  larL:e  anioiiiit  <d'  urine. 
In  January,  isss.  the  sac  discharged  through  the  right  Itiiiu-.*  Iicaccumu- 
lations  occurred  on  several  occasions,  and  on  .Iiine  !t,  is'.M.  the  sac  was 
opened  and  drained.  lie  remains  well,  tliough  there  is  still  a  sinus  through 
which  M  clear.  ]ii'ohahly  urinous,  lliiiil  is  discliargcd. 

The  sac  may  discharge  spontaneously  through  the  ureter  and  the  lluid 
never  reacciiniulate.  In  hilateral  hyilrcmcphrosis  there  is  a  danger  that 
ura'inia  may  supervene.  There  are  instances,  too,  in  which  hlocking  of 
the  ureter  on  the  sound  side  hy  calculus  has  been  fcdiowed  hy  ura-mia. 
And,  lasllv,  the  s;',(  may  suppurate,  and  the  condition  change  to  one  ni 
jiyoneplirosis. 

Treatment. — Cases  of  interniittcnt  hydronephrosis  which  do  not  cau.-e 
serious  syni])tonis  shoidd  l>e  let  alone,  it  is  stated  that,  in  sacs  of  moderate 
size,  the  ohst ruction  has  heen  overcome  hy  shampooing.  If  jiractised.  it 
should  1)0  done  with  great  care.  When  the  sac  reaches  a  large  size  aspira- 
tion niav  he  performed  and  rejieated  if  lU'cessary.  Tuiiclure  should  he 
made  in  the  Hank,  midway  hetweeii  the  ilium  and  the  last  ril).  If  the  (Iiiid 
reaccumulates  and  the  .sac  hecomes  large,  it  may  he  incised  and  drained,  or. 
as  a  last  resort,  the  kidney  may  he  removed.  In  women  a  carefully  adapted 
]iad  and  hatidaL^e  will  sometimes  prevent  the  recurrence  of  an  inlermilteut 
liydroneplirosis.f 


XI.     NEPHROLITHIASIS  ih'oxd  falmluf,). 

Definition. — The  formation  in  the  kidney  or  in  its  pelvis  of  con- 
cretions. Iiy  the  do]iosition  of  certain  of  the  solid  constituents  of  the  urine. 

Etiology  and  Pathology. — In  the  kidney  sulistance  itself  the  .repa- 
ration of  the  urinary  salts  produces  a  condition  to  which,  unfortunately, 
tlie  term  infarct  has  heen  a])]ilied.  Three  varieties  may  be  recognized:  (1) 
The  uric-acid  infarct,  Tisually  met  with  at  the  ajiices  of  the  pyramids  in 

*  Sowers.  \p\v  Yorlc  Jlt^ilical  IJoeonl,  1888. 

f  Sue  iUustnitive  ciises  in  my  Lectures  on  Abiloininc.l  Tumors,  1804. 


-     - 


gf^2  DISEASES  OF  THE  KIDNEYS. 

S,„;,I1  gv,lt.v  v«"'l»-l.«.  mwl  >««■.  ,a  ,  ,1,^  ,  ,,;,,„„,,„.    t|,os>  i„ay  be 

rn^wl  in  1l,f  "ri'ii-  I"'  '""8  1'"""'*  »'"""'  1""""  '"-  '"  -     -     ' 

-;  -r!;.*-'»:"' ^"--^^^^^  1,;:'^...,..  .0,. 

^•""^-  .      -,  •  •     J-  f  .oir.nl,i«      The  orifice  of  the  urotor  may  1)0 

(0  The  (len.lnt.c  form  of  ^'^  ^,    "^- ,  JJ^*^^;;!' „,,,  ,,,.  ocnipiea  by  tbo 
l,locke<l  l.y  a  Y-sl.aped  .tone.     ^''^  ^1^^^    .^^^^'^S     These  are  the  re- 
e.mereti.m,  ulueh  forms  a  -o- -  !<;-  ^  f  ^^^^^^  ^..^e  moulds  of  in- 
niarkablc  coral  calaih,  uhuh  lonn  .n  ^"^       ^        ,5,^,  ^^     ,,,,io„s  corrc- 
,,ndn.ula  ana  calyces,  t'^/;;  -;;;;;,^™^^r       tlli^e  Sts  in  stone  of 
r'Z  ;:.lv;:  r:^  blS^f.;;^  mo^iaea  as  nyrtl.  ...sion  prepara- 
^^^^.emically  the  varieties  c.  calcnU  are:  0  )^ic  ac.    1.  ^ar  the  tnost 
important,  .hieli  n.ay  form  the  ren=U  -\^;;^'^'  ,;„„,;, a  the  color 
deidritic  stones.    They  are  very  l^'^^'  'J'  ^,   ''  ^^^'^,;;^  ";,,  ,  ense.    Usually 
reddish.    The  larger  stones  are  usually  ^   ;^\^^  j  ^^^^4^,,,,  ,,„,posed  of 
the  uric  acid  and  the  urates  are  mixed,  but  ui  chiklicn  1 

urates  alone  may  occur.  „n„„.,,v  -Inned  calculi,  studded  with 

,.iS  :;^f  :;:ni'''^^;;'a"r  v=  i^;;^'.  >...o.... .-,  .- 
=b:;inr"^;:f«r=^^^ 

oftencr  deposited  about  the  uric  acid  or  ^'' ^^^'I'^'^Zlun.,  carbonate  of 
(t)  l?arc  forms  of  cal.uli  are  made  up  of  c^.tlnt,  xantniuc, 

lime,  indiuo.  and  nrostealith.  aisciw-ed.     Thcv  may 

The  mode  oi  formation  of  calculi  has  ^'^^  V^^^^^';  ,;,..,, aienf.  sueh 
he  produced  by  an  exeess  of  a  sparui,  y  sdu^J  ^^  \;;;,.^  ,,;,  ,,  , 
as  cystine  or  xanthine;  more  fr  quentl>  ^^  J^'' ^^''^■^■^^  n.i.erts  thus 
verv  acid  urine  .hich  favors  its  ^cposi  u,  J'  ^^^^  ^^^^  ^,^,.,,^^ 
l,,ielly  states  the  conditions  -Inch  lead  0  th  01 ma  on^ 
concretions:  high,  acidity,  poverty  an  ^"^'^^'V,  .'-",„  nav  deter- 
percentage  of  uric  acid.     The  V^^^-^^f^^^^^^^,,,  f^,n  the 


NEPIIKOLITrilASTS. 


S93 


ly  rocog- 
lilicance; 
ininoni;!, 
met  with 
U,  t'onn- 

iccuv;  (") 
lal  grains 
■('  may  be 
yiiiptoms, 

l)oan,  and 
-mailer  of 
'iial  colic, 
av  projec- 

or  may  bo 
leil  by  the 
u'c  the  re- 
ads of  in- 
ions  corrc- 
n  stone  of 
n  ]irepara- 

r  the  most 
ir  the  largo 
d  the  color 
0.  I'sually 
omposcd  of 

lidded  with 
y  hard,  and 

me  and  the 
I  amount  of 
tic  salts  are 
les. 
t-arbonate  of 

They  may 
redient.  such 
ric  acid  in  a 
[{oberts  thus 
the  uric-acid 
m,  and  high 
IS  may  detcr- 
iius  form  the 
[lud  shreds  of 


epithelium  may  form  the  nuclei  of  stom-.     Tlie  qucsilon  of  bacunal  in- 
fection lias  1o  be  considered,  as  in  the  case  of  gall-stones. 

l!enal  calculi  are  most  .•ommon  in  tlie  early  and  later  period,  of  liie. 
They  are  moderately  frequent  in  this  country,  iail  tliere  (h)__not  appear  to 
be  Jpecial  districts,'  corresp(Uiding  to  llie  "  .tone  counties"  in  Kngland. 
:Men  are  more  often  alfected  than  women.  Sedentary  occupations  seem  to 
])rcdispose  to  stone. 

Tlie  elVects  of  the  calculi  are  varied.  It  is  by  no  m.ans  uncommon  to 
find  a  dozen  or  more  stones  of  various  sizes  in  tlie  calyces  without  any 
destruction  of  tlie  mucous  membrane  or  dilatation  of  the  pelvis.  A  tur- 
bid urine  fills  the  pelvis  in  which  there  are  numerous  cells  from  the  epi- 
thelial liniim.  There  are  cases  of  this  sort  in  which.  api)arently,  the  stones 
may  go  on  'forming  and  are  passed  for  years  without  seriously  iin])airing 
the' healtli  and  without  inconvenience,  except  the  attacks  of  renal  colic. 
Still  more  remarkable  aie  the  cases  of  coral-like  calculi,  which  may  occupy 
the  entire  pelvis  and  calyces  without  causing  pyelitis,  but  which  gradually 
lead  to  more  or  less  induration  of  the  kidney.  Tlie  most  serious  ell'ects 
are  when  the  stone  excites  a  suppurative  pyelitis  and  pyonephrosis. 

Symptoms.— Patients  may  pu^s  gravel  for  years  without  having  an 
attack  of  renal  colic,  and  a  stone  may  never  lodge  in  the  ureter,     in  otlur 
instances,  the  formation  of  calculi  goes  on  year  by  year  and  the  jiatient  has 
recurring  attacks  such  as  have  been  so  graiihically  described  by  Montaigne. 
in  his  own   case.     A  patient   may  pass  an   enormous   nnnilier  of   calculi. 
Some  years  ago  I  was  consulted  by  a  commercial  traveller,  a  i  extremely 
viL'oroiis  man!  who  for  many  years  had  had  reiieated  attacks  o.  renal  colie, 
and  had  jiassed  several  hundred  calculi  of  various  sizes.    His  c(  llection  idled 
an  ounce  bottle.     A  iiatient  may  pass  a  single  calculus,  ami  never  be  trou- 
bled auain.     Tlio  large  coral  calculi  may  excite  no  symptoms.     In  a  re- 
markable specimen  of  the  kind,  presented  to  the  :ilceiill  Medical  Museum 
by  J.  A.  Macdonald,  the  jiatient,  a  middle-aged  woman,  died  suddenly  with 
ura'inic  symi)toms.     There  was  no  pyelitis,  but  the  kidneys  were  sclerotic. 
Jlcuai  rolir  ensues  when  a  stone  enters  the  ureter.     An  attack  may  set 
in  abruptly   without  ajiparent   cause,   or  may   follow   a   strain    in   lifting. 
It  is  characterized   by  agonizing  i)ain,   which   starts  in   the  Hank   of  the 
alTected  side,  passes  down  the  ureter,  and  is  felt  in  the  testicle  and  along 
the  inner  side  of  the  thigh.     The  pain  may  also  radiate  through  the  ab- 
domen and  chest,  and  be  very  intense  in  the  back.     In  severe  attack<  there 
are  nausea  and  vomiting  and  iV.2  patient  is  collapsed.     The  iieispiration 
breaks  out  upon  the  face  and  the  pulse  is  feeble  and  (piick.     A  chill  may 
])recede  the  outbreak,  and  the  temperature  may  rise  as  high  as  Ui.r.     No 
one  has  uuiro  graphically  described  an  attack  of  "the  stone"  than  Mon- 
taigne,* wb.o  was  a  sulTerer  for  many  years:  "Thou  art  seen  to  sweat  with 
]iain,  to  look  ])ale  and  red.  to  tremble,  to  vomit  well-nigh  to  blood,  to  sulfer 
stranue  contortions  and  convulsions,  by  starts  to  let  tears  drop  from  thine 
cyes.'^to  urine  thick,  black,  and  fnghifiil  water,  or  to  have  it  suppressed 
by  some  sharp  and  craggy  stone,  tliat  cruelly  jiricks  and  tears  thee."     The 


*  Essays,  Book  III,  13. 


^^ 


DISEASES  OF  THE  KTDNEYS. 


804 

•  f  W  n  v,r-nl)lo  Porio.l.     In  short  attncks  tlioy  do  not  last 
syniptoins  i.orsi>t  for  a  ^. m.        F  ^.^^   ^   ^i,^.   .„. 

longer   than   an    >-"'';,   y^'lj^.^^'^^t  Lqu.nl,  occasionally  rainful, 
,i„.n..  w.tl.  tcMnporary  f  l'!'f-   ,^^'\\*"' ,,1      '  \,,    nstancos  in  wlmh  a  largo 

-'  '";■  ^';X;r;ri.;:t  ;:^ 'rpn-lJllu-^irl  li;;! other  kidney      In  rare 

junount  <it  elear  iiiinL  i>  jm  hc      i  ,  ;  i         „  ^heii  the  kidmy 

.  ti,..  <,.<.ivli(>n  of  ur  ne  is  comijlotely  suppiesf-cu,  l\lii  . 

Ktruetion  r  ,,,i;„  i,,mv,<<rd  there  is  more  or  loss  aching  on  the 

'""■';; W',n-„.  „™»1U-  in  llH.  l».,k.  wln.l,  in  .,/„.„  „o  more  *'--  f;";,-- 

nstanees  m  which  tlie  pam  nas  i.;,i„..,.c    nnd  there  are  several 

!:;;;T;::,r:.r' r,;'^:S,..:.ij  ^^'-^'v"-;- :r" '" "  ™"' 

hv  fever,  in  which  the  temperature  ma     i^      10^   ot  ^^^_^^.^^ 

Attacks  of  this  description  may  recur  at  mtenal.  loi 


NEPHROLITHIASIS. 


805 


o  not  Li^^t 
a  (lny  <ir 
y  ituinrul, 
i-li  a  liuge 
.  Ill  rare 
tho  kiilncv 
nia.  Tliiri 
\-  (lisoasi'd, 

kMid  liavt! 
u  ilobert-, 
rossL's  both 
lay  not  ap- 
Jovelop  for 

sometime:* 

nor  coma. 

c'l"  the  ol)- 

iiing  on  tlu! 
'y  the  stone 
A'ery  rarely 
is  common, 
le  abdomen, 
A  a  grating 

very  definite 
le  most  im- 

a  dull  sorc- 
is  usually  on 
Liid  there  are 

side.  Pain^i 
e  are  several 
ley  for  stone 

for  a  couple 

len  the  stono 
he  stones  are 
bi"t  in  some 
exeriiou  and 
ky  line.     The 
irolor.gt'd  ride 
(luanlities. 
the  back,  not 
chill  followed 
\  followed  by 
become  turbid 
m\  the  pelvis, 
ouths  or  eveu 


years,  and  are  generally  mistaken  for  malaria,  unless  special  attention  is 
paid  to  the  urine  and  to  tiie  existence  of  the  pain  in  the  back.  'I'liis  renal 
intermittent  fever,  due  to  the  presence  of  calculi,  is  analogous  to  the  iic|)atic 
intermittent  lever,  due  to  gall-stimes,  ainl  in  both  it  is  important  to  remem- 
lier  that  the  most  intense  paroxysms  may  occur  without  any  evidence  ol' 
sii}ipuration. 

{b)  More  frequently  the  symptoms  of  purulent  iiyclitis,  whieii  have  al- 
ready been  (k'scrii)cd,  are  present;  imin  in  the  renal  region,  recurring  chills, 
autl  iiiis  in  the  urine,  with  or  without  indications  of  pyonephrosis. 

(1)  J'niirid. — 'riicre  are  instances  of  stone  in  the  kidney  in  which  pus 
occurs  ciintinuously  or  intcrinittcntly  in  the  urine  for  many  years.  On 
many  occasions  between  IST.")  and  iN.sl  1  examined  the  urine  of  a  physician 
who  had  ]iassed  calculi  when  a  student  in  181:.,  and  has  had  pus  in  the 
urine  at  intervals  to  18!)1.  In  si)ite  of  the  prolonged  suppuration  he  has  had 
remarkable  mental  and  bodily  vigor. 

Patients  with  stone  in  the  kidney  are  often  robust,  high  livers,  and 
gouty.  Attacks  of  dyspejisia  are  not  uncommon,  or  tlu'y  may  have  severe 
headaches. 

Diagnosis.- -IJeual  may  be  mistaken  for  intestinal  colic,  particularly 
if  the  distention  of  the  bowels  is  marked,  or  for  biliary  colic.  The  situa- 
tion and  direction  of  the  pain,  the  retraction  and  tenderness  of  the  testicle, 
the  occurrence  of  luvmaturia,  and  the  altered  character  of  the  urine  are 
distinctive  features.  Attention  may  again  be  called  to  the  fact  that  at- 
tacks simulating  renal  colic  are  associated  with  movable  kidney,  or  even, 
it  has  been  supposed,  without  mobility  of  the  kidney,  with  the  accumu- 
lation of  the  oxalates  or  uric  acid  in  the  pelvis  of  the  kidney.  The  diag- 
nosis between  a  stone  in  the  kidney  and  stone  in  the  bladder  is  not  always 
easy,  though  in  the  latter  the  i)ain  is  ]iarticularly  about  the  neck  of  the 
bladder,  and  not  limited  to  one  side.  Jmportant  jioints  are  the  reaction 
of  the  urine,  which  in  stone  in  the  bladder  is  almost  invariably  alkaline, 
and  the  abundance  of  mucus  with  the  ]ms.  It  is  stated  that  certain  ditfcr- 
cnces  occur  in  the  symiitoms  produced  Ijy  dilferent  sorts  of  calculi.  The 
large  uric-acid  calculi  less  frequently  produce  severe  symptoms.  On  the 
other  hand,  as  the  oxalate  of  lime  is  a  rougher  calculus,  it  is  apt  to  iiro- 
duce  more  pain  (often  of  a  radiating  character)  than  the  lithie-acid  form, 
and  to  cause  hannorrhage.  In  both  these  forms  the  urine  is  acid.  The 
phosphatic  calculi  are  stated  to  produce  the  most  intense  pain,  and  the  urine 
is  commonly  alkaline.  In  a  few  cases  the  Kuentgeii  rays  have  been  of  use  in 
determining  the  presence  of  a  stone. 

Treatment. — In  the  attacks  of  renal  colic  great  relief  is  experienced 
by  the  hot  bath,  which  is  sometimes  suilicient  to  relax  the  spasm.  When 
the  pain  is  very  iutense  morjihia  should  be  given  hypodermically,  and  in- 
halations of  chloroform  may  be  necessary  until  the  eil'ects  of  the  anodyne 
are  manifest.  Local  applications  are  sometimes  grateful — hot  poultices,  or 
cloths  wrung  out  of  hot  water.  The  jiatient  may  drink  freely  of  hot  lem- 
onade, soda  water,  or  barley  water.  Occasionally  change  in  posture  will 
give  great  relief,  and  inversion  of  the  patien*^  is  said  to  be  followed  by  im- 
mediate cessation  of  the  pain. 


I 


■MMta 


89G 


DISEASES  OF  THE  KIDNEYS. 


avoi.linK  ^"'1'1'»  "^'•'•^":"      ,       l'!!     ;».!    in  a  maiuritv  of  tlie  case.,  alka- 

,.„,„t  is  to  k....i>  the  uv,no  f  ^'-1     \;'  •;;  :;;,,,t  idinite  quantity  of  min- 

-P,„,  j,„ient  should  .Innk  <1'',1>  •''''-  .ati4acto rv.     The  citralo 

.,^,  ,,,,,„  *  or  aistilU-l  .aler.  .  hu-h  ..  ju^  ^^^^^    !    ,i„,  j,,  the  back  aro 

;fi:v^;rs:;;:;KrtSo;::iMa;:a,  o,.  oau.  nuncna  spnn.s  ^  th.  couu. 

'trv.  or  at  Vichy  or  Kms  in  J^i'iyi'^"-  j^      ^    ^^,.,t  inaicatod  in 

the  early  sta-cs  ..t  jiout      Su         U  n  ^^^  ^.^^^^^^  ^^^   ^^^^^^  ,, 

,,  the  solvent  t''''^''"^^'"  .^"^"'r''  1  '  ,hni  every  three  hours  in  a 
,ivc.n  in  lar,e  doses,  ha  f  a  f  ™f  ""^^^  ."^  '^',  oral  n>onths.  1  have 
UuuhU.rlul  or  .ater.  Uus  ^^^^''Jl^l^^^,,,  ,,„,iders  the  character 
had  no  success  with  tins  ^^^  '^^  " J  ;  ^^  ,,  /,  ianov,  does  it  seenx  likdy 
-'  the  uric-acid  stones  usu  ^  ^  ^^      \  ,,„;,  ,,,  changes  in  the 

i;;::;-:,;;;!-::;;;;;:;  :i:;l;lA:^:;>a;Kionei  r.  ti. ...  hecon>es  a.. 

•'-;;:;;:\...e  or  pi..ra.ue  as  a  sol^^ 

stones  has  heen  nuuh  discussed  ol  l^K       ^  ^,,,  „„„u„t  ex- 

.olution  of  the  drug  l>as  tins  1--  ^  ,^  ,.  ;^;^^  ^  ,f  ,,  ,.uns  daily  seems 
ereted  in  Hie  urine  as  gnen  ni  the  -fr'l^;  ,^^^^.^,  ^,,^^  that  the  per- 
to  have  very  li^tl-nlU-n-     ^;-;^  ^  -;;;;,„  ^^,^^„,  ,,  ^oses  of  from 

,.„tage  or  Pil---X    *t^,^    ;;Liae  ot  the  body,  Uttlo  ur  no  hdlueueo 

1  to  'i  <'raniu\es,  lla^,  \mhii  i^- i--^ 

asasorvenld'awcett.Gordon). 


Xll'.   TUMORS   OF   THE    KIDNEY. 

,.         i      Of  llie  bcnisn  tumors,  the  most 
Tbese   are  ^'-'^^j-^^;;  ^^^    j.,^^  Jj-cht^.r  frequently  h.  the 
conmu.n   are  the  smal     nodular  /<0  ^^^  described,  and  occa- 

,,,„ias.  the  aberrant  '"''•'■"      ;^^^,  The  adcunnata  may  be  con- 

'ionally  Ul>o,na,  au,u,mu  or  ^^  '^  ^ ^J  ' ;^,.,  ,,,,tlv  enlarged,  contamed 
genital.  In  one  ot  n>y  cases  '^''2^^;^^^,^;.,  ihn)ughout  both  organs. 
;nudl  cy>ts.  an.l  numerous  "'^^'■•*'"^^  "  ,  ^,,,  ,„  eitl^r  primary  or  sec- 
Maligna.it  growths-a,mrr  or  '"^'"^J^^^^^,,  .ivoolar  sarcoma  or 
ondarv.  The  sarcomata  nr.  the  --^  "  ^^^^  tibres-rbabdo-myoma. 
tlu-  reuuukahle  form  -^f  ^'"'"^.^^Xldr  n  G.  Walker  (Annals  of  Sur- 
?-  SnriL^:;;rd^r;He::tri^  the  sublet  to  date.     Carcmoma 

ts  le.  frequent,  andis  of  |;;-;-i:;-:-^n;::^\;f  n.v  cases  the  left  kidney 
:',        ^  1 ,.  ,n-  thThiitorv  ropovts,  are  as  potent  ns  the  waters  of 


Ul 


TUMORS  OF   TIIK    KIDN'KY, 


S'.tT 


uit^l  life, 
he  treat- 
ies, iuka- 
•  of  inin- 
le  citrate 
baek  are 
lelit  I'rniu 
hiri  couu- 

ilieated  in 
ij;  known 
potash  is 
loiirs  in  a 
s.     1  luno 
>  charaetcr 
wm  likely 
.•■es  in  the 
eonies  am- 

it'  iiric-aeid 
ly  a  watery 
amount  ex- 
daily  seems 
lat  the  por- 
ses  of  from 
no  iuiluence 


rs,  the  most 
ently  in  the 
d,  and  occa- 

may  bo  con- 
ed, contained 

both  organs, 
imary  or  sec- 
\r  sarcoma  or 
labdo-myoma. 
nnals  of  Sur- 
^     Carcinoma 

he  left  kidney 
Iron  they  may 

t  as  the  waters  of 


rearli  an  eiioriiious  size.  Morris  stales  thai  in  a  Ipoy  at  the  Midiliesex  llos- 
iiital  tlu'  tiiniiir  weighed  ;>!  |ioiin(ls.  'I'l'i'V  i:r(iu'  rapiilly,  ai'e  often  suit, 
jiiid  ha'niorrliaj;!'  Irecjuentiy  lakes  place  n  them.  In  the  sarcomata,  in- 
vasion ol'  tlu'  pelvis  or  of  the  renal  vein  is  eoniinon.  'I'lie  rhalfilo-inyomas 
rarely  form  very  lar;.;-e  minors,  and  death  oeeiirs  shortly  after  hii'th.  in  one 
(d'  my  eases  the  child  lived  to  the  a^e  (d'  three  years  and  a  half.  'I'he  tumor 
Lirew  into  the  renal  vein  and  inferior  cava.  .\  delaehed  fra;;inent  passed 
as  an  emlinliis  into  the  pnlmonary  artery,  and  a  purtidn  (d'  it  liloeked  the 
tricuspid  oiilice. 

Symptoms. — The  lollowin,^'  are  the  most  important:  (1)  Ihematuria. 
This  inav  l)e  the  lirst  indication.  'i"he  hlood  is  lliiid  or  clotted,  and  there 
mav  lie  verv  eharacteris'ic  nionlds  of  the  pelvis  of  the  kidney  and  of  the 
ureter.  Jt  would  no  doiiht  he  possihle  for  such  to  form  in  the  ha'iiiatiiria 
from  calcnius,  hut  1  have  never  iiu't  with  a  ea<e  id'  hlood-casts  of  the  pelvis 
and  of  the  ureter,  either  ajoiu'  or  together,  except  in  cani'i'r.  It  is  rare 
indeed  that  cancer  (dements  can  he  recognized  in  the  urine. 

(•1)  Pain  is  an  niut'rtain  symptom.  In  several  of  the  largest  lumiiis 
which  have  come  under  my  oh.^crvation  there  has  heeii  no  discomfort  from 
heiiinning  to  (dose.  When  present,  it  is  (d'  a  dragging,  dull  character,  situ- 
ated in  the  Hank  ami  radiating  down  the  thigh.  The  passage  (d'  the  (dots 
mav  cause  great  pain.  In  a  recent  case  the  growth  was  at  first  upward, 
and  \he  svmptoms  for  some  months  were  those  (d'  pleurisy. 

(:')  J^'ogressive  emaciation.  The  loss  of  llesh  is  iisnally  marked  and 
advances  rapidly.  There  may,  however,  he  a  very  large  liiinor  without 
emaciation. 

Physical  Signs. —  in  almost  all  instaiu'cs  tumor  is  ]U'esent.  When 
small  and  on  the  right  side,  it  may  he  very  movahle:  in  some  instances, 
oecuiivinn-  a  position  in  the  iliac  fossa,  it  has  been  mistaken  for  ovarian 
tumor.  The  large  growths  fill  the  Hank  and  gradually  extend  toward  the 
middle  line,  occupying  the  right  or  left  half  of  the  abdomen.  Inspection 
mav  show  two  or  three  hemispherical  projections  corres|)omling  to  dis- 
temled  ■sections  of  the  organ.  In  (diildren  the  abdomen  may  rea(di  aii 
enormous  size  and  the  veins  are  pronnnciit  and  distended.  On  himanual 
paljiation  tlie  tumor  is  felt  to  occui)y  the  lumbar  region  and  can  usually 
be  lifted  slightly  from  its  lied:  in  some  cases  it  is  very  movahle,  even  when 
larg(>:  in  others  it  is  fixed,  firm,  and  solid.  The  respiratory  movements 
have  lint  slight  influence  upon  it.  Rapidly  growing  renal  tumors  are  soft, 
and  on  pal]i:ition  m;;y  give  a  sense  of  lluduation.  .\  |)oint  of  considerable 
im])ortance  is  the  fact  that  the  colon  crosses  the  tumor,  and  can  usually  he 
deteeteil  willuuit  ditlicnlty. 

Diagnosis.  —  In  (diildren  very  l;M'tre  abdominal  tinmu's  are  eillier  I'eiial 
or  retroperitoneal.  The  retrojieritonea;  '-.areoma  (Lohstein"s  caiU'cr)  is  more 
central,  but  may  attain  as  large  a  size.  If  the  case  is  seen  oidy  tow;ird  the 
end.  a  differential  diagnosis  may  be  impossihle;  Inil  as  a  rule  the  sarcoma 
is  less  movable.  It  is  to  be  rememliered  that  these  tumor-  may  invade  the 
kidney.  On  the  hd't  side  an  enlaruvd  spleen  is  readily  distingtd.-hed,  as 
the  edge  is  very  distinct  and  the  notidi  or  not(dies  well  marked:  it  descends 
(luring  respiration,  and  the  colon  li"s  behind,  not   in   front  of  it.     On  the 


■^ 


sits 


DISKASKS  OK   TUK    K11>NKYS. 

zirr;:::i::::":"'----^       -' ' 

i,  incl.iscimi..n  wilhtlu' liN>'i.  .  ,|,,,,,.,,iiv..  mul 

A "^' '  ^■';:'"„;;:  ;::;;:?,;;<    .^<.i;' "-■  ■'■'"■  ^'-  "- 

s;';;;:S'"Mi^^ ;' "-i -- >  u. ......v. ....  .^<  .^^ • 


XI 


„.    CYSTIC    DISEASE    OF   THE    KIDNEY. 


persons   an.    y.t  "*'    ^   ;  ^^;'i„  ^i,.,  ^,,.„;  „  .narbl.  to  an  ovan,..  nr  osm 
(■>)  Solitary  c\>l>.  lanuin     in  .hv^hU  no  otlu'r  rlian-vs. 

,„.,„, ....  o--;'«;;;>';y.^'-:  ';;,;■  :::';;;';.Liacra.,e  si...  N.wn>an 
l;;;:^;:r;;;;t:::i;i;'^  '^'"--"" " 

probability,  rcsnlt  from  "'-^•■>';-^ ';';;;         -,,,  „,;,  .enmrkal.U-  condition   the 
(^•)  '^''-  ^•""^^'■•'f /,W  :\  ;  n;.ra  ion  of  .vsts,  varyin,  in  si.,  fnan 

l<i'l>-X-^-''**''7r"^^;i,      .,:!:„.  .r^ath-  .nlargd,  an.l   to^etlu.  n.ay 
■'  1"'^'  "'  '  '""'  n     lu'ro'tus  tlu.v  n.av  attain  a  si/.,  sull.cient 

wri.^U  (i  or  more  p<.un.l>.     In  tin     <  .         ;      ,,i^.^  allhon-h  in 

to  inMunle  lahor.  ^.l'i^^'VV':;r  i    -ll^Ulen^ble  an.ount   ren.ains   in 

nueroscopieal   sections  it    '>  .  ,„.  ^,,,,,,1^  lU.i.l.  son-etinies  red- 

tho  inters,uuvs.     '1  luj  <•  >t>  -'"*''      ■\,,  ^„.,,  ,,,  ,f  ^  eolloi.lal  eonsislen.e. 
ai.h  l.r..wn  or  even  blaek.s  h  me        -       ;>    '  ,,,      i„,.„  „,i  fat  drops 

Allnunin.  l.lood  -T^^f  ■;      f        ' nd       i       .id 'are  rarely  present.     Tho 
are  fou.,d  in  tlu.  content.     \     '    ;  j,  ;,  ,,,  vet  aeenrately  known 

eysts  are  lined  ^'X  .  ii^>  tened       .t   o  n  n^^^^^^^  ^^^  ,,,;,,. ,p,„ent  rather  than 
hovv  thc'so  cysts  or.pnato.      .  ";'    \  ,.\|,..  f,,t  il,at  in  the  en.hryo  it  is  often 

a  pathological  clumgc  ,s  -^^^'^^^^^X  inM>c-rforate  anns.     Both  Shat- 
asseciated  with  other  an.Hnahcs^M^tuU^  ^^,.^^^^  ^  ^^_,^,,.^^„^._  ^^^^.^.^ 

i„,U  and   Bland  Sntton.  who  ^    -;  ^^\'    ^  IJ.^^  ^.f  ,.,„,,i,tc  ditVcrentia- 
„„t  the  anonndv  of  'l-eloinne       .^   n     hc^  t^  ^  ^^  .^^^^^    1  .^^^  ^^^^_  ^.^^^^^^ 

,„„  ,,  the  Wolilian  bo  .es.  ^^        ^    ,  '  ^,„,,,,,  ;,  ....enital.  vet  from 
;:;;%;d  n^^fo!::,  tirS^^e.^:^---  ahnom.!  on  ear,..l 


CYSTU'   DISKASK   (tl'    TIIK    KIDNKV. 


8!>l) 


li  rciuil 
tcclrd  11 
iliul  tllCi 
ll    tUlllOl" 

live    llIul 

icat  iii'i- 
miiialiitii 

1  iunl  the 

1.  Imt  tlio 

Walker). 


ic  chnimc 
r  of  J)ii\v- 
whiili  tlio 
(ir  cldi'i'ly 

;■('.  or  even 

•  Y  cliaiini'^. 

Xi'Winaii 

too.  in  all 

iililiou  the 
II  size  I'l'oiii 
i^H'ihcr  may 
'A'  suiru-ieiit 
illhouuh  in 
roniaiiis  in 
letinu's  ivd- 

COllriislt'lU'C. 

ul  fat  drop-' 
•osent.  'ni«> 
ati'ly  known 

rather  than 

,•0  it  is  often 

Both  Shat- 

:ully.  belie  x- 

p  diiVerentia- 

the  kidneys 
tal.  yet  from 
nerease  enor- 
tlaiid.  :\re..  a 
al  on  eareful 


<'\ainiiialion  three  year.-  hefore  hi>  dealli,  hut  ihree  inontli-  jUMr  to  this 
dale  llieri'  wei'e  lar;:('  hilateral  tinnois  in  the  renal  reeions.  whieli  were 
readily  ihajiMosed  a>  ey>tie  kidney^.     'I"he  orean.-  weiLrhed    1  pouniU  eaeh. 

Ill  a  large  majority  of  the  ea-es  death  occurs,  either  /'//  iilcm  or  shortly 
after  hirth;  bill  iii>tances  are  niel  with  al  all  a-c>  up  to  fifty  or  >i\ty.  and 
I  see  no  reason  to  suppose  tliat  lhe>e  an'  not  in.-lauee>  of  |)er>istenee  of  the 
eoiie-eiiital  form. 

ill  the  adult  the  tumors  may  he  felt  in  the  lundiar  region  as  large 
nuinded  iiia>ses. 

Tlie  siinipliiiiis  are  ihoi-c  of  chronic  interstitial  nephritic.  Many  of  liie 
ea.ses  have  presented  no  indications  whatever  until  a  sudden  attack  id' 
iiru'iiiia:  others  have  died  of  heart-failure.  .V  rare  teinnnalioii,  as  in  a  ease 
at  tile  rniversily  Hospital,  I'hiladelphia,  is  the  ru|itiire  of  one  (d'  the 
cytits  and  the  proiluction  of  a  perinephritic  ahscess.  The  cardio-va>eular 
changes  induced  are  similar  to  tliosi'  of  interstitial  nephritis.  The  left 
ventricle  is  hyperlrophied  and  the  arterial  tension  is  greatly  increased. 
The  condition  is  eompatihie  witli  excellent  health,  iiieinaluria  may  occur. 
The  dangers  are  those  associated  with  chronic  Uright's  disea.se.  It  is  im- 
portant to  reiiieiiii)er  that  the  coiigloiiicr.-ite  cystic  kidney  is  almost  in- 
variahly  liilateraj.  One  kidney  may  he  somewhat  larger  and  more  cystic 
than  the  other. 

'I'iie  diagnosis  can  sometimes  lie  made,  (ireat  enlargement  of  holli 
organs,  with  liy|)ertropliy  of  the  left  heart  and  increased  arterial  tension, 
would  suggest   the  condition. 

Operative  interfei'ence  is  not  jusliliaiile.  1  know  of  an  instance  in 
which  one  kiiliiey  was  removed  and  the  patient  died  within  twenty-four 
hours. 

(1)  Occasionally  tiie  kidneys  and  liver  present  mimerous  small  cysts 
seattereil  through  tlu'  siihstance.  The  spleen  and  the  liiyroid  al>o  may 
he  involved,  and  there  may  lie  congenital  malformation  of  (he  heart.  The 
cvsts  in  the  kidney  are  small,  and  neither  so  iiiimeroiis  nor  so  thickly  set 
as  ill  the  conglomerate  form,  tlimigh  in  these  eases  the  condition  is  proh- 
alily  the  result  of  some  congenital  defect.  'I'here  are  eases,  however,  in 
which  the  kidneys  are  very  large.  It  is  more  common  in  the  lower  ani- 
mals than  in  man.  I  have  seen  several  instances  of  it  in  the  hog;  in  one 
ease  the  liver  weighed  U)  pounds,  and  was  eonverled  into  a  mass  of  simple 
cysts,  '^riie  kidneys  were  less  involved.  Charles  Kennedy*  slates  that  he 
has  found  references  to  \'i  cases  (d'  eondiined  cy-tie  disease  of  the  li\er  and 
kidneys. 

The  eohinneoeoiis  cysts  have  heeii  descrihed  under  (he  section  on  para- 
sites. l'araiK'])lirie  cysts  (e.vternal  to  tlu'  capsule)  are  rare:  tiu'v  may  reach 
a  larye  size. 


*  Laboratory  Keports  of  the  Royal  College  of  Physicians,  KcUuburgh.  vol,  iii. 


^^k 


you 


DISKASHS  OF  TIIK    KIDNF-YS. 


XIV.     PERINEPHRIC    ABSCESS. 

.•       ,1    n..  •il.out  tlif  ki<liic'V  may  I'oUow  (1) 

„„„,  .ununnnly  tlu'  aiMH'i"l.x.  '  \  .  '\     .^„    ,„,  ,■,,„„  tlu'  pl.'ura,  as  in  .m- 
.   (:.)asaM.Mm4u    (iH.t.NMN  ■  ,,,^i,„i,,iy  at  th.^  pos- 

t-ior  ,nn-t.  tln.n.h  .1..  ,.us  njay  ;'»  i;;;!^;  '  ^,,,,  ,  ,„.,„siv..  Tlu-  ,u,s 
,„„1  t|„,  pnitona'nni.  I  snaliN  "'  '  .  ,  ,-  ;,  ,„i„,  r,,.m  cnntact  witli 
i,  .,■„„  olTcnsiv.  a.ul  -'V'^'-;' .f  !  ^  ^  ,;,i.>ns  an.l  l.uvst  into  tin- 
„„  ,,,,,  ,,..v.l.  It  -y  »;■  ;;  -  ;  ;;  .,  „„.,,  r,.,.,u..nt  direction  .s 
and  1.C-  .lisc.lnn^.d  1"'"  f '  ^  ^^'  ^  „,,  .,,i„,  „>■  it  n.ay  pas.  alon« 
|,„,„  uu.  psoas  n.us.l.,  wl-.n    t  •;.';,.,.,„;„„.     „  ,„ay  p.-Torato  t  u- 

i::-:^:;;;,;::;:  ;:-;;;-;-•- '--^ ^in.s.tp..t,.at.st.u.dadd,.,. 

in  wln..h  tlu.  tatty  .apsuU.  <  1     >  >^  ^,,^„  t,,,  ,„,.j„.,.  .apsul.  w,th  tl.o 

bands  ot  lil.rous  fssm.,  and  -',,,„,,„  ....Uurs  no  syn.plou.s. 
.,,,,,,ost  .lilV.rulty.     Mich  a  ^"'^  "  '  pain.  afT-ravaU'd  by  p.vssu.v.    n 

^     SymptomS.--'l  U.V  -nay        -  -■  ;    ;;„^^,,  ^;  .„,,,„„.  without  pajn 

"-■  """'""■  '"-""•      "  '         n^m  si-n,s  of  .U..p-sc.atod  suppuratu.n  n,ay  b 
th.  .vnal  reg.o.u  ":»  l'^  "     ^        ;;;\,.„ailv  pain,  whicb  n>ay  b.  nd.nvd 
,i..t(.cted.     On  tbi-  allVctcd  sido  tbcR  i>  u.  "-'    .    1  .  ^..^^^j.^^^,  ,!,„,.„ 

';,:\..i,bbovh..od  or  t>H- lHlHo.n    or    ;.  -^  j^.^      ,,,„^.  „,,,,t  U.s 

„,,  uu,h  a.d  In-  assouatcd  -  ^         ^  „,„,,,.  ,„.,  i„  .alki.n:  ti>-ows, 

^vitl,  tbr  thi.h  tb.Nc.l.  so  as  \'V*'''>\    ;\   ,„„,i„  ,,..-.     Tlu"  i-aticnt  l<oc.ps  the 
as  tav  as  possii>lo.  tbo  -^';;^;;;;„;;'  ;;;ir:  i^  .^kin,.  and  has  ,>vat  ddb- 

TluMv  may  be  pns  "\^^-'^"  ""^    ''     u^,  „,i„e  is  cU'ar.     Whon  pus  has 

,,lvi.  ..,.  tlu.  kidney,  but  -  ;;   -  J     "    ,^;  ,;;;.  ^.v..  and  s.oat.     On  cx- 

ornu'd  thcTo  arc  ^>^";'1'>' ;'''',,;    .i.Jt  i^twcon  the  last  rib  and  tlu-  crest 

:yt.  orpuniness  ot  tl^o  J^;-/;;;;;:;;t^,^r:;^;  Uu-  aspirator  ueedle 
The  ^lu.jno.'^  -^  '"'"   \     w"       di  V.Mvutiate  the  primary  fom.s  trom 
.„ould  l>e  used.     We  eamujt  ';1>;;^ ',,.,,„,.   ^l^is.  however,  njakes 
tl,o.e  due  to  perforation  of  the  k  dn.  >  o     '  ,^,„         ,sdde  by 

l-t  liitlo  diiVereuee.  for  the  i;-^-;;  [^       ^         \,.  vertebra.     In  children 
t,,,istory  andexauumamn    o  -  -^   ^^  .^  ,.^,„„,,  ,,,  Uu-re  .s  no 

j.lness  or  teuderne.s  m      ^  '       M  ^,„.-,      ,„„H.nt  dra.naj^e. 

The  hrahiiciit  is  cleai— c.ni>. 


)llo\V     0) 
Jiclvin    til' 

11'  howi'l, 

Xll'IlsiDll 

IS  ill  I'ln- 

thc  !)"'<- 
\e  kiiliu'V 

Til."  inis 
itiict  with 
:  into  tlu- 
ive'ction  is 
puss  uloIl^^ 
I'orato  till- 

111'  1)liUlili'l' 

riiiopliritis 
iimiK'riius 
\v  with  the 
|)louis. 
H'cssurt'.  ill 
itliDiit  jiiiin 
[ion  may  he 
1)0  i-i't'crrcd 
uliato  down 
patient  lii'S 
villi:  throws. 

,t    kcH'llS    till' 

i  o-rcat  (lilli- 

,.(1  I'roni  till! 
hen  pus  has 
iits.  On  I'X- 
inil  the  crest 
luinor   mass. 

ivator  noi'dli' 
•  forms  from 
iwover.  malsos 
ly  possilili'  liy 
In  (>liil(lron 
1(1  there  is  '>" 


SKCTION    \. 

DISEASES  OF  THE   NEliVOUS  SYSTEM. 

I.     GENP:RAL   INTIiODlCTION. 

In  (li>eases  of  till'  nervous  system  it  is  of  the  jireatest  iuiportaiire  to 
kiKiw  aiiiirately  tlie  p<.sitioii  of  the  iiioriiid  process,  and  here,  even  in<.re 
than  ill  the  otlier  (K'paitineiits  of  niedieine.  a  thoroii-h  knowhMl-e  of  anal- 
(Miiy  and  physiolo-y  is  es>eiitial.  For  lull  (htails  the  stinU'iit  is  ivferred  to 
tiu"te\t-liooi<s  on  tile  suhjei't,  as  it  is  not  possiide  to  «hi  more  tlian  toueh  on 
the  sniijeet   in  this  place. 

IJec'eiit  studies  iiave  luoditied  nuv  conceptions  of  tile  rnndamenlal  struc- 
ture of  tlie  nervous  system.     .\t   |iresent   we  tiiiiik  of  it  as  a  eonihinatinn 
ol'  an  immense  niimher  of  units,  called  iiriinnirs.  ail  havin--  an  essentially 
.-iinilar  structure,    i'lacli  neurone  is  composed  of  a  cell  hody.  the  protopla>mie 
processes  or  demli'ites,  and  the  a.xis-cyliiider  process  or  axonc.     'I'he  nutri- 
tion of  the  neurone  di'peiids  in  larac  part   upon  the  ((mdition  of  the  cell 
l.iidy,  and  this  in  turn  in  all  prohahility  upon  the  activity  of  the  niicleu>. 
if  tiie  cell  is  injured  in  any  manner  the  processes  de<:enerate,  or  if  the  pro- 
cesses are  separated   frcnii  the  cell   they  dei;eiierate.      Whether  or  not   the 
neurones  are  orj;-anii-ally  connected  with  one  another  i-  still  in  di>pute.    'i"hc 
weifilit  of  evidence  is  in  hivor  of  com|dete  anatomical  and  relative  pliysio- 
loiiical  independence.     The  terminals  of  the  axone  of  one  neurone  are  re- 
lated to  the  dendrites  and  cell  Imdies  of  other  neurones  hy  cout;icl   (Kaiie'm 
V  CajaT;  or  hy  concrescence  (Held),     it  is  <ienerally  admitteil,  however,  that 
'occasional  coarse  anastomoses  exist  hetweeii  ncinhlioriu--  dendrites  (accord- 
in,;:  to  Do.uiel).  especially  in  the  retina.     The  studies  (d'  .\piitliy  >peak   in 
favor  id'  a  -general  interconnection  hy  means  of  neurojiliril-  and  protopla-ni'c 
hridiics.     In  "■eiieral.  it   may  he  st;ited   that    the  demli'ites  or  protoplasmic 
processes  coniluct   impulses  toward   the  cell   hody   (cellulipe|:il   conduction), 
and  the  axis-cylinder  process  conducts  them  away  from  the  cell  (cellulifu,i;id 
(■(mdiiction).  The  axis-cylinder  process  after  leavin,^  the  cell  .liives  olT  at 
varvinir   intervals  lateral    hranches   called    cnll;iteral<.    wliidi    iim    at    ri>;lii 
an<des'to  the  process.     The  collateral-  and   linallv  the  aNi<-cy|iui|cr  proi c- 
itself  at  their  terminations  split  up  into  many  liiu'  lihrcs,  hu'iuimr  the  end- 
l)ru<lie<      Thc'^e.  known  as  ariiorizations,  surround  the  hody  of  (me  or  more 

001 


I 


'.Xfi 


1)1 


SRASKS  OK  TllK   NKKVol'S  SYsTKM. 


,,f  till'  MIMIIV  «\\\vy  cr 


i.r  inti  rliiii 


,  will,  llu'ir  |.rutoi.lii-mir  i.n.ccssos.    Tlu" 

I  ripli- 
m  fur 
ill  tlif 


'-r ;;;;':;';:;:::;;::';::  lv'::'':;'::;i:u>.'r. ;--' 

mil  n»M\t>.      1  lull   piiiK     t    .  .    I  I  ,..,;„.,, Ill  <i)itial  •■mi    and 

;::-jr,:^:;;;j::;;;,::':^;;"i:'.-"-. .-•;-„„. ■ 

"I"'  is  tlu'  simplest.  .,,,,iin..-   In. in   ill.'  '"'ain  coilcx   nnist    pass 

\   v.,lnnlarv   inntor  iminilM'  Mailin,     linin  ,,iii-.l.-    ami   w 

,1       .    1    ,"  .    two   m'lirnms  l.dnn.   it   .'an    ivarli    the   iiinMi... 

„„,„„.,,   „    l,,n.t    t^^^   n- -i,    ,    ^    ^^  ^^^  ._^_^  ,„„„„.sr.l  of  tw..  >.-.m'nt^ 

tluTcl'nrc  s| 

an  upper  a 

hdilic- 

'""'"' '  ■rpn.coss.s  nf  tlm  lower  im-tnr  nenmnes 


lulor  trad   as  licm,-;-  fi.m 


■1„,  .,xi.-..vlin(lrr  pnKr>M>  .1   tlu    lou   i    '  ,„,  ,p„,,il,- 

,te.l  tn  all  the  museles  ul  the  '-''y;  ^^      '     .  '    ,  ^     ,  '  i,.   ,„eir  c-ell   hodie>. 

;:';:-::j::::-.H;;::::,,;ri:;:        nnn.hes si. 

,,,,„,,!,„nie  pr.u-e»e>  in  tlu    .oii.N  ^^^^^^^_.  ^^,.  „^,,  ,„.„„ 

L„.lo.     Their  axis-evlnnhT  l'-—";    ;'        ,      ,      .„,„„,,„   i„,o   the   pons. 
^^''T'f   '^''^'ir^Jirl  >iat,onsaron;,d,lmpn^^ 

•"'"''""^'-  '""'/■-"":  "        ,;,     ,wer  motor  nenrone^.     The  upper  se.ixment  .>. 


irsses  ami  e(  ,     ,   ■     . 

i„themain.aerosse.ltraet-lhat  ,s  1 

liiive  their  pro! 

whereas  their  a 

l)(>(lie>  oT  the  I 

cTtain  nnniher  of  tlie  a\ 

l„w,r  motor  nenrones  olMhe^same  sHle. 


1  the  hrain  cause  contractions 

)l 


1- 

1- 
aee 


io">'    '" .         .      ,1,,,  1  ,|'4    .  I  ,,  II        le    uain  ciiurv-  > 

^lotor  impulses  ..arlm,  ""  ^^_       ,,;^''  „ j  „.„,,  ,■,,„„  t,,.  vi.ht  side  e 
„1.   „„,,les  on   the  ri.hl    <Hlc  ol   the       "     •  '  ^^,^.„^  .,„,  „,•  ,,„„i,len 

„,^.  ,„,,,i„  i„  ,„„...l..s  uf  the  h.ll  <  -le  ol  th       o      .  ^         ^^^^^^^  ^^^  ^^  ^^,_ 

,„„  „,.,  ,„...>p,ion.  whieli  have  lu.n  --'       '    ;  :  .....sin,  t.kes  phn 

m  th..  npp.T  se-nu'nt  (1mu>.  1  an.    -  .  ,,,;,„,.,„..s.      In   the   pr...1n.'ti..n   ol 

,„„,1,.,.  veMuir..^  th.'aelni.v  ..1    "'     >  j,,^,,      ,,,    ;„    „    .lelmite 

..aeh    n,ov..n..n1    special    neuron.'^    ^"    ,.        "'!     i      thi     .■onihina.i.u,    that 

speciiic  im.v.'incnt  is  the  loult.     m 


„,,vus  o..ulenu.,„rius  an.  w.U-known  ..xe..pl...ns  to  tin.  ruU  . 


uf  tlio  rnot   lilavs  of  thi' 


CMNKKAL   INTKoDlCI'lnN. 


'.»n,T 


,os.  Tlir 
ictliir  ill 
(■  |i(  riiili- 
.  i\m  I'oi' 
111  ill  tlif 
1  in'rviiii> 
st  (if  thf 
iiiid  liiiM' 

iciilll.     till' 

lli|cl>tnii(i 

liiusl    |i:is> 
■;.  ami    we 

'nlll('Mt> — 

,■(.  the  (••'H 
he  vcnlnil 
ral  iH'VVfs. 
the  spiiiiil 
he  (listril)- 
ioiis  ill  till' 
•ell  liodio. 
I'  siiinc  siili- 

liodifs  iiii<! 
-lire  III'  l»ii- 
,r  the  liviiin 
)  tho   ]i"ii>=- 
ilasinii'  iirn- 
si'unu'iit  is. 
1  coiniHisc  il 
if  the  liody. 
1(1  aliiiiit  fi'li 
i(>  liiiily.     A 
.  run  t(i  the 

contract  inns 

riu'lit  side  of 
of  considcrn- 
ti'd  as  a  .ii'i'ii- 
o-  likrs  plact' 

cut.  I'VI'll    tilt' 

iriiductioii  ol 
n  a  di>linit(> 
liinati<iii  that 
(MUi'iils  (if  tho 


IhkIv  arc  rcprc-inhd  in  the  ccnlial  iiitmmi-  -vMnn  \>\  (dinlMnalKins  (if 
nriinmc-  -lliat  i-,  Ilicy  arc  Idcali/.cd.  Mux  nl^ir  nc'\<'ni(nl>  arc  Idealized  in 
,.\ery  part  ni  the  nmiur  |mtli.  and  in  easc^  nf  disease  of  the  ncrvmis  >ystcin 
;i  Miidv  (if  the  iiHitnr  dcfccl  (iflcn  cnaiile>  (Hic  tn  fix  iiimhi  llic  site  (if  tho 
|ii(iee--.  and  il  ucnld  he  liaid  In  (ivere.-li- 
nialc  the  ini|i(iilanec  ><{'  a  tli(ir(iu;:li  kimul- 
i(li;c  cif  such  liicali/.alidii. 

The  axis-cylinder  |ir(ice.-scs  nf  the  hiuer 
iiinidi'  nciii'nnes  inii  in  the  |ieri|ilieral  nerve-. 
I'lach  nerve  ednlains  |ir(iec>-es  uliieli  are 
>iip|i|ied  \i>  delinilc  muscles,  and  we  i:a\i' 
in  lliis  way  a  peripheral  hicalizal  idii.  (Sec 
scelidjis  (111  Diseax's  nf  the  ('ei'eliral  ami 
Spinal  Nerves.) 

The  a\i-cylinder  prdccsses  which  run  in 
the  peripheral  nerves  leave  the  central  iierv- 
<)ii>  system  fi'din  its  ventral  aspect.  The 
ventral  nidts  df  the  spinal  cdrd  are  fnnn 
jdidve  ddwn,  colleetcd  intd  small  (.n'oiips, 
which,  after  jdinin.u'  with  the  dursal  mots 
df  the  same  level  df  the  cdrd.  leave  the  spinal 
canal  hetween  the  vertelira'  as  the  spinal 
nerves.  That  |)art  df  the  cdrd  frinn  which 
the  roots  fiirminj:  a  siniiic  spinal  nerve  ari>c 
is  calle(l  a  seLiiiiciit.  and  corrcspomls  td  the 
nerve  which  arises  from  it  and  nut  td  the 
vertelira  td  which  it  may  he  (ipposilc.  Tiie 
axis-cvlinder  |irdce>ses  which  c'o  to  make  up 
any  diie  peripheral  nerve  do  not  iieccs- 
sarilv  arise  from  the  same  se.irmcnt  of  the 
spinal  Cdrd:   in   fact.  md>t   peripheral   nii'vi^s 

cdiitain  proces-es  from  several  often  (piitc  widely  scjiaratcd  se,Lnnents.  and 
so  it  ha]ipens  that  the  movements  are  represented  in  the  spinal  cord  in  a 
dilVerent  nianiier — that  is.  there  is  spinal  Incalizatidii.  or.  Iietter.  lower  level 
Idealization,  since  it  also  includes  the  motor  nuclei  of  the  cerehral  nerves. 

O'lr  knowledee  of  the  localization  id'  the  muscnlar  movements  in  the 
irrav  matter  of  the  lower  motor  seiinicnt  i>  hir  from  complete,  imt  enoii.Lih 
is  known  tn  aid  materially  in  dctcrinininLT  the  site  df  a  s|iir,al  Icsinn.  .\ 
iiumlicr  df  tallies  have  hciMi  prepared  hy  ditVercnt  dhservers  tii  re|iresent 
diir  present  knowled.iZ'e  of  this  snhject.  They  dilVer  from  each  other  in 
minor  details,  hut  a.uree  in  the  main.  The  followiiitj  is  tho  table  prepared 
hy  Starr,  in  which  llic  names  of  the  muscles  are  ,<rivon  whoso  movements 
are  represented  in  each  of  the  spinal  sei.Miients.  "Nrovements.  not  imisoles, 
arc  hicalizcd  in  the  central  nervous  sy-leni.  a  pnint  carefully  to  he  home  in 
mind  hv  the  student. 


Fid.  1. — DiMLcnim  nf  inntnr  |ialli. 
slidwiiiL;  I  111'  crossiii;;  of  tin' 
luilii,  which  tnki's  iiliicc  in 
tlio  iip|)or  si'j,'infnt.  (\'iiii(ii^- 
hiiclitt'ii.  ciiliiroil.) 


not 


liliri's  i)f  the 


*.»u4 


DISHASKS  OK    TIIK   NKUVdlS  SYSl'KM. 


V.  n 


,,,,      Tl...  nurlci-.f  the  motor  .•en'l.ral  ...rvcs  ,uv  shown  m.  the  I.  t  s.,1       ""  ""      ;^^''. 
,    ,„     .,.  V  ,r,l  n.rv.N  of  that  si,l.  aiv  in.licnt.Ml.     A  k>sion  at   1  woiihi  caus,.  upi">. 

:^      vsis  •;:;;,;;>;•,!■  of  u.  o,,posit,.  .,1.-....,....,™!  ,nono,.u..ia  =  at ., ,,,,... 

"        .  ,■    •      f  .i,wvl„,1,.  oiino^iitc  '-iih'  of  the  boilv— lieiini>lt>KiM  :  at  ...ui.]"'! 

sis  of  opposite  anu  an,l  1...  ainl  low.,-  segment  pa,-alvs,s  of  ""'/'"■'  .^'f  ^1 

..otus  on  the  san,.>  sule-cross..,!  1"'^'  ^    •„; r,^"  J    ,„::^ "    U,  rosont..!  at  lovol  of 
Hos  b.'low   lesion,  and  lower  se'.nnent    pa.ahMs  ol   nui.  u       r  |  ^ 

U.sion-spinal  paraplegia;  at  .!.  lower  se,n,eni   paralvs.s  ol   nn.selcs  looah/.ul  at 
of  lesion-anterior  poliomyelitis.     (Van  Gehuehten.  mo.iifuMl.) 


ick.  till'  liiWPT- 

:  (111  thr  rii:li1 
I  ciiiisc  iipiior 
1 :  at  2.  upiKT 
I :  lit  !!.  iippi'v 
iciit  imrnlysts 
riiiPiit  paraly- 
1  tlic  cxli'i-iinl 
sis  (if  alt  iiiiis- 
I'd  at  IcvpI  of 
ealizi'il  at  scat 


Skiimknt. 
II  and 

inc. 


IV  I'. 


(!KNKI!.\i.    IN'riiolU'lTIoN.  JMi:. 

I,tii<ili:iitiiin  III'  /III'    /■'iiiiitiiiiix  iif  llii'   Si  ij  nil' II  Is  of  llii-   S/iiniil  ('mil. 


V  I', 


I  Mrsi'i.Ki*. 

Slcni(i-Miiis|ipi(l. 
ri'ii|n'/iii-*. 

Scllll'Mi  llllll    lU'l'li. 

I  iiiapliniu'Ki. 

I 

lMaplini;;iii. 
;  Deltoid. 
I  llict'ps. 
'  ( 'onicii-lirai'iiiali-. 

Siipiiialdi-  liini.'iis. 
I  JiJiiiiiilHild. 
,  Supra-  and  iidiii->pinaliis. 

:  Deltoid. 

I  llieeps. 

I I  'oraeo-linu'hialis. 

j  I'raeliiiilis  aiilii'us. 
Siipiimloi'  loiijiiis. 
Siipiiialoi'  lii'evis, 
Klioiiilioiii. 
Tens  minor. 


ItKKI.KX.  ' 

ll\  poclionilruiiii  1^.  liiicU  of  liead  lo  vei- 

.siiddeii    inspiraliou   pro-       lix. 

dueeil  liy  sudden  pii">>-    Ni'eli. 

lire    Ipeliealll    the    lower 

liorder  (jf  i'ili>.  I 

,  I'llpll,       till     lo     7lll     eel-      Necli. 
I     vieal.  '  rppii'  shoulder. 

Dilatalioii   of    tlie   pupil    Outer  iinii. 
proiiiieed    by    iri'ilalioli  '• 
of  neck. 


Seapnlar.  IJaek  of  ^lioiilder  and 

,")llicervieal  tolst  liioraeie.  '     lU'lii. 

Irritalioii  of  skill  over  the  I  t  (liter    side    (jf    arm 

scapula   produces   con-  '     and   forearm,  froiil. 

tnielioli  of  the  seapnlar  :     and  hack. 

iniiscles.  I 

Siipinatia'  haigiis. 
Tappiiii;    its    teiidiiu    ill  | 


VI  I' 


I  t'l  <  n    III  I  in  ■!  •  ■  ■'  I  ■[  "  ■  v-^ 

:  IVcloralis  (clavicular  part).       wi'i-l    produces    llcxiou 
;  Serratiis  niairiius.  id' forcariii.  i 

I'.iccps.  Triceps.  I  (tiller    side     (if     foiv- 

Uriichialis  aiiticiis.  Tii  h  to  (llli  cervical.  arm.      from       ami 

IVcloralis  (clavicular  pari).  Tapping'     eUiow     tendon       back. 
Serraliis  niii^niiis.                      |     produces    exleiisi(j|i    of    ( )iiler  half  of  hiiiid. 
Triceps.  forearm. 

I'lxleiisors    of     wrist      and    I'osterior  wrist.  | 


i     lin^rers. 
I  I'l'iaialors. 


VII  C. 


\'  1 1 1  ( ' 


P  I. 
.\  1 1  ■ 


lilh  to  Hill  cervical.  ! 

'Tappili;;    tendons   causes  i 
extension  of  hainl.  | 

!  Anterior  wrist.  Inner  side  and   back 

and    Ttli  to  Hlh  cervical.  "f    arm    and     foiv- 

'I'lippiiii,' aiiteriorteiidoiis  :     arm. 
I     causes  ilexioii  of  wrist.      Uadiiil    half    of    the 
j  Piiliiiar.     7th  cervical  to       hand. 
'     1st  thoracic. 
Slrokini;     palm      causes 
I     closure  of  liii;,'i'rs. 


I  Triceps  (loiii:  head). 

I  Kxl  elisors     of     wrisl 

I     linijers. 

1  I'roiialors  of  wrist. 

i  I'Mexors  of  wrisl. 

i  Subscapular. 

1  IVcloralis  (coslal  jiarl). 

I  Ijiitissimus  dorsi. 

I  Teres  major.  i 

[  Flex<a's  ut   wrisl    and    fin- 1 

■     L'crs.  I 

III!  rinsic  muscles  of  hand. 

l>'xteusors  of  thumb. 
Intrinsic  hand  muscles. 
,  Thenar     iind     hypollieuar  | 
emiiiPiK'c.s.  ' 

1  Muscles  of  back  and  abdo-    Kpi-asiric.     4lli    lo    Tlh  Skin    of     chesi     and 

'     men.                                             Ilioracic.  alidomeii    in    bands 

Krectores  spina'.                       Tickiint,'    niainmary    re-  riinnin,!;        around 

j;ioiis  causes  ri'lraelion  and  downward,  cor- 

I                                                  '     of  epii;astrium.                 .  respoiidiii^;    to   spi- 

Abdnininal.     7th  lo  lllli  mil  nerves. 

I                                                          thoracic.  I 'pper  ^'luteal  region. 
I                                                       Strokiiif.'  side  of  abdoiiieii 
j                                                       ciiiises      retraction      of 

1     buUv.  ! 


Forearm    and    liaiid, 
inner  half. 


Forearm,  inner  half, 
riiiar  di>lrilmlioii  to 
hand. 


one. 

Sr.iiMKSi'. 

I  1-. 


I.ISKASKS   OF   TllK   NKliVOUS  SYSTKM. 


Mrsi'i.f> 


ItKIM.K.X. 


SknsatidN. 


Illcl-llSoilS, 

Siirloi'iiis. 
1  ,\luM-Usot  iilMloiiicn. 


inii 


II  1.      .  |lir,-,,-oas.     Surlnrius. 

1  l-'lcxiirs  nf  ktico  (lU'UiiiK) 
Uiiiii(li-i<Ti)S  IViuoris. 

III  h.     Uiiindrioeps  fciiiDris. 

i  Inni'i-  rolators  ot  tlnKii- 
1  Al"luclt'i's  of  tliigli. 

^V  1j.     !  Aliducloi-s  (if  tliiiili. 
I  Adductors  <if  I  In.u'h 


.,.,.;,.       I^t    to   :!d    Skill  "vi'i-  K'Vdin   iiii 
luinliiir.  ,1 

SlniUiiig      iii'i''!' .    ""■-''. 
ciUiM's      rrtriu'liiiii      "I 

scrdUiiii.  I  _.     __  . 

I  Outer  ^id(^  (if  thi^''i. 

I'appiii^    tendon    ciUises 

extension  of  li'f^.  I        

\  ''  l^'ront  iind  inner  side 

1     oftliii?li. 


sln^inj,    buttoeU    eMU.e.jlm>ersideoffoot 


V  li. 


FleX.M:sofUnee(|.Vrrier).  ^  ,.,....... .^^-.^^      ,,^,^,      ,,j  ^ 

Tibialis  anlieas.  |     ^\\l\l^,^^r,                 ^         \ 

(UitWiird  i-i.tatovsof  tlii.i;li. 

Flexors  of  knee  (Ferrier).  | 

Flexors  ot  alike. 

|'',xtensors  of  to 'S.  _   ... . 


'  I'.aeU  of  thi.Lrli,  t'iick 
I     (,f    le.i:.   and    ouler 
pari  of  fool. 

^■lekUng     sole     of      foor  l.e,   an.l   foot,  onler 

eauses    llexion    of    toes,     side. 

''''■"."•''.'•  i.,,rr,M,t        <     and  retraetion  of  le.i:.       ; 

utvn^ie  muscle'- ol  tool.  --     -- 

"  WnT  relW.       Achilles    Skin  over  saennn. 


1  1,,  11  S.  '  Flexor>  of  ankle. 

i  hollj;  llexor  of  toes 


111  to      i  I'erineal  muscle 
V  S. 


tendon. 


.\nus. 


l.l^erexlcnsion      of      foot  i  I'erinaMnn.    CenilaW. 
causes     vapid     Hexion : 
ankle-clonus.  \ 

r.ladderalid  rectal  ceiilres.| 


Th. 


;,„,,,  ,u, ho  tuntor  nuclei  nfllu.  cranial  ttofvcs: 


inai 
ahniil  as 


(  Sphinelcr.     (  diary  luuMls  •   ,^>,.„,„  (i„  ,.„nvergenee). 

m    1  levatoriialpchra.  superiorly.     Uutusmuu 
I    Uect  us  superior.      Kect  us  mteri.  .-. 
■|  ()l)li(iuus  inferior. 
TV    '  (ililiiiuus  superior. 

.   ^  (Associated  n.oveiuent  of  levator  palpebne.) 
^  •"(  Miis(des  of  lower  jaw. 

f  Pectus  exteruus,      Kectiis 
Yl    J        iuter.    of   (ipiio-lte    side 
(^      in  lateral  nioveiiuuts. 

Vn.--Facial  inii'"le  . 

1\    I   Muscles  of  pharynx, 
r  il,„wei- facial  i-'rouiO.  x    -'   Muscles  of  (esophagus. 

Xn.',    ;yi,,<elcs  of  ton'.,nie.  xi.   I   Muscles  of  larvnx. 


1,'rom   MM' 
(•riituiii. 


(if  thii:'!. 


1  iiiiicr  sidi'. 


(■   ..I     tliigl" 
to  aiiUlt'. 
■  of  fodl. 


thi.u'li.  li!"''^ 
aiitl    oiiIiT 
foot. 


1    font,   ollirr 


■r  siii'Viiin. 
nn.    (Jriiil.Ml-. 


I  moilull!)   is 
[U'd  in  rol'or- 


tor  iialpfliru'.) 


GENERAL   IXTRODrCTlDN.  <)o7 

Cerebral  Motor  Localization.- -'I'lic  cell  lu.diiv-.  n\'  ihc  npiMT  indtnr  ncu- 

mnrs  .'H'c  luiiiid  in  liic  hinin  cdilrx  nliniil  ihc  li.->iiic  (if  li'nlaiiiln.  mid  ii   is  in 
lliis   rcyioii    tiiat    \\c    lind    llic   iniivcinciiN  of   llic   Imdv    auain    i'c'|iic>i'nli'd. 


■^SisS&SiW;;*^"--^-' 


Tlic  clinical  stndic-  nf  1  limlilini^s  JaclsMin,  and   ilic  cN|icrinicnt-  df  !'•    .iu' 
and    iM'itscli.   and    (if    !•">  ,    icr,    laid    llic    fniiiidation    fur   ihc   ureal    in;  '' 

most  excellent  work  wliicli  lias  been  done  upon  this  snhject.     We  owe  i.uicli 


DOS 


I.ISHASKS   OV  TUK  NHUVOUS  SYSTKM. 


n       1  V  .nul  ln<  •i-.H-iatc-s  I'-.r  tluMV  caivlul  xv.n'k  in  this  .Inve- 
,o   Victor  llnrslcv  an.l    n.  'i; '  '."  '  ,  ,         ,         „„  ,h,ir  wnliu-s  ami 

,,,L.,ts  or  .lu.,r  .x,u.r,nu.ntal  -'•';';;:;:,      x^h.rin.  opcation.  on 

lunnan  hein.s  hav.  -"•■-■^\       .,   ^     ,  ,,„u  .1  ..onvolutiun,  an.l  to  a  l..> 
Thr  motor  a.va  vom^r^.v.  "'^'.''^    •','.■,  -,,,  ,„,t  ol'  tlu'  Unvr  fn.ntal 
.,,,,.  UuM>os..no...utnn.onvo,ntu.n,Uu^^ 

l„  tlu.  orano-onlan-  and   uian   not  c^n 

^,„,,    „,■   this  n-ion    is  oxcital.U-   I'V   Hr.- 

;,i,al    stimulation.      Tlu'    n.ovm.cnts   are 

...it.  sharplv  loraliml,  and  tluMV  aiv  m- 

.'xc-itahlc  a.raslH.tw>H.n  tin.  areas  ol  rqnv- 

...ntation    of   tlu-   hu-cr   .livisions   ol     ... 
l,„.,v.     Tlu.  .lia<;-ran>   (Fi^'.   :5)  shows     lu 
,,,„{,,,  ,.  .iv..n  hy   IVcvor  an.l     l..rs;|  • 
Cn'tain    lan.ln.arks   ar..    nnpoHant.      Mi 
„,,„n    ..r    Ih..    Ilssur..    ..!■    Uola.ul...    whu'h 

^vlH.n  present  in  n.an  is  loun.l  at  a  ,.o.nt 
ah.n,l  nu.lway  or  even  hi^h..r  hetw......  t  u 

,„„.o.in  ..f  tlu.  iH.nusphere  an-l    1h' 
liLur..  of  Svlvius,  marks  the  l,..un.lary  lu>- 
iween    the  ^uva   oi   re,.resentatmn   .'I    t''^ 
ar.u  fr.m,  that  of  the  tVe.     '1  h.  Wei  o 
,h,  sup..ri..r   rr..ntal   suleus  uuheates  tlu, 
division   ..r   the   leu-   from   the  arm   ar..a. 
i;,,„„  above  .lown  the  ar..as  ..f  r..iHvs..nta- 
,inn  .>e..ur  in  this  ..nl.'r:  1..-.  am.,   tare. 
Vu,4     l,i.>.ran..>f.nolor,.n<lscn-       Tlu.se    of    the    lej:    an.l    arm    -"■'•'M'y       '■ 
';™  -ta,i.miuUu.in,..r-       „,,,,,,   ,,alf  ..f  th..   e<u,v..l..t ,.>n,   an.l   t    ■ 
:;;/  ;.isul...      N...   l.nti....h.r       ,1,!  ,,,,  ^,,.,  i.  sprea.l  ont  ..v..  th..  1-   u 

nucleus.    NC,  CuKlat. nucUn.s.      ^^^^^^     The  .lia-ram  in.1u.at..s  the    ...•au/a- 

TIIO.,    Opti..,    tlu.bunus.     The       ^.^^^^    ^^|.   ^,^^,    ,„ovc.nu.nts   ..f   th.'   .liH.-n'"' 

,u,lor  paths  ar."  rc.l  an.l  l.la.'li,       ^^^^^^  ^^^  ^j^^,  ..xtivmiti.'S. 


the  sensory  are  liUie. 


parts  of 


The  eentivs  for  tlu.  trunk  ar.'.  ae..or.l- 


•  I   lU'    HMl>>'       ■■ ,.  1 

■     1        ,, .  iiwt  uitliin  the  lonLritu.iinai 
,,,.S..hafer,sit,naeni,tthema,.nt.^ 

ilssur..  in  the  paraeent.a    1.  In     •  ,.,nv..luti..n. 

i,oa  itt  th.'  l-ster,.>r  part  'J     '      ',";„,  ,,,tor  net.n.tt..  after  U.avnt, 
The  axis-..yl.u.ler  pr.u...ss..>  .1   »'      >  I  ^^^^,,„,,  „,■  „„,  ,,,a,n 

„„  .ray  tnatt.'r  ..f  th..  nu.tor  -.rt..     P  ss  ; :    ;  ";;^^^^.^„,^„  ^„„,   ,,,,  ,,t.ve..n 
atul   forn.  part   ..f  th..  e..r.ma  ''^''l'^     '  ■  ^,„:  ,„„,„,  axis-eylinders 

,,„  ,,,,,  ,an,lia  in  tlu'  ''7^;;;;  ,    l!    V  ,,      ^i.lal  tra..,-o.-tpyin.  t   e 
ar..  .■..Ih'H.'.l  into  a  eotnpa..    In  n.  ^^^.  ^^^^^  ._^,,„,„,,,  ,.,,„„,... 

l<-«-  ^"">  '"•^*"'*'"'  ^""  ^'"'  .'         1       M-Posite  si.le  ..f  the  h.Mly  are 

The  .n'.ler  in  whi.'h  the  nun-..nuM.ts  of  th.    .M'P 


(JPINRRAT.   INTRfiDITTION. 


909 


(lin'C- 
j:s,  anil 
ivc  llu' 
hsfiva- 
oiis  oil 
nils. 
(I  ii  lfs> 

frontal 

ImIiiiIc. 
)t  (.'vrry 
liy  I'U'i- 
■uts   are 

arc  in- 
)l'  irpru- 

;    ol'    t!u' 

lows   the 
lloivlcv. 
It.     Tlic 
).    whicli 
I  a  point 
wfcn  llu' 
I  and  the 
iidarv  lu'- 
,n   ol'   tlie 
,.  level  of 
icati's  the 
iivni   area. 
I'lircscnta- 
irin.   fare, 
■cuiiy    th'-' 
ami  tliat 
tlu'  lower 
ic  localiza- 
'   (lill'erent 

re.  aeeord- 
)n<riiu(linal 
re  is  local- 

"ter  leavini;- 
)f  the  l)i'ain 
,>;s  between 
/is-evlinders 
■  uiiyinii'  the 
nal  capsule. 
|i('  liodv  are 


e  pyrann 


idal 


tract    leave  llie  lieinis|)here  liy   the  cms.   in   wliich   they  occni)y  aliout    tlio 

iinddU'  three  lifths  {\'\ix.  ■>)■     'I'lie  rnovenieiils  of  tlie  ton.iiiie  and   iips  are 

represented  nearest  the  iiiiddh'  line. 

As  soon  iis  tiu'  tract  enters  the  crus,  sonK-  of  its  a\is-cyiin(h'r  processes 

leave    it    and    cross    the 

iiii(hne    line    to    end     in 

arhorizatioiis    aliont     tiu' 

uanylion  cells  in  the  lui- 

eK'iis  of  tlie  third   nerve 

on  the  opposite  side;  and 

in    this   way,   as   the    py- 
ramidal      tract        ])asses 

down,  it  ji'ives  oil'  at  dif- 
ferent levels  lihres  which 

end    in   the  nuclei   of  all 

the  motor  cerehral  nerves 

on    the   opj'.osite   side   of 

the    hody.      Some    lihres. 

howcvci',    .ud    to    the    nu-       Fki.  5.— Diu.ijraiii  of  motor  luid  si'iisory  [mtlis  in  ("nn'ii. 

elei     of     the     same     siile 

(lloche).     From  the  cius,  the  |)yi'aniidal  tract   runs  throuiih  the  pons  and 

forms  in  the  medulla  ohlonjzata  the  pyramid,  which  gives  its  name  to  the 

tract.     At  the  lower  i)art  of  the  medulla,  after  the  iihres  <;oin<r  to  the  eere- 

l)rat  nerves  have  crossed 
the  middle  line,  a  larue 
pro|)ortion  (d'  tlu'  reinain- 
injf  fihi'es  cross,  decussat- 
iiifi;  with  those  from  the 
opjiosite  pyraiind.  and 
pass  into  the  opiiosite  side 
of  the  sjiinal  coi'd,  form- 
ing the  crossed  pyramidal 
ti'act  id'  the  lateral  col- 
umn (fasciculus  cerehro- 
spinalis  lateralis)  (i'ig.  (!, 
1).  The  smallei'  numlter 
(d'  (Ihres  which  do  not  at 
this  time  cross,  descend 
Fid.  (1. — I)iii!j;ra!ii  of  nress-SHPtjon  of  spinal  conl.  sliow-  j^j  n^^,  y,,,,|,.|,l  colunili 
i,,;;  motor.  HMl,  ana  sonsory,l,luo  pat l,s.     LLatcnil        ^^^    ^|^^,    ^.^^^^^^    ^j,^^,_     ,.„,,„,. 

iivniniiilnl  tract.    3,  Ncntral  iivratnidiil  ti'iict.     :!,  ,^        t       l  -i.i 

,;       ,      ,  ,    I.-     t         1   11      ,     ,      r       in<r   the  direct   pvramulal 

Dorsal  roluinns.      4.  Dirort   corpnellar  tract.      '>.  •"  '  ■ 

Vontro-latoral -round  lmn,li,-s.  (i.  Vcntro-lalcrai  tract,  or  I  urck  s  c.dumu 
ascending  tract  of  Oowors.  (Van  nchuchtcn.  col-  (fasciculus  cerehrositiiialis 
orcd.)  ventral  is)  (I'ig.  (1.  'i). 

At  everv  level  of  the 
spinal  cord  axis-cylinder  processes  leave  the  ci'os^ed  pyramidal  tract  to  enter 
the  ventral  horns  and  end  ahont  the  cell  hodies  of  the  lower  motm-  nenrmies. 
The  trad  dindiuslies  in  size  i'rom  ahove  downward.    'I'he  fihres  of  the  direct 


yiu 


DISEASES  OF   THE   NERVOrS  SYSTEM. 


C  VIII 


Via  7  -Diagram  of  skin  aroas  ,.om.s,,.uHlin-  to  the 

(Combined  from  lU-adV  diagrams) 


different  spinal  segments. 


OKNERAI.   INTRODUCTION. 


'.ni 


C  VII 


\\       (VII 


Fifi.  K — Diiiirrain  of  skin  aroa??  (!oriTs|Kinilin;,'  to  (lie  ililTci'L'iil  spiiiiil  segments. 
(Combined  from  Head's  diagrams.) 


012 


DISEASES  OF   THE   NERVOrS  SYSTEM. 


tlic  vciitviil  white  ((imini^sm'e. 


1  lu'  p.Uli    loi   •'■■''.'  .  .,,,1  ,,r  -ii  \v\<\  three  sets  n    iieuniiie>, 

„„,,   ,,„„,.   the   nthe>.       I  lu       ^'     "  ^„„,     ^,,,        „.j;lia    ol 

,,„,,i„.   on    "-   ";-  ,-f        ,   'r,     ;  1„;  eells   have   a   spe..ial    ionn. 
,„,  ..nsery   <-.Te  n   1     '"\  ^;      '      ^^.^^  ^^'^.j,,,,  „„,„  ,,„,,•  leaving  the  eell. 

,,,,,1  ,,nMH      hl.K,  1  con.luet.  away  In.in  tlie  eell 

„,,  ,,,„t,M.lasnne  pn-ee^.e.,  ^  '        '        ;,^^„.^,,  ^^.,„,,,  ,,,,,,,s  we  have,  then, 
istheaxis-yl.n.leriiroee.^.     In  tlu   pnipu    u  ■>  neripherv 

„„,  .u.n.lrit.-s  or  the  h.wer  .ensory  neurune>.        I'^k     ta.t  1       1     .  . 

„h1v  Vniin  their  various  specialized  en.l  oijian^ 


The  axis-eylinder 


^;;:';::!,:'.;::™w :.:;;-; '-r;l;:,:r:s:::;;;.  ":.*:;; 

!•      •   ,,i;      'Vho  (le<eeii(    ii"-  hraiich  vims  iiiit  a  slnni  (iiM.nm. 

liiseieuli.      lii'>  <lisiii(iin^  nuiiiher  of 

eiiiili  as.  lai  a.   .  sonsoi'v  neurone  is  direet. 

<l.)es  not  cross  the  ini.l.Ue  line.     I  lu  '"  ^i'  -  ;\^^   ^^  ^     ^  ^,,^,i,  ^...Unterals 

TlH.  eells  ahont  whieh  the  ---^''-'^^^^^ ,,,"-.,,  ,,.  known 
of  tlio  lower  sensory  neurone  end  are  ol  v.  no  nl,  ^        ^^^  ^^^^___^ 

-rn  r^:x.::iu!;\rt::  ::::^u,:;;,- 1,;;:::.  ronnin.  me  path 

r  n';".!'^^;"   also  end  ..nt  eells  ^vh;>;.  ;-;;;y|;;;;;;;'  .-— ;;;:;- 
the  middle  line  niul  run  to  ^ '^  -MM-^.t;-  ^"^  ^  ^    •^l' ;^^^,^,,,._  ^,,,,,  ^i^^ 

cord  these  eells  are  found  in  tl-''  •ll--"*^!^^.^^      ,-;,;,,, ,,,,iin.  traet 

-s!;:;^:^r-^:-:ti:^v::;i;:ri:a^:(;^^^^^ 

prius  and   faseieulns  ventralis  l';"!"''";^;  ,j  (,,^„.,,,,„  ,.,,,ionli  -rii- 

^"  '';^ '-"^f ''  r;;  i';  ;i; .  -1 ;  r :  di^^^      '■••■■  ^"^-  --^ 

oilis((lolli)an.l  nneleiis    aMi.      1  \""  '"      ,.    ,       „,o(.esses.  after  erossing, 
,,,  ,,11,  of  this  eharaeter.     'I  he.     ^'^'-'  \         ;;,,f  ^i,,  fillet:  eertain 

"-  '--"■''  ^'"^  '"'^''^^  '"  ^'•"  ""t'''/'"";-    V       .       r      il'o     -p'vsent  sensory 

.,.  „u.  longitudinal  bundles  m    he  '"'■->^  '';';':  ,t,s.     The  fibres 

•    paths  from  the  spinal  eord  -jd  ••;;■   ^;   ^  '  :   ,  „     n  ivetlv  to  the  eere- 

'' r T'^''^!;;:;::::^';::! : i'  i-:;;;;-i;.i.-^ portion .. n. .,.-. 

sr^a;i^ 'ir -:  i ;;; "- -^^ 


I 


GENERAL  IXTROniTTlOX. 


913 


tlKii'iifif 

ic  itiotor 
u'uroiH's, 
■V  ill  tlu' 
ngliii  I'l' 
lal    lorm. 

til.'  irll. 
ral  norv- 
•volDjiiciil 
(■  pfriph- 
•('iirc^ciits 
1  tlic  coll 
avc.  then, 
jicriplu'iT 
s-cvlin<l<'r 
il  roots  ol' 
iroct'ss  (li- 
the dorsal 
1(1  I'luls  in 
iiiiml)('r  of 
ranch  may 
dorsal  t'iis- 
any  ("isc  it 
'ct". 

collaterals 
arc  known 
nc  of  tlicni 
o-  tiic  path 
cesses  cross 

the  spinal 
r.  and  their 
ndin.si'  tract 
iteralis  i)ro- 

isoiculi  .li'rfi- 
'or  the  most 
(M-  crosising, 
Uet:  certain 
sent  s(>nsory 
The  rd)res 
to  the  cere- 
ol'  the  optic 
of  nonronos, 
oliition>     '^d 
conduction. 


lint  liy  no  inean>  tli(>  only  one.  Tlie  peripheral  sensory  neui'ones  may 
also  end  alioiit  cells  in  the  cord  whose  axones  run  hut  a  sliorl  diMauce 
toward  the  lirain  hd'oro  endinj,'  a<rain  in  the  ^rray  matter,  and  the  path,  if 
]iatli  it  can  he  called,  is  made  up  of  a  scries  of  these  superim|iosed  neuidues. 
'J'iu'  jii'ay  matter  (d'  the  cord  itself  is  also  helievcd  to  (,|Ver  paths  (d'  sens(UT 
conduction.  All  these  jiaths  readi  the  te-incnlum  and  ojitic  thalamus,  and 
from  thence  are  distrihuted  to  the  cortex  alonjr  with  the  other  sensoiT  paths. 
'I'liere  may  also  I)e  paths  i>\'  sensory  conduction  through  the  cerei.eilum  hy 
way  of  the  direct  cerehellar  tract  and  (iowers'  hundle.  From  this  short 
Hininiary  it  is  evident  that  the  possihle  paths  of  sensory  condiietion  are 
many,  and  that  our  knowled<ie  ot  them  is  as  yet  very  iiidelinite;  for  thi^ 
reason  (nstiirhances  in  scn.sition  do  not  f,Mve  lis  as  nuicii  help  in  inakin<,' 
a  local  dia.uiiosis  as  do  tho.-e  of  motion.  Certain  I'act.s  are  important  to  keep 
ill  mind.  The  dill'erent  jieripheral  nerves  contain  sensory  lihres  from  deli- 
nite  areas  (d'  the  skin,  and  ujion  this  depends  the  jx-ripheral  sensory  repre- 
sentation.    (See  section  on  Diseases  of  tiio  Spinal  Nerves.) 

The  sensory  areas  of  the  skin  are  represented  in  the  spinal  cord  in  an 
cnfiroly  dill'erent  manner  from  the  perii)horal  repro.sontation,  just  as  is  the 
case  in  regard  to  motion.  Tiio  surface  of  the  hody  has  heen  mapped  out 
into  areas  which  are  meant  to  correspond  to  tlio  dill'erent  dorsal  roots  or 
spinal  se<,Mnent.s.  In  Starr's  tabic  the  third  column  iudieales  his  helief. 
His  more  recent  division  of  the  scm.^ory  areas  on  the  limhs  is  pictured  in 
the  American  Journal  of  the  Medical  Sciences,  June.  l.s!).').  Fi^s.  r  and  S 
eml)()dy  the  result  of  Head's  work.  They  are  also  the  areas  iirwhich  the 
referred  pain  and  cutaneous  tenderness  in  visceral  dis(>a.ses  make  their  ap- 
])earaiice.  The  cutaneous  sensory  impressions  are  in  man  conducted  toward 
the  hrain.  jM'ohahly  on  the  op])osite  side  of  the  cord— that  is,  the  path  crosses 
to  the  op]iosite  side  soon  after  cnterin-r  the  cord.  Muscular  sens(>,  on  tlio 
other  hand,  is  conducted  on  the  same  side  of  the  cord  in  the  fasciculi  of 
Coll,  to  cross  above  by  means  of  tlie  axones  of  sensory  neurones  of  the  second 
order  in  the  medulla. 

'rhe  localization  of  sensory  impressions  in  the  cortex  of  tlie  l)rain  is  not 
definitely  determined,  but  in  a  general  way  it  corresj)ouds  to  the  motor  repre- 
sentation. Sensation  seems,  however,  to  bo  more  widely  represented  than 
motion,  and  to  occuiiy  most  of  the  parietal  lobe  as  well  "as  the  central  eon- 
volutions. 

The  jiatlis  for  the  conducti(m  of  the  stimuli  whicli  underlie  the  special 
senses  are  given  in  the  section  upon  the  cerebral  nerves,  and  it  is  only  neces- 
sary here  to  refer  to  what  is  known  of  the  cortical  representation  (jf  these 
senses. 

Visual  impressions  arc  localized  in  the  occipital  lol)es.  The  primary 
visual  centre  is  on  the  mesial  surface  in  the  cuneus.  esjiccially  about  the 
calcarine  tissuiv.  and  here  arc  represented  the  opposite  half-visual  fields. 
Some  authors  believe  that  there  is  another  high(^r  centre  on  the  outer  sur- 
face of  the  occipital  lolie,  in  which  the  vision  of  the  opjiosite  eve  is  chiefly 
repr(>sented.  However  this  may  be.  most  authors  hold  that  the  angular 
gyrus  of  the  left  hemisphere  is  a  part  of  the  brain  in  which  arc  stored  the 
memories  of  the  meaning  of  letters,  words,  figures,  and  indeed  of  all  seen 
57 


f 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


„,ieet.      Tlus  i.  .l.si^.aU..!  in  tl,o  vi.-al  .,oocl.  .ontre  on  tho  diagram 

Topical  Diagnosis.-Tiu>  ^--■-*"  ^^J^^^"^ ^.J,!  ,,.1  oxhuu.tivo 

Iho  motor  i)ath.  disturbances  oi  motion.    If 

Les^ions  in  any  i^art  of  tho  motor  patli  ^'i"-  ,  j^  ^i^,,rc 

.lostrnetivo,  llu-  Imution  of  the  par  'V^'"!  :^^^'j;"^;^;  ^ive  one,  the 
,,  ,„.al,isi.  If,  on  the  other  ham  ^^^^.^  ;^  ,,,,  ,,„,,.,nal 
structures  are  thrown  nito  al.normal  '  \\'  ^  '  ™  \ ^^  ,f  ^i„  ,,,normal 

^f'  '^'''  ':^::^;ZZ:Z^^^^^^  l-^  degenerates  along 
It  :.,!r l^n^h^^SI^l^Ued  secondary  degeneration  plays  a  very  .mpor- 

tant  rob  in  the  symptomatology.  ^^^,,,,,,. -■  ^„  ^^^  onlv  alVects  tho  axis- 

In  the  lo.er  motor  segn.ent  t^e  '^^^  "^  ^^^^^  ,  ,1.0  the  muscle 
ovUndor  processes  which  run  m  the  P^^'  I^  ^  ;^^^^y;,j\;'  a,.oaeration  of  tho 
iibres  in  which  the  axis-cyhnder  V^<^^'^^  „uile  becoming  smaller 
nerves  and  muscles  is  made  ^'^'f  ■"\^^  f :,  >/  ^'^ ,"  ^n  to  eloctricaf  stimula- 
and  llahby,  and,  secondly,  by  change  f  ^^^.j,,,  ^ho  galvanic  or 

tion.  The  degenerated  nervo  gives  ''ll'']l2rJmn^  to  furadie  stimula- 
the  faradic  current,  a.ul  tho  --^^  ^^^  ^  "  e  "t  nic  current.  The 
tion,  hut  reacts  m  a  character  .tic  m.m  or    !  -  j,,  that  of  a 

contraction,  instead  of  being  ^^^  ^^^^^t  a  ^cnkov  current, 

normal  muscle,  is  slow  and  lazy,  ''"^ '^^^^^^^^^  j  ^  tUe  cathode-closing 
and  tho  anodo<dosing  c.mtrachon  m  y  bo  gi^L  ter  t^u 


GF'INKRAL  IXTRODITTIOX. 


91.- 


liagram 

rst  tom- 
s  rt'gioii 
(1  words 
in  I'ront 
I  part  of 
[)ociUupi. 
iR'll,  but 

-ition  of 
■vhiUi^tivo 
K'iivoring 
I  diBturb- 

localiziiig 
V  ilomoii- 
wledge  of 

otion.  If 
suit  there 
'  one,  the 
(ihiKirinal 
altnormal 
motor  seg- 
iou  of  the 
L'  result  of 

Destructive 
s  of  a  neu- 
and  if  the 
;  a  portion 
rates  along 
^ery  impor- 
ts the  axis- 
the  uuiscle 
tion  of  the 
ling  smaller 
cal  stimiila- 
galvanic  or 
die  stimula- 
irrent.     The 
in  that  of  a 
iker  c'livreiit, 
hodc-closing 
always  pros- 
lazy  contrac- 


tion of  tlio  riniscle  to  the  galviinic  curniit,  and  wlun  this  is  prcsi'iit  the 
ninsch'  is  dcgcncratcMl. 

'J'he  iiiyotatie  irritability,  or  inusch'  rellex,  and  tlic  innscjc  tonus  de- 
jiend  upon  tlie  intci^rity  of  the  rellex  are,  of  which  thi'  lower  motor  scg- 
jiient  is  the  cll'erent  lind),  and  in  a  paralysis  dui'  to  hsion  of  this  segment 
tile  muscle  ri'iU'xes  (tendon  reflexes)  are  aliolishcd  and  tliere  is  a  dimiiiislu'd 
muscular  tension. 

liower  segment  paralyses  iiave  for  their  cliaracteristies  degenerative 
ntrojiliy  with  the  reaction  of  degeneration  in  the  all'ected  muscles,  loss  of 
their  rellex  excitability,  and  a  diminished  muscular  tension,  'i'hese  are 
the  general  characteristics,  but  the  anatomical  ndatituis  of  this  segment 
also  give  certain  peculiarities  in  the  distrii>uti(Ui  of  the  paralyses  which 
help  to  distinguish  them  from  those  which  follow  lesions  of  the  upper  seg- 
ment, and  which  also  aid  in  determining  the  site  of  the  lesion  in  the  lower 
segment  itself.  The  cell  liodics  of  this  .segment  are  distrihuted  in  groups, 
from  the  level  of  the  ])eduncles  of  the  brain  throughout  the  whole  extent 
of  the  sjiinal  cord  to  its  termination  o])posito  the  second  hnnbar  vertebra, 
and  their  axis-cylinder  ]>roces,ses  run  in  the  jieripheral  nerves  to  every  mus- 
cle in  the  body;  so  that  the  comjionent  parts  are  n:ore  or  less  widely  sepa- 
rated from  each  other,  and  a  local  lesion  causes  ])ara!ysis  of  only  a  few 
nuiscles  or  groups  of  muscles,  and  not  of  a  whole  section  of  the  body,  a:? 
is  the  case  where  lesions  all'ect  the  u])])er  segment.  I'l.i  muscles  which 
are  ])aralyzed  indicate  whether  the  disease  is  in  the  peripheral  nerves  or 
sjiiual  coi'd;  for,  as  we  have  seen  above,  the  muscles  are  represented  ditl'er- 
ontly  in  the  ])eri|)heral  nerves  and  in  the  spinal  cord.  Sensory  sympt(nns, 
which  may  accompany  the  paralysis,  are  often  of  great  assistance  in  making 
a  local  diagnosis.  Thus,  in  a  ])aralysis  with  the  characteristics  of  a  lesion 
of  the  lower  motor  segmtMit,  if  the  ])aralyzed  muscles  are  all  sujiplied  by 
one  nerve,  and  the  ana'sthetic  area  of  the  skin  is  supplied  by  that  nerve, 
it  is  evident  that  the  lesion  must  lie  in  the  nerve  itself.  On  the  other  hand, 
if  the  muscles  ])aralyzcd  are  iu)t  sujiplied  by  a  single  nerve,  but  are  repre- 
sented close  together  in  the  spinal  cord,  and  the  anaesthetic  area  corresponds 
to  that  section  of  the  cord  (see  table),  it  is  equally  clear  that  the  lesion  must 
be  in  the  cord  itself  or  in  its  nerve  roots. 

Irritative  Lesions  of  the  Lower  Motor  Segment. — Lesions  of  this  seg- 
ment cause  com])aratively  tew  symptoms  of  irritation,  and  our  knowledge 
on  the  ])oint  is  neither  extensive  nor  accurate.  The  fibrillary  contractions 
which  are  so  common  in  muscles  undergoing  degeneration  are  jirobably 
due  to  stimulation  of  the  cell  bodies  in  their  slow  degeneration,  as  in  jiro- 
gressive  muscular  atroi)hy,  or  to  irritation  of  the  axis-cylinder  processes 
in  the  perijOieral  nerves,  as  in  neuritis.  Lesions  which  affect  the  motor 
roots  as  they  leave  the  central  nervous  system  may  cause  spasmodic  con- 
tractions in  the  muscles  supplied  by  them.  Certain  convulsive  paroxysms, 
of  which  laryngisnnis  stridulus  is  a  type,  and  to  which  the  spasms  of  tetany 
also  belong,  are  believed  to  be  due  to  abnormal  activity  in  the  lower  motor 
centres.  These  are  the  "  lowest  level  fits  "  of  ITnghlings  Jackson.  Cer- 
tain poisons,  as  strychnia  and  that  of  tetanus,  act  particularly  \i[Km  these 
centres. 


\ 


DISEASES  OK  THE  NERVOUS  SYSTEM. 


910 

;:;:;ji;;:'';:::;;::ivr::;:l.::r,^::;i4: -".«M.«.4-,  ..,,>u,,.. 

•    (A)  Lesions  of  the  Upper  Mot«r  Segment  ^^^^^^^^^     ^^     ,_^_ 

,,,t,,isr„.s.     In  tins  ca^.  tl.     I''^'">    ■  ,       '     ,     ,  j,,,,,,,,,  in  ihu  t.n- 

^--•!":'  '^'T'tT:: ;  .;:;^  t:;;  i'-\he  ao..u.vation .,. 

an.  --'-^'>  ,;;"'      ^  „       1.  innm..u.o  m).es  to  ad,  on  acn-nnt  ot  .1.  - 

;,„1,  ,.,,„,;t  by  an  cxag.oration  oL  J  ^ -;;-^;^:,f^^;„„,t  of  the  n,otor 

^V.  l.avc-  sren  tluit  the  neurones  '"'  "1"'^  ""  '^     '      ;^,f,„,,  ^i,,  ..eondarv 

,„  „,,  ,,  ,.  oonsulerea  as  "'•^-^•;-'  ^'l  ['^  ^'V'     n    ^  «i  the  lower. 

ll.,„H,ration  in  tl>e  upper  ^^^^'-^V        ,  thw    Mhe  u,M.or  segment  .lo 

together  than  ,lo  those  of  the  l"Wor -g'-  ^  -;^^       ■„,,,, ,,i,  true  in 

"-y  --^"  r'^'r  ^;;.,r"ur      i4   -ll;   .roceies  of  this  segment 
the  internal  eapsA.le,  ^^heIe  •  l'  J^        pyranmlal  traet.     A  lesion  _m 

,,e  eolle.'tea  into  a  eonq-aet  huml  '^^^^^^^^^^^^.^^.^  ^,,  ^i„  ,p,,osite  si.lo 

thi,  re-ion  '>^''''11>;  ^'V'''^  ^r';- ;  The'iwranmlal  traet  continues  in  a  com- 
of  the  ho.ly-tl,at  .s,  ^^^^^^'^  ^  ^^,  ,„,,,,  ,t  dilVerent  levels;  a 
,,aet  l.undle.  pvmg  oil  l>'^'^^^%7  "  ,,,,  ,,alvsis  of  all  the  musele3 
lesion  anywhere  in  .ts  course  -  ^  ^  \.  ^„  {,,,  ,ii,,se  is  ahovo  the 
,.hose  nuch.i  are  situate.!  ^-''-^f '^'  ^  ,  '  j^f  the  body;  ^vhen  below, 
decussation,  the  pan.lys.s  is  ""  ''^^  ^^^'^^J  i,,ion.  Ahove  the  in- 
the  paralvzea  muscles  are  on  the  sanu      ''^^  •>         ^  j  ;,,  the  cortex  the 

tornil  capsule  the  path  i--^  -y^ll^^^  ^j^  of  the  body  are  con- 
centres for  the  inov..nents  of  tl  e    i  j    x  ^  ^^^^^ 

-  :r:;;;;:';;:r;;;;:;nSf  :"f " >.  -  ^'^«  -  --'  - 

„,,t  paralysis  (see  Fij:.  '^  an.1  «P''^!^^l';"^;     ^^  ^,,,         .^  ,notor  segment 

T.;  sun,  np,  the  pa^'alyses  due  ^^J^^!    ;;';,,,  i,  arc  spastic  (the 

a,.o  widespread,  often  ^-"-f  ^j;  ;  ^  i^  t^lcn'^o  degenerative  atrophy, 

tendon  rcilexes  ^^'^.-'^^^^^    t       '  J    irrciction  to  clectricnl  stimulation. 


r.KNKUAli  INTIlODrCTIOX. 


017 


lie  iii- 
l  spinal 
ford  1)1" 
ir  polio- 
.oplcgia, 

jiiuso,  ad 

V     (It'JfL'll- 

VI     C'llllf- 

0  c'oiuli- 
tlio  ton- 
ration  oL' 
usual  ox- 

1-      Cl'lUl't'!^ 

y  nt  the 

lit  of  <lis- 

which  i.s 

lie  motor 
secondary 
he  lower, 
tnnent  do 
cx\  change 

)ro  closely 
nail  lesion 
•ly  true  in 
is  segment 
,  lesion  in 
qiosite  side 
>  in  a  com- 
it  levels;  a 
he  muscles 
s  ahovc  the 
,hen  below, 
ove  the  in- 

1  cortex  the 
ly  are  com- 
;i  may  caii^c 
I) — the  ccre- 

to  an  indi- 
n  lower  scg- 

)tor  segment 
spastic  (the 

ivc  atrophy, 
stimulation. 

the  paralyses 


which  f(dIow  a  complete  transver>e  lesimi  id'  the  s|miiii1  cord.  Here  the 
lindis  are  (d'  cduisi'  complelely  paralyzed,  liul  instead  of  heing  >iia.-tie  they 
are  llaccid  and  the  derp  rclIe\(S  ari'  aiixiit.  Thtic  is,  liowevcr.  no  ni;irl<ed 
atrophy  in  llie  iiiu-rli's.  ami  they  react  normally  \<>  chM'ti'icity.  'I'liire  is 
no  satisfactory  explanation  of  why  the  rellexes  should  he  aho|i^hed  under 
tiu'sc  conditions. 

Irritative  Lesions  of  the  Upper  Motor  Segment.  -Our  knowledge  of 
such  lesions  is  coidincd  for  the  most  part  to  those  acling  <in  the  motor  cor- 
tex. The  alinormal  muscular  coidractions  resulting  from  lesions  so  situ- 
ated have  as  their  type  the  localized  convulsive  seizures  classed  under  dack- 
soiuan  or  cortical  ejiilepsy,  which  are  characterized  hy  the  eonvuMou  hegin- 
niii"  in  a  single  muscle  or  gi'oup  of  muscles  and  involving  other  mns(des 
in  a  deliidle  order,  depending  upon  thi'  jiosition  of  their  representation  in 
the  cortex.  For  instance,  such  a  ctuivnlsjon,  heginniiig  in  the  muscles  of 
the  face,  next  involves  those  (d'  the  arm  and  hand,  and  then  the  leg.  The 
eonvnlsion  is  usually  aceom[)anied  by  sensory  jiheiiomemi  and  foUowed  by 
a  weakness  of  the  nuiscles  involved. 

A  majority  of  lesions  of  the  motor  corlex  are  liotli  destructive  and  irri- 
tative— i.e.,  they  destroy  the  nerve  cells  of  a  certain  centre,  and  either  in 
their  growth  or  "by  their  presence  throw  into  abnormal  activity  those  of  the 
surrounding  centres. 

The  upper  motor  segment  is  invcdved  in  nearly  all  the  diseases  of 
the  brain  and  spinal  cord,  especially  in  injuries,  tumors,  abscesses,  and 
haemorrhages;  transverse  lesions  of  the  cord:  syringomycliii,  ]irogres- 
sive  muscular  atroidiy.  bulbar  paralysis,  etc.  One  lesion  often  inv(dves 
both  the  ujtper  and  the  lower  motor  segments,  and  we  have  paralysis  in 
the  dilVerent  parts  of  the  body,  with  the  characteri.«tics  of  each.  Such 
a  cond)ination  enables  ns  in  many  cases  to  make  an  accurate  local  diag- 
nosis. 

Lesions  in  the  optic  path  and  in  the  diiTeront  spcccli  centres  also  give 
localizing  symptoms,  which  should  be  always  looked  for. 

{(')  Lesionsof  the  Sensory  Path.— Here  again  the  lesion  may  he  either 
irritative  or  destructive.  Jrrilalive  lesions  cause  abnormal  sulijective  si'U- 
sory  im])ressions — jiara'sthtvia,  formication,  a  sense  of  cold  or  constriction, 
and  pain  of  every  grade  of  intensity.  The  character  (d'  the  sensory  symp- 
toms gives  very  little  indication  as  to  the  position  of  the  irritating  process. 
Intense  jmin  is.  as  a  rule,  a  symptom  of  a  lesion  in  the  peri|)hci'al  sensory 
neurones,  but  it  may  he  caused  by  a  disease  of  the  sensory  path  within  the 
central  nervous  system. 

The  exact  distribution  of  symptoms  gives  us  more  accurate  data,  for  if 
thev  are  confined  to  the  distribution  of  a  ])eriphcral  nerve  or  of  a  spinal 
segment  the  indication  is  plain.  If  one  side  of  the  body  is  more  or  less 
conijiletely  affected,  we  must  think  id'  a  lesion  somewhere  within  the 
brain,  etc. 

Dcsfritrlirc  Lesions. — A  complete  destruction  of  tlie  sensory  paths  from 
anv  part  of  the  body  would  of  course  de]irive  tliat  iiart  of  sensation  in  all 
its  cpialities.  This  occurs  most  frequently  from  injury  to  the  peripheral 
sensory  neurones  within  the  peripheral  nerves,  and  the  area  of  anaesthesia 


.j^g  DISEASES  OF  THE  NERVOUS  SYSTEM. 

,U,pn.1.  upon  tl.  n.rvo  i.uuna.     Con.pM.  tnu.v...  l.ion  .f  tho  conl 

^^:^'^~r^ri:B 

imrt  <|t  tlu'  l'"">-       '"^^y        1  ,  ji„     ,,„j  ,„.,  at  timos  involved 

the  ai.ea.cd  l'^'"--  •  '^^  '  hV  U  '  -Vsonsorv  conduction,  and  tl>c  loss  of 
^^^'Tt^ruZnuMo  I  otln  astonishing  how  very  sl^l>t  the 
sensation  1.  i  ot  ^""       \;     ^     ^,^,,„,^  f,,,,,,  ,„  ,.,t.nsive  lesion  of  tlic  ncrv- 

been  described.    It  i.  the  ^"^^i"^""';;  ,li<trihution  trives  hut  uncertain 

dofoct  that  is  o^  -M'ortance  and  o«o    the^d  ^nhuh  n^.       ^^  ^^^^ 

ti;e  nervous  system  for  a  more  detailed  eonsideration  of  the  subject. 


IMAGS  EVALUATION 
TEST  TARGET  (MT-3) 


«V     ^. 


1.0 


I.I 


1.25 


■  5  0         

•^  IIIIM 

16  3 

In  IM 

I. 


1.4 


m 

1.6 


Photographic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


n 


#;5 


in 


^1 


i 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


M 


-    *• 


;» 


^Hmt^ 


1 


INTRODUCTION.  019 


II.    SYSTEM   DISEASES. 
I.    INTRODUCTION. 

Tlicro  aro  oortniii  diseases  oi  tlu'  iiervdiis  system  uliieli  are  eeiifineil, 
if  not  al)S()lutely,  still  in  j:reat  part,  to  delinite  tracts  (cciniliitiatioiis  if 
neurones)  whiili  su+tservc  like  functions.  'I'lioe  tracts  are  called  s//,s- 
Irivs,  and  a  disease  which  is  condned  to  one  of  them  is  a  si/slfin  disfusr. 
Jf  nu>re  than  one  system  is  nivolved.  tlh'  ]irocess  is  called  a  condiined  s_v<tein 
disease.  Just  what  disi'ases  sluuild  he  classed  under  these  names  has  Liiveii 
rise  to  much  discussion  l)ut  to  very  little  a,ureeiiu'nt.  We  cannot  speak 
])ositi\H'ly;  our  knowied^a'  is  as  yet  not  suiliciently  accurate,  either  in  regard 
to  the  exact  limits  of  tlio  systi'ins  them-elves,  or  to  the  nature  and  extent 
of  the  niorhid  process  in  the  s^everai  diseases.  In  the  classi(ication  which 
has  been  adopted  in  this  edition  the  endeavor  lias  been  to  make  the  arranirc- 
nicnt  as  sinnde  as  possible,  and,  while  it  is  based  njion  what  is  lielieveil  to 
l)e  the  best  founded  views  of  the  .systems  and  their  diseases,  there  has  been 
no  attempt  to-  carry  the  olassitication  to  its  logical  conclusion,  nor  have  the 
limits  of  the  theory  been  always  respected. 

In  general  it  may  be  said  that  the  nervous  system  is  composed  of  two 
great  systems  of  neurones,  the  alTerent  or  sensory  system  ami  the  efferent 
or  motor  system,  and  the  connections  between  them.  (See  General  Intro- 
duction.) 

Locomotor  ataxia  is  a  disease  confined  to  the  afferent  system,  and  pro- 
gressive muscular  atrophy  is  (me  of  the  ciferent  system.  Keprosenting  typ- 
ical system  dist'ases  as  we  now  understand  them,  they  have  been  taken  as 
the  basis  of  the  classification.  Several  theories  have  been  advanced  to  e\- 
])lain  why  a  disease  should  be  limited  to  a  definite  system  of  neuroTies.  One 
view  is  Inised  upon  the  idea  that  in  certain  individuals  one  or  the  other  of 
these  sy.stems  has  an  innate  tendency  to  undergo  degeneration;  another  as- 
sumes that  neurones  with  a  similar  function  have  a  similar  clieiiueal  con- 
struction (which  diifi'rs  from  that  of  neurones  with  a  dilfereiit  function), 
and  this  is  taken  to  explain  wliy  a  poison  circulating  in  the  blood  sIkjuKI 
show  a  selective  action  for  a  single  functional  system  of  neurones. 

In  the  afferent  tract  locomotor  ataxia  stands  alone  as  a  system  disease. 
In  the  efferent  tract  progressive  (central)  muscular  atrophy  is  the  chief 
representative,  as  in  it  the  whole  motor  path  is  more  or  less  involved.  The- 
oretically, primary  lateral  sclerosis  is  a  disease  confined  to  the  upper  seg- 
ment of  the  efferent  tract,  while  anterior  poliomyelitis  involves  the  lower 
segment  of  the  tract. 

In  connectiiui  with  progressive  (central)  muscular  alrophy,  the  other 
forms  of  nniscnlar  atrophy  are  considered  as  a  matter  of  convenience.  In 
other  instances,  too,  diseases  arc  arranged  in  positions  to  which  they  might 
not  be  entitled,  had  a  rigid  classification  of  system  diseases  been  maintained. 


920 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


II.  DISEASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM. 

LocoMoroit  Ataxia 

( Tahcn  Dorsalis  ;  Poslcritir  Spinal  Scli-rnsis). 

Definition.— All  ailV.li.m  cliiirnct.rizcd  clinically  by  incoimlinnti.ni, 
^cn^orv  anil  tn.phic  .listurl.aii.rs,  and  iiiv.ilvcMiu'iU  ol'  tho  spocial  sens.-, 
parliciilarlv  the  cvrs.  Anatoniically  liu'rc  are  lound  degenerafon  ot  the 
i.u.terior  vno\>  and  of  the  dorsal  eohmuis  of  the  eord;  sometimes  the  spinal 
Undia  a.Hl  peripheral  lu'rves  are  allVeted.  Foei  of  de.izenerat.on  in  the 
basid  jzan-lia  and  degenerative  changes  in  the  cortex  cerebri  have   been 

^''Etiology.— It  is  a  widespread  disease,  more  fro.pient  in  cities  than  in 
the  countrv.     The  relative  proportion  may  be  jndged   from  the  lad   that 
of  y(il->  ca<es  in  the  neurological  <lispcnsary  of  the  dohns  Hopkins  Hos- 
pital tlu're  were  S'l  cases  of  loc.miotor  ataxia  (II.  M.  Thonia>)      ^^f'^^^ 
attacke.l  m..re  fre.iuentlv  than  females,  the  proportu.n  bi'ing  at  l.sisl  Kt  to 
1      :ilitcliell   has  calle.rattention  to  the  fact  that  it  is  a  rare  disease  in 
the  ne-ro      It   is  a  disease  of  adult  life,  a  majority  of  the  cases  occurring 
betweeii   the  thirtieth  and  fortieth  years.     Occasionally  (;iscs  are  seen  ni 
voun-  men.     The  form  of  ataxia  which  occurs  in  cluldren  is  a  di  lerent  dis- 
"oa^e."  Of  special  causes  svphilis  is  the  most  important.     According    o  the 
fi.ruros  of  Kri).  Fournier.  and  (iowers.  in  from  :.(»  to  Tr.  per  cent  ot  all  cases 
there  is  a  history  of  this  disease.     KrbV  recent  fig:urcs  arc  most  striking; 
of  300  cases  of  taVies  in  private  practice  89  per  cent  had  had  syphilis      Moc- 
bius  goes  so  far  as  to  say.  "  The  h.nger  I  rellect  upon  it.  the  more  firmly  I 
believe  that  tabes  never  originates  without  syphilis.  ,  ,        ,        ,    ,„,-, 

Fxce«ive  fatiLnie,  overexertion,  injury,  exposure  to  cold  and  wet.  and 
.exnal  excesses  are  all  assigned  as  causes.     There  are  instances  m  which 
the  disease  has  closelv  followed  severe  exposure.     Janu-s  Stewart  has  noted 
at    he  Ottawa  lumbermen,  who  live  a  very  hard  life  in  the  camps  dnnng 
Vinter  months,  are  frequently  the  subjects  of  locomotor  ataxia.    Tranma 
ha<  been  noted  in  a  few  cases.     Alcoholic  excess  does  not  seem  to  predis- 
^.e  to  the  disease.     Among  patients  in  the  better  classes  of  life  I  do  no 
^eXr  one  in  which  there  had  been  a  previous  history  o     prohmg^n 
drunkenness.     Tlu.re  are  n..w  a  good  many  cases  on  record  of  the  existence 
of  the  disease  in  liotli  husband  and  wife. 

Morbid  Anatomy  and   Pathology.-Our  conception   of  tab  s 

dorsalis  has  undergone  radical  alteration,  and  the  stiulies  of  l^oydcm    Kcd- 

cb    Atarie,  and  otliers  have  shown  that  it  can  no  longer  be  regarded  as  a 

;,,;  sc. lerosis  of  the  dorsal  cdumus.     These,  it  will  be  rc.nenibered,  are 

,       ;„,,   in  great  part,  of  the  axis-cylinder  processes  of  tiie  spinal  ganglia, 

tl  ev.  wiU,  their  branches,  represent  in  the  ...rd  the  paths  <d  sen.vry 

;onduction.      The   peripheral   sensory   nerves   rei^csent   the    l';;;^l> - 

processes  of  the  spinal  ganglia,  wbieb  important  structures  are  the  t.oplm 

,,„t,vs  both  for  the  sensory  nerves  as  well  as  for  the  axis-cylinder  proces>e. 

whicb  make  np  the  dorsal  columns  of  the  cord.     Mane  calls  attention  al.o 


SYSTEM. 


ooiinlin^.timi. 
pocial  t^i'iisis. 
riit'on  of  till' 
ic'S  tlie  fjpinal 
ration  in  tho 
li  luivo  IjL'en 

cities  tliiin  in 
till'  I'act  that 
Hopkins  IIos- 
.).  Males  aro 
at  least  10  to 
ire  disease  in 
ises  occurring 
'S  arc  seen  in 
I  tliircront  tlis- 
•ordin;^  to  the 
lit  of  all  cases 
most  striking; 
vphilis.  Moe- 
niore  lirnily  I 

and  wet,  and 
nces  in  whieh 
ivart  lias  noted 

camps  during 
axia.  Trauma 
eem  to  predis- 
f  life  I  do  not 
'  of  prolonged 
if  tho  existence 

ition  of  tahes 
[  Lcyden,  Ked- 
i  regarded  as  a 
?meinl)ered,  are 
sjiina!  ganglia, 
aths  of  sensory 
e  protoplasmic 
are  the  trophic 
lindi'r  processes 
s  attention  also 


DISHASKS  OF  TIIH   AFFKHKNT  OR  SHNSORY   SYSI'KM. 


0-Jl 


to  the  possiliility  of  the  existence  of  peripheral  or  Icrminal  ganglion  cells 
which  are  found  in  (lill'erei;t  organs — cells  fnnii  which  certain  of  tlie  sensory 
Jihrcs  are  iK'rived  which  go  to  form  the  dorsal  nerve-roots.  Accunliiig  to 
the  general  laws  of  nerve  jihysiology,  already  nientiinied,  lesions  nf  the  nerve 
ganglia  would  \iv  followed  hy  degeneration  of  the  dorsal  root-lilires  and  of 
their  continuation  in  the  cord,  and  this  is  practically  what  the  recent  iheoi'y 
of  tahes  involves,  'i'lie  changes  in  the  dor-al  c<ilimiiis  ai'c  mci'cly  a  se- 
(jueiice,  and  not  the  primary  disea.-e.  The  lilircs  of  the  dorsal  root  are  di- 
vided into  three  sets: 

(1)  The  short  iihres,  which  ]iass  almost  directly  into  the  dursal  I'nrnii 
after  entering  the  cord. 

i'i)  Kihrcs  of  moderate  length,  which  run  upward  in  the  cord;  some 
of  them  enter  the  dorsal  horn  at  its  middle  part,  while  others  pass  into 
I'larkeV  column.  The  (ihres  of  this  gmuj)  run  in  the  fasciculus  cuneatus 
of  IJurdach. 

(3)  A  group  of  long  fihres,  which  are  di'iivcd  chielly  from  the  roots  of 
the  Cauda  c(|iiina,  and  which  pass  the  whole  length  of  the  cord  to  enter 
certain  nuclei    in    the    medulla.      Thev    lorm    the    fascicidiis    gracilis    of 

(Mill. 

The  initial  cord  lesion  in  tahes  is  found  in  the  dorsal  root-zone  and 
in  the  zone  or  tract  of  Lissaner,  a  narrow  portion  situated  hetwei-n  the 
margin  of  the  cord  and  the  ajiex  of  the  posterior  horn.  In  the  fasciculus 
of  Bnrdacli  the  sclerosis  is  in  almost  direci  jiroportion  to  the  duration  n  the 
disease,  slight  at  first  and  centrally  placed,  and  hecoming  wides[iread  as 
the  disease  advances.  The  fasciculus  of  (odl  is  all'ected  slightly  in  the  early 
stages,  Imt  i"  the  advanced  stage  there  is  extensive  sclerosis.  Marie  cor- 
relates the  sclerosis  of  these  dill'erent  parts  with  the  diil'ereiit  group-s  of 
nerve-lihres  of  the  dorsal  root,  the  dorsal  root-zone  and  the  zone  of  Lis- 
saner degenerating  from  the  invoivenieiit  of  the  short  fihres;  the  sclerosis 
of  the  fasciculi  of  Ihirdach  and  the  disajipcarance  of  the  network  of  the 
nerve-fihres  in  the  column  of  Clarke  heiiig  due  to  the  degeneration  of  the 
second  group,  the  (ihres  of  moderate  length;  while  the  sclerosis  of  the  fas- 
ciculi of  Ooll  is  caused  hy  the  degeneration  of  the  third  group,  namely,  the 
long  fihres.  He  suggests  alijo  that  groups  of  fihres  in  the  dilfereiit  dorsal 
roots  are  not  simultaneou.«ly  affected,  and  the  lesions  may  he  in  an  ad- 
vanced stage  in  one  region  and  hut  slight  in  the  other.  "  I'lw  h'sioiis  of  the 
ypinnl  cord  in  tahes  occur  hi/  sriimrnts,  each  dorsal  root  hringing  into  the 
dorsal  column  a  fresh  contingent  of  degenerated  fihres."* 

According  to  this  interesting  hypothesis  the  lesions  of  the  gangU  of 
the  dorsal  roots  are  responsihle,  in  part  at  least,  for  the  iK'ri])heral  neuritis, 
since  in  degeneration  of  the  spinal  ganglia  and  conse(|iient  loss  of  trojihic 
influence  there  would  necessarily  he  degeneratitui  in  the  perijihei-al  nerve- 
trunks.  Possihly,  too,  :\Iarie  suggests,  the  degeneration  of  the  peripheral 
ganglion  cells  may  have  a  good  deal  to  do  with  the  neuritis  of  tahes. 

Ohersteiner  and  Redlich,  while  agreeing  that  the  degeneration  of  the 

dorsal  columns  of  the  cord  is  deiiendcnt  upon  a  disease  in  the  dorsal  roots, 

helieve,  at  least  for  most  cases,  that  the  change  in  the  latter  is  secondary  to 

a  chrouie  inflammation  of  the  pia  mater,  Avhich,  hv  making  pressure  (m  the 

68 


D1SE\RF.S  OF  THE  NEUVOrs  SYSTEM. 

:;:;!;:::i';:";::cu::i"i;:;  ;;t -,..».• ■ • .■•■ '^ 


77,.    /mf/MV./   ,s'/,/|/<'.-n>'>   i>  :  ;'7,' '.irtv,,  vorv  wia.lvintlie.hl- 
;>,...  usually  of  a  shar,  ^^.^  .n|:   W     -  ^  ^^  ^  ^^^^^^^^^^^,,  .,,  ,„..  „^, 

IKuns.     'nu.y  last  f'-''>  >' '^^^^^l'^;,  ^     "  ^.lin,.     O.^asionally  hovpc. 

„„;aovc.lop  at  tlH.  s,t..  o    ^'J^^J:l  ,.,  •„„,.  on  .hon  bcalth  h  un- 

naivM.     Tlu.   ^a-tri.   cns.s   an.     ot      t   ^,^_     ^^„„,,„,,,  ^f  the  feet, 
>anest!u.ia  n,ay  also  l.e  -.-n,   1k>   -     ,  ^^,^^^^^^  ,,^  ,,.,,,. 

tin,lin,.  ete.,  and  at  tunes  ;;  >;  -  ',,,,  .,,,„,  in  about  10  per  cent 

Ornlar  Snwplomx.-i")  <>l*tu  •'"  M  ';>  .vniptoni.     There  is 

,f  U,e  eases,  and  is  ot.en  an  ear  >  -;-,;,.,,  ,,  ;,,;„  ,...1.  to  tol^U 
,  „.a.lnal  loss  of  vs.on  w  ne  n  a  j  ^  '^^  ^  ^._^ •  ,.  ,,  i,,,,,,,,;,  .,f  the 
Mhulne^s.  (h)  IMos.s  wlueh  '>;■!>  '■'-':',;  ,,^  ,^  ,i,,,,  ,„usele  or  -eas.on- 
.xternal  nu-s.-les  of  the  ey.^      "';"''>>  ^,„,,,,,i,  i,  often  transient,  the 

patient   nu.rly  eonM'la.mn.  ^1  at    '   ,     ;  ^,^^  -^-^  .^lex  to  h-h 

bi;^;;:;i"n;,,i;:r».:".:"-'-'^  ' 

"'.v^^i^-  ,  Th..  llr-^t  warnino-  of  the  disease  whieh  the  patient 

]l],uhh;-  Sinnpt'wo^.-]  lu  in.  1  ^^  .         ,      i,la,l,1er.     lneontinen..e  ot 

I- -^ ' ';:;;;".; r'S.:,:i;;;i;-- 1.... .•  i- -- ■'■-" 

urine  oeeurs  ohIy  at  a  laui  .  i.i,_ 

ana  pouer  B.ay  also  he  an  ^^yj^^^^;^;-  ^^^^.,,  ..ter  in  the  disease   hut  at 
Trophic  /),8/„WMmr.s..-nu>e  una  i„f,r.iuent  to  nave 


tie 


,f  a  c-haraeter^t.e  (  ';="- 1^^'^"    •^.  ^„„^  ,,,„t  iniportant  symptom  may 

Lo,,  of  Ihe  A'»..-;n7.-.-nu>  •-■^    >      '"  ,         ,i„„,  jt  is  of  L^reat  mo- 

„,„,  vears  before  the  aeveHmu.n    ^       ---;^..  j    ,^  .^  ,,„„„  the  knee-.-rk 

,„,nt.'sinee  it  is  very  rare  to  nu-et    u  h    ml      l  ^^^^_j^.^,^  ^^.;^^^  ,,,, 

"  „orn,allv  absent.     The  -'"l;'"'^*'  ''l^t  "^^^illW  .-ith  the  lijzhtnin, 

-  --  ''^  ^!l rt^;  S:;^:;;!  ;u;ri^i-ticany  aia,nostie.     The 


pains  and  ptos 


m 


T 


i?o«,  but  in 
>  iiid  ol"  thi> 
S  VITV  liitl.' 
ire  primarily 

lcin>  i'.>'t'i»i'(.- 
s  (.'udoiivori'il 


ICVOS- 


-llu'  in- 


■iiiiixic  stapo. 
ly  in  tlie  tlif- 
li  tlu>  (liHca^e. 

,,,■111  liiihtninj:; 
(.11  in  tlu'  Icirs. 
ioiiiilly  licrpcr^ 
rular  iulrrvals. 

health  is  iui- 
n  the  (lisi'aso. 
ess  1)1'  ill*-'  ''^'*-'t> 

body. 

out  10  per  cent 
torn.  There  is 
s  leads  to  total 
Paralysis  of  the 
cle  or  oecasion- 
11  transient,  the 
iiin  period.  ('?) 
;  ivllex  to  lij:ht 
ry  small— --pini'^ 

hieh  the  patient 
liieontineiiee  ot' 
in  sexual  d.'sire 

le  disease,  hiit  at 
freipient  to  ]iave 
perforating  ideer 

nt  symptom  may 
it  is  of  great  mo- 
10111  the  knee-jerk 
lee-kiek  with  one 
■ith  the  lightning 
■  diaii-no^tie.     The 


DISK.VSKS  OF  TIIK    AFFKUKXT  OR  SEN'.SORY   SVSTKM.  {>•_>;{ 

kiiee-jeik  is  not   h.st  su.Menly,  hu!  gra.lually  .hvreases,  nflen  .lisipprariiiu' 
ill  one  leu-  iiel'ore  the  other. 

These  are  the  nmst  coiiimon  symiitdnis  nt  the  initial  stage  ol  talie<  ami 


f  i 


iieoiirdinat 


mil. 


he  pa- 


iiiMV  persist  for  vears  wiliimit  the  develni.me.it  ( 
(ient  mav  Innkwell  and  fe.d  well,  and  he  trouhled  only  l.y  .u.aMnnal 
•itfieks  (if  li'ditniiiL^  i»aiiis  nr  nf  one  of  th.e  other  subjective  symiit.ims. 
*:\b!elMiw  .'..es  so  far  as  to  stat.-  that  the  typieal  Argyll  Ifohert^m,  pupil 
ineaiw  either  tal.es  or  geiu^ral  paral\sis,  and  that  paralysis  ol  the  external 
nmselo  of  the  eye  developing  in  adults  are  (.f  alnmst  e(,ual  importance,  es- 
peeiallv  if  thev  deveh.p  painlessly. 

Th'e  lime  hetweeii  the  svphililic  infectinii  and  the  necnrremc  nt  the 
lir4  «vmptnnis  of  locomotor  ataxia  varies  within  wide  limits.  .\h..ut  one 
half  tiu'  ca.-es  occur  between  the  sixth  and  (ifteeiitli  year,  hut  many  begin 

even  later  than  this. 

The  disease  mav  never  i.rogress  beyond  tins  stage,  and  when  optic 
afroi.hv  develops  earlv  and  leads  to  blindness,  ataxia  rarely,  if  ever,  siiper- 
vene<  "  There  is  a  sort  nl  antagcmism  between  the  nciiiar  symptmiis  and 
the  progress  of  the  ataxia.  Charcot  laid  considerable  sirens  npnii  this,  and 
huth  Itrjcrine  and  SpiUer  have  since  emphasized  the  point. 

Ataxic  Stage.— .1/ ('/"'•  >•//'»/'/"'"■•>•.— 'I'l'o  ataxia  is  hcli.'ved  to  be  due  to 
a  di-turhance  or  loss  of  the  aiVerent  impulses  from  the  muscles,  and  a  dis- 
turbance of  the  muscle  sense  itself  can  usually  be  demonstrated.     It   .h- 
velops  -rraduallv.     One  of  the  llrst   in.lications  to  the  patient    is   inahility 
1o  net  about  ivadilv  in  the  dark  or  to  maintain  his  e(|nilihriuiii  when  wa>li- 
in-'his  face  with  'the  eves  shut.     When  the  patient  stands  with  the  teet 
to'ether  and  the  eves  closed,  he  sways  and  has  dillicnlty  in  maintaining 
his  posit i(m.  and  lie  mav  be  (piite  unable  to  stand   on  one  leg.     This  is 
known  as  IJoinhero's  svmptoin.     He  does  not  start  olf  pr(.inptly  at  the  word 
of  command.     On  turning  .[iiickly  he  is  aiit  to  fall.     He  descends  stairs 
with  more  diillcnltv  than  he  ascends  them.     (Iradually  the  characlenstie 
ata.xie  gait  develops.     The  patient,  as  a  rule,  walks  with  a  stick,  the  eyes 
are  direct(>d  to  the  ground,  the  body  is  thrown  forward,  and  the  legs  are 
"wide  apart.     In  walking,  the  leg  is  thrown  out  violently,  the  foot  is  raised 
too  hiirh  and  is  brought  down  in  a  stamiiing  manner  with  the  li.rl  lirst,  or 
the  wiiole  sole  comes  in  contact  with  the  ground.     Ultimately  the  patient 
may  be  unable  to  walk  without  the  assistance  of  two  canes.     This  gait  i^ 
viry  characteristic,  and  unlike  that  seen  in  any  other  disease.     The  inco- 
ordination is  not  only  in  walking,  but  in  the  performance  of  other  niove- 
meiits.     If  the  patient  is  asked,  when  in  the  recumbent  posture,  to  touch 
the  knee  with  one  foot,  the  irregularity  in  the  movement  is  very  evident. 
Incoordination  (.f  the  arms  is  less  common,  but  usually  develops  in  some 
-rade.     It  mav  in  rare  instances  exist  before  the  incoiirdination  of  the  legs. 
It  may  be  tested  bv  asking  the  patient  to  close  his  eyes  and  to  touch  the  tip 
(.f  the  nose  or  the  ti])  of  the  ear  v/itli  the  linger,  nv  with  the  arms  thrust  out 
to  bring  the  tips  of  the  lingers  together.     The  incoiirdination  may  early  be 
noliced^by  a  difTiculty  which  the  patient  cxiioriences  in  buttoning  his  collar 
or  in  yierforming  (Uie  of  the  ordinary  routine  acts  of  dressing. 

One  of  the  most  striking  features  of  the  disease  is  that  with  marked 


.,04  DISEASES  OF  THE  NERVOUS  SYSTEM. 

■  ■,.,ll„.,lion  thm'  is  no  l..>^  of  nu.s.ular  powor.  Tl.o  prip  of  llu'  luuuU 
,;.;;;  ...  uniuunur.a,  a.ul  llR.ir  nuUition.  excq,t  toward  tlic  cdo..,  .na>  In 
""iw  ><  a  n.markal.K.  n.us.ular  r.laxatiou  which  enahles  the  joint,  to 

L    Iv     ,  tl.  •  lianas-     <IH«tiv'  «"""■>■  Jistn.-l.a.K«  <•»"  ti-'wlly  h. 

" '     „       '    ,1         ',,1  al„;Ll  .v,TV  vari..t.v  of  son»r.v  .lisCvLa..™  luw 

*■""•"■"■'"'■,       .,',0  Loot,  oaivft'illv  rfa.lioJ  i.,  tliis  ooifify  I'J'  K"»l'l« 

■  .    ,',„1,.  of  -ma-tlisia  a,-o  not  i..io<.mi.."ii;  H.oy  ai-c  ai.t  to 

1  ,,:;;'  ,...,. "V;:,;.;!  so.,..o,.t».     TLo  „.o.t  ,..a,-l<o„  .,istori,a,,<« 

,,,     V  r,......l  ...1  tl.o  vL     Hotardatiot.  "f  tl.o  so,.*o  ,.[  pa...  .«  oo,..„io.i 

"d  r  i.H.r    k    a     1.0  foot  is  il...  tolt  as  a  si.,„,lo  taotil,.  ''"l'";-'"'--; 

;:;;;:.tj„.o.,oSi„..i.o,,a,ys.^t«i.f;*iio^ 

„r  a  ,i.,-l.r.ok  ;...  to    ™'   ™  >  ^0^,^,  "  ol    i...,,air.,l  a..<l  tl.o  patio..t 

"•■  ';;;';i:i:^r:::;:;::s.  tcHo^s  or  „.o  k„».jor.  is  „„o ,.  t,,o  oaHi.. 

,      ,f  fl.o  ,li«oa«o      (looasi.i.iallv  a  oaso  is  ta.nd  in  wl.ioli  it  i=  rc- 
:•:;:;';,';"  Tho  *„  ::i;»  ...ay  a.  li..t  no  inc-oasoa,  ^.t  latcr  are  usually 

"'l:i:y^:';;5ii:r!:.  ^ynip."- "-'«' ""-  -"^ '-  "-«'••  ^"•• 
-r;;:;:';.;;;:t;*M:"lo«:;;;^.rlioar^^^ 
'''-;";;;:;;r^;;;rr.;:!nr;ho  3r:.:^:iniisory  *.u,..anoo. 


■■ 


;  tl\o  haiuls 
3  ilox  theui, 
ISO,  luiiy  bo 

lio  ji)ints  to 
givori  somo- 
■i  tlu'  comli- 

Tlioy  vary 
iil.lo  by  tho 
In  aiUlition, 

in  tho  foot, 

ciiniiilain  of 
n  was  intor- 
s  ocour  loss 
1  usually  l>o 
turbanoo  has 
vy  by  Knapp 
nit  the  ohost 
)■  are  apt  to 

disturbances 
n  is  oonunon, 
pi'ossion.  and 
)o  dolayod  for 

]ihonomonon 
if  tho  pationt 
'  (alloehoiria), 
luscular  sense 
d  tho  pationt 
d.     This  may 

of  the  earliest 
rhioh  it  is  ro- 
er  are  usually 

!  liresont,  but, 

.'.     There  may 

■V  disturbances 
■arious  viscera; 
ral  crises  have 
nireal.  In  the 
md  a  secretion 
1  days  or  even 
rhe  attacks  are 
:ysms  of  rectal 
lommon  in  my 


DISKASES  OF  THE  AFFERENT  OR  SENSORY  SYSTEM.  025 

cxnerionco.     Larvn-oal   .Tis.s   al<n   an'   rare.     There   may    ho   liuo   spa.-m 
Willi  (ly>piuoa  and  n..isy  inspiration.     In  one  in>tanoo  at   least  tlir  patient 

lias  died  in  the  attack. 

Tho  -phineU'rs  are  fre-iuentlv  invdlved.  i-larly  m  the  di-ease  there  may 
ho  a  retardation  or  ho^iianev  in  makin-  water.  Later  there  is  retention, 
and  cystitis  may  occur.  Inless  -ivat  care  is  taken  the  inllammatinn  may 
extend  to  tho  kidnevs.  Constipation  is  extremely  common.  Late  m  the 
disease  the  sphincter  ani  is  weakened.     The  sexual  power  is  usually  lost  m 

the  ataxic  stage.  ,.  .i      r   i  , 

Trophic  r//*/»7C.s.— Skill  rashes  may  .lovelop  m  the  course  oi  tho  li-ht- 
nin-  pains,  such' as  herpes,  co.loma,  or  local  sweatin-.  Altenmou  m  t  u> 
naifs  mav  occur.  A  perforatii^ir  ulcer  may  develop  .,n  the  loot.  u>ually 
l,,noath  the  groat  too.  A  perforating  buccal  uleor  has  also  been  dos<rihed. 
Onvchia  may  prove  very  troublesome. 

*'i'lio  art in-opat hies  or  joint  lesions  alToct  cliioily  tho  knoos.  1  hey  are 
WKiuostionablv  associated  with  the  disease  itself,  and  are  not  necessarily  a 
result  of  trauma.  The  condition,  known  as  Charcot's  j.unt.  is  anatomic- 
allv  similar  to  that  of  chronic  arthritis  deformans.  'I'lio  ollusion  may  bo 
rapid  and  there  mav  bo  great  disintoj-ration  and  dostruotion  of  tho  carti- 
la.H's  and  bones,  loadinu'  to  dislocalion  and  deformity.  Suppuratum  may 
.urur.  Spontaneous  fractures  may  occur.  Among  other  trophic  disturb- 
ances mav  1)0  nu'utioned  atrophy  of  tho  muscles,  which  is  usually  a  late 
manifestation,  but  may  ho  localized  and  associated  with  neuritis.  In  any 
very  large  collection  of  cases  many  instances  of  atrophy  are  found,  due  either 
to  involvement  of  the  ventral  horns  or  to  peripheral  neuritis. 

Ccrebnil  Sijnijilnms. — llomiidegia  may  dovi'lop  at  any  stairo  of  tho  dis- 
ease, more  commonly  when  it  is  well  advanced.  It  may  he  due  to  iKomer- 
rhagie  softening  in 'conse([Uence  of  disease  of  the  vessels  or  to  jirogressivo 
e(U't"ical  change's.  IIcmiaiKosthesia  is  soinotimes  present.  Very  rarely  the 
homiiilegia  is  due  to  coarse  sy])hilitic  disease. 

Donientia  paralytica  fi-oquently  exists  with  tabes,  and  it  may  be  ex- 
tremely diilicult  to  (lotermine  whicli  has  been  the  primary  all'ection;  indeed, 
some  authors  believe  that  these  two  diseases  are  simply  dilVerent  localizations 
of  the  same  moriiid  i)rocess.  In  a  majority  of  tho  cases  the  symptoms  of 
locomotor  ataxia  have  iireceded  those  of  general  paresis.  In  other  instances 
melancholia,  dementia,  or  jiaranoia  develop. 

(c)  Paralytic  Stage,— After  persisting  for  an  iiidofmite  number  of  years 
the  i)alient  gradually  loses  the  power  of  walking  and  be-omos  bedridden 
or  paralyzed.  In  this  condition  he  is  very  likely  to  bo  carried  otf  by  some 
intercurrent  affection,  such  as  pyelo-noithritis,  pneumonia,  or  tuberculosis. 

37/c  Course  of  the  Disease. — A  patient  may  remain  in  the  pre-ataxic 
stage  for  an  indefinite  period;  and  tho  loss  of  knee-jerk  and  the  gray 
atro])hy  of  the  optic  nerves  may  ho  the  solo  indication  of  the  true  nature 
of  the' disease.  In  such  cases  incoordination  rarely  develops.  In  a  ma- 
jority of  cases  tho  jirogross  is  slow,  and  after  six  or  eight  years,  somotimes 
ie?s,'the  ataxia  is  well  developed.  Tho  symptoms  may  vary  a  good  deal: 
thus  the  ])ains,  which  may  have  been  excessive  at  first,  often  lesson.  Tho 
disease  may  remain  stationary  for  years;  then  exacerbations  occur  and  it 


y;,p,  DISEASES  OF  THE   NERVOUS  SYSTEM. 

,nak.s  nu.ia  pn.^n.s.    O.-casinually  tlu'  precrss  .onus  to  be  unv.tr.l    Tl.cro 
'instuuJ  u?  wl.al   .nay   W  .•all-.l   m.,,.  ataxu,     .n  wl.uh     wulnu   a 

•      ,  .,,,^,.,,       ,i„,i„  ,  ,v,,  ,„nntl,s.     Tlu.  .li..aso  .ts.l    rany  .an^.s  .Lath 
:;;;;•;  altc-  ll.r..n.,n,  iK.ln.l.U.n  tlu.  pali..nt  n>ay  hve  lor  lillcrn  ur  twenty 

■'"Diaen08is.-ln  th..  initial  stajio  ti.e  cunil,inati..n  of  li-l.tnin-  i-rins 
ana  tlu^>hs.nc.  .,r  knee-jerk  is  .listinetive      The  ass..eiati..n  -1^-^^^;; 
^,„,     ,,,  „,.  „„  „,„i,  nerves  with   loss  ol   knee-jerk  is  aUo  chauute.  .Ik. 
The  earlv  ocular  l-aisies  are  .,1'  the  -reat.sl  in.portanee.     A  s.,mnt,  ptoM- 
or  the   \v-vll  lloherts.m  pupil  nu.y  he  the  llrst  syn.pt. an,  an.l   ...ay  ex..t 
i,h  ,he  loss  .a.lv  of  tl...  k..e..-j..k.      Loss  of  the  k..ee-,ierk  al....e,  however, 

;;l  ...asionallv   o..<.ur   h.   hoal.hy   i...livi.U.als.     A   h,stc.T   ol    preee.l.n. 
svuhili.  h'u.ls  a.lde,l  weight  to  tho  sy.upt.nas,  an.l  its  p.rs.n,.e  or  ahse n.e 
n,av  lu.  .d-  the  utn.ost  i.np.nla.iee  in  ,ht......inin-  the  .liaon„s,s.     It   the 

p„;.il.ilitv  of  svphiiitie  i..fe.ti..n  ea..  he  .x.ln.le.l.  a  e.ivu.nsta..ee  hut  too 
lardy  .net  with.  ...,ly  the  most  nne.,uiv.,cal  o.unhi..ati....  ol  syn.pton.s  ean 

iustii'v  th.' (lia>!-..osis  of  loeon.ot.ir  ataxia.  ,     •      ,„  . 

Ti.e  .lis.^.s.s  n...st  likelv  to  he  c-onf.,un.l.Hl  with  h.r.Mn..tor  ataxia  a.e. 

,1)  rcriphrral  Xrurilis.-^Vh.  st..ppaue  j;ait  .d'  a.'s...ieal,  ah^oho he.  o.;  dia- 

hetie  na.'alv.is  is  ...lite  ....like  that  ..f  l..eo...ot..r  utax.a.     In     hes.  im.n. 

;   ;  1        pa.alvJ  .-f  the  feet  an.l  the  le,  is  lifted  high  ...  onU.  that  the 
H.S  n.av     h.ar'tlu.  Ih.a-.     The  use  of  the  word  tabes  n.  th.s  .-.^...0..  ..n 

hu,ll   no  l.u....r  h.  .■o„li..ue.l.     1..  the  .'a.-e  eas.s  ...   whuh   the  n....^ 

:      0  nerve.  a.v  pa.li.n.la.'lv  atlWte.l  a...l  h.  wl.ieh  the.'e  .s  tr..e  atax.a     he 
:0   H,  e  of  ,lu.  liJht..i..g  pai.,s  a...l  eye  sy.npton.s  a...l  the  hist.,..  w.ll  sull.ee 
tl      ,.ai.u.tv  of  eases  to  ...ake  the  dia,..osis  clear.     J..  d.ph.l...r.t.e  parah- 
^     u"'    1    loss  of  the  k..ee-j..,'k  a...l  the  a.s.u.iat..d  eye  symptnn.s  ...ay  su,- 
;;;;t  label.  b..t   the  l.ist...y.  the  oxist......  .^f  pa.-alys.s  ot   the  th.'...t,  a...l 

Tlu.  ab-r.i.e  of  liaL.s  I'ender  a  diagn.'sis  easy. 

r)     i'rir   /'.r./,te/m.-Marked   inc...ih.li..ati.n,   w.tl.   spast.o  ,.aralys.s 
is  characteristic,  of  the  eonditi....  wl.ieh  (hnvers  has  tern.ed  atax.e  V^^^^^ 

In  a  ...ajori.y  of  the  eases  this  alleetio..  .s  d.st...-u.sl.ed  als..  U   the  ab- 
'icM.c'o  of  iiains  a...l  of  eve  syn.iitonis. 

%)('nrbraJ  /i/.s^J.-ln  diseases  of  the  brai..   ...volv...,r  the  alTerent 

t,..ut<  ataxia  is  at  ti..,.'s  a  p..o...i.,e..t  sy...ptcnn.  It  is  usu..dy  u..date,-al  ov 
llnnted  to  o..e  li...b;  this,  with  the  hislo.y  and  the  assocated  sy.upto.n>, 

"'<  nTnrW/..  /;/.,..s.._Tl.e  ee.'ebellar  ineoordi..ati.)..  has  only  a  sq.er- 
fi,ial  resc..,d,la..ee  to  that  of  lo<.on.otor  ataxia,  and  is  .....re  a  ^-^^^^^^ 
li  e.,uilibriu...  than  a  t.-ue  ataxia;  the  knee-je-'k  -.-^'^^/^'^  ;  ^^J;^ 
are  ,.o  Ih^.t..!..-  pains.  ....  se..so.T  distu.-banees;  wh.le,  on  the  othci  hand, 
there  are  hea.lacbe.  optic  neuritis,  and  voni.i.nfr. 

(.-,)  Son.e  aculc  alfcrtions  involvi..-  the  dorsal  coh.nins  of  the  coid  n  a) 

be  followed  bv  incoordination  and  rese.nble  tabes  very  ch.sely.     In  a  ca.e 

u  1.  V  c.a.-e,  the  uait  was  eharaeteristie  and  Eon.berg's  sy.nptom  was 

;  tnt.  •  The  k,.ee-,ierk.  however,  was  retai..ed  a..d  there  we.-e  no  oeula 

Ivinptoms     The  condition  had  developed  within  three  or  four  i.io..ths  aa.d 


J 


vi\.  Tluiv 
,  wiiliiii  a 
ilvtii  stage 
ii>i's  (k'litli, 
or  twenty 

[niii^'  iii.ins 
pro^^ressive 
anK-teri!*tie. 
lint,  ptosis, 
1  niiiy  exist 
11'.  however, 
1'  precciliiiu; 
I  or  aliseme 
isis.  H  the 
nee  Ijiit  too 
niptoius  eaii 

•  ataxia  are: 
Kilie.  or  dia- 
tlicse  forms 
■dcr  that  the 
s  conneition 
the  inii^ele 
e  ataxia,  tlie 
■y  will  sullice 
critie  paraly- 
iius  may  sug- 
■  throat,  and 

-;tie  ])aralysis 
ic  paraplegia. 
,o  by  I  lie  ab- 

the  alTercnt 

unilateral  or 

L'd  synii)toms, 

only  a  sTi]icr- 
a  distiirbanee 
jnx'sent,  there 
.f  either  hand, 

the  cord  may 
ly.     In  a  case 

svmptoin  was 
rere  no  ocular 
r  moutlis  aaid 


niSKASKS  OF  TFIF.   AFFEUENT   oR   SENSORY   SYSTEM.  [»27 

tlur.'  w,i>  a  will-niarkcd  hi-lory  of  syphilis.      I'ndcr  large  dos(  s  of  iodide 
nf  potas-ium  the  ataxia  and  other  symplnnw  coinpli'trly  (lisii|ipfari'd. 

((I)  (Iciicnil  /'//;•(■>■  I. s.— In  some  lascs  this  dlVcrs  a  seii.uis  dillicully.  In 
tlic  iirst  jilace,  in  general  paresis,  tabetic  symptoms  often  develop;  mi  the 
nther  hand,  there  are  case-  of  hicnUKilor  ataxia  in  wbieli.  Inward  ihe  end, 
there  are  symptoms  of  general  paresis.  Cases  of  unusually  atiile  ataxia 
with  mental  svmptoms  belong,  as  a  lailc.  to  Ihe  former  disease.  The  (pus- 
tion  will  be  considered  under  general  jiari'sis. 

(T)  N'iseeral  crises  and  neiii'algic  symjitoius  may  lead  to  erna'.  and  in 
middle-aged  men  with  severe,  recurring  attacks  of  gastralgia  it  is  always 
Will  to  liear  in  mind  the  possibility  of  labi's,  and  lo  make  a  careful  exam- 
ination (d'  the  eyes  and  id'  the  kiU'c-jerk. 

Prcnosis. — Complete  I'ccovciT  cannot  lie  exiiccted,  but  ai'i'e-1  (d  the 
p-ocess  is  not  uncommon  and  a  marked  amelioration  of  the  symptmns  is 
freiiucnt.  (>|)tic-nervi'  ati'ophy,  one  of  the  most  sei'ious  cvenls  in  the  dis- 
lase,  has  this  hopeful  aspect— that  incoiirdinaliou  raiely  follows  and  the 
progress  mav  be  arri'steil.  The  optic  atrojihy  it-elf  is  occasionally  checked. 
On  the  whole,  the  prognosis  in  tabes  i-  bad.  The  ex[)erieiue  of  such  men 
as  Weir  Mitchell.  Charcot,  and  (iowers  is  distinctly  opposed  to  the  belief 
tliat  hu-omotor  ataxia  is  ever  completely  cured.*  No  such  in-tance  has 
come  under  my  personal  observation. 

Treatment.— To  arrest  '\w  progrc-s  and  to  relieve,  if  i)o<sible.  the 
pyiuptoms  are  the  objects  which  the  practitioner  should  have  in  view.  .\. 
(piiet,  well-ivgulaled  nu'thod  (d'  life  is  es-i'iitial.  It  is  not  well,  as  a  ride, 
for  a  iiatieut  to  give  up  his  occui>ation  so  long  as  he  is  able  to  keep  about 
and  perform  ordinary  work.  1  know  tabilics  who  have  for  years  conducted 
large  luisinc'sscs,  and  there  have  been  several  notable  instances  in  our  iiro- 
fession  (d'  unn  wiio  have  risen  to  distinction  in  spite  of  the  existence  of  this 
disease.  Ivxcesscs  id'  all  s(Uts.  nuu'e  iiarticularly  (/(  baccho  ct  iriicrc.  should 
he  carefullv  avoided.     .\  man  in  the  pre-ataxic  stage  should  not  marry. 

Care  sliould  be  taken  in  the  diet,  particularly  if  gastric  crises  have  oc- 
curred. To  secure  arre-t  of  the  disease  many  remedies  liave  been  eni- 
|)loyed.  .Mlhoiigh  syjdiilis  plays  such  an  impiulant  role  in  the  etiology, 
it  is  universally  acknowledged  that  lU'llher  mercury  imr  tlu'  ioilide  of  po- 
tassium have  as  a  rule  the  slightc-t  inlluence  over  the  talictic  lesions.  To 
this  there  is  liut  one  exception — when  the  syphilis  i-  comparatively  recent; 
when  the  syni|itoms  devtdop  with.in  two  ytai's  of  the  pi'imary  infection, 
there  is  then  a  possiliility  of  ar.cst  by  mercury  and  iodide  of  potassium. 
TTowever.  they  do  not  always  relieve.  In  two  cases  of  very  rapidly  jiro- 
uressiiii:  tabes  following  syphilis  this  nu'<lication  we.s  of  no  avail,  (tf  renu'- 
dies  whi(di  may  be  tried  and  are  belim-cd  by  some  wi'iti'rs  to  retard  the  pro- 
irress,  the  f(dlowing  are  recommended:  Arsenic  in  full  dose-,  nitrate  of 
silver  in  (piartcr-grain  doses,  Calabar  bean,  ergot,  and  the  ju'eiiarations 
of  gold. 

The  treatment  by  suspension  introduced  a  few  years  ago  has  already 
been  ])ractically  abandoned.     Good  elTects  certainly  have  followed  in  a  few 

*  For  a  study  of  reputed  cures,  see  L.  C.  Gray,  N.  Y.  Mcdicul  Journal,  Xovcmlier,  1889. 


W 


*[* 


yog  DISEASES  OF  THE  NEUVOUS  SYSTEM. 

c.a..s,  Lut   it  was  mnrnsonnl.lo   fnm.   11..  .mls..t.  .'ithrr  n„   thrrai.mti.  nr 
Bcu.mitic  -n.uiHls.  t..  lu.iK.  tlu.l  l.y  su.h  a  luraMir..  pninanml  .han-.'S  nml. 
be  in.hu;i  iM  tlH.  ,mtlu.lo.n..al  .on.li.inn.     Tlu.  l.-n.hts  w.;ro  .1...  m  ;..va 
part  to  >u-.st,on  an.l  to  psyclucal  oIlVcl..     In  any  case  it  nui.l  b.  us.l 

""l.w"hr;,ains.  ..unM.l.t.  -.  in  1..1.  ms  a.lvis.l  by  W.ir  Mi.clu-il.  and 
,.,„„„.,,.i,,,,i,ati..n  in  tlu.  spin..  (ritiuT  l.listcrs  or  tliu  tlH.rino-.antLTy)  may 
,,,  „     ,,,,....1.     Tin.  sovm.  sprlls  wl,i..l,  (■..nu.  on  pavtuu birly  '«  ^er  oxce..es 
„r  ,„v  Kin.l  arc  often  prouM-tly  rHiw..!  l.y  a  l.ot  hall,  or  l.y  a  Inrk.sh  l.at h. 
\   proln„or.l  course  of  nitrate  of  silvc.r  seems  in  some  eases  to  a  lay  th. 
paiL-,  an.l  lessen  the  liability  to  tl.e  attacks.     1  have  never  seen  ill  elleet.    . 
from   its  use  in  spinal  sclcn.sis.     Antipyrin  and  antilehnn   may  he  em- 
nloved,  and  occasi..i.ally  do  K.-.ul,  hut  th.'ir  ana!-.;s.c  pow,.rs  in  tins  ..seas.- 
have  been   preatlv   ..verratcl.     Cannabis   in.lica   is  s..met.mes   uselul.     Jn 
the  severe  paro.xvsms  of  pain  hypo.lerinics  of  morpliia  ..r  ot  cocaine  must 
1„>  UM.,1      Tlie  use  of  m..ri.hia  shouhl   be  postp..n...l  as  Ion-  as   p.,ssil,l... 
I.'U,,,,.i..itv  is  of  v..rv  little  benefit.     Vnv  the  severe  attacks  of  p.stral-ui, 
,;,,,,,l,ia  'is   also    re.iuire.1.      The   larynjical    crises   are    rarely    ^  ^nigennis. 
An  application  of  co..ainc  may  be  made  duriu-  the  spasm,  ..r  a    ew  whitl. 
„,.  .hi.ln.rorm  mav  be  given,  .,r  nitrite  of  aiuyl.     In  all  cases  ul  tabes  with 
increased  arterial' tension  the  prolonged  use  of  nitroglycerin    given  in  ni- 
creasin.r  doses  until  the  physiological  etlVct  is  pr..duccd,  is  ot  great  scrvice 
i„  allavin-  tlTe  neuralgic  pains  and  .liminishing  the  frciuency  ol  the  crises 
Its  u<c  nnist  be  guanl...!  when  th..re  is  aortic  insuihciency.      1  he  spccia 
indicath.n  is  increase.l  tcnsi.m.     The  bladder  sympf-ms  deman.l  constan 
ruv      When  the  or-an  cannot  be  perfectly  emptied  the  catheter  sli..uld  be 
used,  and  the  patient  may  be  taught  its  use  and  how  to  keep  it  thoroughly 

'^"Sink.d's  nu'thod  of  re-education  ofi.-n  helps  the  patient  to  regain  to  a 
considerable  extent  the  ••.•ntrol  of  the  voluntary  m..vciiients  which  he  has 
\uA  I'.v  this  nietho.l  the  patient  is  lirst  taught,  by  repeated  systematic 
efforts,  to  p..rform  simple  movements:  from  this  he  goes  t..  more  and  nmre 
oom,,lex  ,u.,vements.  The  treatment  should  be  auyctc.!  and  ^ipcrvised  by 
a  trained  teach..r.  as  the  result  depends  upon  the  skill  ol  the  teacher  quite 
as  much  as  upon  the  iierseverance  of  the  patient. 


III.    DISEASES    OF   THE   EFFERENT   OR    MOTOR   TRACT. 

A.    OF  THE   WHOLE  TRACT, 
1.  PROdUKssivic  (Ckntual)  Mlscular  ATliOniY 

iPoliomyelitis  Anterior  Chronica  :  Amyotmplnc  Lateral  Sclerosis;  Prosrcssire  Bulbar 

Farali/s>s). 

Deflnition.-A  disease  characterixed  by  a  chronic  degenerati-^n  of  the 
n.ot^.  Z.t.  The  wlude  tract  is  usually  involved,  but  at  times  the  degen- 
eration is  limited  to  the  lower  segments.  Associated  with  itis  a  progressive 
atrophv  of  the  muscles,  combined  with  more  or  less  spastic  rigidity. 


1 


ai'rlltic  111' 
ii;^i's  iiiuKl 
u'  in  givat 
i»l  hv  usi'd 

tdu'll.  and 
utfiy)  may 

llT    I'XCUSSl'S 

irUisli  liatli. 

0  allay  tin' 
n  ill  v[\vL-U 
lay  1)L'  eni- 
this  (lisi'asi- 
usfl'ul.  in 
.K-aine  nuist 
as  ])ossi1ilt'. 
i  <;astralgia, 

dangerous. 

1  i'cw  whitl's 
I'  talH's  with 
nivcn  in  in- 
j,rfat  service 
jl'  the  crises. 

The  special 
ind  cdiistant 
cr  should  1)0 
t  tlioruughly 

)  regain  to  a 
khicli  he  has 
(1  systematic 
■»rc  and  more 
;ui)i'rvised  by 
teacher  iiuite 


^    TRACT. 


\gressive  Bulbar 

cration  of  the 
les  the  dcgen- 
;  a  progressive 
iditv. 


DISKASF.S  OK  TIIR  EFFERENT  0I{    Mi »?(>!{   TI! ACT. 


0-JO 


Three  all'fctidiis.  as  a  rnle  dcscrilicd  apart.  Iirlcmg  IouciIkt  in  this 
catcirorv:  (")  I'mgressive  nmscnlar  atniphy  ol'  spinal  uriuin;  (A)  amyo- 
trophic lateial  .-clero^is;  and  (c)  pr(igivs>ive  luilliar  |iaraly>is.  A  >U>\v 
atropliic  cliangi'  in  the  motor  neurones  is  the  anatnuncal  hasis,  and  the  dis- 
ease is  one  of  the  whole  motor  path,  involving,  in  many  cases,  the  cortical, 
hulhar.  and  spinal  centres.  There  may  he  simple  muscular  atrophy  with 
little  or  no  spasm,  or  |irogressive  wasting  wiih  marked  spasm  and  great 
iiicrca>e  in  the  nUexes.  In  others.  Iheic  are  add<'d  symptnins  nl'  involve- 
meid  nf  the  umtor  nuclei  in  the  me(lnlla — a  glo.-n-lahio-laryngeal  jtaralysis; 
while  in  (illiers.  again,  with  atrophy  (especially  of  the  arms),  a  sjuwlic  con- 
dition ol'  the  leg^  and  liulhar  phci.nmciia.  ireniofs  develoji  and  signs  (d'  cor- 
tical loioii.     These  various  stages  may  he  trat'cd  in  the  >ame  case. 

I'(U'  convenience,  hulliar  ]iaralysis  will  he  considered  separately,  and  1 
>hall  lure  take  up  together  iirnijrcssin  itiusrnhtr  itlriiii/ii/  and  (tnnjnlfiqihi': 
Inlcnil  scliTiisis. 

'J"he  disease  is  known  as  the  Aran-i  >uclienne  type  of  jifngres-ivc  nuiscidar 
atrojihy  and  as  ( 'ruveilhicr's  palsy,  after  the  French  physicians  who  early  de- 
serilicd'  it.  Levy  ami  Loekhart  Clarke  (Irst  demonstrated  that  the  cells  of  the 
ventral  horns  of  the  spinal  cord  were  diseased.  Charcot  sc[)arated  two  tyjies 
— oiu'  with  simple  wasting  of  the  musilcs,  due,  lu'  helieved,  to  degeneration 
confined  to  the  ventral  horns  (and  to  this  he  restricted  the  name  progressive' 
muscular  atrophy — type,  Aran-Dnchcnue):  the  other,  in  which  there  was 
spastic  [laralvsis  (d'  the  muscles  followed  hy  atrophy.  .\s  the  anatomical 
hasis  fur  this  he  assumed  a  primary  degeneration  of  the  pyramidal  tracts 
and  a  secondary  atrophy  of  the  ventral  horns.  To  this  he  gave  the  name 
of  amyotrophic  lateral  sclerosis.  Thcri'  is  hut  little  evidence,  however,  to 
show  that  any  such  sharp  distinction  can  he  made  hctwccu  these  Ivo  dis- 
ease-, and  Leyden  and  (iowcrs  ri'gard  thciu  as  identical. 

Etiology. — 'i'he  cause  (d'  the  disease  is  unknown.  It  is  more  fre(|uent 
in  males  than  in  females.  It  all'ects  adults,  developing  after  the  thirtieth 
yi'ar,  though  occasionally  younger  pt'rsdus  are  attai'ked.  A  large  majority 
id'  all  cases  (d'  jirogrcssive  muscular  atrophy  umlcr  twenty-five  years  of  age 
hclong  to  the  dystrophies.  Cold,  wet,  exposure,  fright,  and  mental  worries 
are  mentioned  as  jiossihle  causes.  Krh  has  lately  called  attention  to  cer- 
tain cases  fdlldwing  injury.  Hereditary  inllnences  are  ])rcsent  in  certain 
cases.  The  rare  form  which  occurs  iu  infancy  usually  ailect:'  several  nu'm- 
bers  of  the  same  fannly.  llcreditary  and  fanuly  iullucnces.  however,  play 
but  a  small  part  in  the  etiology  of  this  disease,  and  in  this  it  is  in  cotitrast 
to  j)rogressive  neural  nniscular  atrophy  aiul  the  dystrophics.  Yet,  in  the 
Farr  family,  which  I  recorded  some  years  ago,  in  which  thirteen  members 
were  afl'ected  in  two  generations,  with  the  exception  of  two,  the  eases  oc- 
curred or  ])rovcd  fatal  above  the  age  of  forty,  and  the  late  onset  s])eaks 
ratlier  for  a  central  alfection.  The  spastic  form  may  develoi)  late  in  life — 
after  seventy — as  a  senile  change. 

Morbid  Anatomy. — 'I"he  esseidial  amitomical  change  is  a  slow  de- 
generation of  the  motor  ]iath,  involving  particularly  the  lower  luolor  neu- 
rones. The  uppt'r  neurones  are  also  involvdl.  either  iirst,  simultaneously, 
or  at  a  later  period.     Assucialed  with  the  degeneraliuu  iu  the  cella  ol  llie 


J* 


r 


DISEASES  OF  TTTE  NERVOUS  SYSTEM. 


i.  incn.i<..l.  and  the  uR.lulh.tnl  lll.irs  air  im.ch  dcruaMMl.      1  In     ,1  it, 

E:';v;::;:-:::::':n:";;;tJi::;;:;;irr^r;L 

;;^;     ,     o  <l.ir..vc.ut  U.v;.ls.  ana  in  s.v.Tal  oa..  ha.  hc.n  .nu.a  to 
ot        •"Vtrx,  tho  ells  o(  wlm-h  have  hocn   fonnd  -log.n.rat.c  .     Tn  the 
M   U      t^'    ...nlial    longitudinal    fasHcnlus    has    la..n     lonnd    .l,sc.a>  d 
f  ho<    <".^  in  whi:^v  no  s.-h.vosis  has  hocn  f<n,nd  >n  t h.  pvvanuda 

ilicls  llle^e  has  l.e.n  a  sd.n.i.  of  tho  vontrodatoral  ground  bundle  (>hort 

^''''iim«toms -Tnv>ndar  pains  n>av  pnnrde  tho  onsot  of  the  ^vasting, 
.inn  au  u,   MIX  j^^,  ^^^^^^.j,  ,„^,^^.l^.s  oi  tho 


do  I 


The  anu- 


nivoidos  is  unalVootod  and  ofton  hyportroi-liios. 

:-.| >  ,;■  --"-fiis;,  t;S: :  :"■ ":  ■--■ 

.  .,1..,  nnt  inicdninion  m  •  nnisounis      ana      j-iut  snuw-.       ^ 

':::i'Z^^Z^^^  ana  lordosis  is  almost  always  prosont.     A  cunous 

1  V  h  .  .nu.olos  (Hl.rillation)  is  a  oonimon  s^mptom,  and  may  ocour 

^"''       r  l«  a       n,    vo        aolid.     It  is  a  most  important  symptom, 

;;;;;::  r     t^  i;,.::^lv' supposed,  a  oharaetoristic  feature  of  the  d.eas. 

\    ,,    .hi  itv  of  tho  musolos  is  inoroased.     Sensation  is  ununpairoi     hut 

U  r;     ;^        V    oil;  i:-.  of  numhness  and  coldness  of  tho  a.Teot.d    imhs. 

Sio  ^Ihanic  and  faradic  irritahility  of  the  mu.eles  prugre.siveh  dimm- 


1 


DISEASES  OF  THE  EFFEIIEXT  OR   MOTOR   TRACT. 


•j:Jl 


('  fdllnwing 
t'  tho  curd 
ihc  ventral 
I'  nrui'iii^liii 
lu>  iil)ros  111' 
va-lrd.     (/') 
'hi.'  iini«i-lis 
cr-nniscular 
atiiiii  of  tlio 
luHi.  where 
wasted.     (') 
aleral  white 
llie  de<j;ener- 
eiitru-lateral 
il   aseeudin.i; 
lends  tdwaid 
raeed  to  tho 
cd.     In  tho 
ml    diseased, 
u'  pyramidal 
iiindle  {>hort 

the  wastinji:, 
iS  are  usually 
lanipulatiun-. 
nteriissei  and 
earpal    l)ones. 
s  and  the  om- 
uhrieales  pro- 
rs  <ir  the  i'nre- 
der-iiirdle  tlie 
mist-les  of  tho 
I'd:  the  upper 
_.  I'l'ehleness  of 

The  platysma 
Lind  tlie  trunk 
ed.  Tho  face 
lidoniinal  nuis- 
orade.  and  the 
skeletons,"  the 
"  Deformities 
nt.     A  curious 

and  may  occur 
rtant  siymptoni, 
}  of  the  disease, 
ininipaircd,  Imt 
'  all'ected  limbs, 
ressively  dimin- 


islies  and  may  heeome  exiinel.  tlie  galvanie  p('r.-i>tin;j:  for  tlie  Inii-rr  time. 
Jii  cases  of  rapid  wa>tin;:-  and  jiaraly.-is  tliere  may  lie  the  reaction  of  defen- 
eration. The  exeitahility  of  the  nerve-lrunUs  may  i.er>iM  alter  the  mus- 
cles have  ceased  to  respmid.     The  loss  of  [lower  is  usually  proportionate  to 

I  he  wasting.  .        ,  ■  ,     , 

The  foregoing  description  apjilies  to  the  group  of  cases  m  which  the 
iitroidiy  and  jiaralysis  arc  ilaccid— '//('/nV.  as  (n.wers  calls  it.  In  other  casts, 
those  which  Charcot  describes  as  amyotiophie  lateral  sclerosis.  s|)a>lic  paraly- 
sis precedes  the  wa'sting.  This  taiiir  atrophy  lir^t  involves  the  arms  and 
then  the  legs.  The  rellexes  are  greatly  increased.  It  i>  one  of  the  rare  con- 
ditions in  which  a  jaw  clonus  may  be  obtained.  The  nio-^i  typical  cimdilion 
uf  spastic  paraplegia  may  be  ]>rodme(l.  On  starting  to  walk,  the  patient 
seems  glued  to  the  ground  and  makes  inell'ectual  attempts  to  lift  the  lues; 
then  four  or  live  short,  <|uick  steps  are  taki'U  on  tlie  toes  with  the  body 
thrown  forward:  ami  iinally  he  starts  oil',  sometimes  with  great  rapidity, 
yiiiiie  of  the  patients  can  walk  up  ami  down  stairs  better  tlian  on  the  level. 
The  wasting  is  never  so  extreme  as  in  the  atonic  form,  and  the  loss  of 
])ower  may  lie  out  of  ]iroportion  to  it.  The  s[ihiiicli'rs  are  unaiVecled. 
Hcxual  power  may  be  lost  early.  Cases  are  met  witii  which  corresimnd  ac- 
curately to  the  clinical  iiicture  given  by  Charcot  of  amyotrophic  lateral 
sclerosis.  These  are  not  very  common,  and  it  is  much  more  usual  to  have 
a  combination  of  tiie  two  types.  .\  llaccid  atrophic  jiaralysis  with  increased 
rellexes  is  often  met  with.  These  diiVcrences  (h'peiid  upon  the  relative  ex- 
tent of  tlie  involvenu'iit  of  the  upper  and  lower  motor  segments  and  the 
time  of  the  involvement  of  each. 

As  the  degeneration  extends  upward  an  impoitant  chr.nge  takes  place 
from  the  develo];ment  of  bulliar  symptoms,  which  may.  however,  precede 
the  spinal  manifestations.  'J'hc  lips,  tongue,  face,  jiharynx,  and  larynx 
may  bo  involved.  The  lips  may  be  affected  and  articulation  impaired  for 
veaVs  before  serious  symptoms  occur.  In  the  linal  stage  there  may  he 
tremor,  the  memory  fails,  and  a  condition  of  dementia  may  develoji. 

(.iowers  gives  tlie  following  useful  classification  of  the  varieties  of  this 
affection:  (i)  Atonic  atrophy,  becoming  extreme:  (•.')  muscular  weakness 
with  spasm,  but  without  wasting  or  with  only  slight  wasting;  and  {■])  atonic 
atrophy,  rarely  extreme  in  degree,  with  exaggeration  of  the  rellexes.  Tlie-e 
conditions  may  "coexist  in  every  degree  and  combination — between  uni- 
versal atonic  atrophy  on  the  one  hand  and  universal  spastic  paralysis  with- 
out wasting  on  the  other." 

Diagnosis.— Progressive  (central)  ninscuh;r  atrophy  begins,  as  a  rule, 
in  adult  life,  without  hereditary  or  family  influences  (the  early  infantile 
form  being  an  exception),  and  tisnally  affects  first  the  muscles  of  the  thumb, 
and  gradually  involves  tho  interossei  and  hunbricales.  Fibrillary  etmtrac- 
tions  aro  common,  electrical  changes  occur,  and  the  deeii  reflexes  are  usu- 
allv  increased.  These  characteristics  are  usually  sullicient  to  distinguish 
it  ifrom  the  other  forms  of  muscular  wasting. 

In  syringo-myelia  the  symiitoms  may  bo  very  similar  to  those  in  tlio 
spastic  form  of  muscular  atrophy.  The  sensory  disturbances  in  tho  former 
disease  make,  as  a  rule,  tho  fliagnosis  clear,  but  when  these  are  absent  or 


r 


JJ32  DISKASKS  OF  THE  NERVOUS  SYSTEM. 

lu,t  little  ,l.-vcl(.iK.a  it  nun-  bo  very  .liiTiciilt  or  evni  impossible  to  dislinguisb 

'^"Treatment.-The  disease  is  ineumble.  1  bave  never  seen  tbe  slij:bt- 
o4  benefit  from  druus  or  electricity.  The  downward  pn-ress  is  slmy  but 
certain,  thoujrb  in  a  few  eases  a  temporary  arrest  may  take  place  ^  itli  a 
bi<torv  of  <vnbilis.  mercurv  and  iodide  of  potassium  may  be  tried,  and 
Cnvc".  ivconmiends  courses  of  arsc.nic  and  the  hypo.lermic  injection  ot 
slrycluiiue.  J'robably  the  most  useful  means  is  systematic  massage,  partic- 
nlarly  in  the  spastic  ca-es. 

Jlulbnr  Parahisis  {dhK-'so-hihin-htrtiuutal  Panth/sis). 

^V1  en  the  disease  alfects  the  motor  nuclei  of  the  medulla  first  or  early, 
it  is  called  bulbar  paralysis,  but  it  has  practically  no  independent  existence, 
as  the  spinal  cord  is  sooner  or  later  involved.  ,.  ,  .    i  <•    ^    •      4i  . 

Symptoms.-rhe  disease  usually  be-ins  w>tb   sli.obt   defect   in   the 
speech    and  the  patient  has  ditliculty  in  i.rom.uncin-  the  dentals  and  lin- 
oinN      The  paralv>is  starts  in  the  ton.ixue,  and  the  superior  lingual  muscle 
"raduallv  becomes  at.opbied.  and  linally  tbe  mucous  membrane  is  thrown 
huo  tran>vcrse  folds.     In  the  process  of  wasting  the  lil.rillary  tremors  are 
<.vn      Owin.'  to  the  loss  of  power  in  tbe  tongue,  the  food  is  with  difliculty 
„u.hed  backlnto  the  pharynx.     The  saliva  also  may  be  increase.l.  and  is  apt 
to  accumulate  in  the  nmuth.     When  the  lips  become  involved  the  patumt 
,an  neither  whistle  nor  pronounce  tbe  labial  consonants.     Ihe  mouth  looks 
l.ir<re    tbe  lii.s  arc  prominent,  and  there  is  constant  drooling.      1  he  food 
il  masticated  with  diflicultv.     Swallowing  becomes  diflicult,  owing  partly 
to  the  regurgitation  into  the  nostrils,  partly  to  the  involvement  ot   the 
pharvngeal  muscles.     The  muscles  of  the  v.ual  cords  waste  and  the  voice 
lieconies  feeble,  but  the  laryngeal  paralysis  is  rarely  so  extreme  as  that  ol 

the  lips  and  tongue.  .  t^    „      r,  u . 

The  course  of  the  disease  is  slow  but  progressive.  Death  often  result, 
from  an  aspiration  pneumonia,  sometimes  from  choking,  more  rarely  from 
involvement  of  the  respiratory  centres.  The  mind  usually  remains  clear. 
The  initient  mav  become  emotional.  In  a  majority  of  the  cases  the  dis- 
ease is  onlv  part  of  a  progressive  atrophy,  either  simple  or  associated  with 
a  silastic  condition.  In  the  latter  stage  of  amyotrophic  latc^ral  sclerosis 
the  bulbar  lesions  may  paralyze  the  lips  long  before  the  pharynx  or  larynx 

becomes  afTectt'd.  . 

The  dia,inosis  of  the  disease  is  readily  made,  either  m  the  acute  c.r 
chronic  form.  The  involvement  of  the  lips  and  tongue  is  usually  well 
marked,  while  that  of  the  palate  may  be  long  deferred.  A  condition  has 
],een  described,  however,  which  may  closely  simulate  bulbar  paralysis. 
This  is  the  so-called  pscudo-bulhar  form  or  bulbar  palsy  of  cerebral  origin, 
r.ilateral  disease  of  the  niot.u-  cortex  in  the  lower  part  of  the  ascending 
frontal  convolution,  or  about  the  knee  of  the  internal  cajisule,  may  cause 
paralvsis  of  the  lips  and  tongue  and  pharynx,  which  closely  simulates  a 
h-ion  of  the  in.'diilla.  Sometimes  tbe  symptoms  api)ear  on  one  side  but 
in  manv  instances  tliev  develop  snddcnly  on  both  sides.     A  bilateral  Ic- 


DISEASES  OF  THE  EFFEREN'T  OR  MOTOR  TRACT. 


93.'^ 


li;:-lingui.sh 

tho  sli-lit- 
s  sluw  l)Ut 
!.  With  ii 
trk'il,  anil 
ijcLtiun  ui' 
ige,  piu'tic- 


st  or  I'iU'ly, 
t  cxisteiico, 

roct  in  the 
ilri  and  lin- 
lual  nuisclo 
L'  iri  thrown 
trcMior^  are 
ill  (iitliiulty 
1.  and  is  apt 
the  jiaticnt 
nouth  looks 
Tho  food 
wing  partly 
iiont  of  the 
id  the  voice 
0  as  that  of 

jften  results 
rarely  from 
mains  clear, 
ises  the  dis- 
ociated  with 
■ral  sclerosis 
nx  or  larynx 

the  acute  or 
usually  well 
ondition  has 
ar  paralysis, 
rehral  origin, 
he  ascending 
e,  may  cause 
,'  simulates  a 
one  side,  but 
hilateral  Ic- 


.«i(in  has  usually  hccii  fuund,  hut  in  several  instances  the  di^ea.-e  was  uni- 
lateral. , 

Tiu'  so-called  (wulr  hulbar  panih/sis  may  lie  due  to  (/()  iKeuioiTJiagie  nr 
embolic  softening  in  the  pons  and  medulla;  [b)  acute  inllammatory  softening, 
anah)gous  to  polio-myelitis,  occurring  iieeasionally  as  a  post-IVlirile  all'ei  Umi. 
It  usually  comes  on  very  suddeidy,  heiur  t!ie  term  apnplcetil'orm.  The 
symi'tonis  in  this  form  may  correspiuul  elnsely  to  those  of  an  advanced  ca>e 
(d  eiironic  bulbar  paralysis".  The  sudden  onset  and  the  associated  symptoms 
uiake  the  diagnosis  T>asy.  in  these  acute  eases  there  may  he  loss  (d'  power 
iu  one  arm,  or  hemiplegia,  sometinu's  alternate  hemiplegia,  with  jiaralysis 
on  one  side  of  the  fair  and  loss  of  powi'r  on  the  other  side  of  the  body. 

2.  riUKiitKssiVK  Xi:ri{.vL  Mr.scri.Ait  .Vntoi-iiv. 

This  form,  known  also  as  the  iieroneal  tyi)e,  or  !iy  the  names  of  the  men 
who  have  described  it  most  accurately  of  laic — namely,  ChareiU.  .Marie,  and 
Tooth— occurs  either  as  a  hereditary  or  as  a  family  allVction.  It  usually 
begins  in  early  childhood,  alfeeting  (irst  the  muscles  ol'  the  I'cet  and  the 
peroneal  grouj);  as  a  result  of  the  weakening  o(  these  muscles,  club-foot, 
either  ])es  o(pnnus  or  ])es  (Hiuino-varus  oeciu's.  in  rare  instances  tlie  dis- 
ease may  begin  in  the  hands,  but  tiie  ujiper  limbs,  as  a  rule,  are  not  alVected 
for  some  years  after  the  legs  are  attacked,  and  the  trouble  then  begin  -i 
the  small  "muscles  of  the  hands.  Sensory  disturbances  are  freipu'iitly  pres.iu 
and  form  important  diagnostic  features.  Fibrillary  cimtractions  and  twitcli- 
ings  also  occur.  The  electrical  reactions  are  altered:  there  is  either  a  loss  or 
a  very  great  decrease  of  the  excitability,  vyhieli  can  be  demonstrated  not 
only  "in  the  atrophic  muscles,  but  also  in  muscles  and  nerves  which  are  ap- 

]iarently  normal. 

This  form  of  muscular  atrophy  seems  to  staml  between  the  central  form 
and  the  muscular  dystrophies.  Occurring  in  families  and  l)eginning  in 
early  life,  it  resonbles  the  latter,  1)Ut  it  is  more  like  the  former  in  that 
fibrillary  contractions  and  muscular  twitchings  are  common,  that  the  snudl 
muscles  of  the  haml  are  apt  to  be  involved,  and  that  electrical  changes  are 
jiresent.  In  the  pronniu'iice  of  sensory  symptoms  it  differs  from  both.  In 
cases  of  acquired  double  club-foot  this  disease  should  he  suspected. 

3.  TiiK  Mfscri.An  DYSTnoi'iiii:s 
(Dystrophia  muscularis progressiva,  EH)). 

Definition.— ^fuscular  wasting,  with  (U'  withoid  an  initial  hyjuMtro- 
phy,  l)eginning  in  various  groups  of  muscles,  usually  jn'ogressive  in  char- 
acter, and  dependent  on  ])rimary  changes  in  the  muscles  themselves.  A 
marked  hereditary  disposition  is  met  with  in  the  disease. 

Etiology.— Xo  etiological  factors  of  any  moment  are  i-nown  other 
than  heredity.  The  influence  may  show  itself  1)y  true  heredity— the  dis- 
ease occurring  in  two  or  more  generations — or  several  members  of  the  same 
-rem^ration  mav  be  aifeeted,  showing  a  family  tendency.  'Many  meml)ers 
of  the  savue  family  may  be  attacked  through  several  generations.     Males, 


r 


934 


DISEASES  OF  TH.'  NERVOUS  SYSTEM. 


a.  a  rnlo.  nro  mov..  fn-iuontly  allVrt...!  tlu.n  f.n.aKs.  I  1h'  .Ii>ra.  is  iisuall} 
trans.mtl.a  ll.nni-h  tl..  in..tlu'r,  tlu.n-h  sli.  may  not  luTsrll  1,.  alUrlud. 
\.  n.anv  a^  'JO  or  ;;«  cum's  liavc  l.oeii  dosorilird  in  livo  {iiMU'rations.  Jii  hrlj  d 
n,.c.<  -1  i  vw  c'cnt  slu.wc.l  no  hcirdity.  Tho  (liHcaso  usually  sets  m  bctoro 
puhorty.  I'ut  may  h."  as  late  as  \Uv  twontieth  or  twonty-liltli  y.ar,  or  ni  some 

instancrs  rvcn  later.  ;„     .  ;„ 

Symptoms.— The  first  symptom  notiec.l  is.  as  a  rulo,  <lumMiu'»  m 
tho  movnnrnts  of  the  .•hil.l,  and  on  examination  crrtain  muscles  ..r  yr.u.ps 
of   museles   seem    to   1...   enlai-ed.   partieularly    those   of   the  calves       J  he 
extensors  of  the  K-,  tiie  jilutei,  the  lumhar  museles,  tlie  deltoid,  trieep. 
and  infraspinatus,  are  the  next  most   fivipiently  involved,  and  may  stan.l 
,u,t  with  oreat  prominence.     The  museles  of  the  neck,  face,  ;'"'\  i";-^'';;'"i 
rarelv  sillier.    Sometimes  only  a  portion  of  a  muscle  is  involve.!.     \\  ith  tlus 
l.vneVtrophv  <.f  .•^<mie  muscles  there  is  wastin-  of  others,  particularly  the 
1,;,;,,,  ,,„;,ion  of  the  pe.-torals  and  the  latissimus  dorsi.    The  attitude  when 
«tandiiV.-  i<  very  .haraeteristic.    The  legs  are  far  apart,  the  >houlders  tlinnvn 
back   the  <i.iiu".  is  irreatly  curved,  and  the  abdomen  i)rotrudes.     1  he  gait  is 
wad.lling  and  awkward.     In  getting  up  from  the  lloor  the  position  assume.!, 
«o  well  known  now  thn.ugh  (lowers"  figures,  is  path..gnom..nic.      I  he  pa- 
tient lir-t   turns  ..ver  in  the  all-fours  p.isition  and  raises  tli.'  trunk  witli 
his  arm-,  the  han.ls  are  then  moved  ah.ug  the  ground  until  the  knees  are 
reachcl:  then  with  one  lian.l  up..n  a  knee  he  lifts  himself  up.  grasps    he 
other  kne...  and  ora.luallv  pushes  himself  into  the  erect  p..sture    as  it  has 
been  expressed,  bv  climbing  up  his  legs.    The  striking  contrast  between  the 
feeoleniU  of  tlie"c!ul.l  and  the  powerful-l....king  pseudo-hyi.ertrophu'  mus- 
cles is  yery  characteristi.'.     The  enlarge.l  museles  may.  however,  '-e  reui- 

^'''''n,r'eom!^".'^'the  disease  is  sl.,w.  but  progressive.     Wasting  p;   ^'oeds 

and  finally  all  traces  of  the  enlarge.l  e..ndition  of  the  muscles  disai,    ar. 

Vt  this  late  period  distorti.)ns  and  ontra.tions  are  common 

'      The  muscl..s  of  the  shoulder-girdle  are  nearly  always  alfected  ear  y  in 

the  .lisea^e.  causing  a  symptom  upon  which  Krb  lays  great  stress.     ^\  .  !i 

,  l,an.l<   und..r  tlie  arms,  when  one  endeavors  t..  hit  th.>  i.atient,  the 

h.ml.lers  a-e  raise.!  t..  the  level  of  the  ears,  and  ..ne  gets  the  impression 

i.s  tlun,.b  the  child  were  slipping  through.     These  "    ,ose  slumlders     are 

very  eharacteristi.^.     The  abn..rmal  m..bility  ..f  the  .h..ulder-blades  gne. 

ti'em  a  winged  a,MU'aran..e,  and  makes  the  arms  seem  much  longer  than 

usual  when  they  are  stretched  out.  ,       ,  • 

The  ,.atients  .-.nni.lain  of  no  sensory  syinpt.nns.     The  atmpluc  mus- 
eles d.)  n'.t  show  the  reacti.m  ..f  degeneration  except  in  extremely  rare  in- 

'*' Clinical  Forms.— V  number  of  different  types  have  been  dcscriljcd. 
d.>peiidin.  upon  the  age  at  tlie  onset,  tlu^  muscles  first  aiVeete.l  ho  occur- 
;:;„',,  of  hvpl.rtropbv,  Ihc  prominence  of  heredity,  etc.  But  Erb  has  shown 
that  tli.'re"  is  n..  sharp  division  between  these  diir..rent  forms,  and  classes 
them  all  under  the  name  of  (hixtrophia  musrulans  pmnnsm-a.  I'or  con- 
y.Miienc."  of  description  lie  sul)divides  the  disease  into  two  large  groups: 
I.  Those  cases  which  occur  in  childhood. 


^■i 


lilSHASHS  OF  TIIK   EFFERENT   Oil   MoToR   TRACT.  03r> 


is  usually 

illVl'lUMl. 

Ill  Krlj'd 
in  hc't'oro 
ir  ill  soiiit' 

iisiiii'ss  ill 
or  groups 
vi^s.  'J'hf 
id,  irict'j.'i 
nay  stand 
d  I'oroarin 

With  this 
nlarly  the 
tudo  when 
ITS  thrown 
riie  gait  is 
;i  assumed. 
The  pa- 
runk  with 
'  knees  are 

grasps  tlie 
',  as  it  has 
otweeii  the 
Dphie  llllis- 
)Y,  I'e  rela- 

:g  pi   eccds 
disap,    ar. 

ed  earlv  in 
ivss.  With 
latient,  tlio 
impression 
aiders"  are 
ilados  gives 
longer  than 

'ophic  nuis- 
.oly  rare  in- 

n  doscrihed, 
,  the  occur- 
I)  has  shown 
and  classes 
r.  Tor  con- 
groups: 


II.  The  eases  occurring  in  youth  and  adult  life. 

The  first  division  is  siilwlivi(h'd  int..  (1)  tiie  hyiiertrnphic  and  (•.')  the 

atmiihic  lunii. 

Vndcr  the  iivpertn-iihi.-  form,  which  i>  the  pseudo-liyperlroi.hic  iiius- 
onlar  paralvsis  of  authcu>,  he  tliink>  il  i<  u-cfnl  to  di>tiiigui,-h  lu'twecu 
the  easc>  in"  which  {a)  tlie  enlarged  muscles  liax.'  undergone  lipomatoMs— 
i.e.,  p>cudo-hypertropliy— from  those  (/-)  in   which   there  is  a   real  hyper- 

'"'tIic  atrophic  forju  al>o  includes  two  suhclasM-:  {a)  Tiiose  cn>es  in 
uhicii  tlie  inu>clcs  of  the  face  are  involved  ..irly:  thi~  corresponds  to  tiie 
i„r„ntile  form  of  Ducheiine— tlie  Landouzy-Dcjcriiic  type.  (M  '1  ho>e  eases 
in  which  tiie  face  is  not  involved. 

I.  Djislniphiii  iinisruhiri.-<  /(;v»//7',ss-(/v/  iiijaiiliim. 

1.  Ilypertroiihic  form. 

(//)  With  ]isendo-liypertroiihy. 
(/;)  Willi  real  hypertrophy. 

2.  Atrophic  form. 

(a)   Witii   primary   involvement   of  the   face   (mlantiie   loriu  ot 

Diulu'iine). 
(/))  Without  involvement  of  the  fact'.  ^     ^ 

IT.  Diislnipliiii    iiiu><rnhiris   pmyrc^s'tra    jiiirinnii    vd  udulli.rum    (Hrbs 

jnvenilc  form). 

Morbid  Anatomy.— According  to  Krh,  the  disease  consists  m  a 
change  in  the  muscles  themselves.  At  lir,4  the  muscle-dl.rcs  hypertroi-hy, 
and  heconie  round:  the  nuclei  increase,  and  the  miis.l.'-fihres  may  hecome 
fissured.  At  the  same  time  there  is  a  slight  increase  in  the  connective  tissue. 
Sooner  or  later  the  muscle-lihres  hegin  to  atroj.liy,  and  the  nuclei  hecome 
greatly  increased.  Vacuoles  and  fissures  api>ear.  and  the  lilu'cs  finally  he- 
come "completely  atrophic,  the  connective  tissue  hecoiuing  markedly  in- 
creased. Fat  may  he  dejiosited  in  the  connective  tis-ue  to  sucli  an  extent  as 
to  cause  hviieilrophic  lipomatosis— pseiido-hypertroi.hy.  The  difVerent 
stages  of  these  changes  may  lie  found  in  a  single  mus<le  at  the  same  time. 

"^The  nervous  system  has  very  generally  heen  found  to  he  willu.ut 
denionstrahle  lesions,  hut  in  certain  cases  changes  in  the  cells  of  the  ventral 

horn  have  heen  descrihed.  , 

Diagnosis.— The  muscular  dystrophies  can  UMially  he  readily  distin- 
guished from  the  other  forms  of  muscular  atro]ihy. 

{a)  In  tiie  cerehral  atroj.hy  loss  of  power  \isually  lU'ecedes  the  atro|)hy, 
which  is  either  of  a  monoplegic  or  heiiiiidegic  type. 

{},)  From  progressive  (central)  muscular  atroj-hy  the  distincti.nis  are 
clearlv  marked.  Tliis  form  begins  in  the  small  muscles  of  the  hand,  a  situ- 
ntion'rarelv  if  ever,  affected  hy  the  dystrojihies.  which  involve  first  those 
of  the  calves,  the  trunk,  the  face,  or  the  shoulder-girdle.  In  tlie_ central 
atrophy  the  reaction  of  degencratimi  is  iu'e<ent  and  fibrillary  twitchings 
occur  in  both  the  atroi>hied  and  non-atrophied  muscles.  In  niaiiy  cases,  in 
addition  to  the  wasting  in  tlie  arms,  there  is  a  spastic  condition  in  the  h'gs 
and  incrcas.'  in  Mie  reflexes.  The  central  atrophies  come  <ui  late  in  life; 
the  dystrophies  develop,  as  a  rule,  early.     In  the  progressive  muscular  dys- 


^^k 


c,oo  DISEASES  (»F  THE  NERVOUS  SYSTEM. 

„,,urrin}:'  in  Imnilics  th..  sy,ni.t...n.  a.v  so  cl>amctor.stu:  nl  a  c.nUal  .l.-ui.. 
tlint  Ilu>  (lia<niosis  iiri'sciits  no  dillHiilty. 

ilio  -nnvral  ..luuactH's  and  tlio  n.ode  of  unset  are  .l.stine.vo.     In  th  ■  ca^e 
„ u     i        neuritis  seen  for  tlie  lirst  tin.e  at  a  period  when  the  wasting   s 
,  k        i  ere  is  ..ften  -linieulty,  In.t  the  abs<.,ee  of  fanny  history  ar.d  to 
"nlntion  are  in>,.ortant  features.    Moreover,  the  panU,s.  .  on    o^  1-    - 
nortion  to  tlie  atropliv.    Sensorv  svuii-tonis  may  he  i-resent,  and  m  tUt  cuts 
In  winLh  the  ^s  Ire  .-hielly  involved  there  is  usually  the  strpp-l^  ga.t  so 
ili'iraeteristie  of  peripheral  neuritis.  ,.,     .      ,  ^,4..,, 

7/)  i'ro  M-essi  e  nLural  nu.seular  atn.phy.  Here  hered,  y  is  also  a  aeto, 
.nd  t lu  W.  usuallv  hegins  in  early  life,  hut  the  distrdnU.on  ot  atrophy 
:  d  nr  V  i  \vhieh  in  this  alfeetion  is  at  first  eondned  t..  the  periphery 
;  1  e  m  nities,  helps  to  distinguish  it  from  the  dystrophies;  while  he 
turn^li  sen;orv%v,npton.s.  llhrillary  eontraetions,  and  the  nuu^kod 
a""    e  in  the  eleetWeal  exeitahility  usually  make  the  .l.tinetion  elear 

.p,„  ,„t,„.,k  iu  the  primary  museular  dystrophies  is  bad  ^^Ung 

.ro.rresses  uniformlv,  uninllueneed  hy  treatment.     Krb  hold.  »'  •'     '       !^ 

W  .Ttv  ind  ma<sa-e   he  progress  i>  oeeasionally  arrested.    '1  he  general  heal  h 

1    :'     ;ef:ilv  loold^aftor,  moderate  exercise  allowe  ,  i-tioi.  w.^. 

1    nnlied  to  the  museles.  and  when  the  i-atient  beeomes  hedlast.  as  is  in- 

"•jS'olcr  or  later,  eare  should  be  taken  to  prevent  contraetures  in 

"^■'The'thlv'Joims  of  progressive  nuiscdar  wasting-progressive  (eentral) 
.ni3  IH  •    .  nhv,  progressive  neural  museular  atrophy,  and  the  museula 

i^ns  make  t  probable  that  the  distinetion  may  m>t  be  so  sharp  as  we 
ve'  V  ain  ases  oeeur  whieh  seem  not  to  belong  to  any  one  of  the 
:  but  t^  s  nd  between  them.  The  <.hanges  in  the  museles  whieh  .^  e 
t lo md,  to  be  eharacteristie  of  the  dystrophies  have  been  found  n  e 
otler  forms.  The  eentral  form  oeeurs  as  a  family  disease  in  infanej,  and 
the  nm-     s  -v-tem  has  been  foun.l  diseased  in  the  dystrophies. 

; :  ..1.,,,;,  ,„o.i™ ...  *;'t,:-;irii\o  ,;:^*s:::'^:;^;;:; 
:;:i;:  ;cr:  ^rrf  :;,i;rw  :;-:™J  :S;:t  ^i^i^i:  ^r 

spending  to  eaeh  there  is  a  fairly  well-deternuned  anatomical  basis. 

B.    SYSTEM   DISE.VSES  OF  THE  UPPER  MOTOR  SEGMENT. 
The  (lue^ion  of  an  uncomplicated  primary  degeneration  of  the  upper 
xnotm  n      on     ha    not  been  decided.    Cases  with  a  clinical  picture  eorre- 

-::;:;i:;  lo  .is  ^-^  - -,-^-- ^^--sj:^-  i:^!-^ 

'Z':£n:::^::^-^^^Ti:'l  two  or  three  has  the  disease  been 


11 


DISKASHS  OF  THE   EFFERFNT  OR  MOTOR  TRACT. 


O.Ti 


inn  IS  (lUite 
l;ir  atroiihy 
Ural  (li^^casc 

r  lu  trauma, 
lu  the  t■a^l.■s 

10  wat-ting  is 
tory  ami  the 
s  out  of  i>ro- 
[  in  the  ca^e.^ 
\)l)(iije  gait  i-o 

alxi  a  factor, 
n  t>t'  atropliy 
lie  periphery 
es;  wliile  tlie 

the  marked 
tion  clear. 

The  wasting 
that  by  elec- 
reneral  liealth 
frictions  witlr 
It'ast,  as  is  in- 
)ntraetures  in 

ssive  (central) 
the  muscular 
certain  recent 
:o  sharp  as  we 
ny  one  of  the 
les  which  were 
found   in  the 

11  infaiu'y,  and 
ies. 

esent  better  to 
0,  as  Striimpell 
ndency  of  the 
ical  types,  into 
:y,  while  corre- 
al basis. 

:gment. 

n  of  the  upper 
d  picture  corre- 
ersist  for  a  long 
come  to  autopsy 
the  disease  been 


so  nearly  conliiud  to  ilie  pyramidal  trad  that  they  can  he  used  h>  an  argii- 
uient  for  the  imlepemh'nce  of  this  comlition.  The  cases  of  MinUowski. 
Dreschlcld,  and  Striimpell  are  not  alisolutcly  (•onchl^ivc,  as  they  are  not 
luiite  pure,  aitiiough  tin'V  go  far  to  prove  that  a  d.'geiieration  in  the  pyram- 
idal tract  mav  lie  nnc(".mplicate(l,  at  least  for  a  long  time.  The  same 
may  be  said  for  the  group  cd'  cases  described  by  i'.cridiardt  and  SlriimpiH 
under  the  name  hereditary  spastic  spinal  paralysis,  in  wliich  the  extensive 
sy^temic  degeneration  of  the  pyranudal  tracts  is  eond)inc<l  with  slight  de- 
generation in  other  tral'ts  (d'  tiie  cord. 

1.  Spastic   I'ak ai.vsis  or  Aiults 
(Talics  (lormlii  Kpti.vnoiliqiie  ;  Prlimtnj  Liilvra!  Si-hrosiK). 

Definition.— A  gradual  lo.-s  of  power  with  spasm  of  the  muscles  of  the 
body,  the  lower  extremities  being  lir>t  and  nio.-t  aifectod,  unacconii)anied 
l)y  iimscular  atrojihy,  sensory  disturbance,  or  other  symptoms.  The  patho- 
l()gical  anatomy  is  undetermined,  but  u  systenuc  degeneration  (d'  the  pyram- 
idal tracts  is  assumed. 

Symptoms.— The  general  siiiiiiihiiiis  of  spastic  paraplegia  in  adults  are 
very  (li^tillctive.    The  patient  complains  of  feeling  tired,  of  stillness  in  the 
legs,  and  ])erhaps  of  pains  of  a  dull  aching  character  in  the  hack  or  in  the 
cahes.    There  may  be  no  delinito  loss  of  power,  even  when  the  spastic  con- 
dition is  well  estab'lishcd.   In  other  instances  there  is  definite  weakness.   The 
stilTness  is  felt  most  in  the  uKU'ning.     In  a  well-devcloi)ed  case  the  gait  is 
most  characteristic.     The  legs  are  nuived  stillly  and  with  hesitation,  the 
toes  drag  and  catch  against  the  ground,  and,  in  extreme  cases,  when  the 
ball  of  the  foot  rests  u])on  the  ground  a  distinct  clonus  develops.     The 
legs  are  kcjit  close  together,  the  knees  touch,  and  in  certain  cases  the  ad- 
ductor si)asm  may  cause  cross-legged  progression.     On  examination,  the  legs 
may  at  liiv*  appear  tolerably  sujtple,  perhajts  Hexed  and  cxtemlcd  readily. 
In  other  '^■ases  the  rigidity  is  marked,  jiarticularly  when  the  limbs  are  ex- 
tended.   The  f-i)asm  of  tlie  adductors  of  the  thigh  may  be  so  extreme  that 
the  legs  are  separated  with  the  greatest  dilliculty.    In  cases  of  this  extreme 
rigidity  the  ])atient  usually  loses  the  power  of  walking.     The  nutrition  is 
well  maintained,   the   muscles  may  be   hypertrophied.      The   rcllexes   arc 
greatly  increased.     The  slightest  touch  upon  the  patellar  tendon  produces 
an  active  knee-jerk.    The  rectus  clonus  and  the  ankle  clonus  are  easily  ob- 
tained.   In  sonic  instances  the  sl'ghtest  touch  uniy  throw  the  legs  iido  vio- 
lent clonic  sjiasm.  the  condition  to  which  ?.rown-Sequard  gave  the  name  of 
spinal  e])ilei>sy.     The  superficial  rcllexes  are  also  increased.     The  arms  may 
be  unaffected  for  years,  but  occasionally  they  become  weak  and  stiif  at  the 
same  time  as  the  legs.     This  was  the  case  in  a  c(dored  boy  who  was  in  my 
wards  for  several  years,     lie  presenti'd  a  degree  of  general  si)astic  rigidity 
that  I  have  never  seen  c(pialled.     The  disease  had  begun  after  puberty, 
developed  gradually,  and  remained  (piite  stationary  for  more  than  a  year 
before  he  left  the  wards.    There  were  no  other  symptoms.  ^ 

The  course  of  the  disease  is  progressively  downward.     Years  may  elapse 
before  the  jiatient  is  bedridden.    Involvement  of  the  sphincters,  as  a  rule, 
59 


i^^ 


938 


DISEASES  OF  TflE  NEUVOL-.S  SYSTEM. 
however,  it   i-  I'inly, 


'riic  seii^nrv  >vini'tnins  rarely 

i;::;;::;:;:;;r;:::ii;:r::;;;;:.;;,:ii.;^;'.™."' .-.-"■ '^■-^- 

,,.lU.„t  lu,.lll..    I  ''■«'•<'  «m|.l.m.s  arc  varo.  ,   ^^  „,„,,;,,  „„„, 

doubtful. 

,    Sr.sr.r  Ta.^m-Vs.s  <,r  iNr.NTs-Sr.vsru.  nnM.K.a.-lWKTu  I'-U.s.K. 

T.-       ,1    ,.    ;..,  ,,..rMlv-i^  with  .-^liasin  ci' all  fNtreiuitios  dating 
porli.m  ..[  the  «.«■»  ii'"  "'"'."  ,  '  j  "  f,  ,|,.,,.„,,i„„  wl.dh.'V  it  is  »  M*"  "' 

i,i„Miy  a,r,.,.i  as  <:;;-;;'-:',':,;;;:;  r, ..irti.. ».", .  „.,. 

:ij;;:;i:'K;:;:;i:::;'::";;;:^.--;:':;:^...:', ..„..,.; 

mature  hirtlv  is  also  oiveii  '>^  '^ ''y:''.  ,  ■  .,    ^ntiniatelv  induce  the 

Morbid  Anatomy.-Tho  l-'^'' f  ;  ,  '  ,  I  ,,,,u  of  nu.nin,eal 
.pnstie  diplegias  or  imrapk-.as  are  njo>t  ^'  1"  "  >  ^  ^  ,,^.^,,^  ,,,„,,  ,,,  the 
ll-norrhage.  The  in^oHau..  ol  '  -  ;; -^  !  ,td  ^  n,ay  c.nue-fnuu 
studies  of  r.it/niann  and  Sarah  .1.  ^f*^"'.,  '  .  f,,,,;  the  lonoiludinal 
t,,,  vein.  or.  as  in  nue  c.se  whuh  1  saw  -  '         ^  jj;^^^  ..^.^^  the  motor 

->-•     '']-  '■^•"""^'■'"T  d  ::  th';'  'iw'ie     ;S  nd  h'thoso  ea.es  n.ay  re- 

„vas,  and  it  seems  prohal.  e  l!  a.  t U  ..  xi  instances  the  eor.'lluon 

suit  frou>  eou.prossion  hv  the  hlood-elot        n  "^    '^     ^  ;';^     .^^  ^^n^,,,.!  ;„ 
n>av  lu.  due  to  a  foetal  '-'•-■'"f-'^V'^T       ij   u  y  n  "f In  two  to  thirty, 

^,„,  anatonmal  condition  was  ether  a  <^  <^      /^J^^     >'  ^^  ^i^,.  ,,,,,  ,,,,  ,,oru 
,,,,„.  ,,  porenccphalus.    From    he  ..  't    ^  '^^  c"^^     ^^    '  .^  ^,,,,  i,,,„  ,,. 
,,„„t„,..ly,  hefore  the  vvramulal  ^^^I'^^J^l^l  ,,,,  ,,,,e  of  the 
sumed  by  some  that  a  non-development  ol  tliese  tract. 


DISKASKS  OF   TIIK   KITKHKN'T   OR   MOTOR   TRACT. 


o.^ft 


tmus  rarely 
1(1  fujoy  i-'-'i- 

/ailily  mailf, 
[  the  uiulor- 
iii  many  nl' 
I'  (i|ii)ii  eiiiu- 
■(■rt'iil  e()U(li- 
■tf  Cloncral 
rapli'j^ia,  ami 
lilt  a  primary 
llu-  iliagno^is 
say  IIk'  k'ast, 


urn  Palsies 


initios  dating 
IVvcrs  or  an 

lan  tho  arm>; 
ari'  increased. 

I'nts  arc  dl'tcu 

ilhc'loid  niuve- 

ik'gia  arc  con- 
ia  a  large  pm- 
ms  may  l»e  so 

it  is  a  ca>o  of 
■th,  and  a  inii- 

cascs,  and  are 
t  ])resentations 
niliranes.    I'ro- 

tely  induce  the 
It  "of  meningeal 

shown  l)y  the 
may  come  fn^m 
he  longitudinal 
over  the  motor 
se  cases  may  re- 
cs  the  cof'-oiion 
isies  collected  in 
im  two  to  thirty. 
\\  was  most  ci-m- 
0  cases  are  horn 

it  has  been  as- 
the  cause  of  tho 


di.H'a.'^e.  This  hypotlionia  has  hern  urged  liy  Marie,  whn  limiis  the  name 
spastic  paraplegia  to  that  gnmp  nf  the  infantile  ca^es  in  which  ihere  is  nn 
i'videncc  (d'  inv(dvement  id'  tiie  iirain — intellectual  distnrliances.  epilep.-y, 
etc.,  and  it  i.s  in  these  cases  that  he  believes  the  pyramidal  tract  has  re- 
mained undeveloped. 

Symptoms. — At  iirst  nothing  ahiiormal  may  he  nuticnl  ahnut  the 
child.  In  some  instances  there  liavi'  heen  early  and  fre(|ucnl  eonvnUion-; 
then  at  the  age  when  the  child  shouhl  begin  to  walk  it  is  noiieed  that  the 
limbs  are  not  used  reaTlily,  and  on  c.\annnation  a  still'iiess  of  the  legs  and 
arms  is  fiaind.  Kven  at  the  age  (d'  two  ilie  chihl  may  not  be  able  to  sit 
up,  and  often  the  lieail  is  not  well  supported  iiy  the  neck  lun^i  h'-.  The 
rigidity,  as  a  rule,  is  more  marked  in  the  legs,  and  there  is  adductor  spasm. 
\Vhen'su|iportcd  on  the  feet,  the  child  either  rests  on  its  toes  and  the  inner 
surface  of  the  feet,  with  the  knees  close  together,  or  the  legs  may  be  crossed. 
The  stilVness  of  the  upper  lindis  varies.  It  may  be  scarcely  nolieealile  nr 
the  rigidity  may  be  as  maiked  as  in  the  legs.  When  the  spastic  condition 
aifects  the  arms  as  well  as  the  li'gs,  we  speak  of  the  condition  as  diplegia; 
when  the  legs  alone  are  inv(dved,  as  parafilegia.  'I'hcre  seems  to  be  no  >uf- 
'  licient  reason  for  considering  them  sejiarately.  Constant  irregulai'  ninve- 
,ments  (d'  the  arms  are  not  uncommon.  The  chihl  has  givat  dillicully  in 
■gVasiiing  an  object.  The  sjia.-m  and  weakness  may  be  more  evident  mi  our 
.'•side  than  the  other.  The  mental  condition  is,  as  a  ruh',  (h'feclive  and  cun- 
vulsive  seizures  are  common. 

Associated  with  the  spastic  paralysis  ar.'  two  allied  conditions  (d'  c(m- 
siderable  interest,  characterized  i)y  spasm  and  disordered  movements.  .V 
child  with  spastic  diplegia  may  i)resent,  in  an  unusual  degree,  irregular 
movements  of  the  muscles.  In  attempting  to  gras])  an  objeet  the  fingers 
may  ho  thrown  out  in  a  stilt',  spasmodic,  irregular  manner,  or  there  may  be 
constant  irregular  movements  of  the  shoulders,  arms,  and  hamls.  with 
slight  incoilrdination  of  tho  head.  Cases  of  this  descrijjtion  have  been  de- 
scribed as  flidirti  spdslirii,  and  tlu'y  may  he  dillicult  to  sejiai'ate  fnun  mul- 
tiple sclerosis  and  from  Friedreich's  ataxia. 

A  still  more  remarkable  condition  is  that  of  hllntrnil  (iIIk'IiisIs.  in  uhich 
there  is  a  condiimition  of  spasm  more  or  less  markeil  with  the  most  exti'am'- 
dinary  bizarre  movements  of  the  muscles.  The  comlition.  as  a  rule,  dates 
fnuuinfancy.  The  patient  may  not  be  able  to  walk.  The  head  is  turned 
from  side  to  side;  there  are  continual  irregular  mouMuents  of  the  face  mus- 
cles, and  the  nu)nth  is  drawn  and  greatly  distorted.  The  extremities  are 
more  or  less  rigid,  jiarticularly  in  I'xteiision.  On  the  slightt'st  attemiit  tit 
move,  often  spontaneously,  there  are  extraordinary  movements  of  the  anus 
and  legs,  imrticularly  of  the  arms,  somewhat  like  though  much  more  I'xag- 
gerated  than  athetosis.  The  ])atieids  are  often  unable  to  lu'lp  themselves 
cm  account  of  these  movements.  The  relh'xes  are  increased.  The  mental 
condition  is  variable.  Tho  jiationt  may  be  idiotic.  1)nt  in  :?  of  the  (J  cases 
which  I  have  seen  the  patients  were  intelligent.  Massalongo.  who  has  caro- 
fidly  studied  this  conditi(ui.  describes  3  cases  in  one  family.  I  have  col- 
lected 53  cases  from  tho  literature,  3:?  of  which  occurred  in  males  and  -.'0 
in  females. 


040 


DISEASES  OF  TIIK  NERVOl'S  SYSTEM. 


■\    lli;in;i)iTAHY  SrAsric  I'auaim.kgi.v 

.IccTibcd  by  (;.e,  Stru.n,.oll    U.v.,1.     H,    "'        ^Juish  in  thi.  form  Uv. 
Sac.hs.  an.l  ..tlKT.     A,.,.a.xn  Iv  ..  j,   ^  i\'  Faiu-y  or  .luhU.-o.'.,  a.,.l 

ilH.  .asL's  liavi.  all  th.  .hanu'lc^  ol  ''«"•,  ,  ,„.^,i„^  „„,„tal  ,l,s- 
...«,  ho^vover,  the  ^^''M'*'''-!-;;  ;,;';.  and  U  was  i.>  relation  to 
t,.,l,aiu.es  epilepsy,  ete.,  may  '-  .^"  '  >  ;'  ,ij\.,.,  „„u.h  stress  had  heen 
then,  that  Krb  nunle  t  'e. ^"^'^'-^';'  \^  j:^;  '  , ,/ ,  ,^,a.nne  de^vneration 
,^,„,  „„„  the  cerebral  'l'-''-\  ,  /  ;'; '^^^  ^n  d  I'or  the  .y.upto.ns.  The 
,.r  the  lowcT  part  "^.»'-  I"^.'';\"^'f  dc^^d  .c^    1  V  t  hs.  Peterson.  IHrseh,  and 

.lisease  develops  later,  usually  bet.e  n  ^-'^  >,^  >  ^;,  V,   ,,  ^,,,,lysU,  only 
U  very  slow,  extending  over  ■»;>">;>•;;„;),;■,,,,„,  later^    Toward  the 

,,,n,s  or  (loll  and  or  the  dire.t  *-•';;;  I)™ •,,,,,,,  „r  inrantile  paralysis 
Amanrolic  Famh,  /'  ''''■•';7--V  ^       >         ,.  h.    The  svuiptonis  as  sum- 

,as  heen  described  by  Saehs^^  V      -n.-i^^'^^^^     tl,at  appear  in  earl^  Wo 
n.arized  by  Sachs  are.   I.  1  ^>'l  ^     n  .^,    j,^^^,^,^j^^  ,^„,i  ,,i, 

(fivst  or  second  year)  and   l-j;    -,!,,,,;,,  n.ay  he  either  tlaeeid 
nmtely  eonM-leto  paralysis  ot  ^1^'     x      '  ^       tendon  rellexes.    4.  Partial 

or  spastic.     :5.   Increased,  ^^•^'^^'"^i^ ^^  ,,iui  subsequent  atrophy  o 
fouivsed  by  total.  bhnd,,ess,n.ud       ban     .,  ^^^^^^  ^,^^   ^^^„,,i 

the   optic   norve).     ;■    Mara>uu,.  ^^J^^  i„,„,   ,,e   nystajrnnis 

voar.  0.  Distinct  fanuhal  tyi-c.  <»'^;  ^'^"'-;;;;.,  ,,  The  pathological 
;t..abisn,us,  hyperacusis,  or  ^^^V^^^^J^Z..,.^  nuu.ogyria,  de- 
,l„„g,s  are  pvinut.ve  type  oi  ^'"^^  '  '''^^,,i,  „,,,„„,,,  ..r  tiu-  tange.U.al 
...norative  changes  in  the  largo  1»;  "'>;,; ^..tter.  The  blood-vessels 
lihrcs.  and  de..rease  of  the  i^'-veB^f  J     ,     ,,„„iaal  cohunns  of  the 

,.e  norn.al./rhere  ^^ ^J^^^:^ ^ ZJr.^  in  six  families;  all  in 
rord.     or  '.'7  cases  collecteil  bv   r5aca., 

^'"''"  ,    Vnn-s  Svi'HTT.TT.r  Shn'AT,  Pakat-VSIS. 

,,,  ,.  aescribcd  a  syn.pton.  r^^^;-!!-,:^^' ^^^^^ 
,,a.alysis.  to  which  much  '>^^-  ;;?;;;  '^^,T  development  finally  of  the 
u.  lavs  stress  arc  a  very  J:'''"l">\"  'Wonoxes  are  greatly  increased  but 
features  of  a  spastic  raros.s;  /I"'  f  "^^^^^.itu  the  exaggerated  deep 
the  muscular  rigidity  .s  ^^fj^'^^Z.^yAl.i.r\.anc.s.v.ivv.^^, 
rcilcxcs.    There  is  rarely  much  pain,  ana  uic  j 


DLSKASES  OF  TIIK   RFPFIRF'NT  OR  MoTOll  TRACT, 


'.•41 


I  Pnmlyitit). 

h  Iviivi'  Itri'U 
Ki'h,  T.Hiih. 
lifi  I'onn  t\vn 
ililh. )()('.,  luul 
lis.    In  tlu'^o 
,  imMitiil  dif'- 
ii\  n'liitioii  to 
ITSti  luul  lii'i'ii 
(|t";ciieriUii)n 
iiptdins.     Tlu! 
.  lliisch,  anil 
jloroi^is  of  the 

^triimiicU,  the 
Till'  pro-rross 
piiralysis,  only 
Toward  the 
11(1  tlu!  bladtkT 
LTO  was  an  ox- 
use  oC  the  cnl- 

mtilo   jniralvi^is 
ijitoms  as  s-inn- 
r  in  early  life 
resis,  and  idti- 
e  either  ilaceid 
;os.    4.  Partial, 
lent  atrophy  of 
ore   tlie   seeond 
are   nystajrmurJ, 
ho    pathoh)gical 
niaerojiyria,  dc- 
f  llie  tangential 
'he  hlood-ves^^els 
columns  of  the 
{aniilie!^;  all  in 


syphilitic  spinal 
nints  n]ion  which 
•nt  finally  of  the 
tly  increased,  but 
exajifreratcd  deep 
•bances  are  trivial. 


|,iit  tlwre  niav  he  parivsthesia  and  tiie  ^'inlle  sensation.  'Phi'  liladiaT  and 
rectum  are  usually  involved,  and  there  in  sexual  failure  or  iuipoteiiee.  And. 
lastly,  iinproveiueiit  is  not  inlre<pieiit.  A  majority  of  instances  of  spsiftie 
pani"ly.-is  of  jidults  not  the  result  of  slow  compression  of  tli.'  lonl  are  asso- 
ciated with  svphilirt  and  belong,'  to  this  ^roup. 

KrI.  ihoii'jht  the  lesion  to  he  a  special  form  of  transverse  myelitis,  hut 
I.erhaps  it  should  bc  classed  with  the  system  diseases,  under  the  iiiime  toxic 
spastic  .-iiinal  paralysis. 

,'').  ScroNii.vitY  Si'Asric  P.\i!.\i,vsis. 

l-'ollowin;:  any  lesion  of  the  pyramidal  tract  we  may  have  spastic  paraly- 
sis- thus,  in'^i  transverse  lesion  of  the  cord,  whether  the  result  ol'  slow  com- 
pression (as  in  caries),  (hronic  myelitis,  the  pressure  of  tumor,  chronic 
meninfro-mvclitis.  or  miiltiide  sclerosis,  defeneration  takes  place  in  the 
pvraniMal  tVacts.  below  the  point  of  <lisease.  The  lejis  soon  l.eeoiiie  stilt"  and 
riVi>l,  and  the  rctlexes  increase.  I'.astian  has  shown  that  in  compression  jiara- 
ph-'ia  if  the  transverse  lesion  is  complete,  the  liml)s  may  l>e  llacci.l.  without 
iiicrciise  in  (he  rellexes— /Hfn//<%»>  /'".x'/'"'  '>f  ""'  •■''■<■>"''•  ''''"'  *''>"ilition 
,,f  the  patient  in  these  secomlary  forms  varies  very  much.  In  chronii'  mye- 
litis or  ill  multiple  sclerosis  he  may  be  able  to  walk  ahmit,  hut  with  a  char- 
acteristic spastic  .-.'ait.  in  the  c(.iu"prcssion  myelitis,  in  fracture,  or  in  caries, 
there  mav  lie  complete  loss  of  power  with  rifiidity. 

It  may  he  dillicult  or  even  impossihle  to  distinj:uisli  these  eases  from 
those  of  primarv  sjiastic  j.aralysis.  Iti'liancc  is  to  he  jilaced  upon  the  asso- 
ciated symptoms;  when  those  are  absent  no  definite  diagnosis  as  to  the  cause 
of  the  spastic  paralysis  can  be  given. 

().    llYSTI-Rir.VT-    Sl'ASTIC    rAUAfl.lXilA. 

There  is  no  s]iinal-cord  disease  which  may  be  so  accurately  mimicked  as 
spastic  iiaraplegia.  In  the  hysterical  form  there  is  wasting,  the  sensory 
symptoms  are  not  marked,  (he  loss  of  power  is  not  complete,  and  there  is  not 
("hat  extensor  spasm  so  characterisdc  of  organic  disease.  The  reflexes  are, 
as  a  rule,  increased.  The  knee-jerk  is  |)resent.  and  there  may  be  a  well- 
developed  ankle  clonus,  (lowers  calls  a((entioii  to  the  fact  tliat  it  is  usually 
a  simrious  chmus.  "  due  to  a  half-voluntary  contractiim  in  the  calf  muscles." 
A  true  clonus  does  occur,  however,  and  there  may  be  the  greatest  difficulty 
in  determining  whether  or  not  the  case  is  one  of  hysterical  paraplegia.  The 
hysterical  contracture  will  he  considered  later. 

C.    SYSTEM  DISEASES  OF  TIIE  LOWER  MOTOR  SEGMENT. 

1.  Chronic  Antkuior  rt)Lio-MYi:LiTis 

{Prngresxive  Muacnlar  Atrophij—Arnn-Dnchenne). 

This  disease  has  been  considered  as  one  of  the  types  making  up  the 

pro-'ressive  (central)  muscular  atrophies.     In  certain  rare  cases  the  process 

is  c'onfmed  to  the  lower  motor  sogmeuts.     They,  however,  diil'er  so  little 


m^ 


<.t4-2 


Dl 


SKASKS  01-'  TllK  NKUVOl-S  SYSTliM. 


(■imii'iii 


Iv  fnrn,  ,nanv  of  tl.o  .nsrs  in   wl.i.h  tl...  pvra.ui.l.l   (nuts  avv  ^u- 
'H,.  s.M..'  .nay  l.e  said  of  chrouir  l.iill>ar  panilvsi. 

',>.    Ol'Ill'll  M.MOI'l.KdlA. 


II 

t'ul 

mult-'ar  ili^nii-t-' 


?i.  AcfTi:  Antkimou  Poi.io-myki.iti^ 

1     1    i;.,v..,l  In  lie  (hie  to  an  iiciilf  intlaniitiatioii 

,  :i:'tf':r;::':.ri '".';:!';:  ;!..;:^n: ;:;: M-n.. .., .<  u. 

,,,,,„„,   ,,,,,..,...11..,,  «...    -^^^^^ 

,';..i,ina  c-a,...  ..I  .1...  '""■'"","";■,,„■;,,.  I    ...      1,      n„l  1 «  '■^M> I- 

,,,,.!  ™".fo?m,..;i»u.,,d.,.i,...,i  ..y  ivv..,.,  I....  ...■  i...»-' ...  "■•■'-  -.-■'- 

Btiology— 'Hio  ta.iK.    .t  tlu   ."■.•'  ,„.  ,„„v,.,...v,.,.li..,i.    Siiu-.. 

ot  paralys.^^totlu  (anu,  m  ,  ,(i,„,,  .„„i  jn  porhaps  a  majority  ..I 

,,„,,„  is  XU.  '';--V;^    ;;^;^,^     •    '    ,1  health.     As  SinkhT  ha.  pointed 
tlie  I'ascs  the  ehihl  ih  attatkul  wnue  montiis.     T-oys  are  more 

out.  the  ••ases  arc  more  common  ^"  \!;™  J^^'  ^,f  <,„,  „;.,„,.re,ue  of 

H,l,,o  to  he  alVeetea  than  ?'^';- ^^^  ^  ^   ^  ^   :^  ^  ^  ^,,,nhe.].     Me.lin  re- 
,,„,,rous  eases  together  m  "rf '7^'  ^/TJ  ^.^^  \i,,  oth  of  August  to  the 

r^f  f-^  r;;;;:^  :;\:.:': :: ;  r ^:'->;^"-  m  t..  instances  t.o 
sn.;;:."!; tho::n;;*9.y .^-e -r^-i-i;;;- i::.:::?.  the  vicinity 

The  most  remarkahle  epulenuc  ,>  <1^,^,   ^    '\3,  (^^,,v  York  Med- 
S^sllmmionso]?  85  .ere  under  .X  years  of  a,o;  18  d.d. 


DISHASKS  (iK  TIIK   KFI'KKl'.NT  oU   MoToll  TUACT. 


\m 


•iictH  lire   111- 


Ilic  iiucU'i  ol" 
III'  llu'  liiwir 
iciihir  imlsiis 
vv  mil  duL'  to 


inllimmaliim 

iUlinll    of   till' 

y  lici'ii  flii^^i''! 
I'i'Viitiiiiis  iiiili- 
tlic  hlood  siip- 
iiiiy  iict  as  tlu! 
slidulil  always 
iccn  cxiilaiiit'il. 
(1  not  a  system 

111,  and  I'lir  llii^ 
I  ho  s[)iiial  cord, 

ivitliiii  till'  tirst 
rrtaiii  luusclcs, 

H    has   lurii   at- 
•xcrtioii.     Siiuo 
rihiitc  this  i'onu 
I'll  fall,  Init  very 
)s  a  majority  of 
kU'r  has  pointed 
r.oys  are  more 
e  occurrence  of 
[1)0.1.     ^Icdin  rc- 
)f  Aii.mist  to  the 
Yo  instances  two 

•s. 

1  in  the  vicinity 
(New  Y<irk  :Med- 
oecurred  during 
ic'd. 


Altluiii;ili  mo-t  rrci|U(iil  in  ihildrcii.  it  dr\cl.i|is  occa>ionalIy  in  yoiin;; 
iidnlts,  or  even  in  niiddlc-a;;i'd  person."*. 

Morbid  Anatomy.— 'I'lie  disiase  is  ot'tcnest  seen  in  either  the  cer- 
vical or  liinihiir  eiilar.uemcnts.  In  very  early  ease-,  mu  h  as  lln'.-e  de- 
seril)ed  hv  l»avid  Druininond  and  (  liarlewood  'I'lirner.  the  hsion  has  heeii 
that  (.!'  an  acute  lueiiiorrha-ic  myelitis  with  de^'eiieration  and  rapid  ilc- 
>triictinii  (d'  the  lar^M'  ;:aii^lion  ceils.  'I'he  condilion  may  he  strictly  mii- 
llned  to  the  ventral  eorniia;  in  >ome  iii>lan.cs  there  is  slijrht  menill^'eal 
involvement.  The  in\esti-atio!is  of  ( loldMlicider,  Sieinerlinjr,  and  others 
have  demon>trated  the  arterial  ori-in  of  the  (Hmmm',  which  is  locali/ed 
in  the  parts  supplied  hy  the  vei  ,ral  median  hraiieh  of  the  ventral  spinal 
arterv.  Occasioiiallv  tlie  chaii^'es  are  fouiMl  in  the  ri';:ion  <d'  di.-trihutioii 
of  tile  ventral  ra<lic"nlar  arteries.  Marie  thim..  that  the  initial  process  is 
cmholism  or  thromhosis  u(  the  arteries  (d'  t'-  ventral  horns,  the  rcMilt 
(d'  an  acute  infection.  In  cases  in  which  the  examination  is  not  made 
for  some  months  or  years  tlie  chan^^es  are  very  eharactcristic.  The  ven- 
tral cornn  in  the  nllVcted  rej;ion  is  ^'reatly  ntropliied  and  the  lar-e  motor 
cells  are  either  entirely  ab;-ent  or  only  a  few  remain.  The  alVecttil  half  (d' 
the  cord  may  he  eonsideraldy  smaller  than  tlii'  other.  The  veiilro-lateral 
(■(diimn  may"  show  sli^dit  sclerotic  chanires,  chielly  in  the  pyrami.lal  trait. 
The  correspomliii^r  ventral  nerve  roots  are  atrophied,  and  the  miiM-les  aie 
wasted  and  gradually  iinder;j,-o  a  fatty  and  sclerotic  clian<:e. 

Symptoms.— in  a  majority  id'  the  eases,  after  sli;:ht  inilisjiosition 
and  feverishness,  the  child  is  noticed  to  have  lost  the  ii-e  of  one  limh. 
Convnlsions  at  the  outset  are  rare,  not  constant  as  in  the  acute  cerebral 
palsies  of  children.  Fever  is  usually  present,  the  temperature  risiii).'  to 
l(»r,  soiiu'timcs  to  l(t:i°.  I'ain  is  often  complained  of  in  the  early  sta<:es. 
This  may  he  localized  in  the  hack  or  hetwcen  the  shoulders;  any  pressure 
nn  the  jijiralyzed  linihs  may  he  painful,  causin^f  the  jiatient  to  cry  out  when 
he  is  moved  in  bed.  The  paralysis  is  abrupt  in  its  onset  and,  as  a  rule, 
is  not  proifressive,  but  reaches  its  maxiuium  in  a  very  short  time,  even 
within  twenty-four  hours.  It  is  rarely  j:enerali/,ed.  The  suddenness  of 
onset  is  remarkable  and  su^'-;ests  a  primary  atl'ection  of  the  blood-vessels, 
a  view  which  the  luviiiorrha-iie  character  id'  the  early  lesion  supports.  The 
distribution  of  the  paralysis  is  very  variable.  Its  irrc;.Milarity  and  lack  of 
gymmetry  is  (piite  characteristic  id'  the  disease.  One  or  both  arms  may  be 
a'll'ected/onc  arm  and  one  leg,  or  both  legs;  or  it  may  bo  a  crossed  paralysis, 
the  right  leg  and  the  left  arm.  In  the  ujiper  extremities  the  paralysis  is 
rar"ly  complete  and  groups  of  muscles  may  be  alfeeted.  As  Uemak  has 
pointed  out,  tiu're  is  an  u])iier-arm  and  a  lower-arm  type  of  palsy.  The  del- 
toid, tlie  biceps,  brachialis  anticus,  and  supinator  longus  may  bo  allVctcd 
in  the  former,  and  in  the  latter  the  extensors  or  ilexors  of  the  fingers  and 
wrists.  This  distribution  is  due  to  the  fact  that  muscles  acting  functionally 
together  are  reiirosonted  near  each  other  in  the  spinal  cord. 

In  the  legs  the  tibialis  anticus  and  extensor  groups  of  muscles  are  more 
affected  than  the  hamstrings  and  glutei.  The  nuis(des  (d'  the  face  are 
very  rarely,  the  sphincters  hardly  ever  involved.  While  the  rule  is  for 
the  paralysis  to  be  abrujit  ai.d  sudden,  there  are  cases  in  which  it  comes 


DISEASES  OP  THE  NEIIVOUS  SYSTEM. 


11 


1 1 
I  f 


i  <•  •>  ,1.,,-  fill-  i1<  (l(Vt'li)|'ili^''lt.  At  liVbt 
o„  slowly  ana  tak.s  from  thrco  to  ''-\'l''  ^  ^'  ^^,  '  ,^',,,,,,  two  and  ihrc. 
the  air.'tcd  Ihnb  looks  natural,  "';;  -;^  ^'^l^  ^  ^otne  time;  but  the 
„.e  usually  fat  very  l;t  '-  Ij'^  ,'  .^^l^lu^ia  and  feels  softaud 
afop!>y  I'-eeeds  raiudl  ,  "^  '^  ";  ^,,^,  ,.„,,,  ,,,,1,  the  reaetion  of  de- 
n„,hy.  Usually  -;-l>: -r  J  ;^t;  .l.d  to  have  lost  their  irritahihty. 
goneration  is  present.      Hu.  mnes  a  ,.onstant  cur- 

^ri.o  museles  do  not  react  to  tl>e  ''><'  "^^  ^^^  ^Jj  ,  ,.,  ,  ,,,aker  current 
rent  they  respond  by  a  sluj;..sh  -"^^^^  ;.^;;^\„  ,  time,  a.ul  then 
t,,„  .s  .u,rn.al  The  para,-  ^  iX^;'^^^  i  rare,  and,  when  the 
t,,,,.e  is  gradual  unprovenu-nt  ^^^'^^^l^^^  ^^;^,,  ,,j,eeted.  The  large 
'>-'*-"•'"'  "'""^""  ''  "'"''1^  llorm;^      .U^i>   e>n.ited,  eannot  be  re- 

,,ses.     There  .s  a     aeeul,  ^'f      1     •^^•^;\,^,  ,tate   of  the   museles,   the 
set   in   abruptly.     The   rapul   wa^tu.-,     '^*^     >^^  distin.n.ish   it   from  the 
eleetrhal   r..aetions,  ^-^  l}\^^''^.^' .'^^'£^^^ln   ehildhood,   the 
eerehral   pal.es.     In   '»»l^'l'  J  .-;^^,^:^;     h    nmseles  at  the  periphery  of 
paralysis  is  bilaterally  ^y"''f  ^^  f  .f^^:  '.^  '  toms.     The  psendo-paresis 
Ihe  lin,bs,  and  is  eontbined  "^^'^^f^'^^^M     U  this  the  loss  of 
of  riekets  is  a  condttton  to  be  -    ^  "  ^^  ;^^^;  ;';„t,  ,ertain  ntovements  are 
power  is  in  the  legs,  rapul  a  ro.        ;  -^    ^      \,^  ^he  skin,  the  eharac- 
possible  bt>t  painful      'he  ^^"    f       ^^  ^,;      ,,,„ts  are  present.     Disease 
leristie  ehang.-s  in  the  Ihuk-s   an      ^  ^    ^.^^^  ^^^,^^,,^  ,ith  eare  be 

of  the  hip  or  knee  nuiy  produee  a  p>.  u.lo  pan.iN 

readily  distinguished.  eomiilete  recovery  is  bad. 

PrognOSiS.-The  outh^ok  n.  '^''>     ;'r^,;,     i;;"la;  the  sudden  onset. 

The  natural  eourse  of  the  disease  >;-;;^  ^  ^^^^   ^na  v    eriod,  then  marked 

the  rapid  but  not  progressive  loss  "t  1  o  ^^i   a  sAatu    a  ^^^^^^  ^^^^^^^^_ 

i,,provement  in  eertain  ]-^^^^ ^'^^^^^  ,.  whieii  the  physieian 
tures  and  deformities.  1 1-^''^  ^  "«  "  ^  th  friends  should  be  told  at  the 
is  so  often  subjeet  to  unjust  "•^*'"^"^.' '"'^J  [^.     '     ,,piete  recovery  should 


I  , 


1)Isi:asi:s  of  the  efferent  or  motor  tract. 


04r. 


;\t.      At  livst 
0  and  tlu'iL' 
me;  but  the 
jols  sul't  anil 
letiun  of  de- 
r  irritn])ility. 
L'onstau':  cur- 
■aktT  current 
no,  and  then 
:ul.  when  the 
I.     The  hxrgo 
i-annot  he  re- 
id  permanent 
;  th(,'  skin  re- 
ji'les  are  usu- 

^rowth  of  the 
rded,  aiul  the 
)id  is  all'ected, 
h  the  glenoid 
udiieed  by  the 

le  majority  of 
inbs  whieh  luis 
i"  museles,  the 
ih  it  from  the 
chiUlhood,  the 
lie  periphery  of 

pseudo-paresis 
this  the  hiss  of 

movements  are 
<in,  tlie  eliarac- 
resent.  Disease 
■an  witli  eare  be 

recovery  is  had. 
he  sudden  onset, 
lod,  then  marked 
ly  cases  contrac- 
;-h  the  pliysician 
dd  be  told  at  the 
■  recovery  should 
toration  of  power 
ule  of  permanent 

lysis  has  a  bright 
t'ry  cannot  be  ex- 
mprovement  may 


jinally  tako  i-hic.'  in  a  liml)  which  is  at  iirst  completely  llac.'id  aiul  lirlpjoss. 
The  following  treatment  mav  be  pursued:  If  seen  in  the  fehrde  stage,  a 
l,risk  laxative  and  a  fever  mixture  may  be  given.  The  clnld  should  lie  ni 
bed  and  the  allVcted  limb  or  lind)s  wrapi^ed  in  cottuu.  As  m  the  great 
luajority  of  cases  the  damatre  is  already  done  when  the  physician  is  called 
and  the  disease  makes  no  further  progress,  the  aiiplication  of  blisters  an.l 
nther  forms  of  counter-irritation  U>  the  back  is  irratioiuil  ami  only  cruel  to 

"  The' general  nutiMtion  should  be  carefully  maintained  by  feeding  the 
child  wdK  and  takimr  it  out  of  door,,  every  day.  As  soon  as  the  clnld  can 
bear  friction  the  atlVcted  part  should  be  carefully  rubbed;  at  lirst  once  a 
dav  subsequently  morning  and  evening.  Any  intelligent  mother  can  be 
tau'dit  svstematicallv  to  rub.  knea.l.  and  pinch  tlie  muscles,  using  either 
thelmre  hand  or,  bet"ter  still,  sweet  oil  or  cod-liver  oil.  This  is  worth  all  the 
(,thcr  measures  advised  in  the  disease,  and  shoul.l  be  systematically  prac- 
ticed for  months,  or  even,  if  necessary,  a  year  or  more.  Klectricily  has  a 
uuich  more  limited  use,  and  cannot  l)e  compared  with  massage  m  main- 
taining the  nutrition  of  the  muscles.  The  faradic  current  shoul.l  be  applied 
to  th(we  muscles  which  re^p.md.  The  essence  of  the  treatment  is  in  mam- 
tainin--  the  nutrition  of  the  muscles,  so  that  in  the  gradual  improvement 
which^akes  place  in  J.arts,  at  least,  of  the  alVected  segments  ot  the  con 
the  motor  impulses  may  have  to  deal  with  well-nourished,  not  atroiihicd 

muscle  fibres. 

Of  medicines,  in  the  carlv  stage  ergot  and  belladonna  have  been  warmly 
recommended,  but  it  is  un'likely  that  they  have  the  slightest  inthien.-,'. 
J.atef  in  the  di<ease  strvchnia  may  be  used  with  advantage  in  one  or  two 
m'inim  doses  of  the  liipior  strychnia',  which,  if  it  has  no  other  etVect,  is  a 

useful  tonic.  •         ,. 

The  most  distressing  cases  are  those  whuh  come  under  the  notu-e  ot 

the  physician  six,  eight,  or  twelve  numths  after  the  onset  (d'  the  par.ilysis, 

when  one  leg  or  one  arm  or  both  legs  are  llaccid  and   have  littl •  no 

uioti(m.  Can  nothing  be  d(me?  A  careful  electrical  test  sluuild  b.'  made 
to  ascertain  which  muscles  respond.  This  may  not  be  api'arent  at  lirst, 
and  several  applications  nuiy  be  necessary  before  any  contractility  is  no- 
ticed. With  a  few  lessons  an  intelligent  mother  can  be  taught  to  use  the 
electricitv  as  well  as  to  apjdy  the  mas.<age.  If  in  a  case  in  which  the  jiaraly- 
sis  has  lasted  for  six  or  eight  numths  no  observable  imi>roveinent  takes  place 
in  the  next  six  months  with  thorough  and  systematic  treatment,  little  or  no 
hojie  can  be  entertaiiu'd  of  further  chaiuic. 

In  the  later  stage  care  should  be  taken  to  lucvent  the  defornuties  re- 
sulting from  the  c(udracti.ms.  tireat  benelit  results  from  a  carefully  aj)- 
])lied  api^aratus.  The  temhm  transplantation  introduced  by  (loldthwaite 
seems  to  be  a  distimt  advantage  in  many  cases.  Kuleid)erg  has  recently 
reported  a  case  (ISitS)  in  which  the  jms  e(|uinus  was  marked:  he  was  able 
to  afford  notable  relief  bv  t.Midon  implantation.  Half  of  the  tendo- 
Achilles  and  a  imrt  of  the  tend.m  of  the  soleiw  were  imidanted  upon  the 
tendous  (d'  the  ver.meus  hmgus  et  ))revis.  the  remaining  half  of  the  tendo- 
Achilles  being  divided.     The  transference  of  the  functions  from  the  ile.xors 


DISEASES  OF  THE  NEUVOUS  SYSTEM. 


!1, , .,...».  ..H^'-«i'^  - "*■'• ' """ """  ""■ 

jirisingly  benelifial. 

4.  AcTTK  ANO  SruAcTTK  Pouo-MV KMTis  IN  A..r,;rs. 

,.,.     •        ,„i,.    ilu.  i.vact  nuuitiTi.art  of  Iho  ilisoiiso 

An  ,uuU.  ,nUo.,ny.ht.s  "-'^       ;..         ,::,„„,  .,  tho  ea..  ae.-v.hM 

in  .hil.ln.n,  is  mu^n./.a.     A      •         ^  ,^^^^  ^,^^.  .u.MoMno.s  ul 

onset,  tlu.  rapul  --''■•^-  ^  ^n  h  J  f-tures.  Multiple  neuritis  n.ay, 
t,,„n..ht  l.y  some  o  be  .\'^  ''  ^^  ;  '  "  ,,,  ,,,t  wasting  and  the  reaetion 
,,„,,.,,,.  s..t  in  with  rapulxy    t  u.       naj     c    ,^^^^  ^^^^^^^^^^  ^^^^^_^^,  ^^^^^^^.  ,,,,,^,,,. 

.,  ,urenerati..n  i-'"-'^!;;;;;;  "^  , ',  ,a«e  of  extensive  multiple  paralys.s 
,„i„,  the  true  ""t"'^'-.,/^^'  '\',  ,\.    ,,  ...u,,  ]oss  of  power  in  eerta.n  ^ii'oups 

!:r:;-;:l;r' •^;:;:::;"  -;^:^  "^^^'  '--'^-  »•*  ^"- ' " 

5    \crTK  AscKNPiN.i  (LanduVs)  Pauaiasi.. 
extending  to  the  trunk  a.u        -^  ^  /      na;kahle  similarity  in  its  syn>p- 

'-^t^is^  and  Pathology  --;rhis.       ;;-=■:;".;;- 

n.ales  ^^■twec.n  the  tw.U.eth  and  c^  ^>      ^^  ^^^  ^^^^^  ^^^^^^^^^ 

l.^ved  the  speedie  fovei..  '^'  ''  ;  ij,,,;\vho  coneludes  that  m  efol- 
,U,  literature  has  been  "'^f  .M;^!;  ^^  •  J^^forms  to  a  peripheral  neu- 
,.v,  syu>pton>s,  eourse    and    ^  ^^';;^^  ^^  ^^  ^.^,^,,  eouelusion.     In  the>r 

ritis.  Nouwerk  and  >>;'  :^'\J  '^^  ,^  ^f  ;  ,,,  „,,ve  roots,  but  the  peripheral 
,,,eaninterstit>alueurd.s.a.  mt  ^^^^^^^   ^^^^^   aestruetne 

,,,ves  were  norn.al  N"  ;  J^"  ^  ",-  espo  ulin,  alterations  in  the  eell 
ehanges  in  the  1h-1  h-    "-  J^^         ^ '^^^  ^,,^'^,,i,  ,,,nt  acts  on  the 

bodies  of  the  ventral  1""  ;  \;;f  j^j  ,,  ,,,ii,lv  the  reason  why  no  lesu)ns 
,,,er  motor  -'"•-'- l^";  J  ;^t';"tbtl.i  tuore'delieate  hist.dogieal  meth- 
,ere  found  .n  some  ^i}^^^:^^XX.  disease,  then,  as  an  acute  po.son.ng 
oils  were  nut  us"l.     ">  "'■'■'      " 

„t  <!«■  l.nvor  mcKT  ''';'"■';'"';;      ,    ,     ,,„„  g„„l„,,llv  propBrinf.'.  utton  iv.lU 
Symptoms.-\Wn^iK     ut         1>.     .        „^.  „„„,  ,,i,|,i„  „  low    .ou« 

,|„.  ,M,„l.vsi,  ,.[  the  le;.-s  I'"'''™''     :''';';'  ;.o„li,«  h,  .....re  ac.te  oases,  t  je 
„«,  „,re.....,l,  «...l  . ,.  m,  »-;;>-,,:  „„  „«t  „Haeke,l,  an,l  lh,nl  y 

:i:;;;;:.K!:';;re:Ji;io"!^si"«*"'  "-^ ""™'"""-  '"'^ """" 


d 


COMUIXKD  SYSTEM   DISKASRS. 


'.'4; 


ts  wero  sur- 


rs. 

L'  tho  diseaso 
■m  detii-vilK'il 
iddi'iinot^ri  ut' 
'iu"'iitiun   are 
louritiri  may, 
tho  rcat'titiii 
u'  may  (U'tir- 
i|il('  paralysis 
iTtaiu  groups 
i^ldw,  may  Ijo 

'i'liir  )<iihniijuc 
raly^^is  usually 
s  arc  iuvulvoil, 


0  It'LT^,  raiiiiUy 
,  invulving  the 
y  ill  its  syiiip- 
j\v  >rroiii)od  Ijy 

t  cdinmoiily  iu 
soiiu'timos  I'ol- 
tulU'iU'd  from 
.■s  that  ill  etitil- 
poiipheral  lU'U- 
isidii.     In  tlu'ir 
it  the  ])orii)horal 
caso   destriu'tivo 
tions  in  tlie  cell 
jront  acts  on  the 
)ii  why  no  lesions 
listologieal  meth- 

1  acute  poisoning 

>ssing.  often  with 
ithin  a  few  hours 

of  the  trunk  arc 
e  acute  cases,  the 
iclvcd,  and  iinally 

The  reilexes  are 


lost,  hut  tlu'  muscles  neither  \va.>le  imr  shdW  ek'ctrical  changes.  The  seii- 
sury  syiiilitoms  are  variable;  in  sunu'  cases  tingling,  miinhiicss,  and  hypcr- 
U'sthcsia  have  l)een  present.  In  the  more  characteristic  ca-^es  sensation  is 
intact  and  the  sphincters  are  uninvolvcd.  Knlargemeiit  of  the  >pleen  has 
been  noticed  in  several  cases.  The  course  of  the  disease  is  varialih'.  it 
may  provi'  fatal  in  less  than  two  days.  Other  cases  persist  for  a  week  nr 
I'or  two  weeks,  in  some  instances  rec(i\('ry  h.is  occurred,  lail  in  a  largt'  piu- 
jiortion  of  the  cases  tjie  disease  is  fatal. 

'i"he  iliaijiKisis  is  dillicult.  particularly  fi'oiii  certain  i'ni'nis  df  multiple 
neuritis,  and  if  we  include  in  Landry's  pai'aly>i~  the  cases  in  which  scn>.i- 
tion  is  involved,  di^liiulioii  hetucen  the  two  alfections  is  impossii)le.  We 
a]ipari'ntly  have  to  rccogni/.e  the  existence  of  a  rapidly  advancing  mntor 
paralysis  without  involvement  of  the  s|)hincters,  without  wasting  or  elec- 
trical changes  in  tlu'  muscles,  without  tro|)hic  h'sioiis,  and  without  fever — 
features  sullieient  to  distinguish  it  from  cither  the  acute  ci'Utial  myelitis 
or  the  polio-niyeliti>  anterior.  It  is  douhtfuK  however,  whether  these 
charactc'rs  always  siiHi(e  to  enable  us  to  dill'ereiitiate  the  ca.ses  of  multiple 
neuritis. 

(!.  AsriiDNic  ({{n.iiAit*   ''auai.ysis 
(Myasthenia  grdvin  pscudo-iutrahitira  ;  J:  Mflainn  Si/iiipt<iin-ciiiiiph'.i), 

During  the  last  few  years  much  attention  has  hcen  given  tn  this  re- 
markable at1\'ction,  of  which  a  niimher  of  cases  have  bei'ii  reported.  The 
chief  characteristics  are  the  i'a]iidity  with  which  the  muscles  become  ex- 
hausteil,  the  great  variability  of  the  symptoms  from  day  to  day.  the  occur- 
rence of  remissions  and  relapses,  the  sudden  attacks  of  ]iaralvsis  of  re.-pira- 
tion  and  deglutition,  and  the  absence  of  muscular  atrophy,  the  reaction  of 
degeneration  and  sensory  synii)tonis.  The  onset  is  usually  acute  or  subacute, 
chielly  in  young  ])ersons.  The  external  eye  muscles,  the  muscles  of  mastica- 
tion, the  facial  muscles,  the  muscles  of  deglutition,  and  certain  sjiinal  mus- 
cles may  he  (jiiickly  involved.  Any  repeated  efforts  with  the  aifected  muscles 
causes  them  to  become  com])letelv  exhausted  and  paralyzed  for  the  time 
being.  They  recover  their  })ower  after  a  rest.  In  certain  cases  there  is  a 
true  jiarcsis,  which  i)ersists.  After  repeated  stimulation  by  electricity  the 
muscles  may  hecome  exhausted  and  cease  to  res])oml  (myasthenic  reaction, 
(Jolly).  The  alTection  may  ])rove  fatal,  and  as  no  well-defined  anatomical 
lesions  have  heen  discovered,  a  dynamic  change  in  the  lower  motor  neurones 
lias  heen  assumed  to  exphiin  the  condition. 


IV.   COMBINED   SYSTEM    DISEASES. 

When  tlie  disease  is  not  confined  within  the  limits  of  either  the  afTereut 
or  ciTerent  systems,  but  affects  both,  it  is  known  as  a  roinJiiiii'd  si/slcni  di^rast'. 
Some  authors  contend  that  the  diseases  usually  classed  under  this  head  are 
not  really  system  diseases,  but  are  diffuse  jirocesscs.  This  is  the  view  taken 
by  Loyden  and  Goldscheider,  who  limit  the  term  system  disease  to  loco- 
motor ataxia  and  progressive  muscular  atrophy. 


DISEVSES  OF  THE  NERVOUS  SYSTEM. 
,„„l  „r  til.-  vnli„l  l.mn,.     '""'-',,      ,    .,„!  ,„|,„„„.     llurins  l''''  H"''"' 

"■'■ '''7;''!:::;;:;:: ;,.  1    n;™lVr»i.u.  sy,,,,-........  «.«i  »i.on  s,,..,  .i.. 

;;;:>,;;i:':r  ir'M.,.o^j-,;:t';;,;!itr'; .^  „.. .,.  .,..,.- 

;ri:i:;'n>';:":;.»r;i::''u™ui'-'V".-"' '  ^j--  "■---  '^  "*"""• 

limiteil. 

i.  nut  .no.  nuu-kod  in  tl^  -;;  -  -^^  j^^.^l^^t  ot  the  lateral  eol- 
tho  nx.t  .one  oi  tl>e  -"-^^  ^  '  ;  tlu'  ;vnuni.Ial  traets,  and  then,  may 
-uns  i.  aitVuse,  not  f -»\;.^  ^'  ^^^^^  u>at  in  n>any  ease,  the  di^r.bntion 
iK.  an  annular  s.lero>,>     f''^!''''  ,    ,„,|  „,.t  to  a  true  systemic  .1e- 

of  the  selerosis  .s  ''-.^i;    ;;,  i^^,      S,...  of  the  dorsal  spinal  arh.ry. 

generation,  the  vessels  ">  "l;  "  -^,,        ^jj^^t  eomplains  of  a  tired  feel- 

^     The  ,,jwptoms  are  ^vell  detined.     it  pat  ,„„j,toms  of  true 

i,,  in  tlie  le,s.  not  often  of  -;  ^^  ^  "j,/!^^  ":,,aualiy  develops  with 
tabes  are  absent  An  ^^^  ZX^^'n..E  from  the  outset,  and 
proK^ressive  weakness.      1  ht   r  i  ^^^  ^^^^  ^       ^j^^^.^^,  ^ 

Ihoa.  n.av  h.  -ell-developed  ai^eclou  ^  ;^  ^^^,^^  ,,,,,  ^f  lateral 
on,  but  It  is  rarely  so  "f  .'l^^'^l.;  .  "  ^  j,  ,  ^viu-eharaeterizod  feature, 
sclerosis.  Imoiu  the  -^'^[/"^'""""fVor  swaying  when  the  eyes  are 
and  the  dinieulty  of  waU.nig  -  ^  ^^  ^  ^^^^.L'o  attraet  attention, 
closed  may,  as  in  true  ^^I'^'n  ^"^  t';^  ^^  ■  \^^.^^^  jj^.a  on  the  ground 
In  walking  the  patient  use^  a  ^  '  '^'  '^\\ .  j  ^.^^^.^i,,,  ^nd  sudden  descent 
t,c  legs  far  apart,  but  the  shunpi   g  ^-  ;  ^  ^  ^^  ,,tend  to  the  arms, 

of  the  feet,  is  not  olten  seen.  '-  «  ^.^,„^  ^,,^,,,,,,,  to  a  dull  aching 
Sensory  symptoms  are  -^^^^^  ,Xvs  usually  become  involve.  .  Lyo 
P--  in  the  sacral  regjon  ^^^  l'^  ^  ^^  nientaf  symptoms  may  develop, 
<vmptoms  are  rare.     J^ate  m  uic 

snnilar  to  those  of  genera    V^^!^"^-  ,p,,^,  ...mbination  of  marked 

In  well-marked  cases  the  ,l,a!,n^^  ^^  ^-  ^^  ^^^^  ,j„,„,  are 

cliaracten>tic  h.uiiii.b. 
an  important  point. 


i  ] 


i  I 
l.f 

II 


'4 


COMHINKD  SYSTKM   PISKASES. 


049 


irly  tyiiical 
cUiro  eui'iv- 

a  tiio  otlKT 
ig  life  these 
lied,  iiiiiy  IT 
leii  sueh  ilo 

^;t  I  he  symp- 
systeins,  and 
ije  is  UJVUiUy 


clinically  by 
licuUy  by  in- 

Mtsure  to  colli 
a<r  ciiutrast  to 

iliunns,  which 
V  localized  in 
;'he  lateral  eol- 
iUid  there  may 
ho  distribution 
10  systemic  de- 
1  sjiinal  artery, 
of  a  tired  feel- 
uptoms  of  true 

develops  with 
ho  outset,  and 
>gs  slowly  comes 
cases  of  lateral 
•terized  feature, 
en  the  eyes  arc 
ttraet  attention. 

on  the  ground, 
I  sudden  descent 
end  to  the  arms. 
0  a  dull,  aching 
L'  involved.  Kye 
:ns  may  develop, 

nation  of  marked 
)r  less  spasm  are 
jory  symptoms  is 


2.  riUMAUY  ('()MiiiNi:n  Sei.r.itdsis  (Pitnam)- 

Tn  addition  to  the  ataxic  i.araj.legia  just  nientioucd.  here  may  be  con- 
sidered certain  cases  whicli  arc  characterized  anatomically  liy  a  relatively 
.lironic  sclerosis  of  the  dorsal  columns,  of  the  laUral  columns,  cliielly 
the  ].yrnmi(lal  trad,  and  also  of  tlie  ccrcl^cllar  tra.t.  Willi  tli.-e  are 
iKually  associated  more  acute  changes  in  adjoining  areas,  either  .litliis.'  m- 
sv^ti'inic,  some  grade  of  degeneration  in  the  gray  matter,  and  mv(dve- 
liient  .d'  the  nerve~roots.  This  form  has  been  stu.ii.'d  liy  .1.  .1.  I'nt- 
nam  and  Dana.  The  cases  are  usually  in  women—;  out  .d  li'  collc.ted 
bv  Dana;  the  ages,  fnuu  forty-five  to  sixty-four.  The  di-case  runs 
a^•ather  raj.id  course.  Neuropathic  inheritance  is  picseut  m  some  in- 
stances.    I'utnam  thinks  that  possibly  both   lead  and  arsenic  play  a  part 

in  the  etiology. 

The  syiiiiilimis  are  both  sensory  and  motor,  llic  on.set  is  usually  witli 
numbness  in  the  extremities,  progressive  h.ss  of  >trcngtli.  and  emaciation, 
rarajdegia  graduailv  dcveloi)s.  before  which  there  have  luvii.  as  a  rule, 
spastic  sviiiptoms  with  exaggerated  knee-jerk.  'I'lie  arms  are  alfected  less 
than  the'legs.  Mental  symptoms  suggestive  (d'  denu'iitia  imralytua  may  de- 
velo]i  toward  the  close. 

Thi'  ilitoiiinsis  of  this  mixed  sclcnxis  rests  upon  the  combination  <1 
H-ns(U-v  and  motor  svini«toius  with  the  i)resence  of  exaggerated  rcllrxrs. 
As  stated,  the  sensory  features  consist  cliielly  of  para'stlicsia.  and  tlieiv 
niav  be  dillicultv  in  distinguishing  the  condition  from  multi|)le  neiintis. 
The  freqiu'iicy  .d'  the  disease  in  more  or  less  enfeebled  or  aiuemic  woim  u 
]iast  middle  life  is  also  an  important  feature. 

3.  IlKKKUiTAiiY  Ataxia  (Fricilirlclt's  Ahuia). 

In  18(il  rriedreich  rejiorted  (i  cases  of  a  form  of  luveditary  ataxia,  and 
the  atfoction  has  usuallv  gone  by  liis  name,  rufortuuately,  jKiraiinjocbnius 
mitltiph-x  is  also  called  Kriedreicirs  disease;  so  it  is  best,  if  his  name  is  used 
in  connection  with  this  airection,  to  term  it  l-'riedreicirs  ataxia.  Jl  is  a  very 
diU'erent  disease  in  many  resiiects  from  ordinary  talx'S.  It  may  or  may  not 
bo  heroditarv.  It  is  reallv  a  family  disease,  several  brothers  and  sisters 
being,  as  a  rule,  alfected.  'The  lb?  cases  analyzed  liy  (irillith  occurred  in 
71  unrelated  families.  In  his  series  inheritanci-  <d'  the  disease  itself  occiirn  d 
in  only  'M  cases.  Various  iiitluences  in  the  parents  have  been  noted;  ah'o- 
holisni  in  only  7  cases.  Svidiilis  has  rarely  been  present.  Of  the  1  IM  cases, 
.S(>  were  males  and  5T  females.  The  disease  sets  in  early  in  life,  and  in  (Int- 
lith's  series  IT)  occurred  before  the  age  of  two  years.  ;5!)  before  the  sixth 
year,  1.-)  between  the  sixth  and  tenth  years.  -H)  between  the  elevcntlwind 
iifteenth  years,  18  between  the  sixteenth  and  twcnti.lh  years,  and  n  be- 
tween the"  twentieth  and  twenty-iifth  years. 

The  tnorhiJ  nuohmni  shows  an  extensive  sclerosis  of  the  dorsal  and 
lateral  columns  of  the  s|'.inal  cord.  The  i.eriphery.  and  the  .■eivbellar  tracts 
are  usnallv  inv(dved.  The  ol)servations  of  Dejerine  and  Letulle  are  of  spe- 
cial interest,  since  thev  .seem  to  indicate  that  the  change  in  this  disease  is 


(T 


^\ 


■'i 


h 


PISKASES  OP  THE  NERVOUS  SYSTEM. 


950 

,,   ,,,„.o.liar   (.ctu,1..rn.nl)  .d.Tosi.,  .lilT.rin.  ..nliryly   fn.,n   the   onlin.ry 
u     n^      wi  .     A-...nlinK  to  tins  vi.w,  Kn...ln.i.-1,  s  .hsras.  is  a  j^hus,.  o 

""Sympt0ms.-'riu.  ataxia  dillVrs        ...wl,at    I'ro.n  th.  ordinary  fonn. 
,-i.  i^;^!^d,naf..n  l....ins  in  ,h.  l.,s.  .a.t  -  P^;;^^'- J^^^!  :^: 

'"'   "    ;       n  i  V    uluntavv  nx.vcnu.nt  tl.c  adion  is  ov.rd.mo,  tin- 

i:  ';:;;:;"  .;.::':..      1.  'nu.  lunm  rr.iu..n,ly  n.ovos  ai.out  an  ol.J.ot 

sH:;i;r^,;:::L..'=^ 

,  •       "  \  .trikin.^  feature  is  early  def..rnuty  of  the  feet       T  eio 

U,  in  tlu.  .1i«.a».'  ''"■"""■V"";""';,,,,  ,li|,l,„lt  «],.„  ..■v.'ml  iiK'nAcrs  ..f 

;-""»';■;';■,;!;  ,:: ,;;  ;;:';„;.  ;;;.,«„„.,  »,„',  .„„,„;„,  ,,>.,..i,  make 

;;::';  ;';:;::';r;;i ::";»;:;  :;;:Haru; 'r ....  -...any .... .,.«».  .0.  „«. .. 

taken  to  i.revent  eontractures.  i„„,„i;t.„.v  ataxia    described  1)V 


AFFECTIONS  OF  THE  MKNINT.HS. 


i".n 


1  nnliniiry 
1  <ili(>.-is  (if 
ion  is  still 

iiury  I'onii. 
It  is  swiiy- 
it  llio  cl'iir- 
.111  may  or 
111(1   is  very 
I  somewhat 
cnlonc,  tiie 
voTTXtendL'd 
lit  an  object 
•0  iriT<nilar, 
1  iuid  siioul- 
axia,  that  is 
rcct  or  whrii 
11(1  ami  Iniily 

oxos  an'  lost 
.•onstant  and 
ally  normal, 


cases,  2't  in  one  ramiiy.  ami  .1.  II.  NclVs.  i:i.  apiiear  \n  liiloiig  to  this  type. 
The  cei'elielliiiii  has  lii'fii  i'ouiid  aticphii'd  in  '.'  lax's. 

■1.  I'uocKK.-sivi:  Intkiistiti  \i.  II vrKuriioi'iiK    Ni:i  kitis  or  Im-ams. 

I'lidcr  this  iiii|iosinLr  title  Dcjerine  and  Sottiis  (Ic-iTiiied  a  rare  and  iiiter- 
cstiii.Lr  all'cctioii.  it  is  a  laiiiily  di>ease,  and  he;:iiis  in  early  life.  The  symp- 
toms are  those  ty|iical  (d'  loei)niotor  ataxia,  to  which  is  added  pi'o,ure>>i\e 
muscular  atrophy,  witli  involvement  (d'  the  face  and  a  hypertrojiliy  and 
liardeiiini:'  <>f  the  perii)heral  nerves.  As  the  name  indicates,  it  is  an  inter- 
stitial hypertrophic  neuritis  with  secondary  involvement  of  the  dorsal  lol- 
iiinns  (d'  liie  cord.  This  disease  has  hceii  associated  with  proizre^>ive  neural 
muM'ular  atrophy,  luit  Dejerine  has  shown  that  it  is  ([iiite  di-tiiict. 

O.    To.XIC    I'oMlUNi;!)    Sll.KIKlsiS. 

Certain  jioisons  cause  changes  in  the  lateral  and  ihu'sa!  cohinins  of  the 
cord  that  rescniliie  those  of  the  coniliined  system  diseases.  They  have  hccn 
dcmoi'stratcd  in  |ielhi^n'a  and  in  crunti,-!!!.  and  have  already  iieeii  descrihed. 
In  jiornicioiis  atuemia  and  many  chronic  wasting  disease  iliese  scleroses 
occur,  and  ai'i'  iu'lieved  to  lie  dui'  to  the  action  (d'  poisons  produce(l  within 
the  svstein. 


ojitic  nerve 
f(.et.     There 

of  the  feet, 
curvature  of 

•sis  comes  on 
■r  walk, 
lid  scanning; 
lintaiued,  but 

1  members  of 
form  of  inco- 
lus,  the  i»o-i- 
c  speech  make 
i\  with  chorea, 
With  hered- 
io  does  not  set 

"are  should  be 

,  described  by 
fter  the  age  of 
;han  "  groggy." 
legs  ultimately 
Suncrer  Bro\vn"s 


III.     DIFFISE   DISEASES  OF  TIIE   XEKVOUS  SYSTEM. 
I.   AFFECTIONS   OF   THE    MENINGES. 

DiSKA.sKS    OI'   Till-;    DrU.V    MaTKU    {I'dclniniriliinjitis). 

Pachymeningitis  Externa.— rrn7>m/. — ThemoiTliage  (d'ten  occurs  as  a 
rcsidi  of  fracture.  Jnilainmation  of  the  external  layer  of  the  dura  is  rare. 
Caries  of  the  bone,  either  extension  from  middle-ear  disease  or  due  to 
syphilis,  is  the  ])rinciiial  cause.  In  the  syphilitic  cases  thert'  may  l)e  a 
great  thickening  of  the  inner  talile  and  a  large  collection  of  pus  betueeii 
the  dura  and  the  bone. 

Occasionally  the  pus  is  infiltrated  between  the  two  layeis  (d'  the  dura 
mater  or  may  extend  throimh  and  cause  a  dura-arachnitis. 

The  symptoms  (if  external  |)acliymeniugitis  ate  indelinite.  In  the  sy|  h- 
ilitie  cases  the  re  may  be  a  small  si  ms  comniiinieating  with  the  cxteri(U'. 
Compression  sym|itoms  may  occur  with  or  without  jiaralysis. 

i^pimtl. — An  acute  form  may  occur  in  syphilitic  aU'ections  of  the  bones, 
in  tumors,  and  in  aneurism.  The  symjitonis  are  those  of  a  compression  of 
the  cord.  A  chronic  fiu'iii  is  much  more  common,  and  is  a  constant  accom- 
paniment of  tubercuhnis  caries  of  the  spine.  The  internal  surface  of  t!ie 
dura  may  be  smooth,  while  the  external  is  rough  and  covered  with  caseous 
masses.  The  entire  dura  may  be  surrounded  or  the  iiroce>>  may  be  con- 
fined to  the  ventral  surface. 


1^^ 


DISEASES  OP  THE  NERVOUS  SYSTEM. 

Pachymeningitis  Iuterna.-Thi.  "--.  in  thn.   n.nn>:  (1)^  V^^o-^ 

;r:;::r;J,;;in>.. --;;;;:->;;;:;;i'^;;r;r:ri;:;i.i 

,,u-l.ynu..nn^.l.  u..y  '""'^      '    'X^^;. ,      i,  ;,  ,,,narkal.l.  h..w  nuvly  pus 
il  Ivnnul  lu.w.vn  t!u.  dun,  .>..!  anul.noul  memhram.. 

Ccirln-al  /'om//.— Mil.      nn'i  i ),,,.■,„„  trii  vrars  no    n>tani'e  ol  it 

i,  vny  rare  in  ^..u.ral  ''!-'''''''  '''''^r  '         !  '^^,!  ^  ^    .Hal.    On  the  ntiu.- 
^.,,,„.\,„.K.,.  ,ny  uhsorvat.uii  at  ^''^.^  ''"   ,  j  \^    "^^^^^  .vliicli  r.c.i^.a 

,,^,„,,,  i„  uu.  ,K.t-mort.ni  rnom  ol  »'- \'     f       ';  /^  "^^^  unconuiioii. 

-at.rial  from  a  lar.o  '>  '''f '^V^;;^  ^^    ^  ^  i;*^a  Ihvo.  oi  wlii.h 

-"1  -"""  '!'"^'  "T'    w.r    T  0  fn    n    u'    l^'l-  -nditi.m  in  asylum 
'■'>"'^'  '■'•'""  ^''"  T     i  r  :.  f    1  ft  in  1  'isr>  post  niort.ms  at  the  (iov- 

Morl<  may  h.  ^atlur.d    rom  tho  l'^;  ^     '        ,,    \,,  j,„,  30,  ISDT,  iitoro  Nv.ro 
„.nnu.nt  Hospital  for  the  »''^'>"^' ^  ,^^^^    !  ;^   Ku.hvmcmin.itis  "  (Ulaek- 

^•^"•r^  ;;::,:'  ^  uj;::; t  :;^1;^  aUonthm  to  tW  ..  i.)'n,tu.nt  oeeurrenco 
::,t;\.sion  m  haaW  ---'-^-t^^^^Sv  Vio.  that  the  delicate 

''''•^'  "'"'■'r^  "^'^'"  \l".  ;;;       ^  Shal  tundouhtedly  eorreet.    l>rae- 
vascnlar  memhrano  preee.le.  ^'"'.'^  "";,';,      ^,.,,,,.  («)  ^iihaural  vaseular 

tieally  .e  see  one  oi  throe  -'^^^^  ;  ^^^  ^     v^o  penetration  of  hi 1- 

nu.nhranes.  often  of  extremo  ^  f'^'      '/^^^^^^^^^^^^  „\,aato  (so-callea  "  or- 

vcsols  and  .rannlation  tissno  nr^o  '^^^^^^'^  ;,  ,,  ,,,,auval  luvmor- 
ganizatior"  of  an  i'>'''^'"''f  ^7>  Z'"^''  j,.  .  „,,,nhrano  and  hlood-elot. 
f,,,,.;  (.)  a  eomhinati..n  ol  ^l'';  ^;;;' ;^^;^  J     "'    aeo  of  Invniorrha.e 

Ovtainly  the  vascular  7'7';--^  ^  ,  ^,  .^  I  ^mealed  .ith  lar.o  vessels, 
-simply  a  liln-.nis  sheet  of  nuimhc,  t  ucki^  ,  1  ^^^^^^^^^  ^^^.^.^^ 

.vhich  may  form  heant,  ul  ^^^^^^^JVUn^n^  alone,  hut  it  is 
are  iustaiurs  in  .huh  the  ^''1"  ";'^\'\",  '  .'''^^  ,,1,,..,,  ,„av  have  destroyed 
possihlo  that  in  some  of  these  at  W  t^  0  '^^  ;|^  ^^^J^^  ,^f  ,„,i,,ted 
in  trace  of  the  vascular  "^""^"'^  ^  3  VT^m  in  thickness.  Cysts  may 
dots  are  found,  formin.'  ^J'^^-Jj;";,',;:/  h  l.morrha.o  is  prohahly  the 
oecur  Nvithin  this  memhrano.    Tie  ^""^^^^^  ^  bleeding  comes  from  the 

nural  vessels.    Ih.guenin  and  others  hold  that  ^'^^10.^^  ^^^^  ^^^^^.^.^^ 

vessels  of  Ihe  ,ua  maty,  hu    ^^^^^  ^^^nS    the  highly  vascular  suh- 

S  ':z:::':z;l'::^:^<^r..  ..^.  the  thmne.  possihie  .heet^g 


AFFECTIONS  oF   TIIH   MHNMNCiKS. 


ito;{ 


I)  rsoiuio- 

\v(>  are  un- 
ciulirauL'  ot 
illUllU'  ul'  it 
1.     I'uniUiu 

y    tlu'    Vt^lllt 

w  laroly  puri 


I  Miilvr). 

])\  Vivclunv, 
nstiiiU'O  nl'  it 
On  tlu'  ntlii'V 
Inch  i\'(H'i\ril 
\  iiiicoinniiin. 
iroL'  ol!  wli it'll 
on  in  aHvluni 
IS  at  the  Oiiv- 
i)T,  til  ere  were 
^ritis"*  (lUaek- 
I'lieral  paresis, 
ill,  •.'-  chriinic 
rty-two  of  the 

liseases  of  the 
certain  of  the 
ent  oeeiirrenee 

at  the  delicate 
correct.    Trac- 
bdiiral  vascular 
■iilion  of  hkioil- 
(so-called  "  or- 
bdural   ha-nior- 
and   Idood-clot. 
of  Ineniorrhage 
th  hirpe  vessels, 
iier  hand,  there 
alone,  hut  it  is 
;  have  destroyed 
ics  of  Liniinated 
iioss.    Cysts  may 
;e  is  prohahly  the 
r  comes  from  the 
of  the  condition 
Illy  vascular  suh- 
possihle  sheeting 


(if  clot,  wliicli  has  evidently  come  from  the  dura.  The  snhdural  Iimiihu- 
rliaye  is  usually  associated  with  atrophy  of  the  convoliilions,  and  it  is  held 
that  this  is  one  reason  why  it  is  so  conmion  in  the  in.sanc,  especially  in  de- 
mentia paralytica  and  dementia  senilis;  imt  there  must  he  some  other 
factor  than  atrophy,  or  we  should  meet  with  it  in  [ihtliisis  and  various 
cachectic  conditions  in  which  the  cerehial  wa.-tinj,^  is  as  common  and  almost 
as  nuirkcd  as  in  cases  of  insanity. 

The  symptoms  are  indclinitc,  or  there  may  lie  none  at  all,  especially 
when  the  ha'morrha;:cs  are  small  or  have  ocinrred  very  },'radually,  aiul  the 
diiiLMio.-is  caniuit  he  made  with  certainty.  Headache  has  heen  a  prominent 
symjitom  in  some  cases,  and  when  the  condition  exists  on  one  side  there 
may  he  hcmiple;;ia.  The  most  heljifnl  >ymptoms  for  (liaj,niosis,  indicatin,!,' 
that  the  luemorrha^fc  in  an  apoplectic  attack  is  menin^'cal,  arc  (1)  tho.<e 
refcraltle  to  increased  intracerchral  pressure  (slowinj,'  and  irrcffularity  of 
the  jiulse,  vomitinj:,  coma,  contracted  pupils  react  in;,'  to  li^dit  slowly  or  not 
at  all)  and  (•-.')  paresis  and  paralysis,  gradually  increasing  in  extent,  accom- 
panied hy  symptoms  which  ])oint  to  a  corlicdl  origin.  Ivxtcnsivc  bilateral 
disease  may,  however,  exist  without  any  .symptoms  whatever. 

SjiiiuiJ  Form. — The  spinal  iKirhiininiiiniilis  hilmiii,  descrihcd  hy  Char- 
cot and  .Joll'roy,  involves  chielly  the  cervical  region  (/'.  rcrrinilis  lii/inr- 
h-iijihiiii).  Tlie  intersjiace  hetwcen  the  cord  and  the  dura  is  occupied  hy  a 
firm,  concentrically  arranged,  fihrinons  growth,  which  is  seen  to  have  de- 
veloped within,  not  outside  of,  the  dura  mater.  It  is  a  condition  ana- 
tomically identical  with  the  Inemorrhagie  pachymeningitis  interna  (d'  the 
lirain.  The  cord  is  usually  com]iressed;  the  central  canal  nuiy  he  (iilate<l — 
liydromyelus — and  there  arc  secondary  degenerations.  The  nerve  roots  are 
involved  in  the  growth  and  are  damage(l  and  compri'ssed.  'i"he  extent  is 
variahlc.  It  may  he  limited  to  one  segment,  hut  more  cominotdy  involves 
a  cnnsideralile  portion  of  the  cervical  enlargcnu'nt.  The  disease  is  chionic, 
and  in  some  cases  presents  a  characteristic  group  of  symptoms.  'I'here 
are  intense  Tieuralgie  ])ains  in  the  course  of  the  nerves  whose  roots  are 
involved.  'iUey  "t  r-Jiicllv  in  the  arms  and  in  the  cervical  region,  and 
vary  greatly  in  intensity.  'V'hvw  \\\av  'v  hv))era'stliesia  with  numhness  and 
tingling;  atropjiic  change's  may  devcloj),  am\  tUvire  iicfv  he  areas  of  ana's- 
thesia.  Gradually  motor  disturhaiu'cs  ajtpear;  the  arms  heeomv  \vc;;?v-  !Ui(] 
the  muscles  atrophied,  particularly  ii;  certain  groups,  as  the  flexors  of  the 
hand.  The  extensors,  on  the  other  hand,  remain  intact,  so  that  the  con- 
dition of  claw-hand  is  gradually  produced.  The  grade  of  the  atrojdiy  de- 
pends much  upon  the  extent  of  involvement  (d'  the  cervical  nerve  roots, 
and  in  many  cases  the  atro|)Iiy  of  the  muscles  of  the  shoulders  and  arms 
lieconu's  extreme.  The  condition  is  one  of  cervical  |iara|)Iegia,  with  con- 
traetures,  flexion  of  the  wrist,  and  typical  i\iii\n  en  ijriffc.  I'sually  before 
the  arms  are  greatly  atro))hied  there  are  the  symptoms  of  what  the  l''rench 
writers  term  the  second  stage — namely,  involvement  of  th(^  lower  extremi- 
ties and  the  gradual  iiroduction  of  a  spastic  paraplegia,  which  may  develop 
sev(Tal  months  after  the  onset  (»f  the  disease,  and  is  due  to  secondary  changes 
in  the  cord. 

The  disease  runs  a  chronic  course,  lasting,  })erhaps,  two  or  more  years. 
CO 


■ 


^^ 


li 


I! 


f 


k 

I! 


DISKASKS  W  ■nil;  SEBVOl-S  SVSTKM. 

;::;;:;:^;:;;:r^;:;;.lr■.,.::;:.-»;;;',;';;;-^ 

„,,.  11...  r.l.....<.'>s  lay...'-  I  ">"  '       "  ,        ,„,,,,,,  „„v  .,,,,.,•  at  a.,y 

sv,ni.t.....s  ,i..st  nu...t.......l.     '^   ;  '        '"  ^.,,l.  ,„„.  .nrur  lill...l  with  ha..u- 

unlia<!;ii.  i-oiiU..'*'^- 

„,,,,.„. ,.„„lM.Mvn.,  (...»<.■'■,.,■.■/„,,..,„...//..■," """"■■'■')■ 


'=:r.v:;;.o;v..,::..M.;^;;.i":;;:,.;"-"r 


1^ ,,. ....  M....i...itis  i.a.  ^''>>';--i>;;f;;;;^:'  :,.;::;;  ...roses  of  ti. 

,li..as.-s  of  .hil.l.......     l'>a..t.....oKn..ally,  ""'."^l^.^;  ,^.^,,,^,..u.  int,.a...ll..- 

..!•  nu.ni..,iti.U-s-  11.0  ro,,..  .h.e  »';^  •>^";;;;:';  ^       •    o  the  tn.>orclo  bacilh.s. 

'"-^-  "''■  I— ■'"•'""^  '; -S'     T       '   n  cLus,  tlu.  ty,hoi.l  l.a..ll.- 
„„,  tlu.  sl....i.toc.K.....s  ,u..n  nj,.t.s       1  .     r  ^^i    ,i^i,,  ,,„t  a  great  ...a- 

^•>"  -'""  '">^''^'"^-  ""'  ^'''^'t;:;      '      .•  1  >  -m....ti-...l  ,m.M-.,-or,anisn.s. 

ri;;^..r:.ii;;;:;xro;';L^;:::^ 

bv  it.  ,      ...     ■     .,,.,  ,,,,,.,1   form  i.i   the  cases  .luo  to 

•    Tbc  strcploco......s  '"'''^^-'^'^ !;/    j;j^.,     I,,  „,eerativc  on.locar.lil.^ 

traun,a,  to  otitis  „.ecl>a,  a,.l  - ^    f  li^'^^^.y^.^Ueot...!  cases. 

it  is  iu.t  uncon.inon;  .t  oce.UMra  .n  -   "    ~'^-^  ,^  streptococci,  somet.n.es 

The  li.rminal  mcniug.ti.lcs  are  .a.iM.I   !•>  i 

hy  stai.hyloco.^.i.  .^i^.,,1  meninges  may  be  cbicHv 

Morbid  Anatomy.-llo  ';  ;     '/  .^^  „„nin.es  varies.     In 


1 5 


JPI 


^ 


AFFKCTloNS  nT  Till",   MKNINdKS. 


{tn') 


lis  ciiuditiiui. 
fium  iiinyo- 
lic  liivt  it  i> 
ck  and  anus; 
iractt'ristii;  "I 
.  (listinguit'lr. 

:  occur  at  any 
ninj;ilis  hu'ni- 
il  priidncc  tin' 
iv  ciM'xisl  \\i'l' 
l",.(l  with  hii'ni- 


<  the  two  ninsl 
i-onditions  with 
iro  piwlicnhirlv 
ill-j)()X.  typhoid 
tlte  bdiii's  (if  till' 
is  of  the  iH'troiis 
'iiu  from  (lix''"^'' 
in  fioundinjj;  the 
iii'croHos  oi'  tlic 
•r,  the  infection 
iiial  iiifertion  in 
11(1    tlio  wastiniT 
„ur  preat  jzronps 
,co'-us  intraccllu- 
lulicvclc  bacillus, 
tyjihoid  hacilhis. 
,"l)ut  a  great  nia- 
micro-orgauisnis. 
which  not  only 
I'lit  infection.     A 
,.  prohably  cau^ed 

the  cases  due  to 
•ativc  endocarditis 

ses. 

ococci,  sometimes 

ics  may  bo  chicOv 
niniies  varies.  In 
carditis  the  disease 
on  from  disease  of 
ith  abscess  or  with 


tiirondio>is  of  tiie  siiui>es.  In  liie  iion-luh.  iculou^  form  in  childicii.  in  the 
iiHiiingitis  of  chronic  llrighl's  di^'asc.  and  in  caciiictic  condiiioiis  the  iia>e 
I-  UMiaiiy  involved.  In  liie  cases  ^^econdary  to  inicunioiiia  the  elfnsion  1m- 
nealh  the  araciinoid  may  lie  very  thick  and  iMiridenl.  coiii|.lelcly  hidini,' 
the  cunvtdiilions.  'riu'  ventricles  ai.-o  may  lie  involved,  though  in  these 
simple  forms  they  rarely  iiresent  the  distention  and  s(dtening  which  is  mi 
rrc(|uent  in  the  tuherculons  meningitis.  For  a  more  detailed  description 
Ihr  student  is  rclVrri'd  to  the  sections  on  ci  rchro-.-pinal  fever  and  lulieim- 

lous  meningitis. 

Symptoms.— The  clinical  features  of  meningitis  have  already  heen 
(h'scrihed  at  length  in  the  diseases  jn>t  referred  to,  and  I  shall  here  give  a 
general  suiiunary.  1  have  already,  on  several  occasions,  called  attention  to 
the  fact  that  cortical  meningiti-  is  not  to  l)c  recognized  hy  any  symptoms 
or  set  of  symptoms  from  a  condition  which  may  he  produced  hy  the  poison 
of  many  of  the  specitic  fevers.  In  the  cases  of  so-called  cerehral  piuuinonia. 
unless  "the  base  is  involved  and  the  nerves  atl'ccted.  the  ilisease  is  unrecog- 
nizahle,  since  identical  .-ymptoms  may  he  iiroduced  hy  intense  engorgenu'nt 
(d'  the  meninges.  In  typhoid  fever,  in  which  meningitis  is  very  rare,  the 
twitchings,  spasms,  and  retractions  of  the  neck  are  almost  invariahly  a>- 
sociated  with  cerehro-spinal  congesti<ui,  not  with  nu'iiingilis.  Actual  men- 
ingitis does,  however,  occur  in  typhoid  fever,  ami,  as  (»hhnacher"s  cases 
show,  the  ty]>hoid  bacilli  may  he  present  in  the  exudate. 

A  know-ledge  of  the  etiology  gives  a  very  important  r\v\v.  Thus,  ni 
middle-ear  disease  the  development  of  high  fever,  ilelirium,  vomiting,  con- 
vulsions, and  retraction  (d'  the  head  and  iv-V  would  he  extremely  suggestive 
of  nu'iiingitis  or  ahscc.-s.  Headache,  which  may  he  severe  ami  i.,..;.;;i!'fu-; 
is  the  most  comnum  symptom.  While  the  patient  remains  conscious  this  is 
usually  the  chief  complaint,  and  even  wln'ii  semicomatose  he  may  continue 
to  gr(ian  and  to  place  his  hand  on  his  head.  In  the  fevers,  particularly 
in  pneumonia,  there  may  he  no  comidaint  (d'  headache.  Delirium  is  fre- 
(picntly  early,  ami  is  most  marked  when  the  fever  is  high.  Convulsions 
arc  less  conimon  in  simple  than  in  tulierculous  uHMiingitis.  They  were 
not  ]ire.-^cnt  in  a  single  instance  in  the  cases  which  I  have  seen  in  pneti- 
monia,  ulcerative  endocarditis,  or  septicaMuia.  In  the  sim[dc  meningitis 
of  children  they  may  occur.  Kiiile})tiform  attacks  which  coiiu'  and  go  arc 
highly  characteristic  of  direct  irritation  of  the  cortex.  Wigidity  and  sjiasm 
or  twitchings  of  the  muscles  arc  more  connnon.  Stilfness  and  retraction  <d' 
the  muscles  of  the  neck  are  important  sym|itonis;  hut  they  are  hy  iio  nican< 
constant,  and  are  most  frequent  when  the  inllammation  is  extensive  on  the 
meninges  of  the  cervical  cord.  There  may  ))e  trismns,  gritting  (d'  the  teeth, 
or  silastic  contraction  of  the  abdominal  muscles.  Vomiting  is  a  comnum 
svmptom  in  the  early  stages,  ])articularly  in  basilar  meningitis.  (,'onsti|>a- 
tion  is  usually  ]irescnt.  In  the  late  stages  the  nrinc  and  firces  may  be 
passed  inv(duntarily.  Optic  neuritis  is  rare  in  the  meningitis  of  the  cortex, 
but  is  not  imcomnion  when  the  liase  is  involved.  Leube  lays  stress  on  the 
hypcra'sthesia  of  the  skin  and  muscles,  especially  of  the  mnscles  of  the  neck 

and  calves. 

Important  symptoms  are  due  to  lesions  of  the  nerves  at  the  base.    Stra- 


^^ 


niSKASES  OF  TIIK  NKRVors  SYSTKM. 

MM, „  ,..,,,;.,i  ,„,,.v,.  iiiiiv  !>«■  involved,  [.nMliuin-i 

Ur  is  ,..vs.nt.  >•-•'-«»V^^ ii  ;    t^l        M  :...   a„.l   in    i^r..h.-> 
disease  tlieic  liia\  m    im 


.lisease  theiv  .nay  l.e  little  or  no  leve  .  !'  ^J'      i,,,,.  .■,,,,„,os  .,r  the 

,,„„..y  at  llrst.  though  t  .s  ,<  >•''"-';;  •,.,^,\  ',;',,;,., n,e,  even  in 
.  i,„.;.  is  tl,e  slowness  ol  the  ,.nlse  in  """;',  J,i„  ,,,„,,,  The 
„,.,  ,,,,y  stages.     Snhse,uently  .     "'">   '^  "  ^^        , ,    ^     „  ,,,   .vfem.!   to 

a  dislnrlmne.'  (d  tlie  nnnia    in  i  i,,    i,,,r  nuneturo  is  exee.'d- 

!;;;;;;:i^::';™r*t';-;:;:'::«^---. ••••-- 

rational  hasis  for  treatment.  .  ,,,,„j,,„i   n,,, 

Treatment.-'rhen:  ;>-  -.^-       X,:     l'  ^ Ul'^a  to  the  head  and, 

,„urse  .d'  aente  inenm-.tis      A     hc  "  -  ''  ,       ',„.,,,  .leidetion  may  he 

if  the  suhject  is  yonn,^  and  tnH-hh-l  .  P  >  '^  ^^^  ^^,,,  ^^!,,„„  disease  of 
practised.  Ahsolnte  rest  and  'I'-'^'l  f"  "  ,  .'V  Id  in  eonsnltation,  and  if 
Iho  oar  is  i-resent.  a  sur.eon  ^'-''1'  '  !  >^^  '  ,,,,  i„  any  uay  ho  h-eal- 
t,u.ro  arc  symptoms  ''  -'';'"-^---''7'^''^^^\*  ^^  ,,  i  saline  imr.o  will  do 
i....d  trephining  >hould  he  ,.raet.  ed.     "  '     '  "    ,,,,i  ,,     u'tion.     1  have 

,„„,,  u.  relieve  the_  eon.estmn  than  ^^^  ^1^;^^^,:^  ,,  \,,o  back  of  the 
no  helief  whatever  •",;;':->       .'vnn.  with  a.oni.in,  headache 

are  recommended  by  f  "'^. ""*'"'''■  ,,,,^j-,,,  to  tl...  bowels  and  stomach,  and 
The  aiM'I'H'Mtion  of  an  ice-cap,  attention  ^  /  ^,^^.  ,^^,,^,,,,,,. 

,oopin,  the  fever  within  moderaU.  ;;';  ^'^^^  ^  ;i^,tal,  and  in  which 
.neilsnres  in  a  disease  --^"'-^..f^  ^  '^^  ,  "  incke's  Inmbar  pnnctnre 
,he  eases  of  recovery  are  ^^^^^^^^^^^  „i,re  with  snccess  by  Fiir- 
(.ee  iKi^'c  Kn)  has  been  used  as  a  thtrapontc  n  ^^^^.^^.  ^^.^^^ 

,,i„Jen  fiO  cc.  of  clo.dy  fluid  were  -™;;'^'.,;™i    appeared,  and  the 
,,„;i.     The  headache  a.d  "thor  jreWd^        '-^    ^^11^^^^^^^^  ^,^^^^^^  ^ 

-;ro;-^r;;  i^^^nnrS^^^^^^^         trephinln,  and  drama^e. 


SCLKUOSKS  (»!•'  TIIK   HHAIN. 


'Xu 


i|,  iirmliuiii}^ 
idduciii),'  1111- 
iiiujii's  ill  the 
li'd,  ami  [ht- 
tiiatcd  at  tlif 

■  ly   iilii)lislli'<l. 

10;$'.     Ill  111" 
I   in    liri^'lit's 
•mii-i'vl  in  Iri'- 
Viitmvs  of  tilt' 
at  mi',  t-'voii  in 
slower.     Tli^' 
1,1'  ri't'cnvil   to 
ii>  spinal  iiicn- 
turo  irt  oxcL't'd- 
y  ])rovo  indi^- 
X'l'ioli'jiii'iil  *'^- 
s  yii'ld  a  more 

jiv  conti't*!   tlu' 
)  tliL'  head  and. 
.plction  may  1)*' 
Hit'ii  disrar^o  ot| 
iiltation,  and  if 
ly  way  1)0  local- 
"  inirixo  will  do 
ilction.     1  liiivo 
the  back  of  the 
nizinfi  lioadacho 
ntt-r-irritation  is 
loro  patisfaotovy. 
m,  and  nuMX'ury 

nd  stomach,  and 
,ro  tlie  necessary 
il,  and  in  which 
liimhar  puncture 
1  success  liy  Tiir- 
)crclo  hacilli  were 
ppearcd,  and  the 
terhouse  report  a 
r  and  drainage. 


l>osTi;iii..ii  MKMNdiTis  Of  Imams  (.\un-luhrnHlnus  Lrp'owminjills 

I nldnliini ). 

Thi>  tonn  lias  Inm  >p.r,ally  >t.i.lud  l.y  <iee  and  Uarlnw.  and  has 
,,,,,„  ,„ll..d  oeclusivc  nienin^'itis.  (iee  called  it  rrrrind  „inslhnlunns  o  in- 
lants.  from  the  mo>t  prominent  feature  <d'  the  disease.  A  caretul  s  .1,  y 
lias  heen  made  of  11  ea>cs  hy  .1.  W.  Carr.  •'V'''  "'^'^ '"'•;:  .rV;,; 
Muvked  distention  of  the  lateral  and  tliird  ventricles,  genera  ly  o  the  ninth 
also,  with  "eiriision  <dMyini>h.  thiekenin-  of  the  p,a-arachnoid  and  nial- 
tin.'of  the  parts  over  the  posterior  ami  eentral  area  of  the  l.a^e  ol  the  hrain 
from  the  lower  end  oi  the  medulla  to  the  optic  commissure.  I  he  .  i.>- 
i,,H'  is  most  common  in  infants  under  one  yar.  in  .miy  ..  cases  a  le« 
llak.s  of  Ivmi.h  were  found,  and  neither  the  choroid  pleNU>es  nor  the  ..pen- 
dnna  showed  naked-eye  ai-pcarancs  of  intlammation.  Head  retraction 
appeared  early  and  was  persistent  tliron;il.oi.t,  l.ein^-  ahscnl  111  only  one 
JX  It  is  usually  miieh  more  marked  than  in  tiiherculous  meniii-itis.  M 
a  comparatively  nirly  stage,  even  weeks  hefore  .leatli,  ''"'  ''''■^""^  i;'' ^  '"  f 
stupor  or  c.mplcte  coma.     This  form  is  sometimes  met  with  in  oldei  el„l- 

'^'''chronir  Lrplo,.nnn„{th.-'Vh\^  is  rarely  seen  apart  from  >>;i;l' !';>;;'; 
tuhereulosis,  in  whieli  the  meningitis  ,s  assoeiated  with  the  growth  ot  th  . 
.rranulonmta  in  the  meninges  and  aho.it  the  vessels.  I  he  symptoms  in  such 
cases  are  extremely  varialde,  deiu'iiding  .■ntircly  upon  the  Mtuat.on  ol  the 
-n'owth.  They  may  closely  resemhle  those  of  tumor  and  he  associated  with 
localized  eonvulsio'ns.  The  epidemi.'  meningitis  may  run  a  very  chronic 
course  The  lept.micningitis  infantum  may  he  chroni.'.  In  the  cases  re- 
ported hv  (ieo  and  I'.arh.w  the  duration  in  some  instan.es  extemled  even  to 
a  year  and  a  half,  l^lincke•s  innnn.iilis  srrosa  is  c.ii.Mdered  with  hydro- 
cephalus. 

U.    SCLEROSES    OF   THE    BRAIN. 

General  Eemarks.-TlH'  conmrtivc  tissue  of  the  central  nery.nis 
sv<tem  is  of  two  kinds-one.  the  neuroglia,  special  and  i.eeii  lar.  dcrive.l 
fn.in  the  ectoderm,  with  distinct  morphological  and  chemical  characters; 
the  other,  in  the  meninges  and  accompanying  the  hlood-vessels.  derived 
from  the  mcsoihain.  identical  with  the  ordinary  collagenous  hhrous  tissue 
of  the  hudv.  Both  plav  inii.ortant  parts  in  indurative  pnuessi's  m  the 
hrain  and  cord.  A  convenient  division  of  the  cerehro-spinal  sclero.es  is  into 
de<n'nerative,  inflainmatorv.  and  developmental  forms.  ,      ,      , 

"The  clc^iawraliir  xrlrrosrs  comprise  the  largest  and  most  important  siih- 
division.  in  which  in-ovisionally  the  following  groups  may  he  niade:  ((/) 
The  common  secondary  degeneration  which  follows  when  nerve-td.res  are 
cut  off  from  their  tr..phic  centres  (the  severance  of  portions  of  neurones 
from  the  main  portions  containing  the  nuclei);  (h)  toxic  forms,  among  w  iie  1 
mav  he  placed  the  scleroses  from  lead  and  ergot,  and.  most  imi.ortant  of  all, 
the'sclerosis  of  the  dorsal  c(dumns,  due  in  such  a  large  proportion  of  .'ases 
to  the  virus  of  svphilis.     Other  unknown  toxic  agents  may  pos.ibly  ludiiec 


^^ 


I'  * ' 


n 


\^. 


\\. 


W 


w 

(  'I 


>  1 

■  r. 


DISKASES  OF  THE  NERVOUS  SYSTEM. 

1      *.      The  ^vsti'uiic  iiiiili>  in 

,„,H,ar  n,o.t  prone  to  ""'^^^f"''"^^;^  •!„,.,  whieh  is  nu.t  with  as  a 
wUh  change  ,n  tlu-  snmller  .u- e c  ^^^^^^^^^^{^  ,,„„  ,,  the  i..nus  .1 
senile  proeess  ui  the  -''"^'•^"^^'^^•^^.f .  ,  ui.„s  in  tlie  hh-ud-vessels;  hut 
insular  sclerosis  are  due  to  P  '"'>;'  '^;,,,  eases  is  a  prin^ary  degen- 
it  is  nut  yet  settled  ->;f' -;■,/  l^,,^:'  :,  ^i       the  sclerosis  is  secondary,  nr 

„.oup.  conn^risin,  -7-  -;„  ilH.^  ^^h:ii^  ->;^.  t^-^" 

t.tiv.  inllanunation  '^'''""/,"  f,  '  ..^  [,,,^,i,  (vascular)  scleroses,  winch  ari^c 
llist.ao-ically  these  are  'liH-iU  mesodcunu^  ^  ^  ^  _  ^^^  ^;      ^^^^^^.^^j^.    ^^   ^._^^,^,,,. 


a    V  tnese  are  rnuii.>   ..- ,,1         .  ,1 . 

■;;nnect.ve   tissue   ahout    the   hhKKl-ve.el. 


,,,„   ,L.   connective   tissue  ^^l^^^^^^T^^,,^  .^^eh  Strihnpell  hoUl^ 
^■'■r  u;U^>n;";nt  Z::^;^:T:.Z1  ....  i.  .>  con.non,y  touud 

,,,..u.ter.  and  en^lu-ace  the  -^^f;;^':^,^  ^,  ,.W,..>sis  ot  the  dor- 
,„velia  aud,  ac^ordiu,  to  recen       ku  ii    u  ^stologieally  tins 

sal  eohnnns  in    iM.edre.eh  ^  '^^  xu  ;•  ^^^^^_  ^,^^^^  ,1,,  ,i„v,,s. 

fornr  is  dilVcrcnt  iron;  tl- ord,n^>     a  net  •     n^^^^^^_^^  ^.^^^^^^,    ^^^^^^^^^^ 
,„.tieal  sclerosis  met   with  a.  a  conduit      _^  ^^^^^   i,,^^,,..,!,,^,.  that  "-nany 

0)  Miliary  sclerosis  is  a  t;;";;  -^1-   J-  '^j     u't\>ere  were  ,rayish-rcd 
ent'conditions.     Gowe^  mentu  -  a    -  m    ^^^^^^^  ^^^^^^  ,  ^  ^^^^ 

s,.ots  at  the  junction  ^^  !  ^J^f  ^^  'l^^naition  .n  whiclu  on  the  surtace 
,.o,v!ia  was  increase<l.      I  hou  i>      ■  ,,,je.tions.  varying  Ironi  a 

.,f  „,.  convolutions,  there  are  ^'-  >y  ^^  ^^_  l^iLle  nodules  of  this  sort 
half  to  live  or  more  '-^^;;;;^^';j  .  t^'  ,ndant.  '  So  far  as  is  known  no 
avenot  uneomm.^n•.  sometnne>  tht> 

smiptoms  are  ,.roduee_a  ^y /";'"';         .       ,,,   ,„   ,„tirc   hemisphere    or  a 
•      o)  Diffuse  BC  erosiS    whu  .   ma    2-       U.hr  has  heen  applied  to  ,t 
.inole  lohe.  in  wh.di  ca.e  tlie  tcnn   ^    ,,„,.aition  in  general  medical  prae- 
,  V  the  yrench.     It  is  not  an  ^"1'"^^'^^  V            n  hceiles.     In  extensive  c.^r- 
I.  but  occurs  most  frequently  "^l^'  ;,    ^W  t",,,„lly  dilated.*     The 
ieal  sclerosis  of  one  hemisphere    >>^       "       '  ^,  V„„  ,,r,eted.     There  may 
!;.nptoms  of  this  --'i^ion  de,u.ml  n    -    ^    n^             ^^  .^ithout^  nnu.. 
tie  a  considerable  ext^.t  «--',;,,  .i,,,,  !s  hemiplegia  <.r  diplegia 
„,ontal  impairment.     In  a  majontx 
with  imbecility  or  idiocy.  _ 


I]. 


St'LKROSES  OF  THE   liUAIN. 


'.tnn 


iinic  \n\U\^  111 
)\<d\  coUinin> 

ini't  with  as  a 
I'  iIk'  i'oriiis  111' 
,(l-vossds;  1)111 
riiuary  di'jXL'H- 
,  ric'condary,  nr 
iscl  l)y  l<-'>i"ii~ 

[  loss  I'Xtciisivc 
qiK'UL'O  of  in'i- 
;es,  and  abscess. 
<os,  which  arise 
.ihly  a  simihtr 
StriimiK'H  holds 
mnnonly  I'otiiul 

ircly  lu'uvoiiliar 
anal  in  syringo- 
osis  ol"  the  dor- 
stologically  this 
,  that  the  dilYuse 
hovit  tlhekeninir 
)aljle  that  many 
;i  the  eetoderniie 


to  several  dilVer- 
wcrc  <;rayish-red 
n  which  the  nen- 
li,  on  the  svirt'ace 
,,  varying  from  a 
dules"  of  this  sort 
:U'  as  is  known  no 

hemisphere,  or  a 
been  applied  to  it 
leral  medical  prac- 
lu  extensive  cor- 
llv  dilated.*  The 
octed.  There  may 
;  or  without  nuuh 
niplegia  or  diplegia 


veniidesrription  of  tlio 
e  Elwyn  Institution. 


(;i)  Tuberous  Sclerosis. —  in  Iliis  rcmarkalile  form,  wliich  is  also  known 
as  iivpertropliic  sclerosis,  Ihrre  arc  on  liie  convolutions  areas,  projecting 
lii'Vond  the  surfaces,  of  an  opaipie  white  color  and  exceedingly  lirni.  'I'iic 
sclerosis  mav  not  dislnrh  the  syinnictry  of  the  convolulion,  hut  siin|dy  cau.^c 
a  "M'cat  enlargement,  increase  in  the  density,  and  a  change  in  the  color. 

'riusc  three  forms  are  not  (d'  much  practical  interest  e.\ce|)t  in  asylum 
and  institution  work.  The  last  variety  forms  a  well-cliaractcri/.t'd  di,-ea>e 
of  considerable  imiiortance,  namely: 

(1)   iNsn.AH  Sci.KriOsis  {Srlfnisp  ni  phK/iirs). 

Definition.  —  .\  (dironic  all'ection  of  the  brain  and  cord,  characterized 
bv  localized  areas  in  which  the  nerve  el'Miients  are  mori;  or  less  replaced  by 
connective  tissue.  'I'liis  may  occur  in  the  brain  or  cord  alone,  more  com- 
monly in  lioth. 

Etiology.— This  is  obMiire.  Kahlcr,  Marie,  and  others  assign  great 
im[iortan(e  to  the  infectious  disease.^  particularly  scarlet  fever.  Jt  is 
found  most  commoidy  in  young  persons,  and  cases  are  not  uncommon  in 
children,  in  whom  I'ritdiard  states  that  nu)re  than  oO  cases  have  been  re- 
ported. .Sachs  has  recently  reviewed  the  whole  subject  (.Jour,  of  .\eiv.  and 
Mental  Diseases,  IS'IS). 

Morbid  Anatomy. — The  scU'rotic  areas  are  widely  dislribuled 
Ihrougli  the  brain  and  cord,  and  eases  limited  to  cither  part  alone  are  almost 
unknown.  The  grayish-red  areas  are  scattered  indilVerently  through  the 
white  and  gray  matter  (VI.  W.  Taylor).  The  [)atches  are  most  ai)Uiidant 
in  the  neighborhood  of  the  ventricles,  and  in  the  pons,  cerebellum,  basal 
ganglia,  and  the  me(lulla.  The  cord  may  l)e  only  slightly  involved  or 
there  may  be  irregular  areas  in  diU'erent  regions.  'I'he  cervical  region  is 
most  often  the  seat  of  nodules.  The  nerve-roots  and  the  bi'ancbes  of  the 
Cauda  equina  are  often  attacked.  Histologically  in  the  .sclerosed  patches 
there  is  very  marked  ])roliferation  of  the  neuroglia,  the  libres  of  which  are 
denser  and  firmer.  The  gradual  growth  destroys  the  medulla  of  the  nerves, 
but  the  axis  cylinders  persist  in  a  remarkable  way.  'i'here  is  as  a  conse- 
(inence  relatively  little  secondary  degeneration  of  nerve  tracts. 

Symptoms.— 'I' he  onset  is  slow  and  the  disease  is  chronic.  Feeble- 
ness of  the  legs  with  irregular  jiains  and  still'ness  are  among  the  early 
symptom.'.  Indeed,  the  clinical  picture  may  be  that  of  >|»iistic  paraplegia 
with  great  increase  in  the  rellcxcs.  The  following  are  the  nuist  important 
features: 

((/)  ViiliHiittnl  Tremor  i.r  l<i)-r(ilb(l  Inloilidii  'rmiinr. — There  is  mi  jiaraly- 
sis  of  the  arms,  but  on  attempting  to  jMck  up  an  object  there  is  tremblitig 
or  rapid  oscillation.  A  patient  may  be  uiial)le  to  lift  even  a  glass  of  water 
to  the  nmuth.  The  tremor  may  be  marked  in  the  legs  and  in  the  head, 
which  shakes  as  be  walks.  When  the  jiatient  is  nn  innbent  the  muscles  may 
be  perfectly  (|uiet.  On  attempting  to  rai.se  the  head  fi(Hu  the  pillow. 
trendiling  at  ome  comes  on.  (Ii)  Sraiiriiiifj  Sjweih. — The  words  are  |)ro- 
nounccd  slowly  and  separately,  or  the  individual  .syllables  may  be  acceiiiu- 
ated.     This  staccato  or  svllabic  utterance  is  a  common  feature,     (r)  yijn- 


■4'l 


y  1 


!,5  I 


DISEASES  OP  THE  NEUVOUS  SYSTEM. 


,„,„„,».., .,i.l-ilW..,v  .„,,„■  .,,.,1,  .,...  ..nsmu,«  :u,  u,„....... 

„,,  uiialtc't"!  until  tl,c  U.t  .-I'V    ■;"'-'      .    I      ,,;;oaso,  in  wlik'li  lor  « 
lime  nil  iIk'  svninlomB  may  on  .nno.     \  ortigo  i>  tomni     , 

'"-r:;;;::i:i:=»;-:»=  - '-^ 

l„  „„.  v,.,v  ir,r,nl,.r  -'-'*"';""  r'J'^V  ■:'"::      VolHi.nal  tr™,.,r.  ..an- 

.  '"'iS'^a ;;;:;  :;rt m ntL:;.::,^!. ., ....n-«ro„,.  xj.... 

„„i,a„«,  cortain  oa^,  .  goncral  „aro,s,  a  0  o,  .nmal  ,  _^^_.^^  __^^^^^  ^,_^^ 
shnulato  Ih.'  .li™*  v"y  'I""''}-  '  ',,,';„,,  .,„i,,5  ,|,„t  ..1  all  organ!,' 
,,n,l  .1,0  Jiag„o.U  n,a.v  h.  ''"l""*''''    .„"",;  "in  il.  oarlv  stages  is 

*^l;^;Il:^'.s:r'::.^i,.;^rn;„:ltro: •rw.r.norm 

!S:it;;:^r:;z.s':;:a;:r.^:'t!i,iro,.i,o.o„,^^   ^ 

„,,„  ,v„v,,„l,,  1,0  so|,a,-aUvl  fro,,,  ^'^^;;'^'^,^,,,„.  a  „„t  oa,-rio,l 

Tlio  imlimis  is  unlavorablo.     V  Itimaiuv,  tii,   | 
olt  b,  so„,o  inte,-cu,TO„t  altooti.,,,.  l,.'<"n,o*  »':  "f  '  ,„„„,.^.  „„  ,„„  ,,„„„.» 

T'reatmeBt.-N„  ^«^;^.^^Xt^^r^Z;  havo  tl,!.  slight. 

::t:lSi:l  a  I.Xo,.'::^!" '-■•■ ...  slWor  ,„ay  1,0  ,rio„.  a.,a  ar- 

:jenic  is  rocomnicndocl. 

„,.   CHRONIC    DIFFUSE    MENINGO-ENCEPHALITIS 

(Dementia  Paralytica;  General  Paresis). 
.      1        •      „rr„rro*^ivc  moniimo-euccpliiilitis  associated 

1,  .,„„,.  clnelly  betweon  the  a^s  ^^J^^  ^^^^,,,  ,f  ,,0  cases  arc 
factor  in  only  a   ow  m.tancos     A    'nc  .1    Ini    .       J^^^^^_.^^^^^  .^^  ^^^^  ^^^^.^^ 

in  rnarriea  veo,,le.  Sta  ,s  ^  sho^^^'  ^  ^l^^^^^  ^^^^,,^,,  ^^raetice  tl>e  dis- 
classes ot  sooety,  In.t  in  tin.  '  "".'"^^>  .^n.^,,.,!,,  ,.i,,ses.  An  inq-ortant 
ease  is  certainly  --/;--;;;,::  ,;:!^  ;;V::,Lu.  projects  .ith  all  its 
prclisposinfi  <;•-  J;^,;\  '\,„..,,,tnine.l  anxieties,  deferred  liopes,  and 
stroTi,K>st  "''""'f  ;";y!'.\  J,  ,  '^  The  habits  of  life  so  freciuently  seen  m 
straining  expectation     (.MicKUj. 


; 


CHRONIC  DIFFUSE  MENINOO-ENCEPIIALITIS. 


yci 


iin  impoi'tant 

iti'opliy  somo- 
cis,  as  a  ruli'. 
t  uiK'oininiin. 
1  whith  fur  ii 
11(1  tlu'ic  may 

CO  rospoiiiUnti 

tre'inor,  scan- 
-group.  With 
u<;s.     raralysis 

liystoria  may 
until  near  tlic 

of  all  organii' 

early  stages  is 
e  lu lints  to  he 
lee,  the  nystag- 

The  tremor  in 

writers  regard 
condition  may 

,  if  not  earried 

(>n  the  progress 
have  tlie  slight- 
be  tried,  and  ar- 


5HAL1TIS 

halitis  assoeiatod 
to  dementia  and 

ly  tlian  females, 
e."  Heredity  is  a 
y  of  the  eases  are 
inon  in  the  lower 
I  practice  the  dis- 
5.  An  important 
jjects  with  all  its 
i'erred  hopes,  and 
fretiuently  seen  in 


active  1)ii>ines<  men  in  our  large  cities,  and  well  expirss.'d  hy  the  phras,- 
•>  hurniii"-  the  candle  at  hotli  ends."  strongly  predisiMise  to  tlie  disease. 
The  important  indivi.hial  factor  is  syphilis,  whicii  is  an  antecedent  in 
from  TO  to  W  yw  cent  of  all  cases.  To  this  disease  dementia  i-aralytica 
and  tah.-  dorsalis  are  so  closely  related  that  Fournier  dcscnhcs  them 
under  the  heading  /-.-x  .t//Vr//.//,s  Para^nphUUhnu'^^.  His  recent  work,  with 
this  title  is  full  of  interesting  details  gleaned  from  an  enormous  experi- 
ence He  su<'<'ests  that  these  two  disorders  may  he  not  nu'rely  diverse  ex- 
pressions of  one  and  Flie  same  morhid  entity,  hut  that  they  pos.ihly  may 
he  one  and  the  same  disease. 

Morbid  Anatomy.— The  es.-ential  histological  changes  111  the  cere- 
hral  cortex  are  thus  summarized  hy  llevan  Lewis:  (1)  A  stage  ot  inllam- 
matorv  change  in  the  tunica  adventitia  .d'  the  arteries  with  excessive  nu- 
clear proliferation.  ])rofound  changes  in  the  vascular  channels,  and  trophic 
changes  induced  in  the  tissues  around. 

{•i)  A  stage  of  extraordinarv  development  of  the  lymph-connective  sys- 
tem of  the  bniin,  with  a  imrallel  degeneration  and  disapt)earance  of  nerve 
elements  and  the  axis  cvlinders  of  which  they  are  denuded. 

(:5)  A  stage  of  general  lihrillation  with  shrinking  and  extreme  atrophy 

of  the  parts  involved.  •     i    n   •  i 

The  macroscopical  changes  are:  Increase  in  the  eere1)ro-spinal  llui.l, 
cedema  ot  the  pia.  and  thickening  and  opacity  of  the  meninges,  which  are 
adherent  in  places  and  tear  the  cortex  on  removal.  The  dura  is  sometmus 
thickened,  and  jiachvmeningitis  luvmorrliagica  interna  may  he  present. 

'J'he  convolutions  are  atrophied,  usually  in  a  marked  degiH'e,  and  m 
consequence  the  hrain  looks  small.  This  is  particularly  noticealile  in  the 
frontal  and  parietal  regions.  Flechsig  suggests,  from  his  own  experience 
and  that  of  Tuczek,  that  the  diiferent  types  met  with  are  deiiendent  upon 
the  localization  of  the  malady  in  given  cases,  predominantly  in  the  anterior 
or  in  the  posterior  '"association  centre."  On  section  the  hram  cuts  with 
firmness.  In  extreme  cases  the  gray  matter  may  he  ohscurely  outlined. 
The  grade  of  sclerosis  varies  much  in  diiVerent  cases.  The  white  matter 
may  he  ilrmer  in  consistence,  hut  it  does  not  show  such  imiiortant  clianges. 
The  ventricles  are  dilated  and  the  e])endyma  is  extremely  granular.  In 
addition,  there  are  freu.uently  areas  of  softening  or  luemorrhage  ass<jciated 
with  chronic  arterio-sclerosis. 

The  degenerative  changes  are  not  limited  to  the  cortex,  hut  also  invade 
puhcorticarresiions  and  tlu-  spinal  cord.  In  the  spinal  cord  changes  are  al- 
most constantly  found,  usually  scderosis  of  the  dorsal  fasciculi,  either  alone 
or,  more  commonly,  with  involvement  of  the  lateral. 

Symptoms.— (rt)  Pmdvnma}  i<t(ujv.—'V\\U  is  of  varial)le  duration,  and 
is  characterized  l)y  a  general  mental  state  which  finds  expression  in  syiu])- 
toms  trivial  in  themselves  Imt  important  in  connection  with  others.  Irri- 
tahilitv,  inattention  to  Im-iuess  amounting  sometimes  to  inditl'eivnce  or 
ajiathy,  and  sometimes  a  chauijc  in  clniractcr  marked  hy  acts,  wiiich  may 
astonish  the  friends  and  relatives,  may  he  tlie  first  indications.  There  may 
he  unaccountahle  fatigue  after  moderate  idiysical  or  mental  exertion.  In- 
stead of  apathy  or  indill'ercnce  there  may  be  uu  extraordinary  degree  of 


!i<;2 


DISEASES  OE  THE  NERVOUS  SYSTEM. 


pliysical  1111.1  iiicntiil  rostlossnos*.  The  putient  is  contimially  i-laiuiinj:  aiul 
sclainiiig,  or  mav  lauiu  ii  into  oxtnivajiaiicL'S  and  siioculatiou  of  tlio  \\\Uh-^t 
charactc'r.  A  toimnon  l\atun'  at  this  [leriod  is  tlio  display  oL'  an  un- 
Ijouiulcd  oj^oisiii.  lie  ix-asts  of  his  personal  attaiiinients,  his  property,  hi, 
pu.-iliou  ill" life,  or  of  his  wile  and  children.  Following  these  features  are 
important  indications  of  moral  perversion,  manifested  in  oltonces  agaiiis; 
dcceiicy  or  the  law,  many  of  which  acts  have  about  them  a  susiiicious 
ciTronterv.  Forget fulness'is  common,  and  may  be  shown  in  inatteiit.on  to 
business 'details  and  in  tiie  minor  courtesies  of  life.  At  this  period  there 
mav  be  no  motor  phenomena.  The  onset  of  the  disease  is  usually  msidi- 
.ms,  although  cases  are  reported  in  wliich  epileptiform  or  aiuiplectiform 
seizures  were  the  lirst  .-iymptoins.  Among  the  early  motor  features  are 
tri'inor  of  the  tongue  and  liiis  in  speaking,  slowness  of  speeeli  and  hesi- 
tancy, ineciualitv  of  the  iui])ils.  and  the  Argyll  Kobertson  pupil. 

("/»)  Scniiul  *S/(/r/('.— This  is  characterized  in  brief  by  mental  exaltation 
.,r  excitement  and' a  progress  in  the  motor  symptoms.  "The  intensity  of 
the  excitement  is  often  extreme,  acute  maniacal  stales  are  freciiieiit;  in- 
cessant restlessness,  obstinate  slei'iilessness,  noisy,  boisterous  excitement,  and 
blind,  uncalculating  violence  especially  characterize  such  states"  (Lewis). 
It  is  at  this  stage  that  the  delusion  of  grandeur  becomes  marked  and  the 
patient  believes'^himself  to  be  jioss. -ed  of  countless  millions  or  to  have 
reached  the  most  exalted  sphere  iiossihle  in  profession  or  occupation.  This 
expansive  delirium,  as  it  is  called,  is.  however,  not  characteristic,  as  was 
formerly  supposed,  of  ]iara!ytic  dementia,  besides,  it  does  not  always  oc- 
cur, but  in  its  stead  there  may  Ije  marked  melancholia  or  hypochondriasis, 
(ir,  'in  other  instances,  alternate  attacks  of  delirium  and  depression. 

'  The  fades  has  a  peculiar  stolidity,  and  in  speaking  there  is  marked 
tremulousness  of  the  lips  and  facial  muscles.     The  tongue  is  also  tremu- 
lous, and  mav  be  jirotruded  with  dilliculty.     The  speech  is  slow,  inter- 
rupted, and   blurred.     Writing  becomes  dillleiilt  on  account  of  unsteadi- 
ness of"  the  hand.     Letters,  syllables,  and  words  may  be  omitted.     The  siib- 
ject  matter  of  the  juitient's  letters  gives  valualih;  indications  of  the  mental 
condition.     Tn  nianv  instances  the  pupils  are  une.pial,  irregular,  sluggish, 
<umetinies  large,      "important   symptoms   in   this   stage  are  apoplectiform 
seizuri's  and  paralvsis.     There  mav  l)e  slight  syncopal  attacks  in  which  the 
imtieiit  turns  pale"and  mav  fall.     Some  .d'  these  are  pclil  mal.     In  the  true 
apoplectiform  seizure  the  imtient  falls  suddenly,  becomes  unconscious,  the 
limbs  arc  relaxed,  the  face  is  Unshed,  the  breathing  stertorous,  the  tem- 
j)crature  increased,  and  .leath  may  occur.     The  epileptic  seizures  are  more 
common  than  the  ai>oi.lectiforin  and  may  occur  in  the  disease.     A  delinito 
aura  is  not  uncommon.     The  attack  usually  begins  on  one  side  and  may  not 
spread.     There  mav  be  twitchings  either  in  the  facial  or  brachial  muscles. 
Tvpical  Jacksonian  epilepsy   may  occur.     In  a  ease  which  died  recently 
under  my  care,  these  seizures  were  among  the  early  symiitoius  and  the  uis- 
case   was   rc-^arded   as   cerebral  syphilis.     Paralysis,  either   monoidegie   or 
li.inii)le<Me.  mav  follow  these  epileiitic  seizures,  or  may  come  on  with  great 
suddenness  and  be  transient.     In  this  stage  the  gait  becomes  impaired,  the 
patient  trips  readilv,  has  dilliculty  in  going  up  or  down  stairs,  and  the  walk 


CIlRONIf;    niPFUSE   MENINTiO-KNCKPIIALITIS. 


Don 


may  lie  spastic  or  otcasidiiallv  talictic  This  pari'sis  may  lie  ]iro^i'pssivo. 
'J"Ir'  IviiL'u-jcri':  is  usually  iiuTcasud.  JUadiliT  or  rcital  syinptdms  j;ra(liially 
(!c'Vt'l(>[).  'I'lic  ])atii'nt  hccdiiu's  lu'lpk'ss,  bodridik'ii,  and  comiiicti'Iy  dc- 
iiiciiti'd,  and  iiidcss  care  is  taken  may  tiiillVi'  I'rnni  licdMirt's.  Ucath  occurs 
IVum  cxhaiistiiiii  or  I'mm  some  intercurrent  aU'ection.  'I'iie  aksencc  of  pain 
reaction  on  pressure  upon  the  tdnar  nerve  hcliind  the  clliow  (i5iernacki's 
symptom)  is  apparently^lot  of  any  si)ecial  value.  The  spinal-i'ord  features 
of  dementia  jiaralytica  may  come  on  with  or  precede  the  mental  trouliles; 
in  80  per  cent  of  the  cases  tliey  follow  them.  There  are  cases  in  which  one 
is  in  doubt  for  a  time  whether  tiu'  symjitoms  indicate  tahes  or  dementia 
jiaralytica,  aii<l  it  is  well  to  hear  in  mind  that  every  feature  of  pre-ataxic 
tahes  may  exist  in  the  early  sta<ie  of  /general  |)ari'sis. 

Diagnosis. — The  recognition  of  the  disease  in  the  earliest  stauc  is  ex- 
tremely dillicult,  as  it  is  often  iuipossihle  to  decide  that  the  sli;^ht  altera- 
tion in  conduct  is  anythinjr  more  than  one  of  the  moods  or  phases  to  which 
most  nlen  are  at  times  sul)ject.  The  I'ollowinjx  description  by  l-'olsom  is 
an  admiral)le  presentation  of  the  diajinostic  characters  of  the  early  stage 
of  the  disease:  "  It  should  arouse  suspicion  if,  for  instance,  a  strong,  liealthy 
man,  in  or  near  the  prime  of  life,  distinctly  not  of  the  "  lU'rvous,'  neurotic, 
or  neiirasthenic  type,  shows  some  loss  of  interest  in  his  ail'airs  or  impaired 
faculty  of  attending  to  them;  if  he  becomes  varyingly  absent-minded,  heeil- 
less,  indiiferent,  negligent,  apathetic,  inconsiderate,  and,  although  able  to 
follow  his  routine  duties,  his  a1)ility  to  take  u])  new  work  is,  no  matter  how 
little,  diminished;  if  he  can  less  well  command  mental  attention  and  con- 
centration, conception,  perception,  reflection,  judgment;  if  there  is  an  un- 
wonted lack  of  initiative,  and  if  exertion  causes  unwonted  mental  and 
physical  fatigue;  if  the  emotions  are  intensilied  and  easily  change,  or  are 
excited  readily  from  trifling  causes;  if  the  sexual  instinct  is  not  reasonably 
controlled;  if  the  liner  feelings  are  even  slightly  lilunted;  if  the  jn'rson  in 
question  regards  with  a  placid  apathy  his  own  acts  of  indiil'ercnce  and 
irritability  and  tlu'ir  consequences,  and  especially  if  at  times  he  sees  himself 
in  his  true  light  and  suddeidy  fails  again  to  do  so;  if  any  symptoms  of 
cereljral  vaso-motor  disturbances  are  noticed,  liowever  vague  or  variable." 

There  are  cases  of  cerebral  syphilis  which  closely  simulate  dementia  para- 
lytica. The  mode  of  onset  is  important,  jmrticularly  since  paralytic  synq)- 
toms  are  usually  early  in  syphilis.  The  all'ection  of  the  s])eecli  and  tongue 
is  not  present.  Epileptic  seizures  are  more  common  and  more  liable  to 
be  cortical  or  Jacksonian  in  character.  The  expansive  delirium  is  rare. 
While  symptoms  of  general  paresis  are  not  common  in  connection  with 
the  development  of  gummata  or  definite  gummatous  meningitis,  there  are, 
on  the  other  hand,  instances  of  j)aresis  which  follow  syphilitic  infection 
so  closely  that  an  etiological  connection  between  the  two  must  be  acknowl- 
edged. Post  mortem  in  such  cases  there  may  be  nothing  more  than  a 
general  arterio-sclerosis  and  ditfuse  meningo-encephalitis.  which  may  ]ire- 
seiit  nothing  distiiu'tive,  but  the  lesions,  nevertheless,  may  l)e  caused  by 
the  syphilitic  virus.  There  arc  certain  forms  of  lead  encephalopathy  wliicli 
resemble  general  ])aresis,  and.  considering  the  association  of  jjlumbism  with 
arterio-sclerosis.  it  is  not  unlikciv  that  the  anatomical  .substratum  of  the 


w 


^^ 


,)(}4  DISEASES  OF  THE  .NERVOUS  SYSTEM. 

,li.,.a?o  max  rosult  fn.ni  this  p.-isun.  Tiuunr  lUiiy  soindiim's  simulate;  \n-n- 
.rn-ivc  imn-sis,  hut  in  the  I'uniuM-  tiic  si-iis  ..f  -.'iKTal  nu-iva<o  d  tho  intra- 
.n.niai  p.vssur."  (pain  in  tlic  hca.!,  chok...!  disks,  sl..uin-  -f  the  pulM-rat.'. 
pidjrttiif  V(imitin-i)  iUT  usually  piTsrnt. 

Prognosis.— Tlu'  disisisc  rarely  onds  in  rei.ivcry.  As  a  rule  tlio  prog- 
ress is  slowly  downward  and  the  case  terminates  in  a  few  years,  althou-a 
it  is  oceasioiiallv  prolonged  ten  or  lii'teen  years. 

Treatment.— r he  onlv  hope  of  permanent  relief  is  m  the  cases  lollow- 
in-  svi.hilis,  which  sl.oul.l'he  placed  upon  large  doses  of  iodide  of  p<.tas- 
sium.  Careful  nursing'  an.l  the  orderly  life  of  an  a>yluni  are  the  onlv 
measures  necessarv  in  a  great  majority  of  the  cases.  For  sleeplessness  and 
the  epileptic  sei/.iires  hroinidcs  may  be  used.  Trolonged  remissions,  ^vhicli 
are  not  uncommon,  are  .d'ten  erroneously  attributed  to  the  action  ot  rem.'- 
die«  \ctivp  treatment  in  the  earlv  stage  by  wet-packs,  cold  to  the  head, 
and  systematic  massage  have  been  followed  by  temporary  improvement. 


IV    DIFFUSE  AND   FOCAL  DISEASES  OF  THE  SPINAL 

CORD. 

I.   TOPICAL   DIAGNOSIS. 

We  have  seen  that  a  lesion  involving  a  delinite  part  of  the  gray  matter 
of  the  lower  motor  seoment  is  accompanied  by  h^ss  of  the  power  to  per- 
form certain  delinite  movements.     A  disease,  such  as  anterior  p.a>o-mye- 
]iti«    which  is  cmfined  to  the  gray  matter,  gives  as  its  only  symptom  a 
characteristic  lower-segment  paralysis.     The  muscles  paralyzed  ^cvea      he 
sent  of  the  lesion.     In  manv  instances  a  transverse  section  ot  tne  ^lnnal 
cord  is  involved  to  a  greater" or  less  extent;  if  complete   there  is  lower-seg- 
ment paralvsis  at  the  level  of  the  lesion.     If  the  muscles  so  paralyzed  aie 
the  same  on  the  two  sides  of  the  body,  the  lesion  is  strictly  transverse   for 
obviously,  if  the  cord  is  inv^.h-ed  higher  on  one  side  than  on  the  other  the 
^aralvzed  muscles  wUl  vary  accordingly.     lU^sides  the  paralysis  due  to  in- 
volvement of  the  lower  segment,  the  nuiscles  whose  centres  are  below  the 
lesion  may  also  be  paralyzed  by  the  involvement  of  the  upper  segment  in 
the  pvranddal  tract,  and  present  all  the  chanutenstus  o    such  a  parab^s^ 
The  degree  of  the  paralysis  depends  upon  the  intensity  o    the  lesion  ot    h 
;    amidal  tract,  and  varies  fro,     a  slight  weakness  in  the  Hexion  of  t 
inkle  to  an  absolute  paralysis  of  all  the  muscles  beh.w  the  leMon.      1  he 
.nhincter  muscles  of  the  bladder  and  rectum  are  also  o  ten  paralyzed, 
■"'sensory  symptoms  are  usually  less  prominent,  but  when    he  spnial  cord 
i.  umch  diseased  there  is  a  dulling  of  sensation  all  cner  the  body  In  ow  tb 
lesion      The  ui.per  border  of  disturbed  sensation  often  indicates  the  level 
of  the"  disease.  esp-i^Hv  when  this  is  in  the  thoracic  region    where  the  cor- 
t     lulino-  motor  paralysis  is  not  easy  to  demonstrate.     It  is    o  be  noted 
;      ;;;:  amesthesia  does  not  reach  .piite  to  the  level  of  the  lesion;  thus 
if  the  fifth  thoracic  scLMi.ent  be  involved,  the  anaesthesia  will  include  the 


TOPICAL   DIAG\()SIS. 


wr> 


late  pro- 
ho  iiitni- 
ulM'-nit<'. 

tlu>  pi'og- 

js  iollow- 
iil'  putiis- 

the  only 
siH'.-s  and 
us,  which 

of  ninc- 
tho  htail, 
uont. 


PlXxVL 


■ay  mattiT 
IT  to  \n'V- 
|iiilin-niy(-'- 
pnj)tom  a 
reveal  llio 
the  spinal 

]o\ver-.seg- 
■alyzetl  are 
iverse,  for, 
'  other  the 
due  to  in- 

helow  the 
;egnieut  in 
I  paralysis, 
sion  of  the 
ion  of  the 
sion.     The 
:ilyzed. 
spiTial  cord 
;  helow  the 
'S  the  level 
L-re  the  eor- 
:o  be  noted 
csion;  thus 
include  the 


area  supplied  hy  the  sixth  seu-nunt,  hut  not  that  supplied  hy  ihe  lll'lh.  This 
is  due  to  the  overlap|iin,i:  ol'  the  areas.  There  is  olieii  a  narrow  zone  cf 
hypera'sthesia  ahove  the  aua'sthetie  rci^ion. 

When  the  transvi'rse  lesinu  is  eoinphte  and  the  hiwer  part  nf  tlie  curd  is 
cut  oil'  from  all  inlluenee  from  ahove,  there  is  cduiplete  seiis(U'y  and  inninr 
liaialy.-is.  aiul  tlu'  dee])  reilexes  instead  ol'  lieing  exaj^f^erated  are  lost. 

The  ditl'erent  reilexes  are  dependent  upim  diil'erent  levels  (d'  the  cord 
(see  Starr's  tal)le,  p.  DOo),  ami  their  ai)sence  nr  pri'seuee  may  he  important 
localizing  symptoms. 

Unilateral  Lesions. — The  motor  symptoms  utdch  I'olldw  lesiciris  con- 
fined to  (UU'  half  (if  tiu'  cross-section  (d'  the  spinal  cord  follow  tlie  same 
rules  as  those  given  for  transverse  lesions,  exei'|)t  that  they  are  conlliu'd  to 
(Uic  side  of  the  Ixuly — that  is,  they  are  on  the  same  side  as  the  lesion. 

The  sensory  symptoms  are  [)eculiar.  On  the  side  corresponding  to  the 
disease — the  paralyzed  side — there  is  aiiR'sthesia  corresponding  to  the  seg- 
nunt  of  the  cord  involved;  ahove  this  there,  is  a  luirrow  zone  of  liv|)era'S- 
thesia,  hut  helow  this  there  is  lU)  diminution  in  the  senses  of  touch,  pain, 
or  tem]ierature;  indeed,  there  is  (d'tcn  hypera'sthesia.  The  muscular  sense, 
howevi'r,  is  impaired.  On  the  side  opposite  to  the  lesion  there  may  he  com- 
jilcte  loss  of  the  sense  of  t(Mich,  pain,  and  temperature,  or  it  may  onlv  in- 
volve (Uie  or  two  of  tlu'se,  pain  and  tt  lupcraiure  usually  heing  associated. 

The  following  tahle,  slightly  inodilied  froiu  (iowers,  illustrates  th(>  dis- 
tiihution  of  these  syiniitoins  in  a  complete  hcmi-lesion  of  the  c(U'd: 

Cord. 


Zone  (if  cutniK'ous  liypfnestlicsin. 
Zone  "f  cutiint'dus  aiiM-stli(><iii. 
Lowor    si'gMioiil     luiralysi.s     with 
atrophy. 


Upper  sotriiient  paralysis. 
Ilypera'stliosia  of  skin. 
Muscular  sense  impaired. 
Keflex    action   first   lessened   and 

then  increased. 
Temperature  raised. 


Lesion. 


Muscular  jiower  normal. 
Loss  of  sensiliility  of  skin. 
.Muscular  sense  normal. 
Hellex  action  normal. 
Temperature  same  as  that  ahove 
lesion. 


It  is  only  in  exce]itional  eases  that  all  these  features  are  met  with,  for  thiy 
vary  with  its  extent  and  intensity. 

This  coinl)iiuition  of  symptoms  was  first  recognized  by  lU'own-Seipiard, 
after  whom  it  has  been  luimed.  It  may  follow  tumors,  stab-wounds,  frac- 
ture aiul  caries  of  the  spine,  and  it  is  not  infrequently  associated  with 
syringomyelia  and  ha^niorrhagos  into  the  cord. 

The  explanation  of  the  disturbance  in  sensation  is  not  satisfactory,  ami 
cannot  be  until  (uir  knowledge  of  the  ])atbs  of  sensory  eoudiiction  is  more 
accurate.  These  cases  have  convinced  most  clinicians  that  in  man  the 
paths  for  touch,  pain,  and  tem])erature  cross  in  the  middle  line  soon  after 
entering  the  .spinal  cord,  and  proceed  toward  the  brain  in  the  opposite 
side,  while  that  for  muscular  sense  remains  in  the  dorsal  columns  of  the 


d^ 


g,,(.  DISEASES  OK  THE   NEUVnlS  SYSTEM. 

.HI...  <U]..     W..  hav..  s.vn  tl.at  anatomy  U'M.ls  ....no  sui.i.urt  t..  this  viow. 

:       tl  i      s  tlH.  ..x,.lana„un   that   is  nsnally  givon.     '    "■  -l---^;;  - 
i  „  Is  hav..  thn.w  .  ..m..-  -hmht  ..n  this  vi.w.  ospcMa  ly  th..>..  ..I  M-ut  . 

r!!!:l.vs    whHh  s...Mn  t..  in.ii.a...  tiuU  .!..  ......ry  j.alhs  U.  the  mu.t  l^U 

iruiain  .in  tli.-  same  si.h'  ..f  th."  r.inl. 


II.    AFFECTIONS   OF   THE    BLOOD-VESSELS. 

1.  CoN(ii:sTi()\. 

\n.,rt  fn.n,  actual  n.v.litis.  w.  raivly  s.r  i-.^st  n,..rtrn.  .vi.lHuy.  .,1'  .;on- 

.rnv  n.att.r  ..r  to  a  .Idinitc  i..jrti..n  oi  the  oruan.        he...  .m.lc.  >sa.il>, 

fnm  t       l...s,un.  of  th.-  hody  i...st  n...rt.n,.  a  ,.vat.  r  d.,y..  oi  vascuh.r.ty 
,     ,,lal  ,.orti.m  ..f  tho\.o.-.l.     'Vh.  whit.  n.att.T  .s  .a.vly  i.uu.d  c.,..- 
Z      I    L  L-n  .>.ila.nod;  in  fact,  it  is  .v.ua.ka  U-  h.,w  nm  onn  y  pal. 
Uns  porti....  ..f  tlu.  .-..d  is.     'Uw  ^^-ay  n.attor  ult...  has  a  ro. hh.l  -i-nk    n, 

t  .^rl  •  a  d..,.  .vd.Ush  l.no.  .x.oi.t  who.,  .nyolitis  .s  present.  1  w..  k,  .,u 
UUl"!.nato.nically  ..f  eu.,.litio..s  ..f  eo..,estion  of  t  e  e...-d,  ..  kn...  le.. 
cliuicallv,  f..r  the.e  a.'e  ....  iVatu.vs  i..  a..y  way  char..eter.st.c  ol  .1. 


•i.  An.kmia- 

Su  to.,  with  this  state,     'riu'.-e  ...ay  l.e  extren.e  ^n-ades  of  a.Kv.nia  ..f  the 

00.-^^     u:.      sv.npt...ns.     In   ehl.....sis  a..d   pornieio..s  a...e,...a   th.-vo   juv 

V  Vv  .  pto.n's  p.  intin.  t..  the  eo.'d.  a,..l  tl.e.-e  is  no  .'eas.-n  t..  s..ppose  that 

:;;h-sensalhi>s  i  heaviness  in  the  l.n.hs  a,.d  ti..dinK  are  e.pec.ally  asso- 

""'n.n.e'a;rh;;tve.-.  so...e  ve..v  i..te.vs,i..,  facts  with  ..ef...-enee  to  th.. 

.n.ne  o...   .^  "  :''>7/ ;      \:J      .,ti,,,  ,vit!.  the  ..eeasional  rapid  develop- 

";     ;;i.a    V  d  K.   ::".  a,.at..n.ical  el,a..,e  in  the  nerve  ele,no,.s  s.n.dar 
llt^p. winced  i..  llcrter's  expori,..ents.      ^  ae  ^^'-^  '^  !;^.?;,^""^ 
eolu.nns  of  the  co.-d  i..  pcr..ici....s  a..aM..ia  ..as  alrea.ly  been  dcc.he.l. 

3    Kmholism  and  Thromuopis. 
cl.a.itios  i.i  the  cord. 


luH  View, 

llU'llt;^    (111 

■  Mdtt  (in 
luusl  larl 


■tS  (lf  (.lUl- 

luT  to  the 

va?(.ularity 
jnmd  ctin- 
iinnly  inilc 
i-|iiiik  tint. 
.  I'  we  kiinw 
know  k'?? 


LMiiia  of  the 
I  there  are 
ii])|)0!;e  that 
'cially  asso- 

eiice  to  the 
rta.  In  ex- 
that  within 
1  ])araple^na 
)i(lly.  This 
lid  devohip- 
tho  stomach 
or  ten  days, 
lents  similar 
A  the  dorsal 
crihed. 


may  be  pro- 

with  chorei- 

nection  with 

and  chronic 


1 


AFFECTIONS  OF  TFIH  HLOoD  VKSSFLS. 


•I.   i;\i).\i!Ti:i;rris. 


W, 


It  is  reinarkalih'  liow  l're(|Ueiitiy  in  jieisons  over  fifty  the  arteries  of  the 
spinal  cord  are  ioiiiid  seh^rotie.  'i'iie  fdliowiii;;  forms  may  be  met  with: 
(1)  A  nodular  peri-arteritis  or  endarteritis  associated  with  syphili.-  iind 
soiiietim.s  witii  ^Mimmata  of  the  meiiiiiKi.s;  (-j)  j,n  arteritis  ol)literans,  witli 
^reat  thiekeiiiii^^  of  tht-inlima  and  narrowin.ir  of  the  luiiieii  (if  the  ve->ei>. 
involving  chielly  tlie  medium  and  larger-sized  arteries.  Miliarv  aneiiri>iiis 
or  aneiirisins  of  (he  larger  vessels  ure  rarely  found  in  the  spina!  eord.  in 
the  classical  work  of  Leyden  but  a  single  instance  of  the  latter  is  nn  ntinncd. 

T).  Jl.KMoiiiniAoi:  INTO  Tin:  Simnai,  ^Ii;mi!kam:s;   II.km  \t(ii;i!Ii A(  iii>. 

in  meningeal  apoplexy,  as  it  is  called,  the  hlood  may  he  between  the 
dura  mater  and  the  sj.inal  canal— extra-meningeal  luemorrhage— or  within 
the  dura  mater — intra-meiiingeal  iKemnrrhage. 

{(I)  J'J.rlni-mcniiiiii'al  luiiiKirrlidj/r  occurs  usually  as  a  result  of  trauma. 
The  exudation  may  be  extensive  without  compression  (if  the  cord.  The 
hlood  como  from  the  large  plexuses  of  veins  which  may  surround  the  dura, 
'i'he  rupture  of  an  aneurism  into  the  spinal  canal  may  produce  extensive 
and  rapidly  fatal  lianiorrhage. 

(h)  Iiilrd-mciiiiii/cal  hivmarrlKuic  is  rather  more  common,  hut  i>  rarelv 
extensive  from  causes  acting  directly  on  the  spinal  meninges  themselves. 
Scattered  liiemorrhages  are  not  unfre(pient  in  the  acute  infectious  fevers, 
and  I  have  twice,  in  malignant  small-pox,  seen  much  eirusidii.  i'.leediiiir 
occurs  also  in  death  from  convulsive  disorders  such  as  epilepsy,  tetanu.s 
and  strychnia  poisoning.  The  most  extensive  luvmorrhages  occur  in  cases 
in  which  the  hlood  comes  from  rujiture  of  an  aneurism  at  the  base  of  the 
brain,  either  of  the  basilar  or  vertebral  artery.  In  several  cases  of  this  kind 
1  have  found  a  large  amount  of  blood  in  the  spinal  meninges.  In  ventricu- 
lar a])oplexy  the  blood  may  iiass  from  the  fourth  ventricle  into  the  spinal 
meninges.  There  is  a  specimen  in  the  medical  mu.-^enm  of  Mctiill  C'olkw 
of  the  most  extensive  intraventricular  haemorrhage,  in  which  the  lilo('id 
jiassed  into  the  fourth  vi'iitricle,  and  descended  beneath  the  spinal  ai'acli- 
noid  for  a  considerable  distance.  On  the  other  hand,  lucmorrhage  into 
the  spinal  meninges  may  possibly  ascend  into  the  hrain. 

The  si/inptoms  in  moderate  grades  may  be  slight  and  indefinile.  In 
the  non-traumatic  cases  the  hivmorrhage  n"iay  either  come  on  suddenly  or 
after  a  day  or  two  of  uneasy  sensations  along  the  spine.  As  a  rule,"  the 
onset  is  abrupt,  with  sharp  pain  in  tlie  back  and  svmptoms  of  irritation  in 
the  course  of  the  nerves.  There  may  he  muscular  sjiasms,  or  ])aralysis  may 
come  on  suddenly,  either  in  the  legs  alone  or  both  in  the  legs  and  arm.s 
In  .some  instances  the  i)aralysis  develojis  more  slowly  and  is  imt  complete. 
Tliere  is  no  loss  of  consciousness,  and  tliere  are  no  signs  of  cerebral  dis- 
turbance. The  clinical  picture  naturally  varies  with  the  site  of  the  luemor- 
rhage.  If  in  the  lumbar  region,  the  legs  alone  are  involved,  the  reflexes  may 
l)e  abolished,  and  the  action  of  the  bladder  and  rectum  is  impaired.  If  in 
the  thoracic  region,  there  is  more  or  less  complete  paraplegia,  the  reflexes  are 


^m^ 


9HS 


DISKASKS  OF  tup:  XERVOl'S  SYSTRM. 


iwuiillv  ivhiinc.l.  Mild  IIh'Iv  Miv  si-ns  ..f  disturliniur  in  tlic  lli..nuR'  luives, 
wiicli  ii«  ''inlK'  scMsiitiniis  i.iiiiis.  1111.1  soiiirtiiiics  fni|.ti.m  of  lifrpcs.  In  tlu" 
(.frvical'ivj,M(.ii  till-  Mviiis  as  well  as  the  l.-s  iiiiiy  hv  involved;  tlioro  may 
1)0  (liiTuiilty  in  luvatliin^',  .-tilVnos  of  tlic  iiiii>Llrs  of  the  neck,  and  oi'ca- 
sionally  ]ni|iillarv  syiiiptonis. 

'Vhv  pro^nio.-is  dc|.cn.l>  inii.li  ii|H,n  llir  caii.o  of  the  lui'iiionlia^M'.  I,;- 
covcry  niay^takr  place  in  tlu'  tiaiiniatir  .'aM's,  and  in  iliosc  a^s.R•iaU•d  witii 
till'  infi'ctioiis  disca.-^cs. 

C.   ii.KMoiMiiiACK  INTO  Till:  Stinai.  Coiu)  {nwmtttomijcHo). 

It  is  iiioiv  coininon  in  males  than  in  females,  and  at  the  middle  period 
,,f  lii',.  The  eases  li:ive  followed  either  eold  and  expo^nie  or  overexertion, 
and  most  fir.iiientlv  of  all.  trannmtisni.  It  is  most  freqnent  in  the  lower 
eervieal  iv-iioii,  the  most  eommon  site  for  dislocation  and  fracture  of  tlie 
«pinc  It'^ueiirs  also  in  tetanns  ami  convulsions,  lla'inorrhago  into  the 
(■.nd  inav  follow  injuries  of  the  spinal  column,  ^Min-shot  wounds,  etc.,  even 
when  the  cord  itself  has  not  I.een  touelu-l  (II.  I'ushing).  lIa'morrlia>,'e  niiiy 
1)0  a-sociated  with  tumors,  with  syriii>:o-myelia,  or  with  myelitis;  it  i«  olten 
dillienlt  to  determine  whether  the  case  is  one  of  i-rimary  Ineinorrliago  with 
mvelitis,  or  mvelitis  with  a  secondary  ha'inoiTha>:e. 

'  The  anuhiuirnl  amdifwn  is  very  varied.  The  coid  may  he  enlarged 
at  the  site  of  the  Inemorrhage,  ami  ocea>ionally  the  white  snhstaneo  may 
1)0  lacoratod  and  blood  may  escape  beneath  the  meninges.  The  extravasa- 
tion is  chiellv  in  the  gray  matter,  and  may  bo  limited  or  focal,  or  very 
'  dllhKO.  oxtemling  a  considerable  distant  in  the  cord.  In  a  case  which 
occurred  at  tlie  Montreal  (ionoral  Hospital  under  Wilkin.s  the  hioniorrhago 
occuiiied  a  posit i.m  opiM.sito  the  region  of  the  liftli  and  sixth  cervical  nerves 
and  on  transverso  section  the  cord  was  occup'.ed  by  a  dark-rod  clot  moasnr- 
i„.r  i->  hv  ,^,  mm.,  arnund  which  the  white  snltstanco  formed  a  thin,  ragged 
widl.  The  clot  could  be  traced  upward  as  far  as  the  second  cervical,  and 
downwanl  as  far  as  the  fourth  thoracic  segment.  ■    ■     .    , 

The  sudden  onset  of  the  siiinptomfi  is  the  most  characteristic  toature 
in  Invmatomyolia.  The  loss  of  power  necessarily  varies  with  the  locality 
ntfectod  If'in  the  cervical  region,  both  arms  and  legs  may  be  involvo.l; 
but  if  in  the  thoraci.-  or  lumbar,  there  is  only  paraplegia.  There  is  usually 
los.  of  sensation,  and  at  first  l.iss  of  rollexes.  .Myelitis  frociuently  develops 
and  hecomos  oxtensivo,  with  fever  and  trophic  changes.  The  condi  ion 
may  raj.idly  prove  fatal:  in  other  instances  tliere  is  gra.lual  recovery,  often 

with  partial  paralysis.  •     ,    i     .i 

The  dia.niosis  mav  bo  made  in  some  instances,  particularly  those  in 
which  the  onset  is  sudden  after  injury,  but  there  is  groat  diiliculty  in  dii- 
forentiating  Inrmorrhagic  myelitis  from  certain  cases  of  luemorrhage  into 
the  spinal  meninges. 


! 


(■  niivos, 

1 

\  \\\v 

icre 

may 

lul 

(K'l'll- 

\gQ. 

\l- 

It  I'd  witli 


lie  iH'i'iiul 

I'l'XlTtillH, 

the  lower 
ii'o  (iT  tlic 
■  into  the 
oti'.,  even 
•lia^'o  iiriy 
it  is  often 
lia^^e  witii 

'  enlarged 
:aiiee  may 
extravasa- 
1,  or  very 
ase  wliieli 
omorrliage 
ieal  nerves 
ot  nioasur- 
lin,  rag.ued 
nieal,  and 

tic  feature 
lie  locality 
;  involved; 
}  is  usually 
[y  develops 
!  condition 
very,  often 

ly  those  in 
alty  in  dif- 
rrha-ie  into 


AFFRCTIOXS  OF  TIIK   HLOOD-VKSSKLS. 

7.  Caisson-  Diskasi:  {Dirrr's  l>,trahis!s;  Comprrssnl  An'  Disrasr). 


DC!* 


lliis  remarkaiile  all'ecti.ui,  i I  in  divers  nii.l  in  workers  m  caissons 

IS  characterized  l.y  a  |Mra|.le-ia,  more  rarely  a  -■enerai  |.alsv,  whi.h  super- 
venes on  retnrnmg  from  the  eonipressed  atmos|)|i..re  to  the  surlaee. 

'I'he  <li>e;ise  Jims  heeii  earefnliy  stiidje,!   |,y  the   I'reneh   writers^  i)y   Ley- 
deii  and  Schiijixe  in  (iermany,  and  in  this  eoniitry  parlienlarly  l.y'A.  l'| 
Smith.      Il   has  heen  made  the  suhjeet  of  a  speeiiil   monojrra|.h   hy  Snell 
'I  he  prosure  must  he  more  than  that  of  three  atmospheres.     The  symplonis 
are  espeeially  apt  to  eonie  on  if  tlie  chan.ire  from  the  hiuj,  (,,  (he'ordinary 

atmo-pherie  pressure  is  (iinekly  made.     They   may  s. ■vei...  .mmediat..|y 

on  leavinn  the  caisson,  or  tiiey  may  l)e  <ielayed  for  several  hours.  In  the 
mildest  form  there  arc  simply  pains  ahoiit  the  knees  aihl  in  the  legs,  often 
ol  great  sevrity,  and  occurring  in  paroxysm.s.  Ahdomiiial  pain  and  vomit- 
ing are  not  uncommon.  'I'he  legs  may  he  tender  to  the  toiieh  and  the 
patient  may  walk  with  a  stilf  gait.  Dizziness  and  iicadaehc  niav  aecompany 
tlRw  neuralgic  .symptoms,  or  may  occur  alone.  .More  eoniinonly  in  the 
severe  form  there  is  paralysis  hoth  of  motion  and  scMisalion,  usually  a  para- 
I'lcgia,  hut  it  may  he  general,  involving  the  irunk  and  arms.  .Monople-ia 
and  hemiplegia  are  rare.  In  the  most  extreme  instances  the  attacks  reseni- 
hle  apo|)lcxy;  the  patient  rapidly  hecomes  comatose  and  death  occurs  in  a 
lew  hours.  In  the  case  .d'  paraplegia  the  outlook  is  usually  good,  and  the 
I'aralysis  may  pass  olf  in  a  d;iy,  or  may  continue  for  several  weeks  or  even  for 
months. 

The  explanation  of  this  condition  is  hy  no  means  .satisfactory  Several 
careful  autopsies  have  heen  made.  In  Leyden's  ca.se  death  occurred  on  tlie 
htteeiilh  day,  ami  m  the  thoracic  portion  of  the  cord  there  were  numerous 
loci  of  ha-morrhagcs  and  signs  (d'  an  acute  myelitis.  In  Schuitze's  case 
death  occurred  in  two  and  a  half  months,  and  a  disseminated  myelitis  was 
found  in  the  thoracic  region.  In  hoth  cases  there  were  fissures,  and  a|)pcar- 
anccs  as  if  tissue  h.,d  heen  lacerated.  In  a  case  examined  on  the  third  day 
(/icgU'rs  P.citriige,  mvi)  this  condition  of  tissuring  and  laceration  was 
iound.  It  has  heen  suggested  that  the  symptoms  are  due  to  the  liheration 
111  the  spinal  cord  of  huhhles  of  nitrogen  which  hay.,  heen  ahsorhed  hy  the 
lilood  under  the  high  pressure,  and  the  condition  found  at  the  autopsies 
just  referred  to  is  held  to  fav.u'  this  view. 

A  large  majority  of  the  cases  recover.  The  severe  neuralgic  pains  often 
rcciuire  morphia.  Inhalations  of  oxygen  and  the  use  of  C(mipre,<sed  air  have 
heen  advised.  When  [niraplcgia  develops  the  treatment  is  similar  to  that 
ot  other  forms.  In  all  caisson  work  care  should  he  exercisd  that  the  time 
in  passing  thi.)ugh  the  lock  from  the  high  to  the  ordinary  pressure  he  sulli- 
ciently  prolonged.  Snell  lays  less  stress  on  this  than  on  the  proper  ventila- 
tion of  the  caisson. 


fi] 


rtaik 


970 


DISKASES  OF  TIIK  NKUVOUS  SYSTKM. 


A  vrlro- 


III.    COMPRESSION    OF   THE   SPINAL   CORD 

(ComiinnHit)H  Mi/vliliH). 
Definition.   -I..l.nni>li""  "I'  tl'»'  linutums  ..f  llie  onl  I.}'  ^lo^v  vnm- 
''"Eti^Ogy.-Carirs  of  tlu'  spin...  new  Kn-wths  .UH.uri>m,  an.l  i-iiraMtos 

tt V.'suTlly  called,  alter  the  M.r,.uM  who  Ih.t  do^cribcd  U,  .s  .n  11.0, real 
,„a'j„ri(v  V.    instamrs  a  tulunulous  alV.rlio,,.     In  a  Irw  oases  .1  is  .hw  to 

,,>st  c.o.nn...n   in  early  \.'.V    I'l't  .nay  oeenr  alter  nu.  .lie  aj^e.     it   loUo. 
„  ,  i„  ,  ,Vw  c.as..s      ('on,pres.k„v  oeeasionally  n^-Hs  l-m  aneur.sn,  oi 
l;;;;;;:,;;;.,;  aorta  or  tin.  al^donnnal  aorta.  :.:nu.nu^  1  oMhe  nehae 

''^".Mali'Mianl  growths  ire.inently  eause  a  eoiniMV>sion  parap'.  i-.t- 
,,,,Uoneal  sareon.a  or  the  lynipha.lenon.atous  growths  ol  llo.l^ikm 
r,',v  invade  the  vertc-hne.     More  eonunonly,  however,  the  .nvolvenienl  .. 
sirondarv  to  seirrhns  ul'  the  breast.  _ 

Of  parasites,  the  echinoeoeens  and  the  eystieerens  oeea>,onally  oeenr  .n 
the  s,.inal  eanal.     For  a  nmsterly  eonsi.leration  of  the  Nvhol.  •l.'"^.*-"-  j';"'- 
tiadarly  fron.  a  snr.ieal  standpoint.  l--;l-\--'i;71^ ;  '^  ''"-'-l'"'-* 
(Mitt   a   d.  tirouzgehiet.  der  Chir.  n.  d.  :\led..  ls!H,,  l,d    i). 
^      Symptoms.-These  n.ay  W  eon^idennl  as  they  alleet  the  l,ones.  the 

"''In  VeitebraL~ln  n.nli-nant  diseases  an.l  in  anenrisn.    erosion  of  the 

hod       may  take  plaee  without  produeing  any  deformity  ol  the  sp.ne.    I'utal 

H  nnZ^e    nav  follow  erosion  ..f  the  vertebral  artery.     In  eanes,  on    he 

;        ,      a    it  is  the  rule  to  iind  n>ore  or  less  dofornuty,  an.onn  >n,j  olten 

othd  liano,  i  ..„„,nre<<i()n  is  laroelv  due  to  the  Ihiekenmg 

;;;  ;i;';;; ;.:, ;::,    J «. ;:;"'.';:.» »-i  i"""™™'-.v  i"™;-",  '-'«■-■, 

01  till  (inia  cinu  lui  1  ,.n.nnr.'«i(m  i-^  rare  V  imx  need  direetlv 

i:;;:t;;r";;;;;   i    r;=ant  Ind!  i;:i;;e  ::  ;.  anenVi  •  n  and  tun.,  an 
!;•  .linrioatore.     In  earies,  the  spinal  processes  of  the  alU..e.l  yerteb-a- 
are  tender  on  i)n-ssure,  and  pain  ioUows  jam 
the  spine.     There  may  bo  extensive  tuberc 
formitv.  particularly  in  the  cervical  re- 

{2)  Nerve-root  Symptoms.— These 
roots  as  they  pass  out  between  the  vc.        .•■. 

r„nv  ho  nn  early  SYmi)tom.     It  is  remarkable  ■      ,  .-      .       v  ,• 

^n^iv^  r    i   '  they  eCape  and  the  patient  does  not  complain  ol  rad,atm<^ 

,:u;o  distiintioi  of  the  nerves  from  the  airected  se^ien         Mins 

iro  more  common  in  canccM-  of  the  spine  secondary  to  that  ot    he  bua.t, 

^r  uncases  may  be  a.oni.in,.    ^Phere  -'^y/:--^^^^^^  P^;  ^  .^:^- 

1,,  a.n'slhrsin  <h>lorosa.  in  re-nons  of  the  skm  winch  ar,.  ''"^^'^t^'^'      ,     ,    1  , 

,     „1  painful  iminvssions.    Trophic  disturbances  may  occur,  pa  t.cul,Hl> 

,  e         n    be  ce  vical  or  lumbar  regions  invssure  on  the  ventral  roots 

:ivc  ris     0  vesting  of  the  nn.scles  supplied  l>y  the  affected  nerves. 


x'vonieiits  or  twisting  of 
■ase  without  much  de- 

•  mi  cominession  of  the  nerve 
A  cervico-brachial  neuralgia 
how  fre(iuently.  even  in  ex- 


CoMI'UKSSKiX  OF  TIIK  SPINAL  ('(tKD. 


1»71 


r-li)\V    C'Olll- 

1  iiiU'a«itt's 

lllM';!:^!',   as 
1    tllC  ^M'e'ilt 

I  is  due  til 
nix.  It  is 
It  roUuws 
in'urisiii  of 
'  ihc  (•(I'liai' 

I.  A  ri'ti'o- 
iii's  lii-  -;  " 
)lveiii(.'iit  is 

|)y  occur  ill 
cstion,  jiar- 
l-imiiortar.t 

■   llDlU'S,   tlu' 

ision  iif  tin- 
pine.  Fatal 
ivies,  on  the 
ilitili<I  oi'tcii 
;  thiclvoning 
nets  between 
iced  directly 
id  tumor,  an 
ted  vertebiu' 
!■  twisting  of 
lit  iiiucli  de- 

ol'  the  nerve 
ial  neuralgia 
,  even  in  ex- 

(if  radiating 
nient.  Tains 
)i  the  breast, 
[infill  areas — 
;thetie  to  tae- 
r,  particularly 
ventral  roots 
ed  nerves. 


(:{)  Cord  Symptoms.- (")  Cmintl  i;njinn.-Sn{  iiirrc,|iu.ntlv  th.'  caries 
is  liigh  lip  iietwccn  the  a\i.-  and  the  atlas  or  between  tlie  lainr  an, I  ilic  o.- 
<  il'ital  bone.  In  Mich  instances  a  relrn|i|ffiryiinral  alisirv-  may  lie  |uvs.nl, 
giving  ri>e  to  dilliciilty  in  swallowing,  'riicrc  ni,iy  be  spa>in  ol'  tiic  cervKal 
niiixics,  the  head  may  be  fixed,  and  movcmenl>"mav  cither  be  impossible 
or  cause  gr.'at  pain.  In  a  ca^c  of  this  kind  in  the  MoiiIivmI  (biicral  Hos- 
pital movement  was  liable  to  be  b.llow.d  by  lian>iciil.  in>laiilaiic,,ii-  puraly- 
>is  (d'  all  Unw  extremities,  owing  to  compres.-.ion  of  the  cord.  In  one  of 
these  attack.-  tiie  patient  died. 

Ill  the  lower  cervical  region  there  may  be  signs  ol"  interference  with 
tlie  cilio-s|.inal  ceiilre  and  dilatation  of  tlie  |.ii|.i!.<.  Occasioiiallv  there  is 
llii.-hing  of  the  face  ami  car  of  one  side  or  unilateral  .-wcatiiig.  i)cbiriiiity 
is  not  so  c(,iiiui.m,  but  healing  may  lake  place  with  the  pio.luclioii  of  a 
callus  of  enormous  breadth,  uitli  eomplele  rigidity  of  the  neck. 

(/')  Thonirir  />,//,<//. —The  deformity  is  here  more  marked  and  pivssiire 
symptoms  are  more  common.  The  time  of  onset  of  the  paralysis  \arics 
very  niiich.  It  may  be  an  early  sym|itoni,  even  bebire  the  curvature  is 
manifest.  .More  commonly  it  is  late,  occurring  many  months  after  the  eiirva- 
liiie  has  developed.  The  paraplegia  is  slow  in  its  (levelopmeiit ;  the  patient 
at  first  feels  weak  in  the  legs  or  has  disturliancc  of  sensation,  numbness, 
tingling,  iiins  and  needles.  The  girdle  sensation  may  be  marked,  <ir  severe 
pains  in  the  course  of  the  intercostal  nerves.  Motion  is,  as  a  rule,  imuv 
quickly  lost  tiian  sensation.  Jiastian's  symptom— abolition  of  Ihi'  reflexes— 
is  rarely  met  with  in  compression  from  caries.  Finally,  there  is  complete 
interruption  with  the  production  of  paraplegia,  nsiiallv  (d'  the  spastic  type, 
with  exaggeration  (d'  the  reflexes.  This  may  persist  "b>r  months,  (.r  ("veii 
f'lr  more  than  a  year,  and  recovery  still  hi'  possible. 

{(■)  Lumbar  J!('</!n,i.—\n  the  lower  dorsal  and  lumbar  regions  the  syin|i- 
toms  are  practically  the  same,  but  the  sphincter  centres  are  involved'  and 
the  reflexes  are  not  exaggerated. 

Diagnosis.— Caries  is  by  bir  the  most  freipicnt  cause  of  slow  com- 
pression of  the  cord,  and  when  there  are  external  signs  the  recognition  is 
easy.  There  are  ca,<es  in  which  the  exudation  in  the  spinal  canal  between 
the  dura  and  the  bone  leads  to  compression  before  there  are  any  siiiiis  of 
caries,  and  if  the  root  symiitoms  are  absent  it  may  be  extremcl'v  diilicult 
to  arrive  at  a  diagnosis,  daneway  has  called  attention  to  ])ersistent  lum- 
bago as  a  symptom  of  iinjiortance  in  masked  Pott's  disea.<e.  particularlv 
after  injury.  I'.rown-Sequard's  jiaralysis  is  more  common  in  tumor  and  iii 
injuries  than  in  caries.  Pressure  on  the  nerve  roots,  too,  is  less  frciim^nt 
in  caries  than  in  malignant  disea.se  The  cervical  b.rin  of  pachvmeiiingitis 
also  ])rodiiees  a  i.ressure  paralysis,  the  .symiitoms  of  which  liave  already  been 
detailed.  Pressure  from  secondary  carcinoma  is  naturallv  siii;Lrested"  when 
spinal  symptoms  follow  within  a  few  years  after  an  oiiera'tion'for  cancer  of 
the  breast.  In  jiaraplegia  following  tumor  of  the  vertel)ra  secondary  to 
cancer  of  the  breast,  and  in  the  erosion  of  the  spine  by  retroperitoneal 
growths,  the  suffering  is  most  intense.  The  condition  has  been  well  termed 
pnraph'fiia  thhrosn.  I  have  seen  2  cases  in  which  the  breast  tiuuur  had 
not  been  recognized. 


i 


972 


DISEASES  OF  TIIH  NERVOUS  SYSTEM. 


Treatment.-ln  , „.n..-  ■. -";„:  ^--^Jll^Xlt';,!: 

„„,,„i,,..  ,„  ,1,0 1..,.„,-,-  ,i„'  i»;;;: » ■; ;    ;     ,;    „;,  ..,„;„„„,„„  ,„ 

;:  ;,j;i:^,r:;::'™ri'l;;  ;,Xj,  ,,..>v,-n.y  »..,™--y '1 -':<;: 

lircvcnt  tli 

..Mansion  .uiv.'s  tlie  lu'st  1hM'>-  "'   .^-■•■-■.■-       -  ^    .         ,.,„^. 


1,.  ,lH.  various  mctluKl.  now  uso.l  hy  suvf^co.  >  m.n  ""      -. 
;  n  >..t  of  paraplopa.     Wh.n  paralysis  has  dovclo,-.!.  u .    .  t 
'   iv.s  the  iL  U  on...ov.T,,    n   .s  to    >o  rnn.^^^ 


,     ,  .     '■'; ,",\.  1    K   ^litcholl  in  ISV'i;,  an.d  pursued  witli  rL-niarkahh 

method  u.trodu.ed    >  .1.  K.  -^^  ^^'^  .  ,„,.,,„,,, tion  with  the  Inlirn.ary 

success  l.y  iiis  son,  W  eir  MitehelL   Dunng  '         .  ,,^,,,,,1,1,.  the  really 

Diseases  1  had  numerous  ..pportunitu's  .>l  winu...  • 

f  „or<istent  suspense        even   in  aiM'arentlv   despc.  < 

'mi  .heirs  ..oneluMons  are  that  suspension   slum  d 

■    , ,  K.  ;..  t>.H 'd  -ea.e:  that  used  with  eare  it  enables  .is  sh>wlv 

t:  u.;„Mlie  curve;  that  'jV'^' :'";;:;;;;X:th;.vi:is'.reat  loss  of  power 
placement  of  the  crumpled  tissues,  that  '-j;'- ,_^;;^;,^,^„;,, 


rhe  iiiosl 


for  Xervou 
remarkable  elfeets  o 
and  ])rotraeted   cases. 


"'  ^'7^:"   :  vW  i;riV>;--  •      -    that  used  with  ca,.  it  enables  .is  sh> 
,ei.nii.loved  eaih  ">     ''"  .  o  _    r  .^^  ^^^^^^^^  ^,^^^,^^^^  ^^ 

o  lessen  the  curve;  that  m  tlie>e  '''';  ^        , ,'"      ^      ;,  „,,,t  p,,,  of  po 
placement  of  tiie  crumpled  tissues:    ha    ^     ^   ^^     ;,:;;::;„,,„,,.n   espe- 
Ipo  use  of  the  spine-c.r  or  <  ':^"- ;    !  ,  ^  ;^^^^   ;    ,,,  that  no  case  of  Potfs 
eiallv  in  children,  to  be  combined  xMth  ^""'!^,'^';'';,  •■     .  , .  ....^^  .u^nension 


successful 

he  uvnei 


doubtful  value. 


Lksion 


s  or  THK  Cvrnv  Ec^riNA  axu  Cosrs  Mian-u-AU... 


In  a  fracture  or  dislocation  o 


f  the  first  luinl)ar  vertebra  the  conus  me- 


li 


ixlition  i.s 
lit  in  the 
vssion  liy 

llj)])()l't  to 
)    1UIU'1\    to 

rost  with 
icrc'd  lliiit 

for  laiuiy 
ivst  aloiH'-. 
[irieri  hcal:^. 
rip(.'n>-ion,  a 
i'(>iii;ukal)lo 
_.  Inlinnary 
r  tho  really 
;  (Icsitorato 
;i(>n  should 
.'s  lis  slowly 
f(.rin,  a  rc- 
Hs  ol'  ]w\ver 
nsion,  ("spo- 
isc  of  rott':> 

siisiu'iisioii 
c  ])ull  ]irol)- 

gain  is  not 
vc;  that  tin) 
varied,  pro- 
lyrtlv  of  timo 
2,  and  pcnsa- 
ro  any  signs 
>on  tried  for 
istances  been 

csli  air,  good 
istances  is  of 


•bra.  Tnjury, 
itself,  but  the 
iiil  ]ioriion  of 
von  to  lesions 
irburn's  work, 
•egion.  tumors 
.  and  some  of 

tbe  conus  me- 


TI'.MOKS  OF   TllH  Sl'IXAL  CoKD   AND   ITS  MK.MIil{ANHS.  j);;} 

(luUaris  may  be  c'om])ressed  with  the  last  sacral  lU'rves  given  oil'  from  it. 
Ill  a  ease  rejiorted  by  Kirehholl'  there  was  laeiTation  of  the  eoiui>  witli 
(■(iiii]ilete  |iai'aly.-i>  of  the  blaihhr  and  leeliiiii.  a  ea>e  wliieh  is  lield  to  lavnr 
the  view  tliat  tlie  ano-vesical  centre  in  man  is  situated  in  this  region  of  the 
cord.  'J'licre  arc  several  instances  on  record  in  which  injury  cd'  the  eauda 
Ciiiiina  ha>  product'd  paralysis  of  the  bladih^i'  and  rectum  alone,  sometimes 
with  a  slight  ];alch  (d'  amesthesia  in  the  neighborhood  of  the  coccyx  ov  tin' 
perina'um.  More  eommoiily  branches  of  llu'  sacral  or  lumbar  nerve  ro(]ts 
ale  iiivolve(l,  producing  an  irregularly  distributed  uu:)tor  and  sensory  paraly- 
sis in  the  legs.  A\'lien  the  lumbar  neive  roots  from  the  second  to  the  lifth 
are  eom[)ressed,  there  is  paralysis  of  the  muscles  of  the  li'gs,  with  the  ex- 
eejition  of  the  llexors  of  the  ankles,  the  peron;ei,  tho  long  llexors  of  the 
toes,  and  the  intrinsic  muscles  of  the  feet,  and  loss  of  .sensation  in  the  front, 
inner  and  outer  part  of  the  thighs,  the  inner  side  of  the  legs,  and  the  inner 
side  of  the  foot.  The  sacral  roots  may  ah)ne  be  involved.  Thus  in  a  case 
which  I  have  re|iorte(l  the  ])atient  fell  frcun  a  bridge  and  had  paralysis  of 
the  legs  and  of  the  bladder  and  rectum.  When  seen  sixteen  years  after  the 
injury,  there  was  slight  weakness,  with  wasting  of  the  left  leg;  there  was 
complete  loss  of  the  function  in  the  am)-vesical  and  genital  eenti't's,  and 
ana'sthesia  in  a  strip  at  the  back  part  of  the  thigh  (in  the  distriimtion  of 
the  small  .<eiatic),  and  of  the  perina'iim,  scrotum,  ami  jienis.  The  urethra 
was  also  insensitive. 

Starr's  table  and  Head's  figures,  given  in  the  general  introduction,  will 
be  found  useful  in  determining  the  nerve  fibres  and  segments  involved  in 
these  eases  of  injury  of  the  eauda  equina. 


IV.   TUMORS   OF   THE   SPINAL   CORD    AND    ITS 
MEMBRANES. 

New  growths  may  develop  in  the  cord  or  in  its  membranes,  or  niav 
extend  into  them  from  the  spiiu'.  The  first  two  alone  will  be  considere(i. 
Occasionally  lipoma  and  ]iarasites  occur  in  the  extradural  space.  Within 
the  dura  fibromata,  sarcomata,  and  syphilitic  and  tuberculous  growths  are 
most  common.  In  the  cord  itself,  and  attached  to  the  pia  mater,  the  tu- 
berculous, syphilitic,  and  gliomatous  growths  are  most  frccjiu'tit.  Of  .Vi 
eases  of  tumor  of  the  sjiinal  cord  and  its  envelopes,  analyzed  by  [NFills  and 
Lloyd,  only  o  were  parasitic.  Of  these,  'iD  were  some  form  of  neoplastn,  of 
which  sarcomata  were  ntost  common,  5  were  gummatous,  and  -t  tuberen- 
lous.  Ilerter  has  recently  reported  1]  cases  of  solitary  tubercle  in  the  eord, 
and  has  analyzed  others  from  the  literature.  Of  54  oases  in  which  the  age 
was  given,  l."j  occurred  between  the  ages  of  fifteen  and  thirty-five,  and  Ti 
before  the  fifth  year.  The  tumor  is  most  eommoii  in  the  dorsal  and  Itiinbar 
regions,  and  is  usually  met  with  in  connection  with  tnberrulous  le«inns  else- 
where. 

The  anatomical  effects  of  tumor  are  very  varied,  f^low  compression 
is  usually  ]miduced  by  growths  external  to  the  cord,  and  it  is  remarkable 
what  a  high  grade  of  compression  the  cord  will  bear  without  serious  inter- 


074: 


DISEASES  OF   THE   NEIIVOUS  SYSTEM. 


forcncc  witli  it?  fun(•tioll^l.  In  case?  of  prolnrifroil  intoiTU])tion  ascenaiiig 
and  (U'S(rn<lini:  (lcL'cncratii)n>;  occur.  Tnniors  (U'vclopinfj:  witliin  the  cord 
may  Iwul  1o  syrin^M.-niyclia.     And,  lastly,  tumors  not  inlrcMiuontly  oxcito 

intense  nivelitis. 

Symptoms.— These  will  naturnlly  vary  a  .uood  deal  with  the  segment 
involved  and  with  the  degree  of  pressure  and  the  extent  of  impliealion  of 
the  nerve  roots. 

Within  the  cord  the  syniptnnip  are  those  of  a  gradually  progressing 
paraplegia,  which  may  at  first  have  the  picture  uf  a  i'.rown-Sequard  i)araly- 
sis.  Atrophy  follows  the  involvement  of  the  ventral  cornua.  and  vaso- 
motor disturhanecs  may  he  marked.  The  rellexes  are  lost  at  the  level  of 
the  lesion,  hut  if  this  he  in  the  thoracic  cord,  the  reilexes  are  retained  in  the 
legs.  The  sym].tonis  are  apt  to  he  complicated  with  those  of  acnte  (ir  suh- 
aciite  myelitis,  whieii  may  com]iletely  alter  tlie  clinical  picture.  Tumors 
of  the  sjiinal  mend)ranes  "are  characterized  hy  the  early  onset  and  persist- 
ence of  the  root  svmptoins,  which  consist  of  radiating  pains,  the  girdle  sen- 
sation, and  hviicnesthcsia,  or  ana>sthesia  in  various  portions  of  the  trunk. 
There  may  even  he  severe  pain  in  the  aiiivsthetic  areas.  Irritation  of  the 
motor  roots  mav  cause  spasm  of  the  nniscles  supplied,  or  wasting  with 
paralysis.  The  "piirapl^f-''''  t^<il"'>'\'''"'^  ^"""'  ^''"'^  "^^^''"  ^'"'  occurrence  of 
the  root  svmptoins.  In  the  thoracic  region  the  level  of  the  growth  is  usu- 
ally accurately  defined  liy  tiie  level  of  the  pain  and  the  condition  of  the 

reflexes. 

The  diagnosis  of  tumor  within  the  cord  is  sometimes  easy,  tiu^  ciiarac- 
1eristi<'  features  being  the  constancy  an.l  severity  of  the  root  symptoms  at 
llie  level  of  the  growth  and  the  jn'ogre-^sive  paralysis.  Caries  may  cause 
identical  svmptoms,  hut  the  radiating  jwins  are  rarely  so  severe.  Cervical 
menimritis  sinnilates  tunuir  very  closely,  and  in  reality  produces  identical 
elVects"  hut  the  very  slow  jirogress  and  the  bilateral  character  from  the 
outset  mav  l)e  suHicient  to  distinguish  it. 

In  chronic  transverse  myelitis  the  symptoms  may,  according  to  (iowers, 
simulate  tumor  very  closely  and  present  radiating  pains,  a  sense  of  con- 
striction, and  i^rogressive  jtaralysis. 

The  nature  of  the  tumor  can  rarely  be  iiulicated  with  precision.  \\  ith 
a  marked  syphilitic  history  gumma  niay  naturally  be  suspected,  and  with 
coexisting  tuberculous  disease  a  solitary  tubercle. 

Treatment.— Tf  the  iiossibility  of  syphilitic  infection  is  ]n-esent  the 
iodide  of  potassium  should  be  given  in  large  and  increasing  doses.  For 
the  severe  pains  counter-irritation  is  sometimes  lienefieial,  i)articularly  the 
thermo-cauterv;  nior])hia  is,  however,  often  necessary. 

In  a  few  instances  tumors  of  the  cord  or  of  the  membranes  are  amena- 
ble to  surgical  treatment.  The  removal  by  ITorsley  of  a  growth  from  the 
spinal  membranes  was  one  of  the  most  brilliant  of  recent  oiierations. 

Ah.^rrss  of  the  rnrd  is  a  rare  lesion,  of  which  only  :^  or  4  cases  have  been 
described,  all  metastatic.    It  may  occur  without  meningitis. 


1) 


SYUIXGOMYKLIA.  <j75 


V.    SYRINGOMYELIA. 

Definition. — A  filioinatim^'  now  I'uriiiutinn  ahimt  tho  rciiiinl  onnal  of 
till'  spinal  (111(1,  witli  cavity  rorinatioa. 

Etiology  and  Morbid  Anatomy. — Syrin^fomydia  must  he  dis- 
tin,i;iiislic(l  Irom  dilataTion  ol'  the  central  canal — liydnniiyi'liis — sliudit, 
^Madis  of  wliicli  arc  not  very  iincoinnioii  cither  as  a  congenital  condition  or 
as  a  result  of  the  pressure  of  Inuiors.  'I'he  cavity  of  syringomyelia  has  a  vari- 
alilo  extent  in  the  cord,  sometimes  running  the  entire  length,  hut  in  many 
cases  inv(d\ing  only  the  cervical  and  tluu'acic  regions  or  a  m(M-e  limite(l  ai'ea. 
It  is  usually  in  the  dorsal  portion  of  the  cord  and  may  extend  oidy  into  one 
dorsal  cornu.  'J"he  transverse  section  may  he  oval  or  circular  or  narrow 
and  lissure-like.  It  varies  at  ditl'ereiit  levels.  The  condition  is  now  re- 
garded as  a  Illinois,  a  development  of  emliryonal  neurogliar  tissue  in  which 
luemoiThage  av  degenei'ation  takes  place  with  the  form;ition  of  cavities. 

t)f  litl)  cases,  I'M  were  in  men,  'u  in  women  (Schlesinger).  A  largo 
majority  of  the  cases  begin  liefore  the  thirtieth  year.  The  disease  has  heeii 
met  with  in  three  menihers  ol'  the  same  family. 

Symptoms. — The  clinical  featnres  are  extremely  complex.  In  the 
classical  I'orni  there  are  irregular  ])ains,  ehielly  in  the  cervical  region:  mns- 
cnlar  atrophy  develops,  MJiich  may  be  coulined  to  the  arms,  or  sometimes 
extends  to  the  legs.  The  reflexes  are  increased  and  a  spastic  condition 
(leveloiis  in  the  legs.  I'ltimately  the  clinical  picture  may  be  that  of  an  amy- 
otrophic lateral  sclerosis.  The  tactile  sensation  is  usually  intact  and  the 
mnsciilar  sense  is  retained,  l)nt  painful  and  thermic  sensations  are  not  recog- 
nized, or  there  may  be  in  rare  instan(es  complete  ana'sthesia  of  the  skin  and 
of  the  mucous  membranes  (Dejerine).  This  condtination  of  loss  of  pain- 
ful and  Ihernnc  sen.silions  with  jiaralysis  of  an  amyotrophic  typo  is  re- 
garded as  pathognomonic  of  the  disease.  The  special  senses  are  nsually 
intact  and  the  sphincters  nninv(dvod.  Trophic  tronbles  are  not  nncom- 
mon.  Owing  to  the  loss  of  the  pain  and  heat  sen.sations,  the  |)atients  are 
a|)t  to  injure  themselves.  S(X)liosis  also  may  bo  present  in  these  cases. 
The  loss  of  painful  and  thermic  im])rossions  is  due  to  the  fact  tlnit  those 
pass  to  the  brain  in  the  peri-ependyma!  gray  matter,  ])articnlarly  that  por- 
tion in  the  dorsal  roots,  which  is  almost  constantly  involved  in  syringo- 
myelia. The  tactile  sensation  is  retained  hecanse  the  postero-lateral  column 
is  nninvolved. 

Sciil{\siiigcr,  in  his  recent  monograph  (IS!),")),  recognizes  the  following 
types:  (1)  With  the  classical  featnres  ahov:.'  described,  which  may  begin 
in  the  cervical  or  lumbar  regions:  C^)  a  motor  type,  with  the  picture  of 
an  amyotrophic  or  a  spastic  paralysis — the  sensation  may  hi'  undistnrix'd 
for  years;  {',])  with  pre(h)niiriant  sen.sory  featnres,  simidating  hysterical 
hemiplegia,  (U-  with  general  \nun  and  tem|ierature  ana'sthesia;  (I)  with 
pmnonnced  trophic  (hstnrbances — to  this  type  belong  the  cases  described 
as  ^lorvan's  disease,  an  all'ection  characterized  l)y  neuralgic  pains,  ciita- 
mxnis  ana'sthesia,  and  painless,  destructive  wliitlows;  and  (5)  tlie  tabetic 
tyi)e,  either  a  combination  of  the  symptoms  of  tabes  in  the  lower,  and  of 


^^^ 


DISEASES  OF   Tin:  NKIIVOUS  SYSTEM. 

li.  In  tlu.  iiinuT  oxtrnnitios,  or  a  iniro  tal.otic  symptom-eoiu- 

^:;rz:t,::iZ,7^:u:%.^''-<^'''''^"^'«^^"^^ so,,,.™!.-... 

\,li;n.i.athi('s  ocriir  in  about  10  vw  c'nt  ot  the  cases. 

pin.l  cases  the  diagnosis  is  easy.     The  co.nlHnat.nn  o    an  an,>o- 
„,.,  ,  •       ,  ,,vsis,  the  pielm-e  ot  prosvessive  nu.euhu-  a.n.phy  ul  the  Aran- 
'Zl;;:.,;,;'  .y^e,  .1,1,  'retention  of  taetUe  and  loss  ot  tlu-ue  an     ,.un 
........ti<.n    is  i)rol)ahlv  pathognomonic  ot  tiie  disease.     01  allec  .on.    sUh 

utu'.;.a     he  cont^nnded,  ana-sthetic  leprosy  K^lu"   .n..t  unp,,r  a,,, 
.i,H.e  the  ana.sthesia  and  the  wasting  nu.y  c  >sely  -»' f'^';,    J,,  '     ',;   , 
rule    in  lenrosy  troi-hic  changes  are  more  or  less  marked.      1  uit  is  oil.  n 
;:^:'ot  phalanges  and  there  is  no  characteristic  dissociation  ot  .ensory  an- 
jiressions. 

VI.    ACUTE    MYELITIS. 

Etiology.-Acute  myolitiB  results  from  many  causes,  «";\  ";'^>Vf  ^^^ 
the  CO  nff  limited  or  citemled  portion-the  gray  ma  tor  chiet  y.  or  t 
g    ;r    I    vhite  matter  together.     It  is  met  .ith:  («)  A.  an  '- ^-l--^ 
a  ^.tion  following  exposure  to  cold,  or  <.xertion,  and  leading    o  i    ml  bs 
of  power  with  the  symi.toms  of  an  acute  ascen.lmg  pa  aljs.s.     (b)  A     a 
tS^i    1.     infectimis  diseases,  such  as  small-pox.  typhus,  and  measle. 

?        a  -ult  of  traumatism,  either  fracture  of  the  spine  or  vc.y  sevc... 
nicular  eifort.     Comnssion  without  fracture  -7/'-'«^';^^;  '  j^^^^.^^^ 
rare.     Acute  nu'elitis,  for  instance,  scarcely  ever  iollows  lail.  j  ^^^^^f;^ 
)  In  diseases  of  the  h<.nes  of  the  spine,  either  caries  or  cancer  a 

more  common  cause  of  localized  acute  transverse  myel,  ,s  tlian  "    ^ h    d  m^ 
nIVeetion      (e)  Tn  disease  of  the  cord  itself,  such  as  tumois  and  sh>1h1  s, 

n    ^  htte     oi  her  in  association  with  gummata,  in  which  case  it  is  usually 
a  ll"Imi^^ation;  or  it  may  hdlow  within  a  year  or  eighteen  months  ot 

'"■CS'li^tomy.-In  localized  acute  myelitis  alfecting  white  and 
.r.v^mmc^iTmet  with  after  a<.cident  or  an  acute  compression,  the  cord  ,s 
a:;;   ll^^a  injected,  the  consistence  greatly  -^-^^^ir"? 
the  membrane  an  almost  ditUuent  Ihud  may  escape.    In  less  inten.c       m 
m   "     on  at  the  affected  area,  the  distinction  between  the  gray  a m    .hH.- 
,a         is  lost,  or  is  extremely  indistinct.     The  tissue  may  be  ^^''^Z 
"        ol  en  the  ease.  liaMuorrhagic     It  is  particularly  m  these  1"""^ /"« 
To  ex  e  ^  on   of  disease   from  without   or  to  acute  compressu>n,     h  t   . 
^,d  dliinite   involvement   of   the  white   nuitter^     In   oU.er  mst^      ..     he 
,rr,v  matter  is  cliielly  alVected.     There  may  be  localized  aieas  thiou        n 
tl      e         i.     vhich  the     gray  nu.tter  is  reduced  in  consistence  and  luvm- 

times  thnuigh  the  Imnbar  and  the  greater  part  of  ^l  ^  .<1""'  •^;  "    '.'^  ,,. 
thorach.  and  ..ervical  regions,  there  is  a  diiVuse  myelitis  of  the  giaN   sub 

stance. 


1 


iin-coiu- 
iiln'iin)- 

II  aniyo- 
10  Anin- 

painl'i'l 
)iis  with 
ili(,rtaiit, 
lilt,  as  a 

is  ul'UMi 
sury  i  in- 


lay alToit 
y,  or  tlu' 
I'pondont 
rapiil  loss 

(/*)  As  a 
[  nioask's. 
}ry  severe 
lit  tliis  is 
aecidoiits. 

I'his  is  a 
he  dilViise 
I  sy[»hilis; 

is  usually 
mouths  oi 

white  and 
the  cord  is 
m  ineisiuf,^ 
use  grades, 
and  while 
ijeeted,  or, 
t'orins,  due 
\,  that   we 
itanees  the 
Ihrouuliout 
and  ha'in- 
vity  fornia- 
iiyelitis  tlio 
Vnd,  lastly, 
cord,  sonie- 
\  or  in  the 
e  gray  snh- 


ACUTE  MYKLITIS. 


'I  ( 


Ilistologieally  the  nervi  lilins  are  iiuieh  swollen  and  irregiihirly  ilis- 
torleii,  tile  axis  eyiiiulers  are  lieaded,  the  luyclin  droplrts  are  aiuindant. 
and  the  laminated  ixxlics  laiown  as  lorpora  amylaeea  may  lie  seen.  'J"he 
granular  i'atty  cells  are  also  numerous  and  there  may  lie  linieoeytes  and 
red  hlood-corpiiscies.  Changes  in  the  Idood-vesscls  are  striidng;  the  smaller 
veins  are  distendi^d  and  may  sliow  varicosities.  The  iierivaseiilar  lymjili 
spaces  contain  niimeroifs  leucocytes,  and  the  smaller  arteries  themselves 
aic  i'ri'(|iiently  the  seat  of  liyaline  tliromlii.  The  ganglion  cells  are  swollen 
and  irregular  in  outline,  tiie  protoplasm  is  I'xtremely  granular  and  vacuo- 
lated, and  the  nuclei,  though  usually  invisililc,  may  show  signs  oi'  division, 
and  the  processes  oi'  tiie  cells  are  not  seen. 

In  cases  which  persist  I'or  s(uue  time  we  li;ive  an  oppoi'tiinitv  of  seeing 
the  later  stages  of  acute  myelitis.  The  acute,  inliammatory,  hypera'inic  or 
red  softening  is  succeeded  liy  stages  in  which  the  alfected  area  liecoiiies 
more  yellow  from  gradual  alteration  of  the  lilood-pignient,  and  linally  white 
in  color  from  the  advancing  fatty  degeneration.  In  cases  of  comi"ires-ion 
myelitis,  a  sclerosis  may  gradually  he  produced  witii  the  anatomical  pictin\' 
of  a  chronic  dilfiise  myelitis. 

Symptoms.— (rO  Amlv  ('cnlnil  MijiJUis.—U  is  this  form  which 
comes  on  sjiontaneously  after  cold,  or  in  connection  with  syphilis  or  one 
of  the  infectious  diseases,  or  is  st'cn  in  a  typical  manner  in  the  extensiiui 
from  injuries  or  from  tumor.  'J'lie  onset,  though  scarcely  so  alirupt  as  in 
lucimn'rliiige,  may  lie  sudden;  a  jicrson  may  he  attacked  on  the  street  and 
have  dilliciilty  in  getting  home.  In  some  instances,  the  onset  is  preceded 
hy  jiains  in  the  legs  or  hack,  or  a  girdle  sensation  is  present.  It  may  lu' 
marked  hy  chills,  occasionally  hy  convulsions;  fever  is  usually  ]iresent  irom 
the  heginning— at  first  slight,  hut  snhseijuently  it  may  hecoine  high. 

The  motor  functions  are  rapidly  lost,  sometimes  as  (piickly  as  in  L:ni- 
dry's  ascending  paralysis.  The  j^arajdegia  may  lie  complete,  and,  if  the 
myelitis  extends  to  the  cervical  region,  there  may  he  impairment  of  mo- 
tion, and  ultimately  complete  loss  of  ])ower  of  the  u])])er  extremities  as 
well.  The  sensation  is  lost,  Init  there  may  at  first  he  liy])era'sthesia.  The 
reflexes  in  the  initial  stage  are  increased,  hut  in  acute  central  myelitis,  un- 
less limited  in  extent  to  the  thoracic  and  cervical  regions,  the  retlexes  are 
usually  aiiolislied.  The  rectum  and  Madder  are  paralyzed.  Trojihio  di<- 
turhances  are  marked;  the  muscles  waste  rapidly;  the  skin  is  often  con- 
gested, and  there  may  l)e  localized  sweating.  'Y\w  temperature  of  the 
affected  limbs  may  he  lowered.  Acute  hed-sores  may  develop  over  the  sacrum 
or  on  the  heels,  and  sometimes  a  mnltiiile  arthritis  is  ])resent.  In  these 
acute  cases  the  general  symptoms  heconie  greatly  aggravated,  the  pulse 
is  rapid,  the  tongue  heccmes  dry;  there  is  delirium,  the  fever  increases,  and 
may  reach  1()T°  or  IDS"'. 

The  course  of  the  disease  is  variable.  In  very  acute  cases  death  follows 
in  from  five  to  ten  days.  The  cases  following  the  infectious  diseases,  par- 
ticularly the  fevers  and  sometimes  syphilis,  may  run  a  milder  course. 

The  (lidfinnsii^  of  this  variety  of  acute  myelitis  is  rarely  dilTicult.  In 
common  with  the  acute  ascending  paralysis  of  Landry,  and  with  certain 
cases  of  miilti]'le  neuritis,  it  presents  a  rapid  and  progressive  motor  paraly- 


^^ 


c)-8  DISEASES  OF  THE  NERVOUS  SYSTEM. 

.i<     From  llu-  foinuT  it  i.  distin^ui.lH.l  l.y  tlu>  >uuro  nmrkod  invnlv.nu.nt 

of  .OLsation,  tho  tro,.luc.  .lislm-l.uurs.  the  paralvHs  ol  blad.k-v  and  .vduu., 

the  ™,   .1  w  stinjr,  tlu.  cUrtrual  .La,.;.*.,  and  th.  i.v.r.       n.ni  mat.  .■a.es 

,  u    iplo  nouniis  it  n.ay  be  n>oro  dillicult  to  distingu.h,  as  the  ...ory 

features  in  these  eases  n.ay  be  nmrked,  thou^d.  there  is  rarely,  .1  .'^v^,  n 

,le  neuritis  eom,dete  ana.thesia;  the  wa.tin,,  n.oreover   .s  nu.re  rapM 

,„  -.litis.     The  bladder  and  reetum  are  rarely  .nvolved-  luu.gh  -n     x- 

,  t  .  nal   cases   they   nn.y   be-and,   n.-.t    in.portant   ul   all.   tho   trnplue 

eh'anjzes,  th..  devcdofanent  of  bulk.,  bed-sores,  ete.,  are  not  seen  in  niulfple 

"'"[Jo''tr»/.  Trausvn-se  MycUlis.-Tho  sy.nplou.s  naturally  ditlVr  with  the 

^'"Or^i'te  U.I::;:;;.  mventis  in  the  ll.r.rir  rc,unu  the  most  eonnnoii 
situat  on.  pnHluees  a  very  Vharaeteristic  pieture The  sympto.ns  ot  oi^et 
ar    variable.     There  may  be  initial  pains  or  numbness  and  t.n^dnig    n  the 
..The  paralvsis  may  set  in  cpiiekly  and  beeonie  eomp  ete  withm  a 
fc:;"days;  bl.t  more  eommonly  it  is  preceded  for  a  day  or  two  by  sen>a- 
Ims  oi  pain,  heaviness,  and  drawing  in  the  legs.     The  paralysis  of  tl  o 
tZ  Ihubs  i/usuallv  complete,  and  if  at  the  level,  say,  ol  tho  sixth  tluvrae 
;^,^,,„,„,  t,,,  ,,,aon,inal  museles  are  involved.     Sensation  may  bo  pa  t    1  > 
0      omp  etely  lost.    At  the  onset  there  may  be  numbness,  tingling,  or  esen 
vner  1  lui>  in  the  legs.     At  the  level  of  the  lesion  there  is  often  a  zone 
Xiu.  V  tl    s    ,  whiciris  .liseovered  by  passing  a  test-tube  containing  ho 
tl  tr  aon.'  the  spine,  when  the  sensation  of  warmth  changes  to  ono  of 
"   I  1     a  ^    A  gi  die  sensation  may  ocnir  early,  and  when  t^he  lesion  is  in 
h     !  t       ion  it  ^  usually  folt  between  the  ensiform  and  um^n heal  rogioi  s 
IM  e    ellex  functions  are  variable.     There  may  at  first  be  abolition  ot  tho 
,.;.:„""  nently,  the  rellexes,  which  pass  through  the  seginen  s  lower 
;  th'e  one  alfected,  may  be  exaggerated  and  the  limbs  may    ake  on 
ondition  of  spastic  rigidity.    It  does  not  always  ^-Pl-"'  ^^  j^;^      ^^ 
Tvllexes  are  increased  in  a  total  transverse  lesion  of  tho  cord.      1  hev  n  a>  he 
n    rclv  1  w     as  first  pointed  out  by  T.astian.     That  this  is  not  due  to  the 
.r     n   n    y^  «H'k  is  shown  by  the  fact  that  the  abolition  of  tho  rellexes 
V  c     t  mio  for  four  or  more   months.     The  trophic  changes  are  not 
:  rk  d     T  e  nniscles  become  extremely  flabby,  but  not  wasted  m  an  ex- 
tr  mo  do.nc      subsequently  rigidity  develops.     If  the  gray  matter  of  tho 
mn    cord  is  involved,  the  flaccidity  persists  and  tho  wasting  may  be 
m    ;    rill  .     The  reaction  of  regeneration  is  not  present.     Tho  tempo  a 
re  of,    paralyzed  -mbs  is  variable.     It  may  at  first  rise,  then  fa  1  and 
"coine      bi  ornial.     Lesions  of  the  skin  are  not  nncommon,  and  bod-sores 
e         t    f  rm.    There  is  at  first  retention  of  urine  and  subsequent  incon 
»;     0      If  the  lumbar  centres  are  involved,  there  are  from  the  mil  set 
V     c  r«vn  Ptoms.     The  nrine  is  alkaline  in  reaction  and  may  rapidly  be- 
onu^  anm m"  ll.    The  bowels  are  constipated  and  then;  is  usually  incon- 
tinence of  ihe  ficoos.     Some  writers  attribute  tho  cystitis  associated  with 
tran«ver«e  myelitis  to  disturlicd  trophic  influence. 

T     'conic  of  eompleto  transverse  myelitis  depends  a  good  deal  upon 
its  cause     Death  may  result  from  extension.     Segments  of  tho  cord  may 


I 

i 


Ivi'IIU'Ilt 

ivctuiu, 

sensory 

ever,  in 

)TG  rapiil 

h  in  ex- 
trophic 

multiple 

with  the 

coninioii 
of  onset 
iig  in  the 
within  a 
l)y  seii^a- 
•;is  of  the 
1  thorarie 
I  partially 
y,  or  even 
en  a  zone 
lining  hot 
to  one  of 
2sion  is  in 
ri\  regions, 
ion  of  the 
eiits  lower 
take  on  a 
r,  that  the 
ey  may  bo 
line  to  the 
he  retlexcs 
es  arc  not 
.  in  an  ex- 
tter  of  the 
ig  may  Vie 
e  tcmpera- 
cn  fall  and 
d  l)ed-sorcs 
iient  ineon- 
the  ontset 
rapidly  l)o- 
lally  incoii- 
ciated  with 

I  deal  niion 
e  cord  may 


TOPICAL   DIAGNOSIS. 


97i) 


he  completely  and  permanently  destniycd,  in  which  case  there  is  persistent 
]iaraplegia.  'I'hi'  pyramidal  lil>res  helow  the  Icsiun  undergo  tiu'  secondary 
degeneration,  an<l  there  is  an  ascending  degeneration  of  tlie  ilorsal  me- 
dian columns,  if  the  lower  segments  of  the  conl  are  involved  the  legs 
may  remain  llaccid.  In  some  instances  a  transvi'ise  myelitis  of  the  thoracic 
r(gion  involves  the  ventral  Imms  ahove  and  lielow  the  lesion,  producing 
llaccidity  of  the  muscles,  with  wasting,  iihrillar  contractions,  and  the  reac- 
tion of  degeneration.  .More  conniu)nly,  however,  in  the  cases  which  last 
many  months  there  is  more  or  less  rigidity  of  the  muscles  with  spasm  or  per- 
sistent contraction  of  the  llexors  of  the  knee. 

{'i)  I'miisri'i-Kr  Mi/clilis  of  the  ('rrriral  Uri/ion. — If  the  lesion  is  at  the 
level  of  the  sixth  or  seventh  cervical  nerves,  there  is  paralysis  of  the  u|)per 
extri'mities,  more  or  less  complete,  sometimes  sparing  the  muscles  of  the 
shouldi'r.  (Jradually  there  is  loss  of  sensation.  The  paralysis  is  n-ually 
coiiiplctt'  Ih'Iow  the  point  of  lesion,  hut  tlure  are  ran'  instances  in  which  the 
anus  only  arc  all'ccted,  the  .■^o-callcd  cervical  paraplegia.  In  addition  to  the 
symptoms  already  mentioned  there  are  scviTal  which  aiv  more  characteristic 
(d'  transverse  myelitis  in  the  cervical  region,  such  as  the  occurrence  (d' 
vonuting,  hiceongh,  and  slow  ])ulse,  which  may  sink  to  "^O  or  Mo,  j)upillary 
changes — myosis — sonu'timcs  attacks  (d'  dysphagia,  dyspmca,  or  syncope. 

Treatment  of  Acute  Myelitis.  — In  the  rapidly  developing  form 
due  either  to  a  dill'use  inllannnation  in  the  gray  matter  or  to  transverse 
myelitis,  the  im]iortaiit  measures  are:  Scrupulous  (deanliness,  care  and 
watchfulness  in  guarding  against  hed-sores,  the  avoidance  of  cystitis,  either 
by  systematic  catheterization  or,  if  there  is  incontinence,  by  a  carefully 
adjusted  bed  urinal,  or  the  use  of  antiseptic  cotton-wool  rejjeatedly  changed. 
In  an  acute  onset  in  a  healthy  subject  the  si)ine  may  be  cup])ed.  Counter- 
irritation  is  (d'  dou!)tful  advantage.  Chapman's  ice-liag  is  soiuetinies  usid'ul. 
Xo  drngs  have  the  slightest  inllucnce  ujion  an  acute  myelitis,  and  even  in 
subjects  with  well-marked  syphilis  neither  mercury  nor  iodide  of  potassium 
is  curative.  Tonic  remedies,  such  as  (pu'nine,  arsenic,  and  strychnia,  may 
be  used  in  the  later  stages.  When  the  muscles  have  wasted,  massage  is  l)ene- 
(icial  in  maintainiMu'  their  nutritio]).  j-'lcctricity  should  not  l)e  used  in  the 
early  stages  of  m\clitis.  Tt  is  of  no  value  in  the  transverse  myelitis  in  the 
thoracic  region  with  retention  of  the  nutrition  in  the  muscles  "of  the  le<^ 


Y.   DIFFUSE   AND   FOCAL  DISEASES   OF   THE   BRAIX. 
I.    TOPICAL    DIAGNOSIS. 

Only  certain  'cgions  of  the  brain  give  localizing  symptoms.  These 
arc  the  cortical  motor  centres,  the  speech  centres,  fjic  centres  for  the  spe- 
cial senses,  and  the  tracts  which  connect  these  cortical  areas  with  each 
other  and  with  other  jiarts  of  the  nervons  svstem. 

The  following  is  a  brief  summary  of  the  cfTccts  of  lesions  from  the 
cortex  to  the  spinal  cord: 


I 


^^ 


f,^,,  DISEASES  OF   THE   NERVors  SYSTEM. 

1.  The  Cerebral  Cortex.— ("»  l)-tnictivi'  l.sidiis  of  ilic  motnr  vnvu\ 
(conlral  gyri.  lolmlii^  i.iinuriitnilis,  ix.stfrinr  i,.,rtia!!-  <.r  the  lluvc  froiual 
-vri   i.^iHruilly  ol'  tlie  iiilViior)  lausc  sjutstir  i^arahisis  in  tlic  uui^clcs  ot  thr 
mmuMto  side  of  tlu'  l)..(lv.    'I'hv  jmralysis  is  at  liist  IliU'.i.l,  l.ul  .■(.ntiacluixs 
-iil.M'.iiiriiilv  .k'Ncln)..     The  o.xti'iit  of  till'  paralysis  ilcix'uds  ui.oii  thai  d 
the  lesion,  "it  is  aj.t  to  be  liniite.l  to  the  niiiseles  of  llie  laee  or  ol  aii  e.\- 
t remit V   "iving  rise  to  the  eerehral  nioiioi.legias  (Fig.  J 1,  1 ).    One  group  ol 
nuiH-ies  may  he  nuieh  nu.re  allVeted  than  otiiers,  espeeially  in   U'.ions  ol 
tlie  lii-iilv  .lilVerentiated  area  for  the  npper  extremity.     It  is  uneommon  to 
lind  aU  tiie   muscle  groups  of  an  extremity  equally   involved   m   cortical 
monoplegia.      Very   raielv    through    small    hilaterally   symmetrical    lesions 
inonoi.legia  of  the  tongue   may   reMilt   without   paralysis  of  the  lace.     A 
lesion  may  involve  centres  lying  clo.-e  together  or  overlapi-mg  one  am.tlier, 
thus   producing  «s.<oeiated    monoplegias— e.  g..   paralysis   of  the   lace  and 
arm,  or  of  the  arm  and  leg.  luit  not  of  the  face  and  leg  without  involve- 
ment of  the  arm.     N'ery  rarely  the  whole  motor  cortex  is  involved,  causing 
paialvsis  of  the  opposite  nide-cortical   heniildej-ia.     I  sr.ally   m   such   in- 
stances there  is  marked  recovery,  so  that  only  a  monoplegia  persists. 

The  motor  area  corresi)onds  also,  at  least  in  large  part,  to  the  regmn 
of  the  cortex  in  which  the  impulses  concerned  in  general  hodily  sensation 
(cutanc.ns  sensil.ilitv,  mns.le  sense,  visceral  sensations)  first  arrive  (the 
MMua-thetic  area),  ('..ml.ined  with  the  muscular  weakness  tlu'iv  is  usually 
M.me  dislurhauce  of  sensations,  particularly  of  those  ..f  the  muscular  seiw.. 
The  storoognustio  sense  is  very  often  alfectc.d.  In  hrac^hial  monoplegia,  for 
example,  a  coiu  or  a  knife  when  placed  in  the  haml  of  the  i.aralyxed  liml,, 
the  patienfs  eyes  being  closed,  is  not  recognized,  owing  t..  inappreciat.oii 
of  the  form  and  consisteiu'c  of  the  ol)joet,  and  this  even  though  the  slight- 
est tactile  stimulus  applied  to  the  lingers  or  surface  ot  the  hand  is  lelt  ami 
may  be  correctly  lo.'ali/.ed.  The  sense  of  touch,  pain,  and  temperature  uiay 
be 'lowered,  but  usually  not  markedly  unless  the  superior  and  inferioi 
parietal  lobules  are  involved  in  a.ldition  to  the  central  gyri.  1  anesthesias 
aud  vaso-motor  disturbances  are  conimon  accompaniiiieiits  of  paralyses  ot 

cortical  origin.  -i    i     i    ,. .      'VUn 

ih)  Irritatiyo  lesions  cause  locili/.-d  spasm,  as  described  abme.  llio 
nJ\  varied  muscle  groups  corresponding  to  particular  inovemen  l'-;'"^  "^'>y 
be  i.i.'ked  out.  If  the  irritation  bo  sudden  and  severe,  typiea  attack,  ol 
Jacksonian  epiU'psv  may  occur.  These  convulsions  are  usually  preceded 
„„1  accompanied  by  subjective  sensory  impressions.  1  ingoing  or  pain,  or  a 
sense  of  motion  in  the  part,  is  often  the  si„ual  .//»'/'"»'  (S^'-^^''""^'  ^'^  >^  "^J 
great  importance  in  determining  the  seat  of  the  lesion.  Here,  too,  the 
stereognostie  sense  is  frecpiently  involved. 

Lesions  are  often  both  destructive  and  irritative,  and  we  then  hav, 
combinations  of  the  symptoms  produced  by  each.  For  "^^tance  cer  ain 
muscles  may  l)e  paralvz..!.  and  those  represented  near  them  in  the  coitex 
may  be  the' seat  of  localized  convulsions,  or  the  paralyzed  limb  itself  may 
be  at  times  subieet  to  convulsive  spasms,  or  muscles  which  have  l'^^^"^'^"- 
V  il'ed  may  become  paralvzed.  The  close  observation  of  the  sequenco  of 
h    svnnt  ms  in  such  cases  often  makes  it  possible  to  trace  the  progress 


I 
% 


"1^ 


r  fortux 
■  ironlal 

L'S  of   tllf 

LnicUii't-> 
I  timt  I'i 
)!'  ail  L'X- 

gl'dlll)  ul' 

luuion  ti) 
corlical 

1     lo^iuUs 

iaco.     A 

auotluT, 

I'acL'  ami 

involve- 

,  causiiiii; 

such   iu- 

ts. 

lu'  I'l'U'iiiii 
sensation 
•rive  (tho 
is  usually 
liar  sci\>e. 
)lejfia,  I'or 
zed  limli, 
preciatic)!! 
he  slight- 
ri  I'elt  ami 
ature  may 
;1  inferior 
ra'stlu'sias 
iralyses  of 

ove.  The 
forms  may 
attacks  of 
:  preceded 
]jain,  or  a 
,  and  is  of 
?,  too,  the 

then  have 
CO,  certain 
the  cortex 
itself  may 
!  ])oon  con- 
cqiioncc  of 
:io  progress 


TOPICAL  I)IA(JN'0Sl5i. 


981 


of  a  lesion  involving  tic  ni'dor  cortex.  Tii  these  cases  tlu'  most  frequent 
cause  is  u  developing  tumor,  iliougli  s'lmi. times  hicjil  thickenings  of  the 
mendiraiics  of  the  hrain,  small  aiiseesxs,  imi'ute  ha  iiiui  rhagcs,  or  fiaguiriit-: 
nf  a  fractured  skull  must  he  held  rcsponsiiile. 

In  another  section  lesions  involving  the  centres  for  the  special  senses 
are  considered,  and  we  siudl  simply  refer  to  them  here.  The  symi)toms 
caused  hy  lesions  of  the  speech  centres  will  he  descrihcd  under  aphasia,  and 
it  is  only  necessary  to  note  here  the  near  situation  of  the  motor  speech  area 
(iiroca's  centre)  in  the  left  inferior  frontal  convolution  to  the  centres  for 
the  face  and  arm  on  that  side,  and  to  state  that  motor  ajjhasia  is  often 
associated  with  moimplegia  of  the  right  side  of  the  face  and  the  right  arm. 
Accompanying  the  }iaralysis,  following  a  dacksonian  lit,  of  the  right  lace  or 
arm  there  is  (d'ten  a  transient  motor  ajjliasia. 

According  to  Flechsig.  the  sensori-inotor  centres  are  limited  to  tolerahlv 
circumscriln-d  areas  in  the  ccu'tc'X,  which  dill'er  from  other  jiortions  in  that 
they  are  provided  with  ])rojection  fihrcs  which  connect  them  with  lower 
centres.  The  remaining  ureas  (d'  the  cortex,  amounting,  he  helieves  to 
ahout  two  thirds  of  the  whole,  ure  devoid  of  pi'ojection  (il)i'cs  and  are  con- 
cerned entirely  in  associative  activities.  These  latter  areas,  the  ''  association 
centres"  «['  Mechsig,  are  three  in  nundier:  (1)  The  anterior  associntion 
centre,  including  the  whole  of  the  frontal  hihe  in  front  (d'  the  sonucsthetic 
area;  ("i)  the  middle  associiition  centre,  corresponding  to  the  cortex  of  the 
island  of  ifeil;  and  (.'!)  the  large,  jiostcrior  association  centre,  including  the 
Ijra'cuneus,  the  superior  and  inferior  jiarietal  lohules,  the  supramarginal 
and  angular  gyri,  and  the  whole  of  the  temporal  and  occipital  lohes  e.U'cpl 
the  auditory  and  visual  sensory  areas. 

Mechsig  attrihntcs  the  liigher  i>sychic  functions,  especially  those  con- 
nected with  the  personality  of  the  individual,  to  tho  anterior  association 
centres,  while  the  intellectual  activities  which  have  to  do  with  knowledge 
(d'  the  external  world  he  helieves  corrcs])ond  to  the  functions  of  the  large 
jiosterior  association  centre.  Whether  these  views  he  true,  and,  if  so,  in  lurw 
far  they  may  he  applied  practically  in  the  localization  of  diseases,  especially 
of  the  mind,  the  futnre  has  to  decide. 

2.  Centrum  Semiovale.— Lesions  in  this  jiart  may  inv(dve  either  i)nijec- 
tion  fd)re,«  (motor  or  ,«ensory)  or  association  fihrcs.  "  If  involvement  of  tlu' 
motor  path  cause  ])aralysis,  this  has  the  distrihution  nf  a  cortical  palsy  when 
the  lesion  is  near  the  cortex,  and  of  a  |)aralysi<  due  to  a  lesion  of  "the  in- 
ternal oapsnlo  when  it  is  near  that  region."  The>e  lesions  of  the  motor 
filu'cs  may  he  associated  with  sym])t()ms  due  to  interruption  in  the  other 
.'systems  (d'  fihres  running  in  tho  centrum  senuovale;  there,  may  he  sensory 
di>tnrliances— hemiana\«thesia  and  henn'anopia — and  if  the  lesion  is  in  the 
left  hennspherc  one  of  the  dill'ereid  forms  of  afihasia  may  accompanv  the 
jiaralysis. 

3.  Corpus  Callosum.— This  may  1)0  congcnitally  ahs.'ut  without  symp- 
toms. An  acnte  lesion  involving  a  large  jiorticn  of  the  corpus  callosum 
may,  however,  yield  symptoms  suggestive  of  its  hiealizatinn  in  this  reaion. 
In  the  case  recorded  by  ]?einhard,  in  which  the  situation  of  the  lesion  was 
suspected   ante-mortem,  there  was  disturbance  of  eipiilibration   (without 


DISEASES  OF  TIIK   NKIl VOL'S  SYSTKM. 


9S2 

.,,,,1,;  „f  ,1...  ..o,.,,us  .allo.um.      IM    I'.ristuw.-s    1   n.s.s  tluTo  ex  .led,  a, 

..n>s  ..onnnun'.u  all.  ,a.M  in  .1..  h.a.l  an,l  ,.art.al  or  nuupU  e  henu- 

uX    with  gradual  exteiMon  of  the  ,.a,aU>.^  m  the  oppu-te  .ule  ol    l.e 

i;^  '  Toward  the  end  ot  life  there  was  d.turi.anee  ot  speeel,  d.ibei,Uy 

/,.,„,,„i,,,„,  i,u.untine.ue  ot  unne  and   ta-ees  and  denienOa.     ll.'-'e  the 

n,pn..n.  have  in  then,  no.hin,  that  ean  he  lo„k..d  npon  as  patho-Mumvue 

•„,|.l,l.  ,„anv  ol'  the  phenunu.na  were  .h.uhtle.s  dependent  upon  un uh.nu.nt 

„,  ,1,.,  ,„,.j,;. ,u,„  and  assoeiation  lihres  of  the  eentrnn,  sen.iovale. 

l„    „HH,als  in  whieh  the  eorpus  eallosnni  has  h.en  eul  ex,u.nnu.ntall> 
„,„>,,,.ssive  en.aeiatiun  has  heen  nu.ntiuned  as  a  ..haraeler,.tie  phenomenon 
^     I    Internal   Capsule    (^,^^     l).-Thron,h    tins    pass    w>t Inn    a    rathe 
,,,,,ow  area  all.  or  nearly  all.  of  the  projeetion    id.res   (h-th   n.o  u,    and 
^     orv)  whieh  are  eonneete.l  with  the  eerehral  eor.ex.     It  .s  d.vded  into 
In  anterior  Innh.  a  knee,  and  a  posteri.>r  lind.,  the  latter  -J--  '"J^ j;^  ; 
thalan.o-lentienlar  portion  (its  antc.rior  two  thirds)  and  a  retro-lenti  ula 
„  (its  posterior  third,.     In  eonsidering  the  eil^ets  o    a  g.ven  I^k.. 
s    „  involving  the  llhres  uf  the  internal  eap>nlo,  it  is  not    o  he  loi-got  eu 
;,,  the  relatioi,s  of  the  two  Tnuhs  of  the  c.apsule  to  one  anotlu.r  and  to  the 
nee  vary  eonsi.lerahlv  in  diiVcrent  l.ori/.ontal  planes.     M"^'''  "^     '-'  ^  " 
?^on  i,i  the  hihliography  is  dependent  npon  negleet  t..  '1™ ';;,;:.  ;';^- 
„u>tal  level  of  the  le.^ion.  as  well  as  its  situation  in  an  antero-po^teiioi  d 
mtion.     The  prineipal  hundle  parsing  through  the  'l"*^'"";'. '"l'^'     ^   •- 
n    nl.  ;.  that  whieh  eonneets  the  frontal  gyri  and  the  media     .nndm 
.l.He  of  the  pednnele  (erns)  with  the  nnelei  of  the  pons.      Ihese  Id.  e> 
n  rifngal.  and   innovate  ehietly  the  hnver  motor  .nude,   governing 
;     ,t  iinu  -vated  mnscles,  espeeially  those  of  the  "y--  ''^'"V't'.n   i 

ruba        tho>e  of  the  month,  tongue,  and   larynx.     In   lower  honzonta 
^;:;  tlelo  ilhres  are  situated  near  the  knee  of  the  ^^V^^J^^^^^:!^;^: 
of  the  knee  of  the  eai-sule  whieh  transmits  espeeiallj   the  librc.  pa.an 
on  th      erebral  eorti  to  the  nnelei  of  the  faeial,  hypoglossal  and  thin 
l;;;';xr  The  path  whieh  supples  the  nuelei  governnig  the  museles  n.ed 
in  <neeeli  liasses  lhrouu:li  the  knee.  ,      ..     ,  .■    .     c  +!,„ 

■ 'nu  mramidal  tra  t  goes  throngh  the  thalamo-lenticnlar  portion  of  the 
'X  ^  T   e  nio  or  fibr^  are  arranged  aecording  to  deiinite  nuiscde  gronps 

are  relatively  large.  ii    4  ;,  +i>,.c,.  frnm  i-lio 

The  fibres  to  the  soma'stbetio  area  of  tlie  cortex-tbat  in  tho.e  f  o         e 

ventr    1    eral  oroup  of  nnelei  of  the  thalamus  and  the  tegmental  ladu- 

,      -    nT^^      in,  uilses  eoncerncd  in  general  bodily  sensation    pass  up- 

'  -d  ti        '^h      -teriov  part  of  tlie  thalama-lentienlar  portu)n  o      be 

call.!    Some  of  Ibeso  fibri  pass  througb  the  aut..ru.:  two  tb.rds  oi  the 

,„  cterior  limb  alongside  of  tbc  fibres  of  the  pyram,da    tra.'t. 

^     Vhr^ugh  the  reU'u-lentieular  portion  of  the  posterior  l,mb,  opposite  the 


ly.  The 
or  tluvi.' 
isted,  ai 
tc  lifiai- 
k'  of  llu; 
(lilliuiiUy 

Here  tllL' 
nlvfllU'lll 

iiiii'iitally 
iKiiiU'imii. 
a  ratln'i' 
lotoi'  ami 
idi'd  into 
ling  <il'  a 
Imtitular 
veil  I'ocal 

forgotten 
iinl  to  the 
■  the  cun- 

tlic  Imri- 
sterior  di- 
iilj  ol'  the 
l)\indlo  in 
hese  lilire^ 
governing 

neck,  and 
horizontal 
the  region 
•es  pa:^sing 

and  third 
.ir^eles  Used 

tion  of  the 
H'h'  gnmps, 
heing  ante- 
.iscle  grou]) 
iits  tlian  to 
!rs  and  toes 

se  from  the 
[■ntal  radia- 
n,  pass  up- 
•tion  of  the 
liirds  of  the 

opposite  the 


r 


1> 


TOI'ICAL   I)lA(iN'()SIS. 


US3 


po.-terinr  ihird  of  the  lateral  surface  oi  tiie  thalanms.  pass  (1)  the  filires 
carrying  impulses  concerned  in  the  Mii.-ations  of  the  oppn.-ilc  visual  Held 
(ci|itic  radiati'iii  from  the  lateral  geuicidiite  Imdy  to  tlir  vi>ual  sense  area  in 
tlie  occipital  cortex);  ('.')  the  lihres  carrying  impulses  ((Uicerned  in  audi- 
tory sensatinns  (radiation  from  the  medial  geniculate  Imdy  to  the  auditory 
Miise  area  in  the  cortex  (d'  the  tem|ioral  IoIm);  (:!)  the  lihres  (prohaldy  ceu- 
ti'ifugal)  conni'cting  tiu'~cortc\  of  the  Icmpofal  loln'  uith  the  nuelci  of 
the  pons. 

With  thi>  piclinunary  knowledge  concerning  the  internal  cap>uli'.  it  is 
not  dillicidt  to  understand  the  symptoms  which  result  when  it  is  di>ea-(d. 

Since  here  all  the  lihres  of  the  upper  motor  segment  are  gatheri'd  to- 
gether in  a  compact  iiundle,  a  lesion  in  this  region  is  apt  to  cause  comiileto 
liemiplegia  of  the  ojiposite  side,  followed  later  hy  cfuitractures;  and  if  tlu? 
lesion  involvi's  the  hinder  portion  of  the  jiosterior  liud)  there  is  also  henu- 
aiuesthcsia,  including  even  the  special  senses  (Fig.  I).  As  a  rule,  however, 
h'sions  of  the  internal  lapside  do  not  involve  the  whole  strueture.  The 
disease  usually  alVects  mainly  either  the  anterior  or  posteri(U'  portions,  and 
even  in  instances  in  which  at  lirst  the  sympliuus  jioint  to  total  inv(dvement, 
there  is  a  di.sippearaiu'c  (dten  o['  a  large  ]>art  of  the  jihenomena  after  a 
short  time.  Thus  when  the  pyramidal  tract  is  destroyed  (lesion  (d'  the 
thalamo-leiiticulai'  portion  of  the  ca|isu]c)  the  arm  may  he  all'ected  more 
than  the  leg,  or  rin-  rrrsii.  The  facial  jiaralysis  is  usually  slight,  though 
if  the  lesion  he  well  forward  in  the  cajisulc  the  paralysis  of  the  face  and 
tongue  may  he  marked. 

Jlemiana'stliesia  alone  without  involveuu'nt  of  the  motor  fihres,  due  to 
disease  of  the  cai)sule,  is  rare.  There  is  usually  also  at  least  partial  paraly- 
sis of  the  leg.  When  the  retro-lenticular  portion  of  the  capsule  is  deslroyid 
the  hennana'sthesia  is  accompanied  hy  henuanopsia,  disturhance  of  hearing, 
and  sometimes  of  smell  and  taste.  The  occurrence  id'  hemichorea,  marked 
tremor,  or  hcnuathetosis  after  a  capsular  hemiplegia  ))oints  to  the  invidve- 
meiit  of  the  thalamus  or  of  the  hypothalamic  region  in  the  lesion. 

Charcot  and  others  have  descrihed  cases  in  which  as  a  result  of  disease 
of  the  internal  capsule  there  has  heen  ])aralysis  of  the  face  and  leg  without 
involvement  of  the  arm.  In  such  instances  the  lesion  is  linear,  extending 
from  the  posterior  ])art  of  the  anterior  lind)  of  the  internal  capsule  hack- 
ward  and  lateralward  to  the  leg  region  in  the  posterior  lind)  of  the  capsule, 
the  region  for  the  arm  esca])ing. 

Capsular  lesions  when  pure  are  not  accompanied  hy  ajdiasic  symptoms, 
alexia,  or  agra])hia.  A  "  suhcortical '"  motor  aphasia  may  occur,  if  along 
with  complete  destruction  of  the  anterior  lind)  of  the  internal  capsule  on 
one  side  there  he  associated  a  lesion  of  the  caudate  nucleus  on  the  opposite 
?ide  large  enough  to  interfere  with  the  adjacent  fihres  going  to  the  nuclei 
governing  the  muscles  of  s|)eech. 

5.  Crura  (Cerebral  Peduncles). — From  this  level  through  the  pons,  me- 
dulla, aiul  cord  the  upper  and  lower  motor  segments  are  re[)resented,  the 
first  hy  the  fihres  of  the  pyranddal  tracts  and  hy  the  fil)res  which  go  from 
the  cerehral  cortex  to  the  nuclei  of  the  cerehral  nerves,  the  latter  hy  the 
motor  nuclei  and  the  nerve  fihres  arising  from  them.    Lesions  often  alTeet 


y^_j  DISKASKS  OK  TIIK  NERVOUS  HYSTKM. 

,,„.!,.     Tims  a  sii.^rK"  U'>m\  iii.u   '";"''''';,..    ,,,„i  ,,i,„  i„v.,lvo  llu' 

-"i.-.  i"  ""■  "I "":  ";''>:;;;;  ;l-:,t;:  ,';;S,  .i-s v„iv,.  .1,.  i«.c 

ll,„  .,H,,.,.i..r  oolliolllns  (,ml..ri"V  ,|,„„lr.-.-.u.„a    ';'"'"  I'  '':,,' ',,'|,,i 

i"  "■■•''""  -'"""■"■■"  ■■"""■"'  """\ '":  !'"■ :;;;:; :'  ;  ■      "  .'; 

;„':,„„ .,,IL i,.,vc. iK..n ,,.,,.n,iiy «"•;';;■;,„, ^;f ;.'";;,;  ■     .t'"',;,:,', 

--;;:r;;::!::r''X:;;i;;;:;'i':s;;^ 

fv<nn  tl.o  l.iM.n-rapi.  •:  ui   .    of        ■;  ^^;'      ,  ^^^  ^,,,,j  .i.ie  rocoivos  i.n- 
cially  noto.l.     Sine  tho  n-ntra  '  >     ,    „„^.  ,- ,,  „„,.  aull  the 

pulses  from  both  c-ars.  los.on  ot  tl>o  ^'"1     >'    '    '^^^^^    the  more  dcfoc- 
l,,arin,  on  Loth  sides,  though  tljo  '^'''^     '  "'  j^^  !        Li,a  by  disturb- 

„,.e  of  .nastieation.  own.g    o  V^r^>- ^^^^^'^^^  ^  \„,,i,,,     The 
root  of  tho  tri.^omnuvs.     Iho  f'^"  *'>     ^    *;  '   \^  ,  .^uadri.u.Mnina 

^»t*^:i;li;:'S™i'"r;!s:o::v;;n.i,,...,™!.,.,J,....ia.. - 

'"'7' Pen,  and  MeduU.  OMoBgata.-U.io.s  in.^vln,  n,„  ,,yr™iM 


sties  of 

)lvo   tlu- 

hi  tin 

ilcl.    iltlll 

i  |iartiiil 
Hiilii:.  'il 

VJ,  lirini- 

tlie  bii^o 
iiul  IIUH- 

|)iinilysi?(. 
ill  dl"  llio 
111  lesion, 
new  tiiat 
tlu!  iiutsl 
If  luuji'i. 
;h  as  yi'l 
li-litly;  if 
lor  vision 
lillary  w- 
lijiari'iitly 
ens  ol'  the 

the  oilier 
,iiy-.station 
lemiiiseiis 
ss  tlu-oujj;h 
late  body, 
ion  of  tlie 
[>  temporal 

lulrigeniina 
were  espc- 
Hcives  im- 
ly  dull  the 
nore  defee- 
by  disturb- 
;eneepluilie) 
,lvc(l.  The 
ladri.Lreinina 
medial  leni- 

]ivrainidal 
this  region, 
ns  is  apt  to 


T(»I'I(AI.   IUA(iN(>SlS. 


osr. 


(aii-(!  11  lo\ver-se;:inenf  paralysis  of  tlie  face  mi  llir  saiiif  <u]v  (dc-t ruction 
of  ilu'  niiiifii-i  of  the  facial  ncrvi-  or  of  its  I'dui  lilnc-)  and  a  >paslic  paralv- 
>is  of  the  arm  and  le^' on  the  opposite  >ii|('  (injury  to  pyramidal  trad)  ( l'"i;.'. 
II,  I).  'I'lic  abihiccns,  the  motor  part  nf  the  trigeminus,  anil  ilic  liypo- 
-|o»us  ncrvc^  may  also  be  paraly/cil  in  tin'  same  manner.  When  the  cen- 
tral lilircs  to  the  niiclens(if  the  hypo;;|()s>iis  are  in\o|\eiI  a  peculiai'  form 
of  jinarlhria  re>nlt.«.  If  the  nuclen.-  il,-elf  be  diseaM'd.  suallouing  i.-  inler- 
IVred  with. 

When  the  sen>ory  libres  of  the  llfih  nerve  are  interrnpled.  together 
with  the  sen-ory  tract  (the  nieilial  lcmni>eus  or  fillet)  for  the  re>t  of  the 
body,  wliitli  has  already  ia'o>>ed  the  middle  line,  thei'e  is  a  crossed  sensory 
paralysis— i.  e.,  (li>tiirbed  >ensation  in  the  distribution  of  the  liftli  on  the 
.-ide  of  the  legion,  and  of  all  the  rest  of  the  body  nn  the  opposite  side. 

.\  paralysis  of  tlu  exteinal  rectus  muscle  of  oim  eye  and  of  the  internal 
rectus  of  the  other  eye  (conjugate  paralysis  cd'  the  muscles  wliieh  tiii-n  the 
eye  to  one  side),  in  the  absence  of  a  "  forcc(l  po-itioii  "  nf  the  cveballs,  is 
highly  characteri.«tic  of  certaiii  lesions  (d'  the  pons,  in  sm  h  cases  the  in- 
ternal rectus  may  still  be  lapable  (d'  functioning  on  convergeme.  or  when 
the  eye  to  which  it  belongs  i.s  tested  independently  (d'  that  in  Hhich  the 
e.vternal  rectus  is  jiaraly/ed.  'I'liis  form  (d'  paialysis  is  lonnd.  as  a  rule, 
only  when  the  nodule  lies  just  in  IVont  of  the  altdiicens  oi'  involves  the 
mieleiis  itself,  or  includes,  besides  the  root  lil)res  of  the  abduceiis,  that  por- 
tion of  the  formatio  ri'liciilaris  thai  lies  between  them  and  the  fasciculus 
longitndinalis  mcdialis  (von  .MonaUow).  Tlu'  cases  of  conjugate  paralysis 
just  rcd'errcd  to  may  be  complicated  by  other  disturbances  of  the  eye-muscle 
movements,  in  which  case  the  interpretation  (d'  the  symptoms  niav  be  ren- 
dered (lillicult.     'I'lie  facial  nerve  is  (d'ten  inv(dved  in  these  paralvse>. 

Jn  lesions  of  the  pons  the  patii'iit  ofti'ii  has  a  tendency  to  fall  toward 
the  side  on  whi(di  the  lesion  is.  |)r(diably  on  ac<'onnt  (d'  implication  id'  the 
middle  pediiiu  le  of  the  cerebellum  (brachinm  pontis).  Still  more  ficiiuent 
is  the  simple  motor  hcmi-ataxia  eonse(piciit  upon  lesion  of  the  medial  lem- 
niscus, and  perhaps  (d'  longitudinal  bundles  in  the  formatio  reticularis. 
This  is  often  accompanied  by  disturbance  ui'  muscular  and  cutaneous 
sensations.  Only  when  the  lesion  is  very  extensive  are  there  disturb- 
ances of  hearing  (involvement  (d'  the  lateral  lemniscus  or  corpus  tra^te- 
zoideum). 

The  sym]itoins  produced  by  inv(dvement  of  the  ditl'crent  cerebral  nerves 
will  be  considered  ill  detail  in  another  section. 

a  Cerebellum.— The  functions  of  this  part  of  (he  brain  are  still  under 
consideration.  Luciani,  whose  monograph  is  exhaustive,  regards  it  as  "an 
end  organ,  directly  or  indireitly  related  to  c<'rlaiii  perijiheral  sensory  organs 
and  in  direct  efl'erent  relation-hiii  with  certain  ganglia  (d'  the  eereb'ro-spinal 
axis,  and  indirectly  with  the  motor  a|)paratus  in  general.  It  is  functionallv 
homogeneous,  each  \nu-t  exercising  the  functions  of  the  whole,  but  having 
ppeeial  relations  to  the  niuseles  of  the  eorrespoiuling  side  id'  the  body" 
(Krauss). 

Lesions  of  the  lateral  lobes  affect  the  corresponding  side  of  the  body, 
while  lesions  of  the  middle  lobe  (vermis)  afl'eet  both  sides.     Partial  removal 
03 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


9S0 

\  „    •-  f.nmnloto  roiiioviil  bv  oxtroim- 

operation.     Durin,  tlu>  1i-t  n^^  or  .  ^  —    ;  ;^    ,,,,  astasil  of  tno 

iuito.     ThCTo  is.  iuror.linj:  to  Lv.ciaiu,  aMlun  a.  •  ,  ^^^.^.i 

;;;l.U.s  o,,  tl.  si-U.  or  tl.  '-''y  J-  i;;^.:   r^lsa  ^  ;;  ;"  the  cou.o  o^  a 
or  walk.     .Ml  tl>^'^^'  symptoms  mas  gKUluaii>  u 

iVw  months  ^,^,,^  symptou>s  in  m  cases  of 

W.  ('.  Krauss  ha>  anal\/(<i     m  .  .,1,,^^.^.  SarLoma  m 

disease  of  tins  part.    J^^"  '»;;;^';    '^f  l^^^  ^^  Vl;    lor  of  unspecified 

,0  eases:  tubercle  ,n  2^;  ^-7^^^;  ^^  ''.^■..fteninp,  endothelion.a,  cyst 

oriunn  in  H?;  cyst  in   . ;  and  l^'^'^J^l''  i,..„iorrha-e.     The  left  l.)he  was 
and  sarconia,  cancer  gumma  fibroi  a  ad  h.^^^  ^^    ^  ^^  ^.^^^ 

atrected  :5->  times,  the  righ  lobe  M  ^  '"^  "  '  "  '  ^V-cti.-n.  'i  m-re  n.ay  bo 
^rUu.  tun.or  constituted  by  far  the  ;-■  ^^  ^^^^^  ml  does  not  involve 
„o  svmpton,s  whatever  )f  it  is  in  ^^'^'^  ^'^'^J^^;,,^^,,,  ,l,sence  of  one 
the  middle  lobe.  There  are  not  ;-  >  ^^^^  ^^^^  JJ^  .vhich  throughout 
M,  hemisphere,  but  also  ^   ^^^^^   ^'  ,    '    '^'^     i,!     ^,.,,tioi,s  of  the  brain 

^;;^?;:br^l;;^tnr;mt;^s:;^^^ 

--:;;;.p      nentso......n.;^^^^^^ 

nervations  of  Lucani.  In  ^l"!/  \^  '  'j^,,^^  ^.^^on  reilexes  are  sometimes 
,onstaiit.  and  as  to  atonv.  while  ^^^  1^^^^  ;™  ^^,  !,,;„„,.  There  may  be 
absent,  they  are  as  a  rule  ^f  ^f  "?  ^  ;;''  ^  .iPs  experiments  make  it 
oven  muscular  rigidity  '-  ;'-\^,,^ "  ;,  ,  ",,  ,i,l.  .l^ercises  constant^ly 
seem  likely  that  the  -■■■^■^'  ^  \^  ' ,  :  ,  ^i,..  cerebral  lu.misphcre  of  the 
an  inhibitory  einna  upon  > -  ^^  ;^' ^^^^  •  ,„^  eonjunctivum).  Thus  aft^r 
,,He  side  (probably  ^-'^^  that  much  milder  fanuhc 

removal  of  one  eerebellai    >^;'  ;  "     ^  '  ^^.„,,,,  ,,,l  forth  moYemcnts 

,,„,,ation  of  t^lie  -•;^r;>^;;^;     .^^  :\,  ythnulate  the  bon.o-latenil  motor 
of  the  arm  and  leg  than  that  "<^^^    "■  admiiiistrati.>n  of  al)sndhe  were 

^xtz::r'^i:':^'^^^^^^ -" ""-"- 

bellum  are  as  follows:  .       (y^.tions  of  any  other 

Vnii,,,  which  is  niore  -f  !;/;";/  ^',  to  involvement  of  the 
region  of  the  brani.  Some  ^f  ^'^^  nn  m  t  on  bv  means  of  wlihh  the 
„ervus  vestibularis  or  its  nuc  e,  '  '  ^  '^  !  ^,„;„,  The  sym,)tom  was 
semicircular  canals  are  coniieded  ^^'!''  ^^^,  ^  ^^  ,  ,„.ted  in  1:5.  The 
present  in  IS  of  the  oases  of  Kraus.  -  <'"»."•,  ^^^ J,;,.  Though  most 
Urtb^o  appears  to  be  entirely  indepemlent  ol  )  '^  '^  ;  ,^  ^,^,  ,ther. 
",;:;ntK  associated,  either  ^y^>H>t<nn  n..y  be    n  .  n    w  t   -d^^^^.       ^^^^^^ 

Thi  vertigo  of  cerebellar  f  ;^f^^'^  f'^"  '^;     '.e  1     Iv  itself  is  moving. 


1> 


TOPICAL   DIAGNOSIS. 


OS  7 


oxtronic 

tho  co- 
il f  tor  the 

prodoiu- 
ia  of  liK' 

lU)^   stiUlll 

lursc  oi  Li 

)  easi.'S  of 
u'L-oniii  in 
nspoeitk'il 
loma,  cyst 
t  lobo  was 

IT  times. 
>re  may  lie 
lot  involve 
lU'O  of  one 
lu'onii'hout 

the  brain 
y  the  eere- 

irm  the  ob- 
lenia  is  not 
(  sometimes 
lore  may  be 
its  make  it 
;  constantly 
•here  of  the 

Thus  after 
Idcr  faradie 

movements 
literal  motor 
l)siiiHie  were 
the  explana- 
iir  disease  is 
of  tho  cere- 

nf  iny  other 
>iniMit  of  the 
if  which  llie 
svmjHoin  was 

'in  -1:5.  The 
Thouilh  most 
lut  the  other. 
?  feeling  that 
■If  is  niovinii'. 

cases,  not  ro- 


jiorted  in  ?:'i.  Optir  Dcurilis  was  found  in  (W!  cases,  not  rejiorted  in  'J.'i. 
\'ery  seriou-  distnrlianccs  of  vision  may  result  from  prt'ssure  on  the  acjue- 
ductus  cerebri,  leading  to  increased  pressure  in  tiie  third  ventricle:  this. 
tlirougii  hu!j:inii  of  tiie  tloor,  can  directly  injure  the  chiasm  or  optic  nerve. 

Of  symptoms  which  are  desi<.niated  as  more  ])articnlariy  cereliellar, 
(itd.rid  is  the  most  important.  In  cerehellar  ata.xia  the  jrait  is  irregular  and 
.■staggering,  often  zigzag,"~and  in  attempting  to  walk  the  jiatient  sways  to 
and  t'ro  like  a  druid<en  man  {ili'inarche  d'inrsup  of  tlie  French  writers).  As 
a  rule,  the  patient  walks  and  tends  to  fall  toward  the  atTected  side,  but  the 
rule  is  not  certain.  Tiie  ata.xia  of  cerebellar  disease  is  to  be  sliarjily  dillVi- 
entiated  from  the  ata.xia  of  tabes  dorsalis,  t'nun  cortical  ataxia,  and  ju'ol)- 
ably  from  the  ata.xia  accompanying  diseases  of  the  tegmental  portion  of  the 
pons  and  cerebral  peduncle.  Cerebellar  ataxia  is  both  static  and  dynamic. 
The  o])ening  or  closing  of  the  eyes  is  of  less  iidluence  than  in  spinal  ataxia. 
A'ery  inijxirtant  for  differential  diagnosis  is  the  fact  that  when  the  i)atient 
lies  in  bed  movements  tolerably  well  coordinated  can  be  carried  out.  The 
coarse  nature  of  the  incoordination  distinguishes  cerehellar  ataxia  from 
that  due  to  lesion  of  the  cerebral  corte.x.  In  tho  hitter  the  liner  movements 
(buttoning,  etc.)  are  especially  apt  to  be  involved,  and  there  is  usually 
lieini-j)aresis  or  mono-paresis,  and  often  disturbance  of  muscular  .sense  and 
of  the  atereognostic  sense  (von  .Monakow).  Cerebellar  ataxia  may  de])end 
upon  the  withdrawal  of  the  influence  of  the  cerebellum  upon  the  cerebrum. 

J'ar('t:is  of  the  trunk  muscles,  manifest  in  an  inability  to  ])erform  he 
movements  of  liending.  erection,  and  lateral  llcxion  of  the  trunk,  may  be 
present  (Ilughlings  Jackson).  Risien  ]{ussell  holds  that  the  paralvs's  is 
"probably  directly  due  to  the  withdrawal  of  the  cerel)ellar  iniluence  from 
the  muscles." 

Other  hss  constant  but  suggestive  sym]itoms  are  neuralgic  ])ains  in  the 
region  of  the  neck  and  occiput;  blocking  of  the  vena;  (laleni  and  dilatation 
of  the  lateial  ventricles,  causing  in  children  hydrocejjhalus;  jjressure  on 
the  mid-brain,  pons,  or  medulla  oblongata,  producing  paralysis  of  the  cere- 
bral nerves,  rhythmical  ccmtractions  of  the  head  or  extremities,  nystagmus, 
tremor,  anartliria.  auditory  or  visual  disturliances.  There  may  i)e  glyco- 
suria and  bilateral  rigidity  from  pressure  on  the  motor  [)aths.  Sudden 
death  may  occur.  Forced  movements,  especially  rotation  of  the  trunk, 
forced  positions  (of  the  head  or  trunk),  and  a  ju'culiar  forced  ])osition  of  the 
eyes  (one  turned  downward  and  to  the  side,  the  other  upward  and  inward) 
are  almost  iiathognomonie  of  disease  of  one  brachium  jjontis  (middle  cere- 
bellar peduncle). 

The  reflexes  are  very  variable;  they  were  absent  in  Iv'  cases.  In  pure 
cerebellar  lesion  they  are  probably  intact  or  exaggerated,  but  when  the 
cerebellar  disease  involves  other  structures,  directly  or  indirectly,  through 
action  at  a  distance,  or  when  there  is  associated  disease  of  the  sj)inal  tracts. 
the  reflexes  may  bo  abolished. 

Symptoms  of  general  mental  disturbance  may  accompany  cereliellar  dis- 
ease, but  they  are  not  characteristic.  There  is  often  irritability,  enfeebled 
memory,  and  toward  the  end  sopor  and  coma. 


I 


988 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


U.   APHASIA.* 

1  ,„wi<t<  of  iTCC"i)tiv(\  iiorcoptivc,  and  pinissivc 

Tl,e  .1K.(H.1>  ">-■'>'•••'■  "/■"\'^,.    J."       hi  ,1   .an.  aphakia,  and  cou- 

anco^of  wl».h  l'>'"'l"-\'''\''  '  \,',,  .  ■      ^iv,  Uu-  distuvlnnu..  of  speech 

.rsultmo-  mmi  l^^'^''^    \  ,     inlliuMifo  of  tl>o  c.-rtrx,  without  prmiary 

's::^z::t:zt::f:i  t  l.m  in  t..  n^amia, .. .... .,... 

has  iH'on  api-liod  (r.astuin).  Ku«m;ud.  Wornicko,  Lichtheiiu. 

spooch),   It   IS  nocessaiN    tliat   uc   ic  u n   .  toachin-  a  duhl  to  say 

olhors  (perceptive  speech  -nuponent.  ^  ;,,;;/      i^^i.^utorv  nerve) 

,,,/,.  th,  sound  of  the  uttered  wo  d  ^'"^  '^.j  /  j  ,,  an  in.pulse  is  sent 
„Hi  ,eaches  the  auditcu-y  poreeptivo  ^l^  ;'",',  ^  i„  ,,,  medulla, 
to  the  emissive  or  u.otor  centre  l'-^';'  '  .^  ^  ,  *J  '  ^^j.,,,,  .,.,,,  ^re  in 
through  which  ,i,c  >;-^-  "^.;:rtM:.T  ;  child  radually  acquires 
L>chthenu  s  schen.a  C'  ^^^  j  ^^j  ^^  winch  are  stored  at  the  centre 
in  this  way  mem.rw.  of  '         '  ^'^    ^^  j^.  ^„^.,„,.,i,,  ,t  the  cor.rdi.u.ted  nuis- 

A,  and  motor  mrm-uws--the  '  '"'^.^   '\     .\       ^^^  necessary  to  utter  words- 
enlarn>oven,entso    t   e    .ps     ;..^o   a        ;,n^  ^3_^^_^  ^^^   ^^^^^^.^^^^^_ 

appearance  ot  the  word  ^>f  '  *^  '  ^  ^^.^.  ,  ^he  word  are  distinct  from  each 
of  the  muscular  movement  ^l^'^^^^'j  ^  '  w,,,^,  ^o-rethcr  what  is  termed 
other;  vet  tlu.  are  intmm  ely  c.nn    t       an  Hmm  ^  .^ 

tl->  ^ronJ.vna,c  In  ^^'^^;;;^J:  ^^^iJt-M^^^n^  concept ions-the 
liis  education  ideas  as  to  the  use  ot  c  ^^  ,,)litional  or  intel- 
eentre  for  which  is  -l'^^"*^'',  ^^Jj  /  /'  ^  path  would  he  I.  M  m,  and 
1-tual  speech,  as  m  utteru^  the  ^^^j^^^J}^  .  .nemories  "  are  as  a  rule 
in  wrltln<;the\^ord.  1.  M,  \\. '•  Uoe  Yv^  3).  When  the  word 
stored  or  centred  in  the  left  l;^'"";!'l\^  1^  ,  ^  ,  [;  ae  not  onlv  the  activ- 
-.  bell  "  is  heard,  the  --^a  state  w  .u:h  -  ^^-^  ^^,^  ^^^,^,^^, 
ities  of  the  auditory  perccption<^(m^ 

-Ti^^^r;;:^::;^^^^  t.: 

v..ars.  dnef  of  whicl.  .nay  be  P  '^-"^ J'  ' ^^^^^     ™,',,  (HHti«h  Medina  Journal.  1807- 
works  of  Wyllio  and  VM^r^nd    ho  Me^^J^^^  ^^^^  ^.^,,.,„^  publications 

rVti^rr'Jl— :vr:tnS.::.lrs  „.na.uel.,ana  Mlrall...  work  are 
Ilnong  the  most  important  recent  contributions. 


u 


APRASIA. 


989 


'missive 
nd  c'on- 
(lit^turb- 
luv.cr  of 
[  spc'L'fh 
f:;iivern- 
priiuarv 
aiilu'inia 

I'Utlieim. 
liticirdi'i's. 
iiiu'iit    ill 

)lK'lltS    ol' 

ssioiis  (if 
1(1  to  s!iy 
iry  lU'i'vo) 
so  is  Pt'iit 

medulla, 
he  arc  in 
s-  ii((iuircs 
[he  eeiitre 
iited  mus- 
T  words — 

Hiistiaii). 
siiat  mrin- 
percejitive 
l)ell  wlien 
ory  of  the 
r  memories 
:  from  each 
t  is  termed 
iicquires  in 
)tionR — the 
ml  or  intel- 
,  M  m,  and 
re  as  a  rule 
II  the  word 
y  the  nctiv- 
he  activities 

I  the  past  fow 
h  {1808).  Tlio 
Journal.  1807- 
us  publications 
.lluii's  work  arc 


of  a  wliolo  scries  of  cerdiral  centres,  wjiicli  in  the  manifold  ox]ieriences  cf 
lil'<!  have  hccM  occupied  at  one  time  or  another  in  some  way  willi  some 
psychic  atlriiintc  of  the  cxlcrnal  ohjcct,  or  with  coiiil)iiiiii,L;-  and  coiirdinal- 
in^^  various  iiii|ircssioiis  of  it. 

Tiie  relations  of  lan;j;iia^^e  (heard,  read,  sjiokcii.  and  written)   involves 
then  (a)  sensory  perccptiic  centres  (hearing  and  sight  and,  in  the  liliiid, 


r^wi'     iAi.til  far'      ftt 

h  m  a         0 

Fi(i.  10.— Lichtlu'iiii's  soliema.  A,  auditory  area  in  cerebral  cortex,  in  which  siro  stored 
the  memories  of  tlie  sounds  of  words;  n  A.  auditory  coiidiR'tion  piith  from  cochlea 
to  temporal  lobe;  (),  visual  area  in  cereliral  cortex,  perception  centre  for  written  and 
printed  words;  w  (),  visual  coniluction  path  from  retina  to  occipital  lobe ;  M,  speech 
ceiUre  in  which  are  sL(U'e(l  the  memories  of  the  muscular  nioveiuents  which  produce 
spoken  words  (Bustiiin's  glosso-kiiia'sthotic  centre) ;  M  m,  path  uloiiy  which  im]iulses 
travel  to  innervate  the  lower  nueUi  which  govern  the  muscles  concerned  in  speech ; 
\V,  area  in  cereliral  cortex  in  which  are  stored  the  memories  of  the  muscular  nmve- 
nieiils  concerned  in  writiuij  (Mastian's  cheiro-kina'sthetic  centre);  W  li,  path  alonu; 
which  impulses  travel  to  innervate  the  lower  luiclci  which  f,'overn  the  muscles  used 
in  writing;  I,  areas  of  association  in  cortex  ))y  int'uns  of  whicii  the  activities  of  the 
various  sensory  perception  centres  may  be  united  to  higher  units  (conceptions,  ideas, 
thoughts,  etc.),  and  whence  the  centres  JI  aiul  \V  may  lie  incited. 

touch):  (/))  emissive  or  motor  centres  for  speech  and  writing;  and  (r)  higher 
psychical  centres,  through  which  we  ohtain  an  intellectual  conception  of 
what  is  said  or  written,  and  l)y  which  we  express  voluntarily  our  ideas  in 
language. 

Ajihasic  disturlmnces  for  convenience  of  description  are  arhitrarily  di- 
vided into  two  chief  forms — sensory  and  motor. 

(1)  Sensory  Aphasia;  Apraxia;  Word-blindness;  Word-deafness.— By 
ajiraxia  is  understood  a  condition  in  whicli  there  is  loss  or  impairment  of 
the  power  to  recognize  the  nature  and  characteristics  of  nl)jects.  Persons  so 
affceted  act  "  as  if  they  no  longer  possessed  such  ohjcct  memories,  for  they 
fail  to  recognize  things  formerly  familiar.  A  fork,  a  cane,  a  ]iiii,  niiiy  he 
taken  u\)  and  looked  at  hy  such  a  jierson,  and  yet  held  or  used  in  a  manner 
wliich  clearly  shows  that  it  awakens  no  idt'a  of  its  use  And  this  symp- 
tom, for  which  at  first  the  term  hlindness  of  mind  was  used,  is  found  to 
extend  to  other  senses  than  that  of  sight.  Thus  the  tici.  of  a  watch,  the 
sound  of  a  hell,  a  melody  of  music,  may  fail  to  arouse  the  idea  whicli  it 


r 


n 


n 


i! 


n 


99^  DISEASES  OF  THE  NERVOUS  SYSTEM. 

^o.no.y  a.ai.n.,,  a..  ^^  i-^-^^rx,  Un;:;;::;^!":;  "- 

..,  taste  no  luufjcr  calls  up  tl>o  "«  «"J  ^  ,,,,„^„'^,^  ,,,,,„  ,,lU,.l  int.,  l-lay, 
Uu,s  it  is  loun.l  that  .acl,  or  all  ''  *  ^  ;,^^  >  J  ^^^  ,,,j,,t  exciting;  thorn. 
„„v  rail  to  arouse  an  ">^^>  '^i;'  J  "  ^  !  ,:  i.o  the  L  or  inu-ort  oi  au 
K.,;.  the  j,^eneral  sy.ni.to.us  ol  "^'i'"'  >^.  I  !.^ ';„,.) 

j,j,..t  the  ter.n  aprana  .s  now  emploj  I  '  ^  ...ociated  with  ^arie- 
^praxia  nuw  oeeur  '>''>->  /"'HitSa  may  be  able  to  read,  but 
,i,„  ot  sensory  and  motor  aphakia.  -^^^^  ;^\'  ;  /^  ^^^^^i,  ^vhile  blind  to 
tl„  .ords  arouse  no  i"tol  -gent  unp  --  "l^Z.  may  be  stimulated 
na.mory-pi.'tures  aroused  '^^'^;'^^\'^;^^'^^  ,  ,raxie  patients  unable  to 
,.y  toueh;  thus  there  '^-  '>-^';";'  r  \  ^  "^  ;^:^.V  y  toueh  name  them  eor- 
i^^^^oflt  tm::fl;^.t^:;tl-;«:ess  a^d  m.nd.dea.ness  are  the 

exists  .n  the  left  hennsphere  m  -^^^"    ^^j'^  ;,,„;  involves  the  angular 
„,„ere  in  left-handed  perso   .         a  duea^    ^^^J^  ^^^^^^^^      j.„^,  ^^,,  ,, 

and  supran,arg>na    gyn  or  ^^^^  ^\^,,,^i  ,,,a  transitory,  and  ,s  asso- 
the  ••  nnnd-s  eye      nu.y  at  tinu     be      '^^^  ^^  remarkable  case  re- 

eiated  with  n>any  ionns  «V"';  lor  an  "ry  to  the  head,  had  sulferod 
j,,ted  by  Macewen,  the  pabon  ,  ^^^^^,  ,,,,ivsis.  Ho  .-as  psy- 
vith  headache  and  melam  u.l.a,  f  '  ^^  .^.^^i  ..i^Jtly  well  and  could 
chically  blind  and  though  he  -^^'^'V  '[ ,  ^  /^  rp  ossi.,n.  A  man  before 
feud  letters,  objects  cnveyod  no  J"\^'l  *^^";  "/,  ,^^\^,,,,  ,,„til  the  sounds 
his  eyes  was  recognized  as  son>e  object,  1'"^  m.t  u  v  ^^^^^^  ^^^^^^^ 

0    the  voice  led  to  the  recognit.on  throng  ^     ."    ,,  ^,  ,.,,  f^.nd  to  be 

.as  trephined  over  the  -^^^-^f^^;;;^:^,^  i    'b^ain  in  this  region.    The 
depressed  and  a  portion  had  bee.  dm ui  m  ^^^^  ^^  ^.^^^  ^^^^^^^ 

pa  iont  recovered.     ^I'^^^-'.'^'V"  !^^,   ^..^  '    ,  ,et  with;  thus  a  young  man 
Ijthor  nuuufestations  of  nnnd4.hmlno^  a  c  me    .       ,  ^^^^^^  ^^^^^  ^^^  ^^^  .  ,^ 

.-ith  secondary  syplnl.s  l-;-;;^^^;^"';: awakening,  the  memo,T-l-- 

he  remained  nnconscun.s  for    "  "^;^    .'"^^^  ^^^  ^^.i^hcr  knew  his  ,.aronts  nor 

■  turos  of  faces  and  places  ™  '^   ''' "'V  ^"^  j^,/,,,  n^ed;  ho  had  no  aphasia 

^^'-'-•^'  -r  '']::^-:'  ta  r^r-l^^-  ^ompMo  tactile  amnesia, 
proper,  and  no  paial>sis.     -V'';"' 

as  in  the  cases  reported  by  ^'•\;  ;•;;';     ^^-^^^  „,,tor  aphasia.     In  nncom- 
^Vord-blindness  may  occur  alont  t  appearances  of 

plicated  cases  the  patient  is  ->    -f    ;^^';,    J^  or  written  page.     The 
lords,  and  does  not  recognize  th         '"  ^  ^  '  ^  ^^.^.^^  ,.,„ectly, 

patient  mav  be  ahlo  to  pronounce    ho  ^^^  ^^^  «  "       \  jt  is  rare,  how- 

C  he  cann.  1  road  --^^^^f^f^^^t^^^  IZ^.  of  facility.    There 

ever,  for  the  ,.  tient  to  bo  '^1'1^'.^";^"*\,    ,  '  '    nd   has  vet  been  able  to  do 
Z   nstances  in  which  ^1- if -"*.  nmUd  ^  ronl    1^  ^^^.^^^^  .^^  ^^^^^^ 

,,atheniatical  problems  and  to  -oc^'^^ P^ '  ;  -    ^  ^,,^,  ^^^ 


m 


APUASIA. 


901 


n  oilor 
d;  iiml 
to  iilay, 
f  tlioiu. 
•I  oi  an 

[\  •>.  aric- 
■ad,  but 
)lind  to 
mulated 
liable  to 

;  are  the 

le  lesion 
ht  henii- 

angulav 
idnet;!-  of 
\  is  asso- 
•  case  re- 
l  suifered 

was  psy- 
md  could 
in  before 
lu'  sounds 
The  skull 
und  to  be 
:ion.    The 

amnesia, 
oung  num 
>  of  which 
emory-pic- 
nucnts  nor 
no  aphasia 
le  amnesia. 

In  uncom- 
earances  of 
page.     Tbc 
tc  correctly, 
5  rare,  bow- 
lity.    There 
1  able  to  do 
ions  in  cases 
d  supramar- 
ianopia,  and 

ard  and  per- 


ceived as  such,  awaken  no  intelligent  perceptions.  A  person  wiui  knows 
nothing  of  French  iuis  mind-deafness  so  far  as  tl' •  Frcncli  language  is 
coiicerncil,  and  though  he  recognizes  tlie  words  as  'ds  whi'ii  spoken,  and 
can  repeat  tiieni,  they  awaken  lU)  auditory  memories.  Tlu'  musical  faculties 
may  be  lost  in  aphasics,  who  may  l)ecoine  note-deaf  and  unahlc  to  apiire- 
ciate  melodies  or  to  read  music  {uiniisia).  This  may  occur  without  the 
existence  of  motor  apiuTsia,  and,  on  the  other  hand,  there  are  cases  on 
record  in  which  with  motor  ai)hasia  for  ordinary  speech  the  patient  could 
sing  and  follow  tunes  correctly.     Miml-deafness  is  also  known  as  auditory 

amnesia. 

Wunl-dinfiicss  is  a  con<lition  in  wliicli  tiie  patient  m)  longer  under- 
stands spoken  language.  The  iiuniory  of  the  sound  of  tiie  word  is  lost, 
ami  can  lU'ither  be  recalled  m)r  recognized  when  heard.  Jt  is  usually  asso- 
ciated with  other  varieties  of  ai)hasia,  though  there  are  cases  in  whicii  tlie 
patieiil  lia<  l)een  alile  to  read  and  write  and  speak.  Tiie  lesion  in  word- 
deafness  has  been  accurately  delined  in  a  numl)cr  of  cases  to  lie  in  the  pos- 
teric:-  [ortion  of  the  superior  temporal  convolution  and  the  transverse  tem- 
poral gyri  on  the  left  side  (Fig.  ;5). 

In  irdi  11(1  ri/  i<ensuri/  aplKtsia  of  WernickeV  type  there  is  loss  of  power  to 
understand  spoken  words  and  to  repeat  words  i)ronouiiced  before  the  jia- 
ticiit.  The  i)atient,  as  a  rule,  cannot  read  (alexia),  and  is  usually  unable 
to  exjiress  his  tlioughts  in  writing  (agraiihia).  Spontaneous  speech  may  be 
somewhat  interfered  with,  and  on  account  of  the  intcrferenje  with  speech 
control,  resulting  from  the  loss  of  memory  of  the  sounds  of  words,  there 
mav  be  a  little  iiarajihasia. 

In  the  so-called  ptnr  ironl-dcafnesa  (Wernicke's  subcortical  sensory 
a])liasia)  the  symptoms  diU'er  from  liiose  of  the  most  common  form  of  sen- 
sory aphasia  in  that  the  power  to  read  and  to  write  are  retained.  Besides, 
there  is  but  little  if  any  ])arapliasia. 

In  the  so-called  lrant<curti((il  kciisi,)-;/  aphasia  the  i>aticiit  has  lost  the 
])ower  of  understanding  siioken  words,  although  he  is  capal)le  of  spontane- 
ous speech  and  also  of  repeating  W(U'ds  ])ronoiinced  before  him.  Spontane- 
ous writing  is  imi)ossible.  He  can  read  aloud  from  a  manuscript  or  printed 
page,  but  docs  not  understand  what  he  reads.    There  -s  some  jiarapliasia. 

(2)  Ordinary  motor  or  ataxic  aphasia  is  a  condition  in  which  the  mem- 
ory of  the  ctl'orts  necessary  to  ])ronounce  words  is  lost,  owing  to  disturii- 
ance  in  the  emissive  centres.  This  is  the  variety  long  ago  recognized  l)y 
Broca,  the  lesion  of  which  was  h  calized  by  him  in  the  left  inferior  frontal 
convolution.  The  patient  may  not  be  able  to  utter  a  single  word;  nuu-e 
commonly  he  can  say  one  or  two  words,  such  as  "  no,"  "  yes,"'  and  he  not 
infrequently  is  able  to  rejieat  words.  When  shown  an  object,  though  not 
able  to  name  it,  he  may  evidently  recognize  what  it  is.  If  told  the  name, 
he  is,  as  a  rule,  unable  to  rejieat  it.  A  man  knowing  the  French  and  Cier- 
man  languages  may  lose  the  ])ower  of  exiiressing  his  thoughts  in  them,  while 
retaining  his  motiier-tongne;  or,  if  comi)lete]y  aphasic,  may  recover  one 
before  the  other.  As  the  third  left  frontal  convolution  is  in  close  contact 
with  the  centres  for  the  face  and  arm,  these  are  not  uncommonly  involved, 
with  the  production  of  a  partial  or,  in  some  instances,  a  complete  right- 


'J'j2 


DISEASES  OF  THE  NEllVOUS  SYSTEM. 


„,„,  ,„„„i,,,,.,i,.     I/,,,.M,  ..,■  i-iliiy  ...  r 1,  .....■,...  ».n.  ..........  ..pi...-" 

and  also  willi  wonl-l-lmdiu^^.  i„aliilitv  In  ^^■^■\W-ai|raphln. 

l.ut  tluMv  an.  instance,  ol  -'  "-H^  -^^^^  ,  ^     •  ,    ,,.,.  nn-clu  thus 

,  l..t..nt  nu>y  ^^^^^f   ^  ^iVq^-ostion  uhHluT  tluTo  is  a  spccia    wv.fn, 
,„ay  copy  pcvUH-tlj.      t  '-    "  ^,,^,  ,„,,  „f  the  second  Irontal 

,..„„,,  „  ,,,  ,,.c.n  P''>-"  .  ,^,;'  ;  ;  '  ^  ,  i.u.s  vvith  tl,c  n>otor  area  tor  the 
,onvolutionj.ut  ,t  seen.s  kel  "''',;";,  ,,,,,^,  ,,,  l„„kc..l  upon  as  the 
„,,,H,r  exlren.ity.  Frun>  tl.e  al.o  e  ^^^^^^  J^^^^^  ,,e  separated-vi.., 
oJ^linary  form  oi  .notor  'M'^^-,  ->;-;-  ;-;;^;i,^^i  „!,,,  aphasia. 
,)        ,,,  ,vord-dund.ness  and  (>    tic  ^";  i,i,htheini  and  Wer- 

'-■'<'■)  -  '•"'  '^"•"'  '"'1'''"'  ''  *'";    7";        .u    ..  w^'"h  and  of  rep;.atin, 
,U1.,  in  which,  though  the  lunve    "  ;l  "^      "  ^    ^   „  ,,^^^,^  t,  Hi„,,ir  ,.,th 

:;;;;!;r;;L;; :;:;;-- ;:--'-  "" 

„t  ,„„t.,r  ,.,.1...=....  '"'"';'•'',"  'J'  I,  ;,„,  ,,„ti.,,t  .a„  ,„..l,..vl.....l  '|...k.-" 

;;;;;l  :;;!;;:::r';:;t^;K:'::;;.t;i^.,......i...  »h. a .... 

copy  another  individuals  writm-.  ;^,^^^  ^„„^^,j.. 

''^"*-  '^ '  ^""y  '"Ti^d-:":::   :'t;; :'  c-reeti .  hut  ■.  co,. 

stands  what  is  said,  and  speaks  '^'"  '""-  ,5^  j,i„,,  j,,  the  proper 

stantly  tends  to  nusplace  words,  '>-\";;,       ^^  ,„     ,  ,,,ui,it,  exan.ph'S 

,„,,;.     It  is  precisely  these  .^'s  -!>-'>  ^'^^  ,     f,o:n  a  state  in  uhieh 

„,  paraphasia.     All  grades  oi  tins  n         -          ;  ;,.  j,,,^  ,^,  ,,,,,,  H,e  pa- 

"-1V  a  word  or  two  '--P  -^  J,  j  V,^  tion  tract  is  interrupted  he- 
tient  talks  .largon.     ]n  these  oa    .  ,^^^_^^  .^  -^  ^,^^^^,. 

twoen  the  audit.uy  perc^.p  ne  ;>'''\  ^''^ "  ,  •  ,  '  .p,  e  lesion  is  usually 
ti„H.s  known  as  Wermcke  s  ''/^'-r';^  Z;^,  ^  f  "tho  f  ontal  and  ten^poral 
i„  „,,  i,„„la  and  in  the  convolutions  ^^  >'*  \  /      ,^  ^^  ,^„„,,„,  „f  lads, 

,,Ues.     Lichthein.V  schema,  thongh  -n,    o  -  1  _^^  .__  ^^,^^^.    .^^^ 

is  oxtremelv  useful  to  the  hegmner,  and  will  a,.i,t  iiu 
,  ,,„i,„al  idea  of  the  varieties  *>f  ^Pl;;';';';  ^    ,,,  ^ho  ideation  centres 

"'"'.,"■  s  u.i,„,  „,  A.  tlu.  rn,trn  f..r  ll..'  nmlit.r.v  ,„..,«..vi..,  ol  .„v.l*  (L'tt 

word-hlindiiess.  w     .   \   At  .nid  O  AI  causes  the  conduc- 

1    Interrni^tion  of  the  tracts  umtmfe  A  ^I  an.l  O   M 

ti-  "l"l>-i''  ''f.^'^''';'^r-i:!:!!''M'?nroca's  convolntio.)  causes  ordinary 
5    Destruct  on  of  the  centre  M  (l>roca.  '  c;necch 


I 


r 


APHASIA. 


903 


•fvaphln. 
imliility. 
licli  the 
■h;  lluiri 
iUi.l  yet 
wvitinjf 

I  I'r.nital 
ii  for  the 
111  as  the 
(hI — vi/.., 

aphasia, 
md  Wer- 
lally  met 
repealin,;;' 
iself  with 
,0,  lUiable 

that  form 

to  speak 

1(1  spoken 

1,  and  can 

'ill  uiider- 
it  lie  eon- 
the  proper 
>  exanqiles 
.'  in  whieh 
eh  the  pa- 
ni|ite(l  he- 
it   is  somo- 
is  usually 
(1  temporal 
cr  of  facts, 
\  obtaining 

ion  centre?, 
centres,  A 

words  (left 

rto\),  causes 

the  conduc- 

scs  ordinary 

II  speech. 


A  Ic.-ion  at  ^I  usually  destroys  also  the  ])o\ver  of  writing.  The  centre 
iur  memories  (d'  tiie  iiioveineiits  made  in  writiiii,'.  \\\  is  di>tinct  from  tiiat 
(.f  sjieich.  It  is  callctl  hy  r.a>lian  the  "  (■lu'irod<ina'>th('t ic  "  centre.  A 
iisioii  at  .M,  wiiicii  wiiiild  (h'>troy  the  ]io\ver  (d'  voluntary  s|ieecli,  inijiht  leave 
(pell  the  connections  hctwecii  ()  W  ami  .\  \V,  hy  which  the  patient  could 
(i.py  or  write  from  dictation.  According  to  Wernicke's  eonee|iii(in.  ]iure 
word-deafness  (siiiicorlii'al  sensory  aphasia)  would  he  {\w  to  a  loioii  in  the 
jiatii  rt  A,  transcortical  sensory  a|)hasia  to  a  lesion  in  tiie  path  A  I,  pmv 
woi'd-duiiihiK's.s  (siihcortical  motor  apiiasia)  to  a  lesion  in  the  path  M  ;/(, 
and  transcortical  motor  aphasia  to  a  lesion  in  the  patii  I  .M.  While  iin- 
(louhtcdly  there  are  groups  of  cases  separable  clinically  corresponding  to 
tlu'se  various  types.  >till  patlndogical  examinations  have  already  shown 
that  the  iioiiienclalui'e  is  faulty  and  will  not  stand,  thoiigli  the  number  of 
cases  thus  far  thoroughly  studied  at  autopsy  does  not  sutlice  for  the  con- 
struction of  a  coiiiplcte  classilication  on  a  pathological  basis. 

The  ])roblcms  of  ajihasia  are  in  rt'ality  excessively  com|ilieated,  and 
the  student  must  not  for  a  moment  suppose  that  cases  are  as  sini|ile  as 
diagrams  indicate.  A  niaj(U'ity  of  them  are  very  complex,  hut  with  patience 
the  diagnosis  of  the  dill'ereiit  varieties  can  often  he  worked  out. 

The  following  tests  slunild  he  a]>|ilied  in  each  case  of  aphasia  after 
having  determined  the  ]»rescnce  or  absence  of  ]iaralyses,  and  whether  the 
]iatient  is  right-handed  or  left-handed:  (1)  The  jiower  id'  recognizing  the 
nature,  uses,  and  relations  of  objects — i.e.,  whether  apraxia  is  ])resciit  or 
not:  Vl)  the  power  to  recall  the  name  of  familiar  objects  seen,  simdled.  or 
tasted,  or  (d'  a  sound  when  heard,  or  of  an  object  touched;  (.'i)  the  ])ower 
to  rinderstand  spoken  words:  (I)  the  capability  of  unilerstaiuling  printed 
or  written  language:  (•'))  the  power  (d  appreciating  and  understanding 
musical  tunes:  ((!)  the  power  of  voluntary  s|ieech — in  this  it  is  to  be  noted 
]iarticularly  whetlu'r  he  misplaces  words  or  not:  (T)  the  ]iower  (d  reading 
aloud  and  of  understanding  what  he  reads;  (S)  the  power  to  write  voliin- 
t:irily  and  (d'  reading  what  he  has  written;  (!>)  the  power  to  copy;  (1(»)  the 
jiower  to  write  at  dictation:  and  (11)  the  power  of  repeating  words. 

Till'  Dii'dicii-lcfidl  iis/irrls  of  aphasia  are  (d  great  importance.  Xo  general 
principle  can  be  laid  down,  but  each  case  must  be  considered  on  its  merits. 
Langdon,  in  reviewing  the  whole  ([ueslion.  concludes:  '•Sanity  e<tal)lisheil, 
any  legal  (hieniiK'nt  should  he  recognized  when  it  can  be  proveil  that  tin,' 
]iersoii  making  it  can  understand  fully  its  nature  by  any  receptive  channel 
(viz..  hearing,  vision,  or  muscular  sense),  and  can.  in  ailditioii.  express  assent 
or  dissent  with  certainty  to  i)ro])er  witnesses,  whether  this  expression  he  by 
sjiolcen  s])eech.  written  s])eech.  or  ]iantoniiine." 

Prognosis  and  Treatment. — Tn  y(niiig  ])ersons  (he  outlook  is  good, 
and  the  ])ower  of  sjieech  is  gradually  restored  ap])arently  by  the  education 
(d  the  '•('litres  on  the  opposite  side  of  the  brain.  In  adults  the  condition  is 
less  hopeful,  )iarticnlarly  in  the  cases  of  complete  motor  a])hasia  with  right 
hemiplegia,  '^riie  patient  may  remain  sjieeehless,  though  capable  of  under- 
standing everything,  and  attempts  at  re-education  may  be  futile.  Partial 
reeovi'iT  may  ficcur.  and  the  patient  may  be  alile  to  talk,  but  misplaces 
words.     Tn  sensory  ajihasia  the  condition  may  be  only  transient,  and  the 


,,5,^  niSEASES  OP  THE  XEKVOrS  SYSTEM. 

"'THi '. '■•'»trzr''i;::"'™--""^'°^^"^ 

UuMit  to  write  with  the  Ifft  l.and. 


,„.    AFFECTIONS   OF   THE    BLOOD-VESSELS. 

1.    IlYlT.U.KMI.V. 

congestion  o.  t.>  l.ain  ..  in  U.  V^ ^V^tZ:::!^:t  ]::^Z 
corcLral  pathology.     I  'l'^;'''      '\,  ^      Z^.r^^W.  conceded,  l.ut  how  far 

of  Wood  hi  tlK.  ^^'-^-\,  ^^"^i^  ,    ,  ^,    ,  ,voup  of  syn>pton,s  ..  not  Huhe 
those  chanj^cs  an"  associa  cd  w    h  a   1^     ^   ^     I       ^^^j  ,      ^^    (.,i.,i,  ,vl>o 

.o  eh.ar.     The  whoh"  suhjc..t  h>^  ^     o  ne^e-eells  and  U>e  i-o.sihility  .t 

rightly  insists  that  the  "^•^'•'V;";yJ';,;u^.erehval  tissues  is  dependent 
i,Uen.lnu,,e  of  gases  l.etween   l.e     J   .m    th       ^^^^^    ^^^^^^^^  ^^^^  ^^^^ 

„,t  „„ly  upo..  the  an.ount  ol  '>     "       /   \^.„„,,i        ,,,r,  npon  tlu-  vehuMty 
itsehenueaUonstitntu.n,ande.p     .   1>.   M^  U^^  ^^  ^,,^  i^i,„,i  jiow 

of  the  current  in  the  eerehia      -f^^     ^         ^^     j.i,  ,,,iter,  much  mure 

i,  the  cerehral  cap.lh>ru.  ^^f^^';^^^^^  ,,.„,  tl>e  height  of  tl>o  ar- 

,,,  the  tension  of  tl>e  -'''IV'l.n^^Um.    designated  as  "  cerehral  hyper- 

terial  pressure.     In  many  ol    ho  ^«»J'  ^^^^^  ,^o-nre,  for  with  ihiecidity 

ZnJ  there  is  really  a  -"f  ^.t'^^v    M--lysis  o£  the  sympa- 

and  widening  of  the  --^^^    ^    ;  ;;  Z^^,  there  must  follow  as  to 

thetie,  the  arterial  F^'^^^"« /""^      "^  ,,f  the  vessel  walls  a  deerease  in  the 
,,,,Uoftliediminut.onoftliet  n-m        he     ^^      ^  ^^^^^^^  ^^^  ^,^^  ^      ,^.^,1 

velocity   of   the  hlood-ilow.     ^^\    ,\!  ',,^,^,ti,,  .hes  rise  not  to  -  an^v- 
avteries,  due  say  to  irritatum  ot  t  -W)^^  -^^,,  ,,  ,,,eular  tension 

,,i,-'  as  generally  I.  ^-VVO^'^^J^' ^   cerehral    capillaries.      It   has 

^-'^L  .r„.  i.,^r...  has  iieen  .^^^^  ^^i^  ;-:,';;;:^:;tr:^;: 

conditions,  with  inerc^ised  actum  »^^-,  j*  ;;^,,,,,;,.ion  of  certain  cus- 
traction  of  the  superheuil  ^^^^;ffjZl^  eaises  are  plethora,  unc- 
tomary  discharges.  ^^"-"^  J^^j^Ja  ^^i.u  excessive  brain  work,  and  the 
tional  irritation,  such  as  i^  "-*^^"^*:^  ,,,,,^  ,,,a  nitrite  of  ainyl. 
action  of  certain  -^^-^--:'- ^f  .  ;.  tn^r^obstruetion  in  the  coi.bral 
Passive  hypcro'ima  was  said  to  u.  uu  .^  ..,..,:.„.    „^  ;,.  mitral  ste- 


•u(l  to  result  uom  um.-w , 


AFFECTIONS  OF  TIIH   IJLOOD-VKSSELS. 


ddi 


owers  of 

and  pii- 
irritablo. 
,  not  t')o 
pvogro^>, 
in::lakin^,' 
It  may  1a: 


nt  part  in 
he  amount 
ut  how  far 
.s  not  ([uito 
.U'ifiol.  wlio 
)~sil)ility  of 
;  (k'pt'ndont 
t  aliso  upon 
the  vi'Uu'ity 

blood  ilow 
much  more 
it  of  the  ar- 
obral  hypcr- 
th  lUiccidity 

the  sympa- 
ollow  as  the 
erea^e  in  the 
the  cerebral 
Kit  to  •'  aniB- 
•uhir  tension 
ries.  It  has 
her  active  or 

I  with  febrile 
surface,  con- 

if  certain  cus- 
lethora,  func- 
rt-ork,  and  the 

lyl 

II  the  cerebral 
in  mitral  ste- 

aneurisms  and 
3  in  prolonged 


.straininjx  cITorts.  In  its  most  intense  furm  it  is  seen  in  the  <  (inipi'cs.-iun  df 
tiie  superior  cava  by  tumors  and  in  death  from  stran.uulatinii. 

The  anatomical  (lianues  in  conizcslion  of  the  inain  aic  by  no  means 
striking,'.  Such  an  active  hypeneniia  is  iievi'r  visible  po>I  mortem.  'The 
veins  of  the  corK'x  are  distended,  the  j^iay  matter  ha>  a  dee|icr  color,  and 
its  vessels  are  J'nll.  'i'lu.'  aiteiics  at  tiie  liase  and  in  the  Sylvian  li.-siires 
contain  blood.  >i'othiii,u,  iiouH'ver.  can  lie  more  uncertain  or  indeiinite  than 
the  pcjst-mortem  apjiearanccs  uf  su-called  hyiienemia  of  the  brain.  The 
most  intense  distention  u(  the  vessels  is  seen  in  early  diMtli  durin;,'  the 
specillc  fevers,  or  in  the  secondary  passive  conj,'cstion  due  to  (liisiiiK  lion  in 
the  su])erior  cava  or  in  the  lesser  circulation.  Jn  a  majority  of  these  cases 
of  s'o-callcd  hyperu'iuia,  while  the  total  mass  of  blood  in  the  brain  may  ex- 
ceed the  normal  by  a  considerable  amount,  yet  the  velocity  of  the  i  urreiit 
is  so  much  less  than  nornud.  that  as  a  result  the  brain  really  has  a  smaller 
supjily  of  blood  than  is  normal — that  is,  the  jiatient  actually  sull'ers  from 
ceiei)ral  "  anaemia  "  rather  than  from  "  liy]ierieinia." 

Symptoms. — There  are  no  characteristic  or  constant  features  of  dila- 
tation of  the  cerebral  blood-vessels.  It  may  exist  in  the  most  extren'ie  grade 
without  the  slightest  disturbance  of  the  cerebnd  functions,  as  is  witne.-sed 
freipiently  in  the  pressure  l)y  tumors  on  the  su|)erior  vi'ua  cava.  Ilow  far 
the  headache  and  delirium  of  the  early  stage  of  the  infectiiuis  fevers  is  to 
be  assigned  to  dilatation  of  the  blood-vessels  of  the  brain  it  is  not  easy  to 
determine.  The  headache,  dizziness,  and  unpleasant  sensatinns  in  aortic 
insuiliciciicy  and  in  some  instances  of  hypertrophy  (d'  the  heart  have  been 
attributed  to  the  cereliral  congestion. 

As  a  sejiarate  clinical  entity,  congestion  of  the  brain  rarely  comes 
under  observation.  I  have  no  knowledge  of  instances  assoeiated  with  de- 
lirium, fever,  insomnia,  and  convulsions,  or  of  the  so-called  apoplectiform 
variety  described  by  some  writers.  Very  ])lethoric  j)ersons  are  subject  to 
attacks  of  headache  with  Hushing  of  the  face  and  irritability  of  temper, 
attacks  which  may  recur  frecpiently  and  are  sometimes  relieved  by  bleed- 
ing at  the  nose.  These  have  usually  been  attributed  to  congestion  of  the 
brain.  'When  the  so-called  jiassive  hypera'nua  reaches  a  high  grade,  there 
uuiy  be  tcn-jior,  dulness  of  the  intellect,  and  ultimately  deej)  coma. 

Leube  suggests  that  the  symptoms  usually  referred  to  active  hypenemia 
in  the  acute  infectious  diseases,  like  diphtheria  and  erysipelas,  or  in  the 
instances  in  which  hypertroi)hy  of  t)io  heart  accompanies  disease  of  the 
ki(hu'ys,  may  after  all  be  toxic  in  origin,  lather  than  due  to  alteration  in 
the  circulatory  relations.  At  any  rate,  lie  believes  that  it  is  not  ]K)ssiblo 
to  make  a  diagnosis  of  such  a  hyperivmia.  Flushing  of  the  face  is  by  lU) 
means  a  safe  guide.  Possibly  an  examination  of  the  eve-grounds  mav  be 
helpful. 

2.  Anm;m[a. 

This  may  be  induced  by  loss  of  blood,  either  (piickly,  as  in  haemor- 
rhage, or  gradually,  as  in  the  severe  ])rimary  ami  secondary  amemias. 
The  anaunia  may  be  local  and  due  to  causes  which  int-crfere  with  the  ]>l(iod 
supply  to  the  brain,  as  narrowing  of  the  vessels  by  endarteritis,,  pressure, 


H 


Q,„,  DISKASKS  OK  THE   NKRVOUS  SYSTHM. 

,,,n'nwin-  ..!•  tl...  aurti..  nrilirr.  nr  it   .nay   fallow  nn   um..,,-!:.!  .li-lril.utinn 

of  il„.  \M   in  .■.....■MU...,. •  .lili.ti.tinn  of  .vrt.i.i   vaMuh.r  trrntorus. 

TluK  nu.i.l  .!i-lcntinn  ..f  tlir  iiiL'stinal  vessels,  s.1,1.  as  uciirs  alt.T  tlu- 
,,,„.,;,|  ;,r  asutu-  tlni:l.  inav  cause  s.ul.len  .leatl.  Inm.  eerehial  air.e.n.a. 
Th,  ennnnnneM  illustrati-.,,  of  this  is  the  I'aiuliMK  lit  In.m  emnfnu.  lu 
whieh  the  l.hMMl  supi'lv  tn  th..  l.rain  is  iiHullieient  -n  aeeount  et  tu-  .l.nun- 
i.h..l  arfTial  pres-uiv.  AnaMuia  of  the  .erel.ral  vessels  may  he  eause.l 
l,v  ,„v.<ure  of  llui.l  i.i  the  venlrieh'S.  The  |.artial  aMaMiua  results  trom 
,;,,,i;,,„i„„  „!•  |„,„H-hes  of  the  eireU.  ef  Willis  hy  en.hulisn.  nr  thruinh(,si.s 
Lin-flture  of  one  earotid  .^onwliines  eauses  a  transient  marked  anaMnia  ami 
(li-.turl>anee  ol'  finutiou  <ni  one  side  ot'  tht>  l)rain. 

Tiu'  anatonneal  eon.liti.m  of  the  hrain  in  ana'nua  is  very  stnkinj^. 
Tin.  m..mhranes  are  pale,  only  the  large  veins  are  full,  the  small  vessels 
over  the  "vri  are  emptv.  and  an  unusual  amount  of  eerehro-spiual  luid  is 
,,n-ent  '  On  seetioii  hoth  the  j^rav  a:  .1  white  matter  look  extremely  pale 
,n„i  th..  cut  Mirlaee  is  moist.      Very  few  pinirh,  vnsnilosa  are  seen 

SymptomS.-riH"  elVeets  of  auamia  of  the  hraiii  are  well  illus  rated 
l,v  a  faintin-  lit  in  whieh  lo.s  of  e.uiseiousness  follows  the  heart  \v.'al<ii.;ss. 
When  the  result  of  ha'inorrhaov.  tiu'ie  are  drowsiness,  gnddim'ss.  inability 
to  stand.  Hashes  of  lioht.  dark  spots  hefore  the  eyes,  and  noises  in  the  ...rs; 
,h,  re-piratiou  lieeonu's  hurried;  tlu'  .kin  is  e.H,l  an.l  eovered  with  sweat; 
the  pupils  are  .lilated.  there  may  he  v.mdtin-.  headaehe.  nv  delirium,  an.l 
.,,,,duallv.  if  the  hl.vdin-  eontinues,  eons.M.iUMiess  is  lost  an.l  d.^ith  may 
ueeur  with  .■.a.vulsinns.      In  or.liuary  syne.,pe  tlu'  l.>ss  ..f  e.msei.msness  i. 
u-uallv  transi.nt  an.l  the  reeumlH.nt   posture  al..ne  may  sul li.e  t..  restore 
„„,  ,,i,ieiit  t.,  e.u.>.i.u,sn..ss.      In  th.'  more  ehnuiie  f..rms  .,!  hra.n  aiueuna. 
<ueli  as  result   fn.m   th.'  -ra.lual   imp..verishment  .d   the  bloo.     as  m  pro- 
traeted  illm-s  .,r  in  starvati.-n.  the  c-on.lition  kimwn  as  irrUahle  weaknes. 
results      Aleiital   elVort    is  .litr.eult.  the  sliditest   irritatmn   is   i.,ll.,w..d   hy 
undne'exeitenumt.   the   patient    e.implains  .d"  giddiness  and  nois..s   ,n  the 
e.,rs  .)r  there  mav  1...  hallueinati.ms  or  delirium.     These  syiiipt.)ms  are  met 
with  in  an  extreme  .ura.le  as  a  result  of  prolonga.!  starvatmn 

Tl,.-e  svmpt..ms  are  indistiuguishalde  ir.mi  those  due  t..  the  srvcal  .1 
,,n.l,ral  ln-i..i-a.mia.  The  .piality  .d  the  hh.od  is  determrat..l  and  the 
veh-eitv  of  he  hl.unl-tlow  is  diminishe.l.  s..  that  the  e.;rehra  nutr,t..|n  is 
Iniel^ered  with.  It  is  interesting  to  not.-  that  laek  of  suitah  .■  nuln  .on 
dvos  rise  t.>  id,en.uu..iia  .d"  iiu.reas..d  irritahility  in  certain  of  the  cei.^lual 

to   which    the  term   hiithrncephihilJ 


centres,  at  least  for  a  time 

An   int.MVsting   set   of   symptom. 


was  applied  hv  ^larshall  Ifall.  .ucurs  in  th..  .Vhility  produced  by  l'^.  'J"J-- 
diarrllia  in  chil.livn.  The  child  is  in  a  semi-c.anat.)so  cond,t„>n  with  c 
eves  open,  the  pupils  c.ntracted,  and  the  b.ntanc.lle  deiuvs^.n  In  tie 
,:„.li..r  period  there  mav  be  convulsions.  The  e.nna  may  gradually  deepen, 
iho  pupiN  be.„me  dilated,  and  there  may  be  strabismus  an.l  even  retraction 
of  the  head,  svmptoms  which  closely  simulate  those  of  basilar  meningitis. 


1 


AFrPX'TloNS  OF  TlIK   HLOOD-VKSSELS. 


907 


'.).    (l'',l)KM  A    OK    'I'm;    I>HA1\. 

In  the  |iatli(iliiL'y  of  l)riiiii  Ksiniis  (I'dcina  I'nniicily  |il;iyc(!  n  /v'/c  iilinnst 
c'((iial  ill  iiii|iiirliiiu('  to  coiiL.'fHlioii.  It  (uiiirs  uiulci'  the  rulluwiiiL;'  diinli- 
lioiis:  111  ^ciiciJil  iilrii|ili_v  of  tlic  convoliitioiis,  in  \vlii(ii  c.isc  tlir  (nlcniii 
is  I'l'prc'f^cli It'll  liy  an  iiicivusi'  in  the  cfi'rhro-siiiniil  lluid  and  in  lliat  ol'  tiic 
nicshcs  of  lilt'  Ilia.  In  cxlrciiu'  venous  (lilatatioii  I'roin  oli.-tructinii,  as  in 
mitral  stoiiosis  or  in  tumors,  there  may  lie  a  coiKlition  ol'  eoiii^oiive  ledeiiia, 
in  wliieli,  in  addition  to  ^reat  lillili;;  of  tln'  lilood-vessels,  the  Mili-laiice  (if 
the  lirain  it.-elf  is  iimisiialiy  moist.  'J'he  most  acute  odeina  is  a  local  |ir<i- 
eess  foiiid  aniniid  tumors  and  aliseesses.  An  intense  iiililtratioii,  local  or 
jreiieial.  may  occur  in  liri^dit's  disease,  and  to  it,  as  Traiihc  siij:j:ested,  cer- 
tain of  the  iira'inic  sym|itoiiis  may  lie  due. 

The  (iiiiihiiiiicdl  cIkiikjcs  are  not  unlike  those  of  anainia.  When  the 
(edema  follows  |)ro;iressive  atrojihy,  tlic  lluid  is  cliielly  within  and  lieneatli 
the  memhraiies.  The  hrain  sulistaiice  is  ana'iiiic  and  moist,  and  has  a  wet, 
jilisteniii;^'  a|i|icaranee,  wliieh  is  very  characteristii'.  In  some  instances  the 
(edema  is  more  intenst'  and  local  and  the  hrain  sulistance  may  look  inlil- 
trated  with  lluid.  Tlu'  amount  of  thud  in  the  ventricles  is  usually  in- 
creased. 

The  tiiiniplonis  are  in  j^reat  part  those  of  lessciu'd  hlooil-jlou-,  and  art.' 
not  well  deliiied.  As  just  stated,  some  of  the  cerehral  features  of  uru'inia 
may  dcjiend  upon  it.  Of  late  years  cases  have  been  reported  hy  liaymond, 
'J'ciineson,  and  Dercum,  in  which  unilateral  convulsions  or  jiaralysis  have 
occurred  in  connection  with  chronic  l>rii:ht"s  disease,  and  in  which  tlio 
condition  a|i|ieared  to  be  a.ssociatod  with  cedeiua  of  the  brain.  The  older 
writers  laid  <;reat  stress  upon  an  ajioplexia  serosa,  which  may  really  have 
been  a  ficneral  (edema  of  the  brain.  Jnasmuch  as  the  instances  in  which 
(cdema  of  the  brain  occurs  are  often  those  in  which  there  is  also  intoxication, 
or  aiiivmia,  or  both,  it  is  proliably  impossible  to  say  at  the  bedside  deliiiitely 
which  of  these  possible  factors  is  responsible  i'or  the  syiiipluiiisi  in  a  giveu 
case. 

4.  Cerebral  ILTi:MORRiiAGE. 

'J'he  bleediiiix  may  come  from  branches  of  either  of  the  two  great 
groups  of  cereliral  vessels — the  bdsa],  comprising  the  circle  uf  Willis  and 
the  central  arteries  }iassiiig  from  it  and  from  the  first  portion  of  the  cere- 
bral arteries,  or  the  cuiiical  (jroup,  the  anterior,  middle,  and  the  ))osterior 
cerebral  vessels.  In  a  majority  of  the  cases  the  luvmorrhage  is  from  the 
central  branches,  more  particularly  from  those  given  olf  by  the  middle 
cerebral  arteries  in  the  anterior  perforated  spaces,  and  which  sujiply  the 
corpora  striata  and  internal  capsules.  One  of  the  largest  of  these  branches 
which  passes  to  the  third  division  of  the  lenticular  nucleus  and  to  the  an- 
terior part  of  the  internal  cajjsule,  the  Icnticulo-striate  artery  of  Duret,  is  so 
frequently  involved  in  luemorrhage  that  it  has  been  called  by  Charcot  the 
artery  of  cereljral  liwiunrrlintjc.  Iliemorrhages  from  this  and  from  the  len- 
ticulo-tlialaniie  artery  include  more  than  (iO  per  cent  of  all  cerebral  ha'inor- 
rhagcp.     The  bleeding  may  be  into  the  substance  of  the  brain,  to  which 


11 


ii 


tJ 


j)j)^  DISEASKS  OF  THE  NKRVDUS  SYSTEM. 

„,^.  ,„,.,,  ,„,,.,„,,,  ,,..,,,l..xy  is  nppli-l,  ""•  i'-t"  ""-  .n.Mul.ran.s.  in  whid, 
;;:  it  is  ,.rnu..l   nu.niM'.M.al  l.u.n.orrl.a,..;  l-.,!,.  i.uw..v..r.  a,v  u.uall,    u>- 
,,,,„,,„,  ,„„,.,,  „,,  ,.,n„s  L.tnuranial  .,r  (rrrl-ral  haMii-rriia-i. 

.,1.^,    ?  a  ^?^v  in,|.n..tant  ,art;  tl.us  ,!>.  natural  tcwloncy  to  a.^vneraUon 
if  the  v..^s.ls  ii>  a'lva,H.a  iif.  .naU.s  a,,u,.l-y'mu.h  inun.  -•-""  >     '  ^' 
tlu    ifti.th  voar.     It  n.av.  l.uw..v..r.  oc.ur  in  oiuhhrn  under  ten.      )n  a  ,- 
„  to      10  .nvater  liaUlitv  tu  arterial  clisoaso  (associat.od  in'ol^ably  xvUl. 
Ih^  o^.,li..n  ana  tl.e  ai.use  .a'  alcol,..!).  n,en  are  more  snl.jed  to  cere- 
1  u.rrha.'o  than  w.-nH...     Heredity  was  fornuTly  tl.nuoht  tn  he  an 

i      ur  in  this  atreetiun.  and  the  apo,,leetie  halntus  or  hu.h    >s 
t'erre,!  to.      I'.v  tins  is  nieant  a  stout   plethoru'  ho.ly  .,t  nu..lnun  m. 
,      ;         h'.rt    neek.-      Heredity    inlluenees    eerehral     Ken..,rrha,e    entuel) 
tl      n"h  tlu.  arteries,  an.l  there  are  fan.ilies  in  whi.h  these  de^enemtc  c.   I  . 
fv  in  association  with  renal  ehan.es.     The  sec...ndary  hypertrophy   o 
S        u't  hrin-rs  with  it  serious  dangers,  whieh  have  already  been  d,sen.>ed 
..tio^   upon   arteries.     The   speeial    factors   m    mdue.n,   artono- 
!u,.,  i._,lH.  ahuse  of  alcohol,  inunoderate  eatinjr,  sypluhs   and  prolon,.ed 
n        dar  exertion-are  found  to  be  in>portant  antecedents  ,n  a  large  nu,n- 
hcr  of  eases  of  eerehral   iuen,orrha,.e.     Chronic  lead  puison.ng  and  gout 
nl<()  ninv  here  bo  mentioned.  ,     ,     . 

''"t^  endocarditis  of  rhenn.atisn,  and  other  feu.s  ->y  -;;-;>, J,  f 
to  a-oidexv  bv  causing  end.olis.n  and  aneurism  of  the  vessels  ot  the  b.aui. 
Wl  ,1  1  haM,;orrhage^.ceurs  occasionally  in  the  specific  fevers  and  m  pro- 
oun  1  ^  inns  .^f  the  blood,  as  in  leuka.nia  and  pernicious  •unen.ui. 
Tht  1  'citing  cause  of  the  lueinorrhage  is  not  evident  ...  the  .naj-n-.ts 
0  ..  c  'ri  e  attack  niav  be  sudden  and  without  any  prehnunary  synip- 
Jon,;  In  other  instances\-iole..t  exertio...  particularly  straining  ellorts,  or 
the  ..xcitcd  action  of  the  heart  in  e.notio..  may  cause  a  ruptuiv. 

Morbid  Anatomy.-Tl'c   lesions   causing   apoplexy   aie  alnio.t   in 
variaV,h  in  tliT cerebral  arteries,  in  which  the  following  changes  may  lead 

^''"Irrhe  lu-oduction  of  miliary  aneurisms,  rupture  of  which  is  the  m..t 

con  ,0.    caule  of  cereb.-al  lueinorrhage.     The  origin  ot  the  miliary  aneu- 

rs      ""  dUuted.     Charcot   thought   they   resulted   from  <;l>a"^cs   m  the 

///,     periarteritis).     Others,  with  Kichler.  Ziegler.  and  i^-h-    irseh- 

id    fiud     10  primarv  change  in  the  inl!n.„.     The  weight  "f  -'P'n  -n      t 

r  .  however,  is  on  the  side  of  the  view  that  the  nu.ui  is  hrst  degen- 
^;^t:d  iUoth.  Loeweiithal).  They  occur  luost  f-P-^^.'^. -.  '-^-^ 
nrterie.  hut  also  on  the  smaller  b.-anches  ot  the  cortical  Ne.s^eU  (  n  |ec 
'ion  of  'the  brain  substance  they  may  he  seen  as  localized,  small  dark  liodies, 

Zdtl  e  .i.e  of  a  pin's  head.     Sonietimes  they  are  seen  m  nuinbers  upon 

e  u       es  when  carefully  withdrawn  from  the  aiitcrior  l-r  orated  spac^ 

Acco  din.^  to  Charcot  and  r>oucliard,  who  hav-.  descr.bed  them,    hey  aie 

nost    mp,ei,t  in  the  central  ganglia.    In  apoplexy  after  the  fortieth  yea 
"^u.-ht  L  thev  are  rarely  missed.     The  actual  miliary  '"^^'^'^^   '^ 

bv  its  runture-has  occasioned  the  haMnorrhage.  may  lie  dilRcult  to  fid 
ut  if  one  pours  water  carefully  on  tho  area  of  liaMuorrhage,  or,  Letter 


iii)(l-VOS- 

lu'i'ation 

nil  al'k'i' 

On  au- 

bly  with 

to  WW- 

1(1  lie  ail 

build  i.-i 
iiim  size'. 

L'titii'i'ly 
Lite  early, 
rophy  (if 
discussed 
C  arterid- 
ii'dloiijxed 
rge  luiin- 
and  gout 

L'etly  load 
the  Ijrain. 
n\  ill  pro- 
i  'inaMuia. 
u  luajoi'ity 
ary  symp- 
eH'orts,  or 

ilniost  in- 
i  may  load 

s  the  most 
iary  aneu- 
o('S    in   ll'.e 
■ch-llirseii- 
(ipiniou  at 
iirst  degon- 
tiie   eoiitral 
-.     Oil  sec- 
lark  l)odios, 
iidiers  u))ou 
ited  spaces, 
n,  they  are 
loth  year  if 
rism,  which 
ult  to  find, 
>,  or,  better 


AFl'lXTloX.S  OF  TIIK   UI.ool*  VKSSKI-S. 


ono 


^till.  siibmeriros  the  aimplectic  mass  for  a  time,  it  will  ii-n,iliy  lie  fdiirid 
p(..>.-ible   to  do  so,  and   even    to   lind    the   bole   ill    it-   Willi. 

(Ii)  .\nelllisill  of  tlie  iiiailclle-  of  the  circle  of  Willi-.  'i'lie.-e  are  liV 
no  moans  iincomiiion.  and  will  be  considereil  .■.iili-einiently. 

((•)  i'liidarteritis  and  periarteritis  in  tlie  cerolnal  ves-els  most  eomiininly 
lead  to  apoplexy  liy  the  production  of  aneurisms,  either  miliary  or  coar-e. 
'I'liero  are  inslaiices  in  which  the  most  careful  search  fail-  to  reveal  any- 
thing liut  (Iil1'ii-e  degeiieraiioii  of  the  cerebral  ves-els.  particularly  of  the 
smaller  liranches;  so  that  we  must  conclude  that  s|iontaiieoiis  ruplure  may 
occur  without  the  previous  formation  of  aneurism. 

((/)  increased  permeability  of  the  walls  of  the  ve--els  may  account  for 
haiiiorihagcs  iiy  (lidjuilrsls  without  actual  rupture.  Such  luemorrhages 
are  not  uncommon  in  case-  of  contracted  kidney,  grave  aiia'iiiia.  and  various 
infections  and  intoxications. 

'i'he  ha'iiiorihage  may  be  meningeal,  (crebral.  <ir  intraventricular. 

McuiiKjiiil  h(V)iiiirrhnijr  may  be  outside  the  dura,  between  I  hi-  membrane 
and  the  bone,  or  lictweeii  tlu  dura  aiul  arachnoid,  or  between  the  arach- 
noid anil  the  pia  mater.  The  following  are  the  chief  causes  of  this  form 
(if  Incmorrhage:  Kractiire  of  the  skull,  in  which  ca-e  the  blnod  usiiaMy 
comes  from  the  lacerated  meningeal  vessels,  sometimes  from  the  torn  si- 
nuses, Jn  these  cases  the  blood  is  usually  outside  the  dura  or  bolween  it 
and  the  arachiuiid.  'i'iie  next  mo-t  frei|ueiit  cause  is  rupture  of  aneurisms 
on  the  larger  cerebral  vessels,  'i'lio  lilood  is  u-ually  snbarachnoid.  An 
intracerebral  lueinorrhage  may  luirst  into  the  meiiiiigis.  A  >pecial  form 
of  meningeal  luemorrhage  is  found  in  the  new-born,  a.-soeiated  with  injury 
during  liirth.  And  la-tly.  meningeal  ha'inorrhage  may  occur  in  the  con- 
stitutional diseas(s  and  fevers.  The  blood  may  be  in  a  large  (pianlity  at 
the  base;  in  cases  of  ruptured  aneurism,  particularly,  it  may  extend  into 
the  cord  or  ujion  the  cortex.  Owing  to  the  greater  freijueiicy  of  the  aneu- 
risms in  the  middle  cerebral  vessels,  the  Sylvian  fissures  are  often  di-lended 
with  blood. 

InlrarcirJirdl  iKimdrrhdije  is  most  fre(pient  in  the  neighborhood  of  the 
corpus  striatum.  ]iarticularly  toward  the  outer  section  of  the  lenticular 
nucleus.  The  luemorrhage  may  be  small  and  limited  to  the  lenticular 
body,  the  thalamus,  and  the  internal  capsule,  or  it  may  extend  into  the 
centrum  semi-ovale,  or  burst  into  the  lateral  ventricle,  or  extend  to  the 
insula.  Ihemorrhagcs  confined  to  the  white  matter — the  centrum  semi- 
ovale — arc  rare.  Localized  bleeding  may  occur  in  the  crura  or  in  the  jions. 
Ihemorrhage  into  the  cerel)ellum  is  not  uncommon,  aiul  usually  comes 
from  the  superior  cerebellar  artery.  The  extravasation  may  be  limited  to 
the  substance  or  rujiture  into  the  fourth  ventricle.  'I'wice  1  have  known 
sudden  death  in  girls  under  twenty-five  to  be  due  to  cerebellar  luemorrhage. 

Yenlrirulur  llanKirrhmie. — This  occasionally  but  rarely  is  primary,  com- 
ing from  the  vessels  of  the  jilexuses  or  of  the  walls.  ]\lore  often  it  is  sec- 
ondary, following  haemorrhage  into  the  ceivl/ral  sulj-taiice.  It  is  not  \\\. 
fre(pient  in  early  life  and  may  occur  during  birth.  Of  !» 1  ca<es  r  illected 
by  Kdward  Sanders,  T  occurred  during  the  iirst  year,  and  1  1  under  the 
twentieth  vear.     In  the  cases  which  1  have  seen   in  adults  it  I'.i.s  almost 


1000 


DISEASES  OF   TIIK  NKUVOl'S  SYSTEM. 


.!' 


n 


H 


'i  i 
t 


,lwav<  iHTU  cauM.a  l-v  ruptutv  uf  a  v.ssc.l  in  th.  nr„l,l;orh.uH  ..f  the  cau- 
•n.Hhus.  '|-!u.  hlu.,.l  ,nay  l,o  f.un.l  .u  cu.  voutnc-lc  "■•'>•.  -ImuM 
,„„„Uv  it  is  in  l..,h  lateral  vcntn.lvs.  and  n.ay  pa.s  uUu  iIk'  tlm.l  u..- 
;;-raml  ,hn.„.l.  ,lu.  aru^luct  ot  Sylviu.  in,o  the  [uurth  ventruUs  lurtu- 
i„.r  a  complete  niouia  in  l.lo.ul  uf  the  ventriei.lar  syste.u.  Jn  llie.e  ca.e, 
the  clinieal  pietnre  may  he  that  ef  "  apopl,:nc  foudnnjante. 

Snbsr,na,l  Vlnu„cs.^n..  hhn,.l  ,fa.lually  ehan.es  ,u  culof.  an.,         - 
,„,U,lv  tl  e  haMnuolohiu  is  eonverted  into  the  redchsh-brown  iuematuHh,  . 
I         n.nation  ueeur.  about  tl>e  apopK.etie  area.  Hnufn,  and  -"htun,  >t 
u    ,.ltin>atelv  a  delinile  wall  n)ay  l)e  prodnee.l.  .nelo..t.g  a  ey.t  with  lUnd 
t  It^other  .nstanees  a  cy.t  i.  not  t.H.ned.  but  the  connecttve  t.s.ue 

.n.iiferates  and  leaves  a  pi^nettted  sear.  In  tnen.n.eal  baM,>orrha,e  e 
„,,,.a  ,,|.,.,a  ,nav  be  p-adually  absorbed  attd  h;ave  only  a  s^at.u,.^  .die 
lnl,ranes.  In  other  eases,  partieularly  in  infants,  when  the  eilu  ...n  ., 
:  ,  u  d  and  alnnulant.  there  tna;  be  loeali.ed  wastjn,  ot  the  eonvolntu. 
;;,;,;  ,,,^,  ,,,„.iuai.m  ..f  a  eyst  in  the  meninges.  Possibly  -rtain  ot  the 
eases  .if  p.ireneephaly  are  eaused  m  this  way. 

Sec-...ularv  ck-eneratiou  f.dhuvs,  varying  in  eharaeler  aeeord.ng  to  to 
loeati.ui  of  ti.e  ha'tnurvhage  an.l  the  aetual  damage  done  by  it  to  nerve  eell. 
or  their  me.luUate.l  axones.     Thus,  in  persons  dying  ^"'f  y^'"'''^  /^^^^  ; 
cerebral  apoplexy  which  bas  pr.ulueed  hemiplegia  (les,.m  ut  the  motor    u 
"be  CO  tex  oi-  of  the  pvranu.hd  tract  lea.ling  fr.mi  it)    the  dogeiierat...n 
a     ho  traced  throuudi  tlie  cerebral  peduncle,  the  ventral  part  ot  the  pons 
Tpvannds  of  the  medulla,  the  libres  of  the  direct  pyramida      rac    cd 
he  cord  of  the  same  side,  and  the  fibres  of  the  cmssed  pyranudal  tiact  o. 
e       ,  o  ie  side.     After  hannurrhages  in  the  muMle  and  mterior    rontal 
j  ri      ere    olows  dcgenerati.m  of  the  fr.nital  cerebro-cortico-pontal  path 
!  -n.  tl  natgh  the  .interior  limb  of  the  hiternal  capsu  e  and  i^e  niedia 
r,  r  i'^.n  ..f  tlR.  basis  pedunculi  to  the  nuclei  p.intis;  also  degeneration  o     ho 
C  c.:  nl'tin.  tl.;  nucleus  medialis  thalami,  and  the  anterior  part  of  the 
UHleus  lateralis  tha.ann  with  the  cortex  (Hechs.g,  v.  Momiko. 

When  the  tem,u.ral  gvri  or  their  white  matter  are  destroyed  y  a  luv.n- 
orrln.  c'  he  latera  segim.nt  of  the  basis  pedunenli  degenerates  lejenne). 
;^!;:;;:illr  luenuuThaS".  especially  if  it  injure  the  nucleus  dentatus,  may 
lead  to  degenerathm  of  the  brachium  conjunctivum. 

There  mav  be  slow  degeneration  in  the  lem.iiscus  me.hahs,  extendnig  a. 
f.r  as  1  nucdei  on  the  opposite  side  of  the  medull  .  obh.ngata,  alter  luem.u- 
Xt'  s  n  he  central  a^ll  hypothalamic  region,  or  dorsa  part  ot  the  pons 
^^orrhages  destroying  the  occipital  cortex,  or  -'-f-  •--"  ^'[^^ 
iuiurin-^  the  o.-tic  radiations,  occash.n  sl.iw  degeneration  (cellulipetal)  ot  the 
SISis  froln  the  lateral  genicuhite  body,  ami  after  a  time  to  marked 
atronbv  or  -ven  disappearance  of  its  ganglion  (..lis. 

Symptoms. -Idiese  may  be  divided  hit.,  primary,  or  those  connected 
witlX  onset,  and  secondary,  or  those  which  develop  later  alter  tho  earlj 

manifestations  have  jnissed  away.  .    ^.     ^.  .     „  .,,,,„   jhe 

Priman,  S>in,plmns.-Vvi'momUn-y  indications  arc  rare.     As  a  lulo,  tnt 

patient  is  Seized  while  in  full  health  or  about  the  V-riovmance  oi^ou^ 

cverv-day  action,  occasionally  an  action  re.iuiring  strain  or  e.vtia  cx-ation. 


Iio  caii- 

,lt    IIUU'3 

irJ  vi'ii- 
c,  iunu- 

I  nil  iilti- 
uitoitliii. 
hun,ij;  it, 
ith  lluid 
vo  tiifsiio 
liagc!  tlio 
jr  uf  tlie 
I'usiuii  is 
volutions 

II  ol!  thu 

ig  to  the 
erve  lcUs 
s  al'ter  a 
lotor  aiTa 
eiieratiou 
the  pons, 
I  tract  of 
1  tract  on 
ur  frontal 
iital  jiath, 
lie  medial 
ion  of  the 
lart  uf  the 
I. 

)y  a  luvni- 
Dejerine). 
.atus,  iiiay 

ten(lin,>r  as 
:cr  luvnior- 
f  the  pons, 
nnorrhajics 
■tal)  of  the 
to  marked 

I  connected 
n-  the  early 

a  rule,  the 
cc  of  some 
ra  exertion. 


AFFECTIONS  OF   THE   ULOOD-VK-SSELS. 


tool 


Sow  and  then  instances  are  found  in  which  there  are  sensations  of  nnnil)- 
ncss  or  tinuiinu''  oi'  pains  in  the  limbs,  or  even  choreiform  movements  in  the 
muscles  ol'  the  opposite  side,  the  so-called  prehemiii|e,uic  chorea.  In  other 
cases  temporary  disturbances  of  vision  and  of  associated  movements  id'  the 
cye-nnisclcs  have  been  noted,  but  none  of  the  prodromata  of  apoplexv  (tlie 
so-called  "  wai'ninjis '")  is  "xharactcrislic.  The  onset  (d'  the  a|>ople\y,  as 
cerebral  Invmorrhajre  is  usually  called,  varies  greatly.  'J'here  may  be  sud- 
den loss  of  consciousness  and  coini)letc  relaxation  of  the  cxtrennlies.  in 
>ucli  instances  the  name  aiiuplvctic  utivkc  is  particularly  approjiriate.  In 
other  cases  the  onset  is  more  gradual  and  the  loss  of  conscionsne.-s  niav  not 
occur  for  a  few  minutes  after  the  patient  has  fallen,  or  after  the  paralvsis 
of  the  liud)s  is  manifest,  in  the  tyiiical  ap<iplectic  attack  the  condition  is 
as  follows:  There  is  deej)  unconsciousness;  the  jiatient  eanm)t  be  nuised. 
The  face  is  injected,  sometimes  cyanotic,  or  of  an  ashen-gray  hue.  The  |iu- 
jnls  vary;  usually  they  are  dilated,  s  )metinies  une((ual,  and  always,  in  deep 
coma,  inactive.  Jf  the  luemorrhage  be  so  located  that  it  can  ii'iitate  the 
nucleus  of  the  third  nerve  the  pupils  are  contracted  (lucnioirhages  into  the 
jions  or  ventricles).  The  respirations  are  slow,  noisy,  and  accomiianied 
with  sti'rtor.  Sometimes  the  ("heyne-Stokes  rhythm  may  be  present.  The 
chest  movements  on  the  ]iaralyzed  side  may  bo  restricted,  in  rare  instances 
on  the  opposite  side.  The  cheeks  arc  often  blown  out  during  cxi.iration, 
with  spluttering  of  the  lips.  The  jiulse  is  usually  full,  slow,  and  of  in- 
creased tension.  The  temperature  nuiy  be  normal,  but  is  often  found  sub- 
normal, and,  as  in  a  case  rejiorted  by  Uastian,  may  siidc  below  !».")^.  In 
cases  of  basal  luemorrhage  the  tcmpi'rature,  on  the  otlier  hand,  mav  be  high. 
The  urine  and  fa'ces  are  usually  ]iassed  involuntarily,  t'onvulsions  are  not 
connnon.  It  may  be  dillicult  to  (Uride  whether  the  condition  is  apoplexy 
associated  with  hemiplegia  or  sudden  conui  from  other  cau.-es.  An  indica- 
tion of  hemi|)legia  may  be  discovered  in  the  dilfercnce  in  the  tonus  of  the 
nuiscles  on  the  two  sides.  If  the  arm  or  the  leg  '■;  lifted,  it  drops  "  dead  " 
on  the  all'ected  side,  while  on  the  other  it  falls  more  slowly.  Jiigidity  also 
may  be  i)resent.  In  watching  the  movements  of  the  facial  muscles  in  the 
stertorous  respiration  it  will  bo  seen  that  on  the  paralyzed  side  the  relaxa- 
tion permits  the  cheek  to  be  blown  out  in  a  more  marked  manner.  The 
bead  and  eyes  may  bo  turned  strongly  to  one  side — conjugate  deviation.  In 
such  an  event  the  turning  is  toward  the  side  of  the  hemorrhage. 

In  other  cases,  in  which  the  onset  is  not  so  abrupt,  the  jjatient  may  not 
lose  consciousness,  but  in  the  course  of  a  few  hours  there  is  loss  of  power, 
unconsciousness  gradually  develops,  and  deepens  into  profound  coma.  'I'his 
is  sometinu's  termed  ingravescent  apoi)lexy.  The  attack  n.  ly  occur  during 
sleep.  'I'lio  jmtieiit  may  be  fomul  unconsciinis,  or  wakes  to  find  that  the 
power  is  lost  (Ui  one  sido.  Small  luemorrhagcs  in  the  territory  id'  the  cen- 
tral arteries  may  cause  hemiplegia  without  loss  of  consciousness. 

I'sually  within  forty-eight  hours  after  the  onset  of  an  attack,  some- 
times within  from  two  to  six  hours,  there  is  febrile  reaction,  and  more  or 
less  constitutional  disturbance  associated  with  intlammatory  changes  about 
the  ha-morrhage  and  absorption  of  the  blood.  The  ])eriod  of  intlamniatory 
leaction  may  continue  for  from  one  week  to  two  months.  The  patient  may 
03 


1,)0'>  DISEASES  OF  TRK  NERVOUS  SYSTEM. 

"'"^'  '""r;,:       <    ;..       u:!    n,  cchur  .,r  tlu>  l.nv.r  part  of  tl.e  l.a.-k.  or  ou 

fi,.es  in  the  corona  -^-j-';'  ^  ^  ^  jh  K^itilion  of  tho  losion. 
crrohral  lUMlnnoIo;  o,  (;/)  '".^"^      '"  „.„„„n'ha-o  is  povhaps  tho  n.o.t 

'"'•'  thoir  olVoots  aro  g.von  '"  1^^- J  ^  .  1  "  .  ^v  alsl  inaioo  it.  Tl,o 
eonunon  causo,  but  tiuno,^  and  ^i-ot  ^ T,'  ^^j^^;^,!.  ^j,,  f,,,  (e.^opt 
sp^.ial  dotails  of  tho  honnplo^ui  may  ^^^:^'^^'T^^  ho  sanio  sido  as  tho 
i!,  Unions  in  tho  h>wov  part  .    H- P-ms    -   mid    n     -  -  ^^^^^  ^^^^^^^  .  ^ 

„nn  an.l  K.,.  Th.s  n.ults  -^^'^^  ^  '1.  as  thoso  of  tho  arn.  an,! 
proeisoly  tho  sanio  rotation  to  tho  ^'"*  J'  ^     .^,i  „,,,,,  f,,„„  tlio 

U  tho  nbros  of  ^1- :nM-  -0^-  -  '^,  ;  I  ,„,,.  Tl>o  faoial 
cort.'X  .looussatm-  ,p'^^t  as  .lo  th.^so  ol  tlu  "  ;  .    ,  .     ,„  ti,,,t 

l"-^>-^'^  '^  •^^•''''^.'•>1t';;:S.^nu;     oH^;      nm'  Tho  signs 

the  orbicnhu-is  oouli  an.l  tho    mnta   s  nu   cio.  ^^.^^^_ 

.f  tho  faoial  paralysis  aro  nsna^Iy  wo    ^     ;^  "  J^  \     :;,;,„,u;.a  sido, 

^■"'^^  '•'  "'^^''!"^,  tcS    :  d     s      ^InipMl  hut  tho  n^ov^nionts  n,ay  ho 
or  m  raro  oasos  tho  lanal  pai.u.vu  iivi.ooh.ssal  norvo  also 

p,.osont  with  emotion,  as  ^-^  >";^;'    ,  "  ,,       ,       .^ont   tho   lon.uo' 

l- ;rl;r:;;i;;lil  ■  -s;';!  wui,™t  ..i,*..  ..n-ia  "im™uy ...  ,.c.k.„8 

an(i  slowness  are  eommou. 


may  Ito 
d  early 
•hanjii'S 

11'     llKlr-t 

p;,  ur  (11. 
lu  ont-L't 
;  (  [  th.; 

•ail  may 
tH'ivUial 
lead  ami 
sions  tu- 
';iia,  the 
ii'octii)iK 
s  rotated 
L  coi'tieal 
leiglil'"!'- 
L  a  le:^i(iii 
the  con- 
's, as  the 
<s  toward 
itient  im- 
he  motor 
known  as 
arm,  and 
•ts.     This 
[lyramidal 
ion  ill  the 
he  U'sion< 
the  must 
.Mt.     The 
ce  (exeept 
ddc  as  the 
s  stand  in 

0  arm  and 
fr<nn  the 

The  faeial 
ve,  so  that 

Tlie  sIlmis 
slifzht  diin- 
ilyzed  side, 
nts  may  he 

nervo  also 

1  he   ton.auC 
,  the  genio- 
)legia  there 
11    -peaking 


AFFECTIONS  OF  THE  BLUUD-VESSELS. 
\.T.  (i 


1UU3 


Fio.  11. — Dingram  of  nintnr  piitli  from  rijrlit  bviiin.  Tlip  upper  socmont  is  hlnck,  tlio 
lower  red.  Tlie  nuclei  of  the  motor  eerehrjil  nerves  are  shown  fm  the  left  side;  on 
the  right  side  the  cerebral  nerves  of  that  side  are  indicated.  A  lesion  at  1  would 
cause  upper  segment  paralysis  in  the  arm  of  the  opposite  side — cerel)ral  mono- 
plegia; at  2,  \ipper  segment  paralysis  of  tlu;  whole  opposite  side  of  the  IxmIv — 
hemiplegia ;  at  li  (in  the  cms),  upper  segment  paralysis  of  the  opposite  face,  arm  and 
leg. and  low(>r  segment  paralysis  of  the  eye  muscles  on  the  same  side — crossed  paraly- 
sis; at  4  (in  the  lower  part  of  the  ])ons),  upiier  segment  ]iaralysis  of  the  oj)posite  arm 
and  leg.  and  lower  segment  (laralysis  of  tlii>  face  and  the  external  rectus  on  the  same 
side — crossed  paralysis;  at  T),  upper  seirment  paralysis  of  all  muscles  represente<l  lie- 
low  lesion,  and  lower  segment  jiaralysis  of  muscles  represented  at  level  of  lesion — 
spiiiul  paraplei^ia  ;  at  0,  lower  segment  paralysis  of  muscles  localized  at  seat  of  lesion 
— anterior  [»;lioniyclitis.     (Van  (iehuchteu,  moditled.) 


1004: 


DISEASES  OF  THE  NEUVOUS  SYSTEM. 


Tlu 


-n„,  ,,,n  i<   a<  a  ml.',  .n.uv  cnuM.U't.ly  V'WAyy.vd  than  Hu-  1<;l' 
1,,^.  (,l  lowu  inas        .  „.,'iv<i<   in   tlu'  lace  and   arm   is  cumpletc 

.id.  nt  the  iH'ain.     The  .U-r.e  of  ,K.r,nanc.nt  varalys,^  "l^'i   a  lunupk^u 
attack  varies  niiuli  in  (litVcrent  cases 
always,  as  Wernicke  has  imii 

which,  accordinu-  to  l.udwig'  Mann,  ai 


iiiaii'^  111     l"^'  •*•. ■     . 

iML  w.^v.^.  When  the  restitution  is  i)artial.  it  is 
,inted"out.  certain  -roups  of  muscles  wliich  re- 
'n.u.  in  tlie  leo-  the  residua!  paralysis  concerns 
1  flexors  of  the  loot— i.  e..  the  muse  es 
,ire  active  in  the  second  l)eriod  oi'  walk- 
„■  it   forward  while  it  swin,-is.     'Ihe 


;;:';";;;;;,;;':r;;:iuh«:im  .10  ,i,;o.,.;,s,.,.  „(  .i,o  u.,  .,,.1  ,ik.  i.i.n,ar 

;;i;;;h  o;;Ise  tl.  thuml..  those  whid.  rotate  the  arm  outward,  and  tl^e  ...ci- 
''■'  t'ande' tiiere  is  at  first  n,.  wastin,  of  the  paralyml  limbs.  . 

5?S;::S,:,;,f;:;:.:x:r;^t:"-t';:;:;;:::;,,a';,;:;;;: 

,,,i,„anly  m  the  cru>.     in  tlu    (la,.i  ai  c  ^^^^^^^^^_ 

;;;:;;-:r;';-;;;j;r;  3^^ 


not  necessari 
iiaralvsis  of  the  oi 


,,,lv„s  ot  tne  '-  uo-m  HO.  u. .   .,  "  ^1^^  i,t,,,,,  geniculate 

:;ri;;!;r:;;:H*,:!™a"^.u::::r,;,:;, .■.,,,.  :„  .i.:. 


eve 


nt  there  will  lie  liemianoiisia. 


L't  and 


'ij^'pon.  and  ^MuUa.-\.v^\on.  may  involve  the  1-' "^'^  •;  ^   ;)  ^^  ,,^^, 
one  <>r  more  of  the  cerebral  nerves.     H  at  the  ";--';b--  ^    t  n     t he 

„.,„  „..,..  mav  be  involved,  caus.n.  V^^^^^^  ^J^^    ^  ,^^^^,,,, 


^ide  and  hemiiilcLiia  o 


n  the  opposite  side. 


AFFEC'TIOXS  OF   THE   ULOOD-VESSELS. 


100  ■ 


witli  the  (illct  (the  sciisoiT  iract),  ciUisin^i,'  loss  dl'  sciisjitioii  in  tlic  arcii  nf 
(li>tril)iiti(m  «il'  the  lifth  on  tlu-  .smic  siiK'  as  ihc  lesion  and  Ins-  of  .-cnsalion 
(111  tlic  oiipositc  side  ol'  tlu'  body. 

.<t'»w/7/  J)istinii(inrcs  rcsiilliinj  frmn  Crirhntl  //(niiorrliiii/r.—'Vhv^^'  arc 
variable.  Ileiiiiaiia'stliesia  may  coexist  with  liciniplcnia.  I)ut  in  many  in- 
stances there  is  only  sli,uli4  iiiimliiii,<x  of  sensation.  When  the  liemianas- 
thesia  is  marked,  it  is  iiMially  the  iv>iilt  of  a  lesion  in  the  iiileinal  ca|i<iiie 
involviiij^'  the  retrolenticular  iiortion  of  the  ]i(jsteri(jr  limb.  In  C.  L. 
DaiiaV  study  (d'  sensory  localization  lie  found  that  anasthesia  id'  or-anic 
cortical  origin  w^'s  always  limited  or  more  |iidiioiinced  in  certain  jiarts.  a- 
the  face.  arm.  or  lei:,  and  was  generally  incom|i|ete.  'I'otal  aiia'>tliesia  was 
either  (d'  functional  or  subcortical   orijiin.     .Marked  ana-thesia   was  much 

"""■''   <•" mil    ill    sofleiiiiin-    than    in    ha'iiiorrha.y-c.     Complete    hcniiana's- 

thesia  is  certainly  rare  in  liicmorrha.ii-e.  J)isturbanc('  of  the  special  senses 
is  not  common,  liemianopia  may  exist  on  the  same  side  as  the  le.-ion,  ami 
there  may  ln'  dimiiiiitioii  in  the  acuteiiess  of  the  senses  of  heariii;:'.  ta>te. 
and  sniell.  (iowcis  thinks  that  lionionyiuous  lieniian()])sia  of  the  halves  of 
the  visual  lields  opjiositc  to  the  lesion  is  very  fre(jueiit,  thouiiii  often  over- 
looked. 

rsychic  disturbance-,  variable  in  nature  and  degree,  may  result  from 
cei'cbi'al  ha'inon'ha.Lre. 

Tlie  Hcjh'XfK  in  Apujili'iiic  Cases.— \)uv\uu_  \hv  apoplectic  coma  all  the 
rellexes  are  abolished,  but  immediately  on  recovery  (d'  coii,-ciousness  tliev 
return,  lirst  on  the  iion-hemiple-ic  side,  later,  sometimes  onlv  after  weeks, 
on  the  paralyzed  side.  .\s  to  the  time  of  return,  especially  of  the  pat(dlar 
rellexes.  marked  dilferences  are  observable  in  iiidi\i(lual  cases.  The  deep 
rellexes  later  are  increased  on  the  j.aralyzed  side,  and  ankle  clonus  mav  be 
present.  The  plantar  and  other  su])erJicial  rellexes  are  usuallv  dimini-htMl. 
'I'lie  sphincters  are  not  alfccted. 

^i'he  rniirsr  of  the  disease  depends  upon  the  situation  and  extent  of  the 
lesion,  if  sliiiht,  the  heniipleo-ia  may  disajipear  coni|)letelN'  within  a  W'W 
days  or  a  h'w  we-ks.  In  severe  cases  the  rule  is  that  the  h",u-  gradually  re- 
covers before  the  arm,  and  the  muscles  of  the  shoulder  oirdl'e  and  u'pper 
arm  before  those  of  the  forearm  and  hand,     'i'he  face  may  recover  (piickly. 

Except  in  the  very  slioht  lesitms,  in  which  the  hemiidegia  is  transient, 
eliaii<ies  take  place  which  may  be  ,t;rouped  as 

Smnuhd-!/  Si/niplnui.^.—ThvH'  correspond  to  the  chronic  sta.ue.  Tn  a 
case  in  which  little  or  no  improvenieiil  takes  place  within  eiuiit  or  ten 
weeks,  it  will  be  found  that  the  |)aralyze(l  limbs  undergo  certain  clian-es. 
The  le<r,  as  a  rule,  recovers  enough  power  to  enable  the  jiatient  to  izct 
iibout.  although  the  foot  is  dragged.  Occasionally  a  reciirn-iice  of  severe 
syinpt(uii<  is  seen,  even  without  a  new  liaMUorrhage' luiving  taken  |ilace.  In 
both  arm  and  leg  the  condition  of  srrniuJnri/  cunlrarHou  av  Infr  ri<iidU!i  comes 
on  and  is  always  most  marked  in  the  n|»per  extremity.  The  arm  becomes 
permanently  Hexed  at  tlu'  elbow  and  resists  all  attempts  at  extension.  The 
wrist  is  ilexi'(l  npon  the  forearm  and  the  fingers  upon  the  hand.  The  posi- 
tion of  the  arm  and  hand  is  very  charaeteristie.  There  is  freijuently,  as 
the  contractures  develop,  a  great  deal  of  pain.    In  the  leg  the  contracture  is 


T)1SEASES  OF  THE  NERVOUS  SYSTEM. 


(1 


lA 


11 

m 


1,.  ,1      'I'lii-^c  ((intviU'tui'C's  au' 

IH'nnan.n,  a.ul  nunn.ia.    -'1 .       ;\,;„„,.„,  howovcr.  in  .hu  ,  r,,ul- 

.U.rnsis  of  th.  .uolor  path.     '1'^'       "  ,,^,„,i„s  llar.i.U  tlu-  U^  l.as- 

i      ana  c.untra.-lu>v  do  not  .urur.  '"  ^      "  .       J  .,f  ,,,,,Hanl  is  ^ouna  n>o>t 

;;.,.ain.a  ,.^  ,-v.r.    Tins  Z'-''/;    '  ^,^/  ,  ^,,„„,.„  i„  „t.  homiplog.. 

n.av  IH.  nu.n.,on.l  "';\  "''"^'llf-,  s     thotosis.  a.lhn.pa.hu.s   .n   ,1k. 

/.i,,,,  .,r   ,!.■  alVc.-t-l   shU..  ana    •""■''''„.  „-,,,,ia  ,.r  .hilchrn.     'I  >- 

T;::;r;;;:;;-'i;:;.'>:;'''->^  •-'-""•'^■■"' 

in^fuur^  il  ao.s  a.v.lo,..     it  has  luan  tin  n  ^^^  ._^  ^^  ^,,,, 

;:;:;;;;:.,  alt.nUionsn.  tin.  ^ay.n;--^^^^  ,,.   ,„.„   .a,K.a   i.y 

nM-1'"l  '•>■   ^■'>="'^"";    ,  '7        iu  th  t  atrophy  nn.y  lollow  as  a  a,... 

S.nal.n-.gninrl<o.anaoth..>t..         IH  l^   ,,,,„ainin,t.    nUart        h 

,,,.uU    or   the   c'.ivl.ral    K'sn.n,   the    u        '  .;  ^  „f  a  -Innna 

unu'ko-s  cas...  afophv  of  t   .  arm  i;J  -^  _  '  ;,^,,,,  j  a>o  v.ntval  hon>s 

in  tin.  anterior  ...ntral  --'"'^      ';„,'.;„;„„,  it,  corti.al  lesions  .nvolv- 

,va<  norn.al.     'Hu.so  atropines  au   n    A  ^^,,,^  „,  ,,„. 

:,.  tlu.  ao,nain  of  the  t  un   ";-;;;•;!,;,,;„.     Tlu.ir  explanatn.n  ,s 

,,a,  U..ions  involving  ^'-'J;:  J,  "^  "       I        vhiJh  oeeurs  nn.t  fr.pu.ntly  jn 

^-t  c-U.ar.    Tin.  .astn.,'  ol  -    ^^^'     '  ,;,  „„,,,,,  alon^^  with  stunt^a  gro.th 

,„,lron,ana  ''-'^ '." ''^""'f  ^'^i,!   ,  ^  s.parat.a  fron,  the  henuatrophy  o 

'^-iji^nosis.-nn.re  are  three ,.  o^  ea.s  .hieh  o.Ver  inereas.n, 

"^^;T;t-.:;;:r^;h;;r--onsetis..a. 

due^o  thnunhosis  or  to  l'^^';'>";^;"''f;;;,^^.  i„  ,,,,i,i,  the  patient  rapiaiy  lo^es 
r^)  ^^  ^^-  :;;;!^!;';;.:!;;f  ■;:'a^;;ti:  -y  he  stn,  .reate.  partn.aarU 

;;;;;::;;;;:::; ;'  i^  a..p  .^na  when  m.. ...   ^^^^^^^^  ^^^,^^^^_  ^,,,  „^,, 

The  lirst  ,,oint  to  he  'l-"  -\;;  ^  ,  ^    on>a  the  linO.  on  the  p.ua- 
be  ailhenlt.  although,  =^^.  ^  ^•"';'-,  ";",).  .hen  lifted;  ^vhereas.  on  tlu 
,1  <1,1,.  'uv  more  ilaeenl  ami  (IkM)  ni>t.nui>  ,j,|^^^  retlexes 


AFFI-XTIOXS  OF   THE    HLOoD-VESSEf.S. 


KKiT 


l>;clcs  of 

walkiiiil 

a  luiU- 

UVC'S    iVT 

ell  rijiitl- 

U.o-  hav- 

illld  lunsl 

ijmipK'g'i' 
u)st-iiara- 

fs  in  iIh' 
iind  l'i'>'- 
ITll.  'I'll"' 
iav  to  all. 
,1:  fL'i'olinil 

It  in  sonio 
u'  oaj^es  to 
;  ill  a  caso 

ealU'd   l>y 

as  a  direct 
lUart.       In 
if  a  filicma 
utral  horns 
(,n>  involv- 
und  in  eun- 
planation  is 
iviincntly  in 
ntt'il  growth 
iiialrophy  ot 
IK'  ujion  the 

■v  iiu-reusinu' 

i\\AuiX  before 
:t.  are  readily 
the  lesion  is 

raitidly  l<'>t'^ 
•,  particularly 

i,;.  This  may 
4  on  the  i)ara- 
hereas.  on  the 
The  retlexes 
loiitc  deviation 
r\n  favor  of  a 


licmiplefiic  lesion.  It  is  practically  inipossihlc  in  a  majority  of  these  cases 
to  say  uliethcr  tlie  lesion  is  due  to  luciiiorrliau'e,  endiolism,  or  liirniidiosis. 

(;3)  Jiarji'c  liaiiioiTJia,iie  into  the  ventricles  or  into  the  |)ons  may  pro- 
dnce  snddcii  loss  ol'  consciousness  with  coni]ileto  relaxation,  mi  tjmt  the 
condition  may  simulate  coma  I'rom  urainia,  diabetes,  alcolmlism.  opium 
poisoning',  oi'  epilepsy. 

'J'he  pi'c\  ious  history  and  the  mode  oi'  onset  may  i:ive  valualile  injurma- 
tion.  In  epilep.-^y,  com  nlsifuis  have  preceded  the  cmua;  in  alcolndism,  there 
is  a  histoi'y  of  constant  driid\in,u'.  while  in  opium  poisoninjjf  the  coma  de- 
velo]is  more  enidnally:  hut  in  many  instances  the  dilliculty  is  pi'actieally 
very  ureat,  and  on  more  than  one  occasion  1  have  seen  moitifying  ]iost- 
mortem  disclosures  under  the.^e  circumstances.  With  dialietic  conia  the 
hicatli  olieii  smells  (d'  acetone.  In  vcntriculai'  lucmoniia.Lre  the  coma  is 
sudden  and  develops  rapidly.  The  hemiplegic  symptoms  may  he  transient, 
quickly  .irivintr  place  to  comjileto  relaxation.  Convulsions  occur  in  many 
cases,  and  may  he  the  very  syrnjdom  to  load  astray- — as  in  a  case  of  ven- 
tricular liaMiiorrhae-e  which  occurred  in  a  ])ner]ieral  ]iatient,  in  whom,  natu- 
rally enoue-h,  the  condition  was  thouj:ht  to  ho  nra'inic.  KNjzidity  is  often 
jircsent.  In  Invniorrhago  into  the  pons  convulsions  are  lre(iucut.  The 
l)upils  may  ho  strongly  contracted,  conjugate  deviation  may  occur,  and  the 
temperature  is  apt  to  rise  rapidly.  The  contraction  of  the  paipils  in  pontiiu' 
lia'morrhage  naturally  suggests  opium  jioisoinng.  The  dill'ereiu'e  in  tem- 
]ierature  in  the  two  conditions  is  a  vahiahle  diagnostic  ])oiiit.  The  apii|decti- 
I'orm  seizures  of  general  ])aresis  have  usually  been  ])receded  by  abnormal 
mental  symptoms,  and  the  associated  hemi|ilegia  i<  seldom  i»ermanent. 

It  may  he  impossiide  at  first  to  give  a  dedidte  diagnosis.  In  adnussions 
to  hos|utals  or  in  emergency  cases  the  physician  should  be  particularly  care- 
ful about  the  following  ])oints:  The  evanunation  of  the  head  for  injury 
or  fracture;  the  urine  shonld  he  tested  for  albumin,  examiuKl  for  sugar, 
and  studied  microscopically:  a  careful  examination  should  be  nuido  of  the 
limbs  with  rcfereiu'c  to  tlu'ir  degree  of  relaxation  or  the  ])resonco  of  rigidity, 
and  the  condition  of  the  reflexes;  the  state  of  the  ])Upils  should  be  noted 
and  the  ti'iupcraturt  taken.  The  odor  of  the  breath  (alc(diol,  acetone, 
chloroform,  etc.)  should  ho  remarked.  The  most  serious  mistakes  are  made 
in  the  case  of  ])atients  who  are  drunk  af  the  time  of  the  attack,  a  coudiimi- 
tion  by  no  means  uncommon  in  the  class  of  patients  admitted  to  liospital. 
T'nder  tlu'se  circumstances  the  ease  may  erroneously  be  locdcod  upon  as  one 
of  alciduilic  coma.  It  is  best  to  regard  each  case  as  serious  and  to  boar  in 
nnnd  that  this  is  a  condition  in  which,  above  all  otiu'rs.  mistakes  are 
common. 

Prognosis. — From  corfical  ha'niorrhag(\  uidess  very  extensive,  the 
recovery  may  be  comiib'to  without  a  trace  id'  contracfur(\  This  is  more 
connnon  when  the  ha'inorrhage  follows  injui'y  than  when  it  residts  from 
disease  of  the  arteries.  Infantile  meningeal  ha'morrhage.  on  the  other 
liand.  is  a  condition  which  may  prodnce  idiocy  or  spastic  diplegia. 

Large  haMnorrhages  into  the  corona  radiatii.  and  especially  those  which 
rupture  into  the  ventricles,  ra])idly  ])rovo  fatal. 

Tlio  hemiplegia  which  follows  lesions  of  the  internal  capsule,  tlu'  result 


mSKASES  OF  TU.  NERVOUS  SYSTEM. 


m 

m 

*  >  ■ , 

i  : 

I! 
iii 

H 


f  5  I 

■    ,'   i 


1*-""'  '" "  .  n     .„,,..i.U.nt  and  followo.! 

'    L.  .o.na  .lunu,  the  --'^  ;'^'  ,   ^^ J,'  hUtial  iall.     In  the  n.a.Uon 

„ii M„  ,.„.!  -s:--.  i' »';;;",  :',;"t  V  ™>  -  "■""■•"■''"■••  '"r  ;'";S:: 

;  '  ,i',.»rai.i-  ...•  r-.u  iiK'  -*='-;;';''■<,  ,„.  lov,,,,..)  m  the  »"- 

;  ;     Uin,  to  increased  coasulalnWj  ot  the  ^^^.^^^     ^ases  arc  ra  e 

i  embolism  oe.nr  in  l^^'^^-^f'^r^"'' ''  f^^il,,  and  febrile  cond.tmns.    U 
^uUcute  endocarditis  otr.um^-^1^-^^^;,^^^^^ 

i,  nutoh  nu>re  eonnnon  >n  ]^^;^^^J,^,,,  fre<,uently  ,a^es  ^}^J^^ 
fori-  old  sclerotic  valves.     Ihe  unon  ^^^^^^_^.  ^|^.^,,  ^^je  iif-Ur 

;  idle  cerebral  artery,  as  it  enters    >-    ^'  J^^  the  torn.er.    The  poste- 
W  !ulse  of  the  .uuv  direct  ^l^\^;^,  ,,ected.     A  ^^f^^^^l 
,ior  cerebral  and  the  ^^^  ^  ?f  ij^l    ;    Kndudi.m  of  the  cerebral  vessels 
,.a.eaUbe),ifurcat,onoUlaba.  _,,,_o  aoubt,  to  the 

^^^^Knd,olisn>  occurs  -ore  fre;,>e,rtly  ,n  ;;«  -;V,  ^  ^^  , 

,Jter  frequency  of. utrals^en^-^"-;;;./^^,^^^^^^ 
Xewton  ritfs  statistics  "     '    ^'^J^^^^.v,  for  in  this  ser.es  theie  ^^eIC 
that  males  arc  more  frequently  ^ll^"  ;,^  ,,.„„,en. 

about  a-  embolus,  (2)  as  tue 


AFFECTIONS  OF  TllK    HLOOD-VFSSFLS. 


KM  to 


Uoweil 
:  Uuila- 
■pi'nin,', 

iL'VlltUVO 

■t'iiction 
ly  ri^e-S 

k'uUu'ly 

be  deter- 
rdy.  H 
is  certain 


the  vcrtc- 
heart  and 
!)(  a  rocur- 

in  Ihe  an- 
I'rom  alho- 
:;,  may  aUo 
}  ])ULn'\)eval 
in  women 
ed,  and  tlu' 
nt  of  heart- 
•ity  o£  ear^os 
isos  are  rare 
id  it  ions.    It 
is  which  at- 
s  to  the  left 
an  the  riglit 
The  poste- 
(re  ]>hi<:  may 
:')ral  vcsseU  i< 

aouht,  to  the 
i-il  statement, 
•ate.  however, 
there  were  -i-l 

:t,l?  occurs  (1) 
al  wall  (oither 


endarteritis  with  or  withont  atheroma  or,  imrticidarly,  the  sypliiHtic  arteri- 
tis), (;i)  in  aneurisms  lioth  coarse  and  miliary,  and  (1)  very  rarely  as  a  ilirect 
result  of  alinoniial  conditions  of  the  blood.  'I'hrond)osis  occasionally  lol- 
lows  li;,'ation  of  the  carotid  artery.  The  throndmsis  is  most  eonmion  in  the 
midille  ccrclual  and  in  the  basilar  arteries.  Accordiuj,'-  to  Kolisko,  softeii- 
in^f  id'  liuiiled  areas,  sullicivnt  to  induce  hciniiilejria,  may  he  cau.ed  by  sud- 
den collapse  of  certain  cerebral  arteries  from  cardiac  weakness. 

Auidni.iifdl  Chitiiijcs. —  l)e,i,H'ncration  and  softeiun.tr  of  the  territory  sup- 
plied by  the  vessels  is  the  ultimate  residt  in  both  cudxilisin  and  throinbo-is. 
l)loikin<r  in  a  terminal  artery  may  be  followed  by  infarction,  in  which  the 
territory  may  either  be  deeply  iidiltratcil  with  blood  (lia'morrbaaic  infarc- 
tion) or  be  simply  jiale,  swollen,  and  necrotic  (ana'uue  infarction).  Grad- 
ually the  process  (d'  softening  proceeds,  the  tissue  is  infiltrated  with  seruin 
and  is  moist,  the  nerve  fibres  dejrcnerate  and  become  fatty.  'I'bc  neuroglia 
is  swollen  ami  (edematous.  The  color  of  the  softened  area  depends  upon 
the  amount  of  blood.  The  luvmoglobin  nuderjrocs  gradual  transformation, 
and  the  early  red  color  may  give  phice  to  yellow.  Formerly  much  stress 
was  laid  upon  the  diil'erence  between  red,  i/clloir,  and  wliilr  .^ofteiung.  The 
red  and  yellow  are  seen  chielly  on  the  cortex.  Sometimes  the  red  softeinug 
i.s  particularly  marked  in  cases  of  end)olism  and  in  the  neighborhotid  of 
tumors.  The  gray  matter  sliows  many  pnnctiform  luvmorrhages^capillary 
apojile.vy.  There  is  a  variety  of  yellow  softening — the  phujiirff  jinnirs — 
common  in  elderly  persons,  which  occurs  in  the  gray  matter  of  the  convolu- 
tions. The  spots  are  from  1  to  ti  cm.  in  diameter,  sometimes  are  angular  in 
shajie,  the  edges  cleanly  cut,  and  the  softened  area  is  represented  by  either 
a  turbid,  ycdlow  material,  or  in  some  instances  there  is  a  sjiace  crossed  by 
fine  trabecuhe,  in  the  meshes  of  which  there  is  iluid.  White  softening 
occurs  most  fre(|uently  in  the  white  matter,  and  is  seen  best  about  tumors 
and  aljscesses.  Inllammatory  changes  are  common  in  and  about  the  soft- 
ened areas.  When  the  end)olus  is  derived  from  an  infected  focus,  as  in 
nlcerative  endocarditis,  sn])])uration  may  follow.  The  final  changes  vary 
very  much.  The  degenerated  and  dead  tissue  elements  are  gradually  but 
slowly  removed,  and  if  the  region  is  small  may  be  replaced  Ijy  a  growth  of 
connective  tissue  and  the  formation  of  a  scar.  If  large,  the  resorption 
results  in  the  formation  of  a  cyst.  It  is  surjirising  for  how  hmg  an  area 
(-f  softening  may  persist  without  much  change. 

The  ]iosition  and  extent  of  the  softening  depend  upon  the  ol)structcd 
artery.  An  end)olus  which  blocks  the  ndddle  cerebral  at  its  origin  inv(dves 
not  only  the  arteries  to  the  anterior  perforated  space,  but  also  the  cortical 
iiranches,  and  in  such  a  case  there  is  softening  in  the  neighborhood  of  the 
cor])US  striatum,  as  well  as  in  part  o1  the  region  sup])lie(l  by  the  cortical 
vessels.  The  freedom  of  anastomosis  between  these  branches  varies  a  good 
deal.  Thu<,  there  are  instances  of  embolism  of  the  middle  cerebral  artery 
in  which  the  softening  has  only  involved  the  territory  of  the  central 
l)ranchcs,  in  which  case  hlood  has  reached  the  cortex  through  the  anterior 
and  posterior  cerebrals.  When  the  middle  cerebral  is  blocked  (as  is  ])erhaps 
oftenest  the  case)  beyond  the  point  of  origin  of  the  central  arteries,  one  or 
other  of  its  hranches  is  usually  most  involved.     The  embolus  may  lodge 


I.ISIUSRS  OF  TlIK  NKUV(K-S  SYSTKM. 


M 


1010  f 

'H.-  an.  ,nu..i..ny  tvnnnu.1  a  U  -,       '    '^  ^^,^,^,.^,,      ^^,^,,,,,a  Uy  tl.m. 

...fl.nin^  li.nil..a  .o  a  ,m  t,  at  ^  ^  ^^    ^.  ,,,^  ^,,.^,      ...Uuvd  in  tins  wuv. 

S,„no  or  llu.  .no.t  -r"-^^;  '•;  X    !■  -tu.nin,  .nay  .xi^t  .ilhoul  any 

symptoms.- Kxtvns.s.  ^1'    -  >   -     ^    ,..„.,„„rtnn  c.xan.inaliou  ol  tho 

vnlntions.     So.  t<"N/;>'^7'"^.';^,  ^;^     ,„,ton>s.     NVh.n  th.  central  or 
Uh,v  are  ter.ne.l,  w.tlun.t  '■-     "^  ,;    >,.^i^   ,  ,,i,,  ..'c  involve.l   the  synM'- 
->iH.al  hranelu.  oi   the  ••;;;;,,        1   ',     u>e  snue  arterie.      I'ennanen 
t,,,,,are.nnihut..,u.eolha  n-nh.  ^^^^^^,^^^  ^^^,,^„,;,,^   ,^,.^,  ,„,„ivea 

„,  transient   henni^lejiui  ie.nU>.         n  j,„^^.,„,  i  .  ,„,vnunen 

the  sortenin,  in  the  ''>^-'"f .;;'';;;    :iins:iaea  .ith  en,holiMn  and 
,,^„,i,,l...ia.     There  are  eertam  l-eeuhantu.  a 

^vith  thronihoHi.  resi.eetive  y.  ^^^.  ,„,,„,t.t,Huh!e,  or  there 

In  nMis,n  the  patient  ..  ^'^''>\'*'  ••/„,,,.     The   onset   is   snA-len, 

exist   some  of   the  --l•^-•^'''';:;  >  J  ;      Lusm  hloeks  tlu- h^ft  .ni.Ulle 

-itl-nt  prenu.nito>^  synM^om.         J    ;^  :;^,.,,,^,a  ,„,  a,hasia.     In  tluvm- 
,,^,,,,,,,,larterylhehenu,,U.^aisn  ua   >  ^^^^_    ^^^^.^„,^  ,,,,  ^, 

^'-'•^•<  "•>  tl'^'  ^>'*'^"'  '''""^-    ''';  f   .      i   .'lin.^  in  tl>e  tln.uers;  ti>e  si-eeeh 

W.usly  eonMaahiea  or  headache  v.^^>,...^^  ,^,^   ,  ,  ,        ,^ 

„„y  have   been  ^-'">'';'^^*;  ,      ,,  ^  ^  u^ins  at  onJ  part,  as  the  hand    and 
,,H-mory  or  is  ineohe.vn  ,  '>'•  I  ';;,;,  i,,,„nplete  or  variable.     Ahrnp 
,xtendssh,wly,anathehenu    .^um.      -        J^^.,,^,,,  ^,,,  ,,,,„  ,s  small 

l,ss  or  consciousness  ,s  J""*;;   ^^';^^'        „^,osis  ano  to  syphilitu.  a,sease. 

^,,,,,,,,U,vistiesjHdlM'vn-H7     Hl^u  mla^^^^  ^^^^  ^^.,^^  ^ 

rnu.   folh.vvin-  n>ay  ho   the  etKcts  ,  .     i^^.^.^a.     The  elloets 

U  involvon>ent  or  tlu.  nnckn  '^  ^^^^'^  ^^^  '^  ,,„,,,i;  with 
mrah-is.  It  rarely  ocenrs  alono  "^"^f*^  "\,,i/i,  entirely  ocelnded,  there 
^'"'  ;)  lUockin,  of  tho  lasmr  "r^^^^  'U,.  mot,,  paths.  lUdhar 
,nav  ho  hilateral  paralys.s  ^^^]^  ^^^  „,,y  ooenr.  The  temperatnro 
"vmpton.s  n>ay  he  present;  ^f^^y^lXZ  those  of  apoplexy  of  the  pons, 
may  rise  rapidly.  Tho  symp  oms.  m  ^l''^^..^^  ^„y,e  on  its  nied.al  snr- 
V)  ^n.e  ,.slnior  -'•'•''7  /"y^' ^  J     ."on      al  loho.    If  the  nuin  stem 

face  and  the  greater  part  ^^f.^^'^^  ;^  T^^;^    ^.^  aphasia.    T.ncalized  areas  o 
be  throna.osed  there  is  hemumopuv  V  t^h   en  ^^  ^^^^  ^^^^^.^^  ^^^,j,,tal 

iftening  n,ay  exist  -thont  syn    toms^^    II  .^^^.^  ^^^^^.^^^ 

branch  (arteria  --}"^f  ;i:  .f^" "tili-P--    Honua.^^sthesur  may  r  - 


,  <)V  tlicre 
i  siiiliU'ii, 
■  I't  iniildU' 
11  tliniin- 
l  has  yvv- 

lid  Itiss  of 
lian<l.  iind 
..  All  nipt 
111  is  snv.ill 
tic  disease, 
listuvlmuee 

•(ieally  the 
m<n'i'ha^'o. 
.Mit  Yossols: 
Tlio  ctVocts 
tciitc  l)ulliav 

luded,  tliore 
1,^.  r.ulbar 
tciniteraturc 

(,[  the  pons. 

medial  sur- 
le  main  stem 
lized  areas  of 
laiii  occipital 
rina,  passins 
lesia  may  tc- 
:apsulc.    Not 


AFFl'X'TIoXS  OF  TIIK   lU.OdD-VESSELS. 


lull 


iiifietiiieiilly  symmetrieal  ihnnnhnsis  of  tiie  oeeipital  arteries  (d'  the  two 
siiles  ueeiirs,  as  in  l'i>i>ter"s  ucll-knowii  ea>e.  Still  more  l're(|iienl  is  the 
oeeiirreiiee  of  ihromlio.-is  (if  a  liianel!  (d'  the  po.-lerior  eerehral  ol'  one  lieiiii- 
spiiere  antl  a  hraneh  of  llie  nnddle  ecrehral  of  tiie  otiier  (von  .Monakow). 
ll  is  in  siieii  eases  that  liie  mo,-l  pronounced  instances  of  a[>raxia  are  met 

witli. 

(,/)  liilrniiil  ('(irnlid. — The  symptoms  are  varialih'.  As  is  wvW  known, 
the  vcsM'l  is  ill  a  majority  of  cases  lij;ated  uitiioiit  risk.  Jn  other  instances 
transient  heniiiiieuia  foMows;  in  otiiers  a^^iiii  the  hemiplegia  is  permanent. 
'I'liise  variations  dejiend  on  the  anastomoses  in  the  circle  (d'  Willis,  ll 
these  are  larye  and  tree,  no  paralysis  lollows,  Imt  in  cases  in  which  the  pos- 
terior eominimicatini!;  and  the  anterior  commnnicatinf;  vessels  are  small  or 
ahseiil,  the  paralysis' may  per>i>t.  In  No.  r  cd'  my  Klwyn  serie.-  of  cases  (d' 
iiilanlile  hemiple*;:ia,  the  woman,  a;.:cd  tweiityd'our,  when  .m.\  years  old,  had 
the  ri,Ldit  car(did  li.uMled  Inr  ahscess  lollowin;,' scarlet  fever,  with  the  result 
(•r  ]K'rnianent  hemiple-ia.  I'.lockin-r  of  the  internal  carotid  within  the 
>kull  hy  thromliosis  or  emholism  is  iollowed  hy  hemiphriii.  <"'"i>-  "'"'  "^"- 
allv  death.  'I'he  clot  is  rarely  coniined  to  the  carotid  itself,  hut  spreads 
into  its  l)ranches  and  may  inv(dve  the  (>|itithalmic  artery. 

(r)  Miildlc  ('m'/;;w/.— This  is  the  vessel  most  commonly  involved,  and, 
as  already  mentioned,  if  plufified  htd'ore  the  central  arli'ries  are  ^dven  oil', 
permanent  hemiple^da  usually  follows  from  softening  of  the  internal  cap- 
sule. JUoekinj,'  of  the  hranehes  heyond  this  point  may  lie  followed  hy 
hemiplej,da,  which  is  more  likely  to  bo  transient,  involves  chielly  tlie  arm 
and  face,  and  if  on  the  left  side  is  a.ssoeialed  with  aphasia.  The  indi\iilual 
hranehes  passint,^  to  the  inferior  frontal  (prodncinji'  tyjiical  motor  aphasia 
if  the  disease  heOn  the  left  side),  anterior  and  jMisterior  central  gyri  (usually 
causin«:  total  liemiiilej:ia).  to  the  siipramarKinal  and  anjiular  j^^ri  (giving 
rise,  it^the  thromliosis  he  on  the  left  side,  probably  without  exception  to 
the  so-called  pure  (or  subcortical)  alexia,  usually  also  to  right-sided  lu'ini- 
anopsia),  or  to  the  temporal  gyri  (in  which  event  with  left-sided  thrombosis 
word-deafness  results)  may  bo  plugged. 

(/')  Aiilrrior  ('nrhrnl — No  symptoms  may  follow,  and  oven  when  the 
branches  which  supply  the  ])aracental  lobule  and  the  top  of  the  ascending 
convolutions  are  plugged  the  liranches  from  the  middle  cerebral  are  usually 
able  to  etl'ect  a  collateral  circidation  in  these  ])arts.  ^Monoplegia  of  the  leg 
may,  however,  result,  llebetudo  and  dnlness  of  intellect  may  occur  with 
obstruction  of  the  vessel. 

There  is  unquestionably  greater  freedom  of  eomnninication  in  the  cor- 
tical branches  of  the  ditl'erent  arteries  than  is  usually  admitted,  although 
it  is  not  possible,  for  example,  to  inject  the  po.«terior  cerebral  through  the 
middle  cerebral,  or  the  middle  cerebral  from  the  anterior;  but  the  absence 
of  softening  in  scmie  instances  in  which  smaller  tiranches  are  blocked  shows 
how  comideto  may  be  the  comi)ensation,  iirobably  by  way  of  the  cajtillaries. 
The  dilatation  of  the  collateral  branches  may  take  ])lace  very  ra])idly;  thus 
a  jiatient  with  chronic  nephritis  died  about  twenty-four  hours  after  the 
hemiplegie  attack.  There  were  recent  vegetations  on  the  mitral  valve  and 
an  embolus  in  the  right  mii'dle  cerebral  artery  just  beyond  the  first  two 


^,,1.,  DISEASES  OF  TllK   XHllVOUS  SYSTFM. 

,„„,„,„..<     TlH.  c.ntnil  rorliun  ..f  ih.  lun.i.plu.iv  was  suoll.n  and  u.U.ma- 

'"tIu.  li'l.t  an,.,.i.Ir  ..n.i.n.l  was  ...atly  d,la,...l   an.l     y  nu.a.nvu.n, 

.lianu.t.r  was  luun.l  I,.  I.  .usulv  .hnr  tn.u.  that  "';^"  ''„"  g^^,      -^^ 

J        '         ll     .        .ni.I,  an.l  :,u.asun.s  inun.liat.lv  tak.u  to  mluco  th. 

■  n     ',->..■•     or    lu...  tlK.  .nost  raiu.l  a.ul  sulistaKory  -s  v.n.scr  >u   , 

ih       'l      b     K.  ,.nu.tis..l  wh.n.vor  the  arterial  t.us.uu  .s  mud.  mcrea..  . 


nil  accciituatiHl  aortic  sm-nd  sound 


V't  ;.  ,f„;.,.U  .llul  to  tnl.|,  o,„.,„,l.  .„1h;,-  .,y  '■»'•■-•?---> 

bo  light  and  no  nuMlie.no  otlu     ^1  •      -         P^^^  ^^^j^.^^;^,,^  ,i,,„id 

at  least  during  the  lirst  "^''"^'V'^^;,    '  J :    !  ^^    h^,,,  or  linihs,  which  if 
he  paid  to  the  ].osition  occupied  hy  the  paiaO/ed  hm 
swollen  may  he  wrapped  in  cotton  l)att.ng  or  Hanne  ^^_^_ 

The  treatment  of  soflcuu,    -m  thron.hoMs  o    un^-h^  m  k        )  ^^^ 

satisfactory.     Venesection  .  not^  -j^^'  ^^'^^^  ^."rt's  action  is  feehle 
rather  promotes  c.lottmg.    ^''f  ^^ '^^7\  ^  \"    f,,    .  i    \„,v  1,.  given  with, 

„.l,„m  II..-  hc..,i|.U-pia  otion  .els  ''V''  'V'"*  " ,"' ""-3""^,,,,    l.voo  ti...05 

f  r  r;?  :«s "  ;:'^xi^T^:;;ii«^  -  c.,  .«,i.  ■... 


"^^  ^ 


<>. 


.0^.  \*^>Tv% 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


/. 


'/  /.V     mp        Mr, 


4r 


t 


1.0 


I.I 


1.25 


•  50  


1^ 


1.4 


IM 
1.6 


vQ 


<^ 


/a 


:.m 


•c*l 


/ 


/r^ 


"4V^ 


r 


d? 


/ 


Photographic 

Sciences 

Corporation 


4 


,\ 


V 


^9> 


.V 


»'^ 


N> 


*> 


<: 


6^ 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


I'"  Li' 


1 
/I 


■■■^ 


L<? 


r'r 


■■=..^ 


i 


.-■•if.1 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  canadien  de  microreproductions  historiques 


■s®Sii, 


^^ 


APFECTIONS  OP  THE  HLOOD-VESSELS. 


Hil3 


cmhxh  liy  iiuinction  arc  nlsn  indicated.     I'raclically  tlioc  mv  (lie  r.nly  casis 
()!'  hciiiiplcKi!'  i"  ^\''''''>  "''  •^^'•'  '-■•l'>''i" ■'"'■>■  i''>'il'~  '1'""'  tivitnu'iil. 

OlR'valivi'  trcatiiu'iit  lias  lurii  sn.L'flfstfd.  and  wluMi  the  dia<:niisis  of  siili- 
dural  lunnoniia-c  lan  !>(■  mad.'  it  is  jiistilialdc  An  attempt  t<.  naeli  a 
centra!  iia'niorrlia.uc  in  tlie  nciohlH.rliu,,,!  of  tlie  internal  capsule  would  only 
increase  tin-  dania-c  to  the  lirain  suhstancc.  Very  little  can  lie  done  for 
the  hcniii.l.'uia  which  vcnlains.  The  dania-e  is  too  .d'teii  irreparal.le  and 
iHTniaiient.'and  it  is  verv  iinproliahle  that  iodide  of  potassium,  or  any 
otluT  remedy,  hastens   in   the  slij;litcst   degree   Nature's  d.^alin-   with   the 

blood-clot. 

The  paralyzed  limhs  may  he  p'litly  rulihed  once  or  twui'  a  day.  ami 
this  should  hi'  svstcinalically  carried  out.  in  order  to  maintain  the  nutri- 
tion of  the  miisc'les  and  to  ]".rcvcnt.  if  i)o.ssihlc,  contractures.  Th.'  mas-a-c 
shoidd  not.  however,  bo  bi-un  until  at  least  ten  days  after  the  attack.  'I'hc 
rubbmir  should  bo  toirard  the  body,  and  should  not  be  <-ontinued  b.r  more 
than  li'fteen  minutes  at  a  time.  After  the  lapse  .d'  a  fortni-ht.  or  in  severe 
cases  a  month,  the  niuscl(-s  may  be  stimulated  by  the  faradic  current;  laradie 
Ptinuilation  alternatinj:  with  massa-e,  especially  if  applie.l  to  the  anla<;onists 
of  the  muscles  which  ordiiiarilv  underp)  contracture,  is  of  very  <:reat  service, 
even  in  cases  where  there  can  be  but  little  hope  of  any  return  of  voluntary 
movement.  When  contractures  develo]),  electricity  properly  applied  at 
intervals  may  .still  be  of  some  bcnelit  along  with  the  passive  movements  and 

frictions. 

In  a  case  of  com]dete  liemii»le<ria.  the  friends  should  at  the  outset  I.e 
frankly  told  that  the  chances  of  full  recovery  are  sli-rlit.  !'ower  is  usually 
restored  in  the  leg  suilicient  to  enable  the  patient  to  get  abmit.  but  in  the 
majority  of  instances  the  iiner  movements  of  the  hand  are  permantMitly  lost. 
The  general  health  should  be  looked  after,  the  bowels  regulated,  and  the 
geeretinns  of  th'J  skin  and  kidneys  kept  active.  In  itermancnt  In  iniplegia 
in  persons  above  the  middle  period  of  life,  nior-  (U'  less  mental  weakness  is 
apt  to  fidlow  the  attack,  and  the  patient  may  become  irritable  and  emo- 
tional. 

And.  lastlv,  when  hemiplegia  has  jiersisted  for  more  tlian  three  months 
and  contractures  have  developed,  it  is  the  duty  of  the  physician  to  explain 
to  the  patieiit,  or  to  his  friends,  that  the  condition  is  past  relief,  that  medi- 
cines and  electric  ity  will  do  no  good,  and  that  there  is  no  po.<sible  hope  of 
cure. 

0.  AxrrHisM  OF  Tin-  C'KUKiuiAi.  Aitii;i!ii:s. 

]\riliary  aneurisms  are  not  included,  but  reference  is  made  onlv  to  aneu- 
rism of  th'e  larger  branches.  The  condition  is  not  nncomnion.  There  were 
^^i  instances  in  mv  first  SdO  antoi.sies  in  Afontreal.*  This  is  a  cor.siderably 
larger  jiroportion' than  in  Xewton  Titfs  collection  from  (luy's  Hospital, 
19  times  in  9,000  inspections. 

Etiology.— Males  are  more  frequently  affc-cted  than  females,  ()1  my 
13  caPos  7  were  males.     The  disease  is  most  common  at  the  mid.lle  jieriod 


*  Canada  Medical  and  Surgical  Journal,  vol.  xiv. 


-     *• 


lOU 


DISEASES  OF  TIIR  NHRVOL'S  SYSTEM. 


at  tlio  same 


of  life.     One  of  my  ciises  was  a  lad  of  six.     I'itt  dc-cnlns  oiio 
ajic    'I'lic  cliii'l'  causes  are  {'i)  iMidarlcritis,  imIIkt  i-impli"  or  inpliilitic,  wliicli 
"    to  \\i'akm'>s  of  tlu'  wall  and  dilatation;  and  (/*)  (Midxdism.    As  point.  ' 


I'itt, 
n.l 
The    em- 


lean 

out  liy  Ciiureli,  these  aneurisms  are  (d'teii  found  with  eiidocanlitis. 

in  his  recent  study  of  tiu'  >ul.,ject.  cimcludes  tliat  it  is  exceptional  to  !ii 

cerehral   aneuriMii    unassociated    with    fun<ratin^'    endocarditis. 

holus  disapiiears.  and  dilatatiim  follows  the  secondary  inllamnialory  chiMyes 

in  the  coats  of  the  vessel. 

Morbid  AnatOXny.— The  middle  cerehral  hrauehes  are  most  fre- 
(luciitly  involved,  in  my  I'i  cases  the  distrilmtioii  on  the  arteries  was  as 
follows:  Internal  carotid,  1;  nnddle  cerdiral,  T);  l)a.-ilar,  ;{;  anterior  com- 
municalinjr.  ^^.  Kxcept  in  one  case  they  were  saecidar  anil  c(unn\unieateil 
with  the  lumen  of  the  vessel  hy  an  orifice  smaller  th.in  the  circuml\'rence 
(d'  the  sac.  hi  tlie  l.Vt  cases  which  make  u[)  the  statistics  of  Lehert, 
Durand.  and  iiartludow  the  middle  cerehral  was  involved  in  41,  the  basilar 
in  n,  internal  carotid  in  •^;5,  anterior  cerehral  in  11,  posterior  communi- 
cating' ill  S,  anterior  communieatinjj;  in  cS,  vertelual  in  T,  posterior  eere- 
hral  in  (i,  inferior  cerehellar  in  :?  ((lowers).  The  size  of  the  aneurism 
varies  from  that  of  a  pea  to  that  of  a  walnut.  The  luemorrhajre  may  ho 
entirely  meningeal  with  very  sli},dit  laceration  of  the  hrain  suhstance,  but 
the  hleedinj,'  may  lie.  as  Coats  has  shown,  entirely  within  the  suhstance. 

Symptoms.— The  aneurism  may  attain  considerahle  size  and  cause 
no  symptoms.  In  a  majority  of  the  cases  the  first  intimation  is  the  rupture 
and  "the  fatal  apoplexy.  J)istinct  symptoms  are  nuist  freciuently  caused  hy 
aneurism  of  the  internal  carotid,  which  may  compress  the  optic  nerve  or  the 
commissure,  causinj;  neuritis  or  paralysis  of  the  third  nerve.  A  mi'.-.iUir 
may  he  audible  on  auscultation  of  the  sknll.  Aneurism  in  this  situation 
may  give  rise  to  irritative  and  pressure  symptoms  at  the  l>ase  of  the  brain 
or  to  hemianopsia.  In  the  remarkable  ease  reported  by  Weir  ^[itchell  and 
Dercum  an  aneurism  eomi)ressed  the  chiasma  and  produced  bilateral  tem- 
])oral  hemiano]isia. 

Aneurism  of  the  veriebral  or  of  the  basilar  may  involve  the  nerves  fnnn 
the  iifth  to  the  twelfth.  A  large  sac  at  the  termination  of  the  basilar  may 
compress  the  third  nerves  or  the  crura. 

The  diagnosis  is,  as  a  rule,  impossible.  The  larger  sacs  produce  the 
symptoms  of  tumor,  and  their  rupture  is  usually  fatal. 


7.  EN-DAnTi:iUTis. 

In  no  grou]i  of  vessels  do  we  more  fre.pieiitly  see  chronic  degenera- 
tive changi^s  than  in  those  of  the  circle  of  Willis.    Tiie  condition  occurs  as: 

(^0  Arlcriii-srkrosis.  jirodncing  localized  or  dill'used  thickening  (»f  the 
intima  with  the  formation  of  atheromatous  patches  or  areas  of  calciljeation. 
In  the  later  stages,  as  seen  in  elderly  people,  the  arteries  of  the  circle  of 
Willis  inav  be  dilated,  still",  or  almost  nniversally  calcified. 

(/-)  Si'ijihililir  Kihlarlcrills.—M  already  mentioned  under  the  section 
of  syi)hilis,  gummatous  endarteritis  is  specially  ju-one  to  attack  the_ cere- 
bral'vessels.    It  has  in  itself  no  specilic  cliaracters— that  is  to  say,  it  is  iin- 


[i  tlic  ?ainc 


litic,  wliieli 
As  jioillti  1 
litis,  ritt, 
)nal  ti)  liiitl 
The  LMu- 
ory  eliiMyrs 

■   most   fi'o- 
I'rii's  was;  as 
itcrior  com- 
lununicatcil 
rcuiiitVi't'mx' 
of    lA'bcrt, 
,  thf  basilar 
r  coininuni- 
i^tcrior  ooro- 
iL'  aneurism 
lago  ma}'  be 
bstaiu-f,  but 
iljstaUL'O. 
V.  and  cause 
tlio  rupture 
ly  I'uuscd  by 
lU'rve  or  the 
A  nu'.iiuir 
his  situation 
of  tiie  brain 
Mitchell  anil 
ilateral  tern- 
nerves  from 
l>asilar  may 

produce  the 


lie  depenera- 
on  occurs  as: 
eninti  of  the 

caleilleation. 

the  circle  of 

r  the  section 
U'k  tlie  cere- 
say,  it  is  im- 


AFFEC'TIUXS  Ul'^  TIIE   BLOOD-VESSELS. 


Idl.-) 


])ossible  in  j;iven  sections  to  jiiek  out  an  endarteritis  sy[ihilitica  from  an 
ordinary  endarteritis  oliliteraiis.  On  the  niher  hand,  as  already  slated,  the 
nodular  periarteritis  is  never  seen  except  in  syiihilis. 

8.  'riii!().Mi!i)sis  or  Tin;  ('i:i;i;iii! ai.  Simsks  and  \'i;in.s. 

The  condition  may  be  primaiT  or  secondary.  i.ebcH  (is,")!)  and  TnU- 
ni'le  were  ainon^'  the  lirst^to  reeo^nizt'  llie  condition  elinicaliy. 

Primary  thrombosis  of  the  sinu>es  and  veins  is  rare,  it  occurs  {n)  in 
ehihlreii,  jiarticnlarly  durinji'  the  liist  six  montiis  of  hfc,  usually  in  con- 
nection with  diari'luea.  It  has,  in  my  I'xperienee,  been  a  rare  ciuidition. 
1  have  ne\i'r  seen  an  examph'  of  spontaneous  thromliosis  (d'  the  sinuses  in 
a  chilli,  and  only  two  instances,  both  in  conuection  with  meniiiuitis,  in 
which  the  ((utieal  veins  contained  clots,  (lowers  believes  thai  it  is  of  fre- 
quent occurrence,  ami  that  thrond)osis  of  the  veins  is  not  an  uncommon 
cause  of  infantile  henHplei;ia. 

(/*)  In  cimneetitm  with  chlorosis  and  amvmia,  the  .so-called  anhicJdkuiiotis 
aiinis-lliroiiilxisis.  JWaytcm  JJall  has  called  attention  to  this  interestin^r  a.sso- 
ciation,  and  has  re)iorted  I  case  and  collected  10  or  11  others  from  the  litera- 
ture. All  were  in  f,drls  with  anu'uua  or  chhn'osis.  'i'he  lonjiitudinal  sinus 
is  most  freipiently  inv(dved.  The  thrond)osis  of  the  cerebral  sinu.ses  in 
such  cases  is  usually  associated  with  vemms  thrond)oses  in  other  parts  of 
the  body,  and  the  ]iatieuts  die,  as  a  rule,  in  from  one  to  three  weeks. 

((■)  In  the  terminal  sta^L'es  of  cancer,  phthisis,  and  other  chronic  dis- 
eases thrombosis  may  jrradually  occur  in  the  sinuses  ami  cortical  veins.  To 
the  coa^uhnn  developing  in  these  conditions  the  term  marantic  thrombus 
is  ap])lied. 

Secondary  thrombosis  is  much  more  frcipient  and  follows  extension  of 
inflammation  frijui  contiiruous  parts  to  the  sinus  wall.  The  common  causes 
are  disease  of  the  internal  ear,  fracture,  compression  oi  tiie  sinuses  by 
tumor,  or  sui)]uirative  disease  outside  the  skull,  jiarticnlarly  erysijielas,  car- 
buncle, and  parotitis.  In  secondary  cases  the  lateral  sinus  is  most  freiiuently 
involved.  Of  oT  fatal  cases  in  which  ear-disease  caused  death  with  cerebral 
lesions,  there  were  '^'i  in  which  thrombosis  existed  in  the  lateral  sinuses 
(Pitt).  Tubercidous  caries  of  the  temporal  lume  is  often  directly  responsible. 
The  thrombus  may  be  small,  or  may  fill  the  entire  siinis  ami  extend  into 
the  internal  jutrular  vein.  In  more  than  one  half  of  these  instances  the 
thrombus  was  su])])>iratinf:.  The  disease  sju'cads  directly  from  the  necrosis 
on  the  posterior  wall  of  the  tympanuff.  According,'  to  ^'oltolini,  the  in- 
flammation extends  by  way  of  the  jietroso-mastoid  camd.  It  is  not  so  com- 
mon in  disease  of  the  mastoid  cells. 

Symptoms. — Primary  thronil)osis  of  the  loniziludinal  sinus  may  occur 
without  excitinjf  sym])toms  and  is  found  accidentally  at  the  ])ost  mortem. 
There  may  he  nuMital  dulness  with  headache.  Convulsions  and  vomiting 
may  occur.  In  other  instances  there  is  nothing  distinctive.  In  a  ])atient 
who  died  under  my  care,  at  the  Philadelphia  Hospital,  of  ])hthisis,  there 
was  a  gradual  torpor,  deepening  to  coma,  without  convulsions,  localizing 
symptoms,  or  optic  neuritis.     The  condition  was  thought  to  be  due  to  a 


KtlG 


DISEASES  OF  THE   NER VOL'S  SYSTEM. 


icnninnl  niciiin-itis.  In  Ww  clil.irosis  cases  the  head  symptoms  liavo.  as  a 
,.„!,.  l.n.n  marked,  liall's  patient  was  dull  and  stupid,  had  vomiUng, 
d,lalati..n  .d'  tiu"  pupils,  and  doul^le  choked  di-ks.  Sli-hl  paresis  ol  the 
Icl't  ^ide  oeeurred.  An  interestin-;'  IVatnre  in  her  ease  was  tlie  d.'velop- 
„i..Mt  of  swellin-  (.!■  tlie  left  le-.  In  the  eases  rep-'Med  hy  Andrews.  Chureli, 
'I'uckwell  Jsunhard  Owen,  and  Wilks  the  patients  had  headaehe.  vunut- 
i„.r  an.l  delirium.  I'aralvsis  was  not  pres.'.a.  In  l).)U-las  Powell's  case, 
with  sindlar  svmi.toms,  there  was  loss  of  power  on  the  U'ft  side.  Bristowe 
rei)orts  a  ease  "of  great  interest  in  an  aiuiMiiie  girl  ot  nineteen,  who  had  con- 
vulsions, drowsiness,  and  vomiting.  'ren<lerness  and  swelling  developed 
in  the  position  of  the  right  internal  jugular  vein,  and  a  few  days  later  on 
the  opposite  side.  The  diagnosis  was  rendered  definite  by  the  occurrence 
of  phlebitis  in  the  veins  of  the  right  leg.    .The  patient  recovered. 

The  onset  of  such  svmptoms  as  have  been  mentioned  m  an  amemic  or 
chlorotie  -drl  sliould  lead  to  the  siis])icion  of  cerel)ral  thrombosis.  In  in- 
fants the  diagnosis  can  rarely  he  made.  Involvement  of  the  cavernous  sinus 
mav  cause  adema  about  the  eyelids  or  prominence  of  the  eyes. 

-Jn  the  scroinlani  thrombi  the  svmptoms  are  commonly  those  of  septi- 
ca-mia  For  instance,  in  over  1()  per  cent  of  ritt"s  cases  the  mode  of  death 
was  bv  pulmonary  pva-mia.  This  autlior  <lraws  the  following  important 
conclusions:  (1)  The  disease  spreads  of  toner  from  the  posterior  wall  ol 
the  middle  ear  than  from  the  mastoid  c.dls.  (v>)  The  otorrluea  is  gener- 
allv  of  some  standing,  but  not  always.  (:i)  The  onset  is  sudden,  the  chief 
svmptoms  being  pyrexia,  rigors,  pains  in  the  occipital  region  and  in  the 
lu-ok  associated  with  a  septicaMuic  condition.  (D  Widl-marked  optic  neu- 
ritis 'may  l)e  present.  (5)  The  appearance  of  acute  local  pulmonary  mis- 
chief or  of  distant  siiii])uration  is  almost  conclusive  of  thrombosis.  ((.) 
IMie  averao-e  duration  is  ab.uit  three  weeks,  and  death  is  generally  from 
pulmonary  pya-mia.  The  chief  points  in  the  diagnosis  may  bo  gathered 
from  these  Stat emer.s.  ,      i,,,i 

Pitt  records  an  interesting  case  of  recovery  in  a  boy  of  ten,  who  liat 
otorrluea  for  years  and  was  admitted  with  fever,  earache,  tenderness,  and 
uHlema  \  week  later  he  had  a  rigor,  and  optic  neuritis  developed  on  tlic 
ri>dit  side.  The  mastoid  was  explored  unsuccessfully.  The  lever  and 
.■hill-  persisting,  two  days  later  the  lateral  sinus  was  explored.  A  mass  ot 
foul  clot  was  remoyed  and  the  jtigular  yein  was  tied,  after  which  the  boy 
made  a  satisfactory  recoyery.  . 

.\ceor.lin-  to  Griesinger  there  is  often  associated  with  thnmibosi.  of 
the  hiteral  sinus  venous  stasis  and  painful  unlema  behind  the  ear  and  in  the 
neck  The  external  jugular  yein  on  the  diseased  side  may  be  less  dis- 
tended tlian  on  the  oiip.-site  side,  since  owing  to  the  thrombus  in  the  lateral 
sinus  the  internal  jugular  vein  is  less  full  than  on  the  normal  side,  and  the 
blood  from  the  external  jugular  can  How  more  easily  into  it  (Gerhardt).    _ 

Treatment.— Tn  marantic  individuals  rol)orants  and  stimulants  are  in- 
dicated The  posit i.ui  assumed  in  bed  should  fayor  botli  the  arterial  and 
venous  circulation.  The  clothing  should  not  restrict  the  neck,  and  care 
should  be  taken  to  avoid  lending  of  the  neck.  ,  ,       , 

The  internal  administration  of  potassium  iodide  and  calomel  has  been 


1 


AFFECTIONS  OF  THE   BLOOP-VESSELS.  joiT 

roonmmoii.lcd  in  tho  autoclitlioiKuis  fornis,  l)ut  no  treat iiiciit  is  liltclv  to  lie 
of  i\]\\  avail. 

'I'hc  sccdiidarv  I'lU'ins,  (S|ii'('iall_v  tli(,st>  J'dlldwiiiix  u|  mi  iliscasc  <i|'  tlic 
iiiiddk'  car,  arc  <  I'tcn  anicnaljlc  to  i)])ci'atioii,  and,  cs|icciall_v  recently.  iii;inv 
lives  liavi'  been  saved  l)y  sur<,Mcal  intervention  after  extensive  sinus  tlin  ni- 
bosis.  .Maceweirs  worlc  On  I'yo-cnic  Infective  Diseases  of  the  I'.rain  and 
Spinal  Curd  contains  the  most  cxlianstive  jircsentation  of  tlii'  suliject  of 
sinus  thrombosis  and  its  liratmcnt. 

0.    IIk.MII'I.KCIA    i\    ('llII.DIiKX. 

Etiology.— Of  i;55  cases,  ()()  were  m  bovs  and  :r,  in  <:\v\>.  L'i^dit 
liomipk'gia  occurred  in  :9,  left  in  ,j().  Jn  lo  cases  the  condition  was  said 
to  bo  conjionital. 

In  a  ^reat  majority  tlie  disease  sets  in  during'  tlie  first  or  second  year; 
thus  of  tlie  total  numlier  of  cases,  ii.")  were  under  two.  Cases  above  the 
firth  year  are  rare,  only  1(1  in  my  series.  Xeither  alcoholism  nor  syiihilis 
in  the  parents  appears  to  ])lay  an  important  rule  in  tiiis  affection.  "  J)illi- 
cult  or  alinormal  labor  is  responsible  for  certain  of  the  cases,  particularly 
injury  with  the  forceps.  Trauma,  sucli  as  falls  or  imncturinir  wounds, 
is  more  rare.  The  condition  followed  ligatiun  of  the  common  Carotid  in 
one  case. 

Infectious  diseases.  All  the  authors  lay  s])ecial  stress  upon  this  factor. 
In  19  cases  in  my  series  the  disease  came  on  during-  or  jii-t  after  one 
of  tlic  specific  feyers.  I  saw  cue  case  in  which  during  the  height  of  yac- 
cination  conyulsions  develoiied,  followed  by  hemiplegia.  In  a^'great  ma- 
jority of  the  cases  the  disease  sets  in  with  a  convulsion,  in  which'"the  child 
may  remain  for  several  hours  or  longer,  and  after  rccuyery  the  paralysis 
is  noticed. 

Morbid  Anatomy.— In  an  analysis  whicli  I  haye  made  of  90  au- 
topsies reported  in  the  literature,  the  lesions  may  be  grouped  under  three 
headings: 

(fl)  Kmbolism,  thrombosis,  and  lia>morrliage,  comprising  1(1  cases,  in 
r  of  wliich  tlu're  was  blocking  of  a  Sylvian  artery,  and  in  9  lia"morrlia--e. 
A  striking  feature  in  this  group  is  the  advanced  age  of  onset.  Ten  of  tdie 
cases  occurrt'd  in  children  oyer  six  years  old. 

(b)  Atroidiy  and  sclerosis,  comiirising  50  cases.  The  wasting  is  either 
of  groups  of  convolutions,  an  entire  lobe,  or  the  ,  hole  hemispl'rere.  The 
meninges  are  usually  closely  adherent  over  the  alfected  region,  thoii..h 
sometimes  they  look  normal.  The  conyolutioiis  are  atropiiied.  lirm  and 
hard,  contrasting  strongly  with  the  normal  gyri.  The  sclerosis  may  be 
dilluse  and  widespread  over  a  hemisphere,  or  there  may  be  nodular'pro- 
jccf ions— the  hypertrophic  sclerosis.  Some  of  the  cases'  show  rcmarkai)Ie 
unilateral  atrophy  of  tlie  hemisphere.  In  one  of  my  cases  the  atroiihied 
hemis].here  weighed  ICH  grammes  and  the  normal  one  i]r>:i  grammes.  The 
brain  tnsue  may  be  a  mere  shell  oyer  a  dilated  ventricle. 

((■)  rorencephalus,  which  was  present  in  •<> 4  of  the  90  autopsies  This 
term  was  aj)pliod  by  Ileschel  to  a  loss  of  substance  in  the  form  of  cavities 


! 


«■*! 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1018 

l.,,i,.ii,ally.  thru,  ...   ...I....1il^   '"."  r  •"''li    .1      The  ...■inuu-v  cl.a..-o 

in  tl.o  i.iii,i..nty  «.t  tl..M'  ^ax     .>  ■  n  ,  •  .^,j_     rj',,^.  ,tu,lngy 

i'.-...  a  .Ic.lVct  i.,  .U.v.l.r..,...!  ot  ''^'^ '';;!'      •,,,,,,,,,,,,,,  ,,„lH.lis,.,,   an.l 
is  .l..ar  in  the  li.n.U-l  '>"->''"  ,  "'Vn-.n,     in  wl.nh  ih.  r...al  cl.an,... 

,l,.ii.  With  t'oiivuls.on^— olttn   \\  111       .-  ,((,,r_n,,  lo-on- 

u.i.  .■ Mi,.n  is  ,.„..;..  -;;;-;;:;";  ,'l !:,,':;;... :;:'.. «» n.  -- 

'"'"'""  I'™""  "r;,r.;!""'?„i. ;;;  ? ;  r:;:u !:; oL,  u.  ,„..  iin..  .™ii- 

out    n  some  instanvc-.      '  "^  ;'"7'"   '  •  ,.   .,  •   .,  ,..„.elv  (Kriirs  m 

lion  ef  sc.l.>rosis.  ''"^  <,'''-''l'>,.    >:•■';;;:';;;  :;U4  i^'Iu'ntlv  attackoa  by 
lu-altl.v  cl.il.l.v.K  wlucl.   appear  to  lu    tl.a      n.  ^^^^^^^.^^_ 

infantile  l.en.ipl.'^ia.  a,..l  imst-n.nrte.n  p.-oi  ,.  yi  Ns.u.t.n. 
tion  of  thmnbosi.  with  the  disease.  .^^  ^^^^,^,^,,^^     ^^.j,,. 

Symptoms. -(;0  '1  lu;  on.et.     1  '  •      .  ,,,,,  ^.,,,,,  ^he  chiUl 

out  spas...s  ...■  1..SS  of  e..,.sc.,ous.u.ss  '^  '  7^  "  , '  ,„,,  „f  ,onseiousness. 
is  attaeke.1  with  pa.l.al  or  f^^^''\j2^Z<lh\.  is  one  .>f  the  n.ost 
which  n.ay  last  f.-o.n  a  lew  lu.urs  t.   n.a  >    '■>;;.'     ,^,,^,,,t_      rj,,^,  i,,,,,;. 

left.     The  f.ice  is  eo.nnumlv  not  involved  .,,iduallv  disap- 

(/,)  IJesidual  syn,pton,s.     In  ^-^^^'   ^^'^^         paialv. ..    .  ^_,         . 
^     and  leaves  seai'cely  a  trace  as  the  eh.h 


child  'ii'ows  np. 


as  a 


pear? 


The  le 

iiv  .,n,l  more  fnllv  than  the  arm.  and  the  i)aial\- 
rnle,  re.overs  nu.re  raimiU  ami  n>ou  ^^      ^^^^^^^^^.^^^.    ^,^^^^.^  ,^ 

sis  n.ay  he  scarcely  ^J-  '^'^'^Weln  .)  m.u;    '^  ^^^^^_,,^^^^  ;,^  ^,,^. 

a  .haraeteri.tic  I'-U-lopc  put^  „  '    e^'d  at  ri.ht  angles,  the 

l„„d  is  Hexed,  and  the  l...uers  a  e  ^"^^  ^ ^^      '    .        ,,^  ^,,,„,,  ,,,,  head.     Late 
pU.telv  lost:  i..  other  ...sta,..es  the  ar  .   c  a     '      "»  ^^.j^;^,,^  ,,,,,,,sted 

•i.iditv.  which  almost  always  ^^^l^!^'  .;",",     o.lhopanlic  snrjieou 

t,;;.  .a...e  y,nipJe,ia  ^/-'-/^  -';  ^^l    "     '  I.       .ever.\.ot  constant. 
,,,.,  nvst  acc.nrately  descr.hed     ^^ -     "^-^  ^  ^^,/^,,^.  „,,,t.     The  retlexes 

^rS.  S-^^of^I-lt:^  I  ^>'>ve  .nown  them 

:,::  ::;;s;nt.     sensation  is.  as  a  rnle.  no    ^^^         .^  ,,  ,,,,,  ,f  „, 

..,i;!£rt;:ih."™i;rzn^n^^ 

""S^ril^'-O-  of  the  n.ost  serious   consoquoncos   of  infantile 


^MB 


IM(ll'(l   1)V 
L'C'philluS, 

1(1  jioivn- 
y  clianjio 

\i\y  ri'sv.lt 
I'  i'ti(il«t;iy 
lis, 11,   iind 
111  cliaut;!' 
instance-^? 
H't  is  suil- 
ievcs  tliat 
— |)(ilio-i'n- 
■i  (he  ana- 
ly  lio  I'Vi's- 
iiial  (ondi- 
ocrui's  in 
ttacki'd  liy 
1k>  assofia- 

U'lily  witli- 
:'s  the  child 
iisriousnoss, 
)t'  tlio  most 
Tho  hcmi- 
V  cDinitU'te. 
al'trr  suhso- 
.(1  than  Iho 

ually  ilisap- 
hc  h'lr.  as  a 
1  tho  iianily- 
vor,  t!u>ve  is 
irkod  in  the 
:  aii^rl(>s,  the 
almost  eom- 
hoad.     liate 
eh  sntrgosted 
a'dic  sur<reon 
not  constant. 
The  retl(>xes 
known  tliem 

G  cases  of  niv 
f  AVallenberjr. 

s   of  infantile 


AF''i:(TIoN'S  OF  TIIH   liLdOD-VHSSKLS. 


liiHt 


heniii>le^Ma  is  tlie  failure  of  ineiital  develdpiueiii,  A  ((UiMiKTiihh'  luiinlMr 
(,f  ihese^ases  drift  into  the  iiislitutit-ns  for  i'eehle-iniiiih'd  cliiMivii.  'i'hr.  e 
urades  may  he  di^liii.-iii>hed— idiocy,  whii  h  i>  nm^t  c.iMiiiion  when  the 
'heinil>le<;ia  has  existed  fniiu  hirlli;  miliecility.  which  often  iiicrea>es  wilh 
the  develoiMiieiit  id'  cpih'l'sy:  and  l\'ei)le-niimledness  a  retai(hM|  rallur 
than  an  arresleil  develn|iiueiit. 

j.;j,jj,.ps,i,—{)i  the  cases  in  my  series.  11  were  siihjects  ef  eonviil>ive 
sciziiies,  one  of  the  mo^U  distrcssin.u'  se(iiicls  of  the  disease.  The  seizures 
may  lie  eitlur  traii^iiMit  atta.-ks  n\  priit  iiinl,  true  .laeksoiiian  (its,  he,i,Mn- 
nin"^'  in  and  conlined  to  the  aiVccli'd  side,  or  general  convuUions. 

I'iist-linnijilniir  Mnrniinils.—  W  was  in  cases  of  this  sort  that  Weir 
Mitchell  lir.-t  descrihed  the  iiostdieiiii|)lc,uic  inoveiiiciits.  They  are  cx- 
trcinelv  cdimiioii,  and  were  i.resciit  in  ;'.  I  (d'  my  series.  There  may  lie 
cither  slight  tremor  in  the  ail'ected  muscles,  or  iiicoi)rdiiiate  choreiform 
movements — the  .-o-called  iio.-t-lu'mi|ilegie  chorea— oi.  lastly, 

l//,,,/„,s','s. — In  this  condition,  descrihed  hy  lianinioiid.  there  are  remark- 
ahle  sinisms  of  tlie  paralyzed  extremities,  chielly  (d'  the  liii,irers  and  toes, 
and  in  rare  instances  of  the  miistdes  cd'  the  ninuth.  The  imivenieiils  are 
invdluntary  and  somewhat  rhylhinical;  in  the  hand,  nioveiuents  of  addue- 
tieii  <ir  aliductioii  and  of  supination  and  ]irona1io!i  follow  caidi  otlu'r  in 
orderly  se(iuence.  There  may  he  hypercxtension  of  the  Hn<:ers,  during' 
which"  they  ari'  spread  wide  apart,  'i'liis  c(.iiditimi  is  much  nmre  fre(|uent 
in  children  than  in  adults,  in  the  latter  it  may  he  eoiuhiiied  with  heiiii- 
aiKcsthcsia,  and  the  lesion  is  not  cortical,  hut  basic  in  the  nei;;hl)orliooil  of 
the  thalamus.  The  nioveiuents  are  sometimes  increased  hy  eiiiutidn.  They 
usually  persist  duriiii:-  sleep. 

Treatment. — The  possibility  of  injury  to  the  lirain  in  prdtractt'd 
labor  and  in  forcejis  cases  should  be  borne  in  mind  by  the  practitioner. 
The  former  entails  the  <rreater  risk.  In  infantile  hemiplegia  the  physician 
at  tlie  outset  sees  a  case  of  ordinary  convulsions,  perhaps  more  protradid 
and  severe  than  usual.  These  sho'dd  be  checked  as  rapidly  as  possible 
liy  the  use  of  the  liromides,  the  ajiplieation  of  cold  or  heat,  and  a  brisk 
luirjre.  Durinj,'  convulsions  chloroform  may  be  adiiiinistered  \iith  safety 
even  to  the  younjit'st  children.  When  the  paralysis  is  establislied  not  much 
can  be  hoped  from  medicines.  In  only  rare  instances  does  the  paralysis 
ontirelv  disappear.  When  the  recovery  is  partial  the  '■residual  paralysis" 
is  similar  to  tliat  seen  in  other  lesions  of  the  \\\^\)v\'  motor  sej^nneiit.  Thus 
in  the  lower  extremity  it  is  the  ilexors  of  the  \v<i  and  the  dorsal  flexors  of 
the  foot  which  are  most  often  permanently  paralyzed  (Wernicke).  'I'bo 
indications  are  to  favor  the  natund  temlt>iicy  to  improve  by  maintaining  tho 
general  nutrition  (d'  the  child,  to  lessen  the  rigidity  and  contractures  by 
massage  and  jiassive  motion,  and  if  necessary  to  correct  (hd'ormities  by 
mechanical  or  surgical  measures.  ^lucli  may  be  done  by  careful  manipula- 
tion and  rubbing  and  the  application  of  a  jiroper  ap])aratus.  In  children 
the  aphasia  usually  disap|iears.  The  epilcjisy  is  a  distressing  and  (distinate 
symptom,  for  which  a  cure  can  rarely  be  anticipated.  Troldnged  ])eriods 
of  ([uiescenco  are,  however,  not  uncommon.  In  the  .bicksimian  lits  tho 
bromides  rarelv  do  i:o(td,  uiiK'ss  there  is  much  irritabilitv  and  excitement. 


I 


^^ki 


I,,.),,  DISEASES  OF   THE  XKUVuLS  SYSTEM. 

,,|„,,,uiv.  nu.a.urrs.  wlm-1.  have-  Ikh...  .M.TR.d  out  in  several  ease.,  i.ave  not 
,s  'i  rule    Urn  siure^sful.     The  liability  t.)  lVel)le-n.n..le.lMess  is  ti.e  nu.st 
M.rious  outl.K.k  in  the  inlantile  eerehral  imisies.     In  many  ea-e.  Hk  .laniagc 
is  irreparaMe.  an,l  idinev  an,l  inilurility  result.     With  patient    nuuing  an, 
,;i,l,  ,are  many  uf  the"  Lhil.lren  reaeh  a  fair  measure  ot  intelligeneo  and 
M.'lf-relianee. 


IV     TUMORS,    INFECTIOUS    GRANULOMATA,   AND    CYSTS 

OF    THE    BRAIN. 

Tlie  lolUiwin-  are  the  nio.^t  cununon  varieties  el'  new   >rr..vvtlis  within 

''^V)'lnl'ectiOUsGranulomata.-('0  Tuhnrk,  wliieli  may  Un  a  large  ..r 
Muall  -n.wtiis,  usuallv  nuiltiple.  Tuherenhisis  ui  the  -lan.ls  or  bones  may 
bo  c.)e~xistent,  but  the  tubereuh.us  disease  of  the  l.raui  may  oeeur  m  tiie 
absonee  of  other  eiinieally  reeo-nizal.lo  tnbereulous  leM.ms.  1  he  .Iwease  is 
,„„st  freMUeut  early  in  iil'e.  Three  fourtbs  oi  the  eases  oeeur  under  wen  y 
•uul  one  half  of  the  patients  are  under  ten  years  of  ago  ((.owers).  Oi  .J.) 
ca^os  of  tunu.r  in  persons  under  nineteen  eoUeeted  from  various  sourees 
by  Starr,  l.V,'  were  tuberele.     'I'he  nodules  are  most  numerous  m  tho  eere- 

liellum  and  about  the  base.  ,   .       ,      ,        •     i  i    „* 

(b)  .^^iiphilnma  is  most  eomnionly  found  m  the  hemispheres  or  aliout 
the  pons.  The  tumors  are  superlleial,  attaeiied  to  the  arteries  <•>•  tl'^'  '"^'- 
i.in.ves.  and  rarelv  grow  to  a  large  size.  They  may  be  multiple.  1  he  third 
iK'rve  is  partieularlv  prone  to  syphilitie  inllltrali..u.  and  ptosis  is  eommon. 

{•n  Tumors.— (r)  aii<mia  and  ycuroijIioiiKi.—'Ww^v.  vary  greatly  in  ap- 
pearance. Thev  mav  be  linn  and  hani,  almost  like  an  area  of  selerosis, 
'„•  .oft  and  verv'vas.ular.  They  persist  remarkably  for  many  years  Jvlebs 
has  ealled  attention  to  the  oeeurreneo  of  elements  in  them  not  unlike  gan- 
.dhm-cells.  Tumors  of  this  eharaeter  may  c.mtain  the  "  Spmnen  or  spider 
cells-  enorm..us  spindle-shaped  cells  with  single  large  nuclei;  cells  like  the 
iranglion-cells  of  m.rve-centres  ^vith  nuclei  and  one  or  mon-  processes;  am 
translucent,  band-like  iil.res,  tai.ering  at  each  end,  whicli  resu  t  from  a 
vitreous  or  hvaline  transformation  of  the  large  sp.ndle-cells.  A  separato 
ty,.e  is  also  recognizablo,  in  which  the  cells  resemble  the  epeudymal  opi- 

^  '''' (T'sarcmm  occurs  most  ccmnn.mly  in  the  membram's  of  the  brain  and 
in  the  pons.  It  forms  s.ano  of  tho  largest  and  most  dilhisely  mliltrating 
of  intracranial  growths.  Like  carcinoma,  sarcoma  of  the  brain  is  usually 
of  very  raiiid  growth.  . 

(,)  Carrluowa  not  infrequently  is  secondary  to  cancer  m  other  pail.>. 
It  is  seldom  primary.  Occasionally  cancerous  tumors  have  been  found  m 
«vmmetrical  parts  of  the  brain.  ,,     i      i 

•  (/•)  Other  varieties  occur,  such  as  fibroid  growths,  which  usually  develop 
from  the  mombranes;  bony  tumors,  which  grow  sometimes  from  the  falx, 
psammoma.  and  cholesteatoma.  Fatty  tumors  are  occasionally  found  on 
the  corpus  callosum. 


Tl-.MoIJS.  IXFECTKtrs  (i  liANl'LOMATA,  AND  CVSTS  oF  Till:  HK.VIN.    I, ,21 

(;!)  Cysts.— (v)  These  ncciir  Lelwecn  llic  iiicimIm'.iiics  mid  the  l.r.iin.  nx 
il  r.Mlll  nl  !;,,.m..lTliii-e  or  of  .-..rimill-  l'(,ivn,.,.|pli;illis  is  .-l  sc(|U<l  of  cnil- 
i^viuial  .•itn,|,|iy  ,,!•  ,,f  lM.|nnrr|,a-e,  nr  in;iv  !«•  dii,.  |,,  ,•,  (Icvclopiiiental  dc- 
iVd.  Ilvdiiti.l  cvsts  liiive  Iktii  ivIVnvil  {,>  in  H,,.  Mvlion  ,,11  paiiisiics.  An 
inlnv.-tin;,'  variely  dl'  lyst  i.s  tlnil  wliicli  foil,, us  m.vciv  injury  to  Ihe  skull 
ill  early  life. 

Symptoms.-(l)General.-Tlie  n.Ih.uin-  are  Ih,.  nu,.-!  inipurlanl- 
Unnhir/ir.  eiLJu'r  .lull,  aeliiii-,  and  eoiitiniious.  or  sharp,  stahl.in-.  and  |.ar- 
oxvsnial.  It  may  he  dilfiised  over  the  entire  head;  sometimes  it  i.  limited 
to  the  l.aek  or  front.  When  in  the  hack  of  the  head  it  mav  extend  <loun 
ihe  neck  (espeeially  in  tumors  in  the  posterior  fos.sa).  an<l  when  in  the  front 
It  may  he  aeeompanied  with  iieiirai-ie  pains  in  the  faee.  Oeeasionallv  the 
paiii  may  he  sery  h)(ali/e<l  and  as-o,ialrd  «iih  tenderness  on  presMire" 

()l>lir  iirm-ill^  .iceiirs  in  fonr  lifths  (,f  all  the  eases  ((^wers).      It  i.s  usu- 
ally donhle,  hill  oeeasionally  is  found  in  onlv  one  eve.     A  growth  may  de- 
velop slowly  and  attain  e.m>id,.rai.le  si/.e  without  p'roduciuK  optie  neuritis 
On  the  other  lian.i,  it  may  oeeiir  with  ii  very  small  tumor.     .1.  A    Martin 
Irom  an  extensive  analysis  (,f  the  literature  with  refereneo  to  the  loealizin- 
value.  e,uielud..s:   W  Ium  there  is  a  dinVrenee  in  the  inuount  of  the  neuriti's 

111  ••a<h  eye  it  is  more  than  twiee  as  prohahle  that  the  tiii •  is  on  the  <ide 

nl   the   most   marked   neuritis.      It    is  eonstani    in    tumors  of   the  corpora 

.iu;,dri-emina.  present   in  S!)  per  eeiil  of  eerehellar  ti rs.  and  alwent   in 

nearly  two  thirds  of  the  eases  of  tuuHU-  of  the  pons,  medulla,  and  of  the 
(■('■■pus  eall.isiim.  It  is  least  fre.pient  in  oases  of  tuhereiilous  tiim<,r;  nio.s! 
(oninion  in  cases  ot  glioma  and  eystio  tuniors. 

Vumiliufi  is  a  eommon  feature,  and  with  headache  and  oj.tic  neuritis 
makes  up  the  characteristic  clinical  picture  of  crehral  tumor.  An  imror- 
taiit  point  IS  the  ahsonce  of  definite  relation  to  the  meals.  A  chemical  ex- 
amination shows  that  the  v.uiiiting  is  independent  of  digestive  dislurhances 
It  may  he  very  ohstmatc.  particularly  in  growths  of  the  cerehellum  and 
the  jions. 

(Iid,li,iess  is  often  an  early  symptom.  Tlie  patient  complains  of  verti-m 
on  rising  suddenly  or  on  turning  .,uicklv.  Menial  hi,lndmurv.~'V\w  pa- 
tient jnay  aet  m  an  odd.  unnatural  uianner,  or  there  may  be  stupor  ami 
iu'ayiness  '1  he  patient  may  become  emotional  or  sillv,  ov  symptoms  re- 
sembling hyst.ria  may  develop.  Convnhious,  either  genVral  and  resemblin- 
true  epilepsy  or  localized  (Jaeksonian)  in  character.  There  mav  be  .hnriin, 
"I  llii'  puhr.  as  m  all  cases  of  increased  intracranial  pressure 

{-i)  Localizing  Symptoms.-Foca I  symptoms  often  occur,  but  it  must  not 
I'e  Orgotteu  that  these  may  l)o  huUrcclhi  produced.  The  smaller  the  tumor 
ii'ul  the  less  niarked  the  general  symptoms  <.f  cerebral  compression,  the 
more  likely  is  ,t  tliat  any  focal  symptoms  occurring  arc  of  direct  origin. 

(a)  (cutml  Mohr  .l;r«.-The  symptoms  are  either  Irritative  or  d.'strue- 
tive  in  cbaraoter.  Irritation  in  the  lower  thinl  may  i)roduee  spasm  in  the 
muscles  ot  the  face,  in  the  angle  of  the  mouth,  or  in  the  ton-nie  The 
spasm  with  tniglmg  may  bo  strictly  limited  to  one  muscle  group  before  ex- 
ending  to  others,  an.l  this  Seguin  terms  the  .hnml  s„mplom.  The  middle 
tiurd  ot  the  motor  area  contains  the  centres  controlling  the  arm,  and  here. 


1 


j„._,^  DISRASKS   OF  TIIK   NKUVolS  SYSTKM. 

n,.,v  l....rlM  i„  llw  llM'^ciN,  ill  tin-  tluiiiil),  ill  llio  imisclos  .4' 

'  .       L  Iro-      I,    many  inslam-s  tiu'  patiHit  ca„  .M^inun."  acru- 

li',!nl,a>H.l.  sn.i.  as  nmnl.iH-s  a.M  lin.Un^.  wlnrh  nan    1..  l.ll  ln>l  at 

^'";';::n';:<::';;''is  iimmrtant  ...  .U.U.,.,nino.  fl,.t,  i\.  puim  .C  .n^i..,  11- 
J,       ;;.,     s..c-n.l.  th..  unuT  or  nianl.  of  ll,.  spasm;  an.l  llunl    tl.. 

'"'X;;'i,;';;::'^21  in   Hu.  mot,.  ..„.  .11,..  pamhsis,  .lu..h  i.  oft.n 

,  J,  U       .     ln.al  convulsive  s..ixnros;  U.cro  may   Ik-  a  monupl.pa,        ul 

,1    onvolsivo  sriznivs  in  Ih.  arm.  ol'lui  due  to  irntatioii  m    1...- 

,    '"     '  u  nm^h.  tlH-  iH.i.hl.orl,oo.l  or  the  mot,.r  a.va  may  c.iuso  loeal- 

;;;    '    ;,.,  ia-M'U'"tlv.  a.  H..  -mros  aiv  inva.io.l  l.y  tlu>  growth 

;n.U::ZZ-%  L  U.r.  si-lo.  ,rou-,l.s  in  the  tiunl  maital  or  Broea. 

,,,nvoiulion  may  cause  motor  ai>lui>ia.  ,1;  .tnrl,.nue    mav 

(,,)    /..,./•;•.././  7.V.//...->;.'itlH.r   n,otor   nor   sensory   '-<;''';:  ', 

^  ..I       The   Lreneral    -vmptoms   are    otteii    well    marlved.      the   mos 

n.iE;:      atu       o^y;owU./in'this  region  is  mental   torpor  ami  .nulua 
m  •      In  its  .Ntension  cLmnwar.!  the  tuumr  may  involve  on  the  lelt 
i"  ow       rn.n    ;  ..oiivolution  and  produee  aphasia,  or  in  its  progress 

Vv  rd  •  use  irritative  or  destructive  lesions  or  the  motor  area,  hx- 
I;^!;;;:;;,!:';;;.  ti:.  side  or  the  tumor  may  oe<.ur  and  he  helprul  m  diagnosis, 
.,■  in  111..  CISC  reiiorted  hv  Tlioinas  and  Keene. 

'     Timu  rs     >  tlu-  parklo.orn,>ilal  Johe  may  grow  to  a  large  size  withon 
,,,      .      :   vniptom/     'Phere  may  he  wonl-h,indness  ami  -.-1-    uj-l- 
Xu  U,;.  angular  gyrus  and  its  underlying  ulnte  matter  is  iiu..hed,  and 

''""lo'Tmnors  or  the  ornpuai  M.  p-'i>'-/'-->'-i''%^;;;|^ ^ jf i;!;;;:;! 

lesion  may  produce  hlindness.     Tumors  m  Uus  region  on  the  kit  hcim 

1  1  „.,v  he  -issociated  with  vvonl-l.lindness  and  ni.iid-hlimhu>s. 
^^"       T     1  ^  ■;;:;;;;  lir../  I^^x-  ..-•  attam  a  lavg.  si.e  -thout  produ.. 

-tr:;:rinr:;:nr::rtt 

,,„!!,         onrmvolvement  or  the  internal  capsule.     Limited  grow  1.  m 
Hhetlu  nucleus  caudatus  or  the  nucleus  leiitirormis  of  the  corpu    stuatum 
^  ^ot^    e"^      Iv  ^ause  paralysis.     Tumors  in  the  thalamus  opticus  may 
to    wl^r^udl' cause  no  symptoms,  hut  increasing  they  mav  mvohe  the 
it^s  0      u'        ory  portion  of 'the  internal  capsule,  producing  hemuinopia 
3^  I.    nies  heuiiamesthesia.     drowths  in  this  situation  are  apt  to    a  ... 
Hy        i.'  muiritis.  and.  growing  into  the  third  yeiitricle.  '->y  ^-^  ^- 
\l^^;J  „,.  u,e  lateral  ventricles.     In  fact,  1»-^"^^"''^7^">1'\'''' "^^       \.      f 
ciuso  and  paralysis  due  to  involvement  of  the  internal  capsule  aie  the     n 
n  pto      If  tmnor  in  and  about  these  ganglia.     If  the  ventrolateral  group 


;cUs  (if 
t'lis  th(; 
I-  ill  111'' 
e  lU'iu- 

lii'sl  al 

L;iii,  the 
inl.  tb'j 
ftale  »>1' 

is  (il'tcii 
a,  a-^  til' 
ill  tlu'-t; 
SI'  liK'al- 
^n'owlh, 
r  Iji'iiLa's 

luo  may 
'Ik;  !iHi^t 
1  fxradual 

1   lllL-  K'ft 

pro^jrcss 
rca.  1-A- 
iliaguosi^, 

('  without 

-lllilKllU'SS 

livod,  and 

I  bilateral 
k'l't  lu'iui- 

iit  produc- 
iitros.  On 
I  temporal 

/((  |)roiUu;e 
growths  in 
,is  striatinn 
[iticus  may 
involve  the 
heiiiianopia 
pt  to  eanse 
-ause  a  dis- 
.  fr(jm  this 
i-e  the  chief 
iteral  group 


TL'MOllS,  JNFKt  TIOL'S  (iliANLLn.MATA,  AM>  CYSTS  OF  TIIK  HIJAIN.   ](|0;! 

of  nuclei  ill  the  thalamus  he  invdlved  there  may  he  uiiil.ilrral  di-tuihiinee< 
of  cutaneous  and  nuiscular  sense,  heinicliorea,  or  movement  ataxia. 

(Jrowtlis  in  the  rDrjioni  ijiKKlriiji'iiiiiKi  arc  rarely  limited.  Iml  nm^l  com- 
monly involve  the  crura  cerehri  as  well.  Ociiliir  syni|itoins  are  marked. 
'I'lie  |iii|iil  relU'.v  is  lost  and  there  is  nyslairmiis.  In  the  gradual  irmwlh 
the  third  neive  is  involved  as  it  passes  through  the  cms.  in  which  case  there 
will  he  oeiilii-iiiotor  paralysis  on  one  side  ami  liemi|ilegi,i  mi  the  diher.  a 
ciimhiiiatioii  almo>t  charanci'istic  of  unilateral  di-case  of  the  crus. 

('/)  'rumors  of  the  lutiis  and  iiii'didld.  The  symptoms  are  cliielly  llid-e 
of  pi'cssure  ii|i(in  the  nerves  emei'ging  in  thi>  region.  In  disease  nl'  the 
pons  the  nei\('s  may  he  invulved  alone  or  with  the  |iyramidal  tract.  Of  ."i".' 
cases  .'inaly/.ed  iiy  Mary  Putnam  .laiohi,  there  were  !.'!  in  which  the  ceiehral 
nerves  were  involved  ahm",  Di  in  which  Ihe  liinhs  were  ;in'e<ted,  and  Vtl  in 
which  there  was  heiiii|ilegia  and  involvement  of  the  nerves.  Tweiily-two 
of  the  latter  had  wliiit  is  kmiun  as  alternate  paralysis — i.e.,  involvement 
of  the  nerves  on  one  side  and  of  the  limhs  on  the  opjiosite  side.  In  I  cases 
there  were  no  motor  symptoms.  In  tuliercniosis  ((U'  syphili-)  a  growth 
at  the  inferinr  and  inner  aspects  of  tlu'  crus  may  cause  paralysis  o\'  the 
third  nei'\-e  on  one  side,  and  of  the  face,  tongue,  and  limhs  on  the  npjiosite 
side  (syndrome  of  Wehcr).  A  tumor  growing  in  the  lower  |iart  id'  the  ]huis 
usually  involves  the  si.xth  nerve,  producing  internal  strahismus;  the  si'venth 
nerve,  producing  facial  ])aralysis;  and  the  auditory  nerve,  causing  deaf- 
ness. Conjugate  deviation  of  the  eyes  to  tlu'  side  o|i|iosite  that  on  which 
there  is  facial  paralysis  also  occurs.  When  the  motor  cerehral  nerves  are 
involved  the  jiaralyscs  are  of  the  peri]iheral  type  (lower  segment  paralyses). 

Tumors  (d'  the  mcdulln  may  involve  tiie  ceivhral  nerves  ahinc  or  cause 
in  some  instances  a  combination  of  henii|ilegia  with  paralysis  of  the  nerves. 
Paralyses  of  the  nerves  are  helpful  in  topical  diagnosis,  but  the  fact  must  not 
be  overlooked  that  one  or  more  of  the  cerebral  nerves  may  be  ]iaralyzed  as 
a  re>ult  of  a  much  increased  general  intracranial  pressure.  Signs  of  irrita- 
tion in  the  ninth,  tenth,  and  eleventh  nerves  are  usually  jiresent.  and  pro- 
duce diiliculty  in  swallowing,  irregular  action  of  the  heart,  irregular  respira- 
tion, vomiting,  and  sometimes  retraction  of  the  head  and  neck.  'I'iie  hyjio- 
glossal  nerve  is  least  often  all'eeted.  The  gait  may  be  unsteady  or,  if 
there  \i'-  ])ressure  on  the  cerebellum,  ataxic.  Occasionally  there  are  sen- 
sory symi)tonis,  nnmliness,  and  tingling,  'i'oward  the  end  convulsions  may 
occur. 

Diagnosis. — From  the  general  sym])tonis  alone  the  evistence  of  tumor 
may  he  determined,  for  ihe  combination  of  headache,  optic  neuritis,  an<l 
vomiting  is  distitictivo.  A  gradual  increase  in  the  intensity  of  the  symp- 
toms is  usually  seen.  It  must  not  he  forgotten  that  severe  headache  and 
ncuro-retinitis  may  he  caused  by  llrighfs  disease.  The  localization  must 
be  gathered  from  the  considerati(ui  of  the  symptoms  above  detailed  and 
from  the  data  given  in  the  section  on  Topical  Diagnosis  of  Diseases  of  the 
lirain.  ^Mistakes  are  most  likely  to  occur  in  conniM'tion  with  uiiemia.  hys- 
teria, and  general  paralysis;  but  careful  consideration  of  all  the  circum- 
stances of  the  case  usually  enables  the  jiraetitioner  to  avoid  error.  Auscid- 
tatory  percussion  is  occasionally  of  service  in  localization. 


^^ 


10-2-t 


DISEASES  OF  TTIl':  NERVOUS  SYSTEM. 


PrOffnosi8.-Svi.!nlili<'  iHiuors  alono  arc-  ainvnaM.  ^^^--'^^^^^l'''"^ 

.Ii,„„„,  ■„  wliHl.    111.'  .III.  k-iiiai"  '-l''    '    ,    ,       i     „lu,li  llK-  -VII,  ...m,,s 
„.„.,l  to,  „v,.,-  ».„  join-.     ,',,'„,,"  lloall,  iiiiiv  li-  .-.iilil"'"-  l'»'- 

Treatment. ^(.0  •'"''■■  --''i    ,,    .';„„'    n„„1„.iv' Jo  wo  m, 

ami  th.-iv  in  I -morti'm  '-"I"";''  '"  '''""',",       v,,,,,.,.:,l  ionic-  ti-oal- 

„,,„t  IS  imli.ii  0.1  n      III-      '.   -  .       '  II    1,,^,.^  ,„„„,,i„„.s  sivos  inaAo.l 

;:^:1; ,;?';,:', ;:;oii.i ......  n^.  '^--';,„;''':::  irtr,:;;.?';;!,:;' 

;;;-:;:  i;;,:;:rt:;:,r;;,::;M.;i:-:*"M »->- 

"■''";■''■  i-       ■  ,1      Tninoi-^  .it  llio  l.iain  Imvo  l.«'ii  smro.^stiilly  iviii..v.'.l  liv 

:;:;::,:■,:':;::;?.■  "^^^^ «-  - ......  a;; »« .1.0.  -_  .-i;;;  .„- 


onlv  to 


tVaibli'ul  cashes. 


V.    INFLAMMATION    OF   THE    BRAIN. 

1.  Acrxi:  Exci-imialitis. 

I-         t  +iw.  lii-iin  ^iih^itaiK'c.  usually  of  the 

•^''r;;i!lr;;;S""::.-;-""ra^a        ,(^. 


rcinons,   invoivnif. 


!:';s:;:';;;:,;i::;r  i.ss:i'i^:^:::^a^e  «»„  ,..„.,  .„o„,h 


INFLAMMATION  OF  THE   BUAIN. 


Joi 


i    tfCill- 

i'  cuIli- 
w  I' run  I 
11,  hiinl 

miituin.s 

u^Ul'.ly 

L'U,  par- 

lo  coma 

lilis   the 

wo  t'oi; 

■111  oum- 

iTC-lllolH 

ivpurtod, 
)erculuii5 
lie  treat- 
;  proiuiit 
5  marki'd 
lu'  apltli- 
V  not  (if 
ort,  1111)1'- 
;  of  lilllo 

iiidVCMJ  hy 
dluTatioii, 
lialtly  uii- 
'riie"  inc.-t 
dura  and 
ase.  The 
Is  it  in  all 


ally  of  the 
niuniii;  (h) 
itg:  and  (r) 
hose  of  an 
iciil   details 
ndoearditi?, 
reaa,  lirnior 
re  extensive 
aMnorrha.iric 
.>ntial  Ici^ion 
cut,  though 


iluy  m.-iv  li  oI,miii((1  in  tlic  severity  of  the  jjenernl  ini'eefion.  'riie  ino>t 
tyiiicaj  enrejihalil  is  iu  eiinipaiiics  the  meningitis  in  eei'eliro-s|iinal  l'e\er. 

In  acute  mania,  in  delirium  tremens,  in  choi'ea  insaniens,  in  the  mani- 
acal I'oi'iu  of  e.xoiilithalmic  j^oitre.  and  in  the  so-called  cerchial  Inrnis  nf  the 
mali^Uiiant  t'evcis  the  j;i'ay  cortex  is  dee|)|y  coniicsted,  moist,  and  .-wnlleii, 
and  with  the  recent  liner  nu'tiiods  of  ri'scarcii  will  ju'ehalily  show  (  hanuc> 
whi(  h  may  he  cla>.--ed  as  cmcjilialilis. 

The  sjjiiijilifiHs  are  iiorvery  dclinite.  In  scvi're  forms  they  arc  those  of 
an  acute  inrection;  some  cases  have  heen  mistaken  fiu'  typhoid  I'evi  r.  The 
ousel  may  he  ahrupt  in  an  indi\idual  a|i|iarently  healtiiy.  Other  eases 
h.ave  occuri'cd  in  the  convalescence  from  the  fcNias,  particularly  iullueu/a. 
One  of  J.  J.  I'utnanfs  cases  followed  mumps.  The  i^'eiid'al  symptoms  are 
th(.se  which  accompany  all  severe  acute  all'ections  ol  the  hi'ain — headache, 
sommdem-c,  coma,  delirium,  vonutinjr,  etc.  'j'he  local  symptoms  are  very 
varied.  dcj)endin^r  on  the  extent  (d'  the  lesions,  and  may  he  irritative  or 
]iaralytic.  I'sually  fatal  within  a  \'vw  weeks,  cases  may  dra.y  on  for  weiks 
iir  luoiiths  and  recover. 

2.  Aiisci:.ss  Ol'  Till-;  IJiiAix. 

Etiology. — Suppuration  of  the  hrain  suhstance  is  rarely  if  ever  ]iri- 
mary.  imt  results,  as  a  rule,  from  extension  of  inllammation  from  ncinji- 
horiny-  ]iarts  or  iid'cction  from  a  distance  throujiii  the  hlood,  'I'he  (pieslion 
of  idiopathic  hrain  ahscess  need  scarcely  he  considered,  tliou;:ii  occasion- 
ally instances  ot-cur  in  which  it  is  extremely  dillicult  to  assign  a  cause. 
There  arc  three  impoHant  etiological  factors: 

(1)  Trauma.  Falls  ii]ion  the  head  or  hlows,  with  or  without  ahrasioii 
of  the  .<kin.  ^lore  commonly  it  follows  fracture  or  ]Minctiired  wound-.  In 
this  gr(mp  meningitis  is  fre(piently  associated  with  tlie  ahscess. 

(■J)  J'.y  far  the  most  imjiortant  infi'ctive  foci  are  those  which  arise  in 
direct  extension  from  disease  of  the  middle  ear  or  of  the  ma-toid  cells. 
I'rom  the  roof  (d'  the  mastoid  antrum  the  infeeticm  readilv  passes  to  the 
sigmoid  sinus  and  induces  an  infective  thronihosis.  In  other  instances  the 
dura  hecomes  involved,  and  a  snh-dural  ahscess  is  formed,  which  may 
readily  involve  the  arat-hnoid  or  the  ])ia  mater.  In  another  group  the  in- 
ilammation  extends  along  the  lym]»h  s])aces.  or  the  throiuhosi'd  veins,  into 
the  suhstance  of  the  hrain  and  causes  suppuration.  ^lacewen  thinks  that 
without  local  areas  of  meningitis  the  inl'eefive  agents  may  he  carrieil 
through  the  lymph  and  hlood  channels  into  the  cerehral  suhstance.  In- 
fection which  extends  from  the  ro(d'  (d'  the  mastoid  process  is  most  likely 
to  he  f(dlinved  hy  ahseess  in  the  tein|)oral  lohe,  while  infection  extending 
from  the  ])osti'ri()r  wall  caust's  most  freipicntly  sinus  thronihosis  and  cere- 
hellar  lih^cess. 

(;))  In  se]die  processes.  Ahscess  of  the  lirain  is  not  oftt'ii  found  in 
jiyaMuia.  In  ulcerative  endocarditis  miilti])le  foci  of  suppuration  are  eoin- 
moii.  Localizeil  hone-disease  and  siii>])iii'atioii  in  the  liver  are  occasional 
causes.  Certain  inllammations  in  the  lungs,  iiarticularly  hronchiectasis, 
■ivhieh  was  present  in  17  of  38  cases  of  these  .so-called  "  pulimjiial  cerehral 


I 


^^ 


1020 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


i 


aLsccssos-  r..lU'(.Ud  l.y  H.  T.  ^Villian..on,  arc  liable  to  )0  followoc  l.y  al.- 
.,.o.<  It  i<  an  .Kcasi.mal  (•..inplicalioii  of  empyema.  Al.seess  ol  the  Urain 
,„av  "follow  tl.e  siKTilie  fevers.  I'.ristoue  has  ealled  attention  to  its  oeeur- 
ivn'ee  as  a  se.niel  of  iniluenza.  The  larjiest  number  of  eases  oeeur  betwoen 
,,„,  twontieth  an.l  fortieth  years,  and  the  eon.lition  is  nu.re  irequml  m  men 
tlian  in  women.  Holt  has  ..oiieeted  2:>  eases  in  ehiUlren  under  hvo  years 
o£  a-e   the  eliief  eanses  of  whieh  were  otitis  medui  and  trauma. 

Morbid  Anatomy.— The  abscess  may  be  solitary  or  multiple,  dit- 
fa.e  or  cireumscribed.     Traetically  any  one  of  the  dilVereiit  variet.es  ot 
,,vo-enie   baeteria    mav    be   eoneerm.d.      The   baeteriulogical   examination 
ohcai  shows   a   mixtuiv   of  dUferent  varieties.     Oeeasionally   eultures  are 
sterile    owin-  to  .leath  of  the  baeteria.     In  the  acute,  ra].idly  fatal  cases 
tnllowing  mjurv  the  suppuration  is  not  limited;  but  in  lon-stand.n-  cases 
,1,0  abscess  is  enclosed  in  a  delinile  capsule,  which  may  have  a  thickness  ol 
r,„m  ■>  to  .-.  nun.     The  pus  varies  much  in  appearance,  dcpend.n-  upon 
,1,,.  -.vv  o(  the  abscess.     In  early  cases  it  may  be  mixe.l  with  reddish  </cv<n,s 
■uid  softcne.l  brain  matter,  but  in  the  solitary  encapsulated  abscess  the  pus 
i.  distiiutive.  bavin-  a  j:rceuish  tint,  an  acid  reaction,  and  a  peculiar  odor, 
.onietimes  like  that  <.f  suli-huretted  hydrogen.     The  braui  sul,stance  sur- 
,,,undiu-  the  abscess  is  usually  unlematous  and  iniiltrate.l.      liie  size  varies 
1,,„H  tiiat  of  a  walnut  to  that  of  a  large  orange.    There  are  cases  on  record 
in  which  the  cavitv  has  ..ccupied  the  greater  portion  o    a  hemisphere.    Mul- 
linle  abscesses  arc"  usuallv  small.     In  four  ilfths  of  all  cases  tl.e  abscess  is 
'\itarv.^    Supimration  occurs  most  frcpiently  in  the  cerebrum,  a.ul  the 
,,',01,11  lobe  is  uiore  often  involved  than  other  parts.        he  cerebellum  ,s 
loxt  most  common  scat,  particdarly  in  connection  with  ear-disease. 
Symptoms.-l-oHowing  injury  or  operation  the  disease  may  run  an 
.n,/.coiuse,  with  fever,  headache,  delirium,  voiiiiting,  and  ngors.     1  he 
vmptnms  are  those  of  an  acute  nieningo-encephalitis.  and  it  may  be    e 
.iitr.  ult  to  determine,  unless  there  are  localizing  symptoms,  wlietlier  the  e 
.    vallv  suppuration  in  tlie  brain  substance.     In  the  cases  following  car 
li..a<e-the  s  inpt.m.s  may  at  first  be  those  of  meningeal  irritation,      iiie.e 
;,,  1,,  i,,ital,ilitv,  restlessness,  severe  headache,  and  aggravated  earaelu. 
0     er  strikii.o-  svmptonis,   particularly  in  tlie  more  prolonged   cases,  arc 
d     w  in  ss,  slow  ;.er;.bratioii,  vomiting,  and  optic  neuritis.     In  the  c.roiuc 
of  bi'ain  abscess  uliich  may  follow  injury    otorrluea.  or  local  lung 
trouble    there  mav  be  a  latent  period  ranging  Iroiu  one  or  tuo  week,  to 
ve      "mouths,  or  even  a  year  or  more.     In  the  -  silent      regions    when 
10 \d.cess  b.  comes  encapsulated   tiiere  may   be  no   symptoms   wbateve. 
1, rim-  the  latent  period.     During  all  this  time  the  patient  may  be  uiide, 
cul  observation  and   no  suspicion  be  aroused  of  the  exist.Mu.e  of  sup- 
mi  ition.     Then  severe  headaehe,  vomiting,  fever,  set   ,n    perhaps  with  a 
So,  too.  after  a  blow  u,u.n  the  head  or  a  fracture  the  sympto.iis  -d 
the  lesion  may  be  transient,  and  months  afterward  cerebral  symptoms  of  the 
nio«t  nfrtrravalod  character  may  develop. 

Tl.riocalization  of  the  lesion  is  often  diirieult      Tn  or  near  the  mo  tor 

re.non  there  may  be  convulsions  or  paralysis,  and  it  is  to  be  remembe.cd 

iTit  an    1  scess  in  the  temporal  lobe  may  compress  the  lower  motor  centres 


INFLAMMATION  OF  THE   RHAIN. 


1(121 


mill  ]ir()(1nfO  pnraly.«is  of  tlic  iirm  iiinl  fnco  ainl  nu  tlic  Ic'ft  side  rnii^o  njihiisia. 
A  lar;^('  alisccss  may  exist  in  tlu'  fnmtal  Inlic  witlmiit  caiisiii;:  paralysis,  luit 
ill  tlicsc  cast's  tlicri'  is  almost  always  soiiu'  iiiciital  duliu'ss.  In  the  t('m|i(iral 
Idlio,  till'  (■(iimiKHi  scat,  tlici'c  may  lie  iki  I'dcali/.in^'  syiii|iti)ms.  So  also  in 
the  ]iaricto-occi|iital  rcj^ion;  tlioMj:h  licrc  early  cNaminatioii  may  lead  to 
the  detection  of  lieiniano|iia.  In  abscess  of  the  eerehellnm  vomiting  is  com- 
mon. If  the  middle  lohc  is  ail'ected  there  may  lie  stai^jreriiij; — cereliellai' 
incoilvdination.  LocaliziiT},'  symiitoms  in  the  pons  and  other  parts  are  still 
more  inicertain. 

Diagnosis. — In  the  acute  oases  there  is  rarely  any  doiilit.  A  considera- 
tion of  po.-tilile  eti(dogical  factors  is  of  the  highest  im|iortance.  The  historv 
of  injury  lolloweil  hy  fever,  marked  cerehral  symptoms,  the  development 
v1  ri<iors,  delirium,  and  |icrhaps  paralysis,  make  the  diagnosis  certain,  in 
chronic  ear-disease,  such  cerdiral  symptoms  as  drowsiness  and  torpor,  with 
irregular  lever,  super\i'niiig  upon  the  cessation  of  a  discharge,  should  ex- 
cite the  suspicion  of  ahsci'ss.  Cases  in  uhich  sup]nirative  processes  exist 
in  the  orhit,  nose,  or  naso-pharynx,  or  in  which  there  has  lieen  subcutaneous 
jihlegmon  of  the  head  or  neck,  a  parotitis,  a  facial  erysipelas,  or  tuberculous 
or  syphilitic  disease  (d'  the  bones  of  the  skull,  should  be  carefully  watcheil, 
and  inimi'diately  investigated  should  cereb''  '  symptoms  appear,  it  is  piir- 
ticularly  in  the  chronic  cases  that  dillicnl.i  ,•«  arise.  The  symptoms  resem- 
ble those  of  tumor  of  tlic  brain;  indeed,  they  are  those  of  tumor  plus  fever. 
Choked  disk,  however,  so  commonly  associated  with  tumor,  is  very  fic- 
(piently  absent  in  abscess  of  the  brain.  In  a  iiatient  with  a  history  of  trauma 
or  with  localized  lung  or  pleural  trouble,  who  for  weeks  or  months  has  had 
sliglit  headache  or  di/zine.-^s,  tlu'  onset  of  a  rapi'l  fevi'r,  especially  if  it  hi'  in- 
termittent and  associated  with  rigors,  intense  headache,  and  vomiting,  point 
strongly  to  abscess.  The  ]ui]se-rate  in  eases  of  cerebral  abscess  is  usually 
accelerateil,  but  cases  are  not  rare  in  which  it  is  slowed.  Macewen  lavs  stress 
ujion  the  value  of  ]ierciission  of  tlu'  skull  as  an  aid  in  diagnosis.  The  note, 
which  is  uniformly  dull,  becomes  much  more  resonant  when  the  lateral 
ventricles  are  distended  in  cerebellar  abscess  and  in  conditions  in  which  the 
vcnie  (ialeni  are  eompressed. 

It  is  not  always  easy  to  determine  whether  the  meninges  are  involved 
with  the  abscess.  Often  in  ear-disease  the  condition  is  that  of  meningo- 
encephalitis. Sometimes  in  association  with  acute  ear-disease  tlu'  symp- 
toms may  simulate  closely  cerebral  meningitis  or  even  ab.scess.  Indet'd, 
Cowers  states  that  not  only  may  these  general  symptoms  be  produced  by 
ear-disi'ase,  but  even  distinct  optic  neuritis. 

Treatment. — A  remarkable  advance  has  been  made  of  late  years  in 
dealing  with  these  cases,  owing  to  the  im|)nnity  with  which  the  brain  can 
be  explored.  In  ear-disease  free  discharge  of  the  inflaniinatory  products 
should  be  jiroinoted  and  <'arcrid  disinfection  practised.  The  treatment  of 
injuries  and  fractures  comes  within  the  scojie  of  the  surgeon,  'i'he  acute 
symjitoms,  such  as  fever,  heiidache,  and  delirium,  must  be  treated  by  rest, 
an  ice-caf),  and,  if  necessary,  local  depletion.  Tn  all  cases,  when  a  reason- 
able suspicion  exists  of  the  occurrence  of  abscess,  the  trephine  shoidd  he 
used  and  the  brain  explored.     The  cases  following  ear-disease,  in  which 


^^ 


1028 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


tlic  sni.]mir,lloii  is  iirthc  temporal  \r.hv  or  in  tlic  (•crcliflliiin.  ofi.T  <ho  most 
I'iivonil.lc  chaiu'cs  ol'  iwovr  v.  'I'lu'  localization  <an  rarely  W-  ina.K'  ac- 
curately in  these  cases,  and  llu'  op.'ralor  must  he  gui.lcd  more  by  general 
,,„,,,,„nical  and  i.atholocrical  knowle.l-e.  In  cases  <d'  injury  the  trephine 
should  I..'  applied  over  the  seat  ni  the  i)lo\v  or  the  fracture.  In  ear-disea.e 
the  supiuiration  is  most  Iminent  in  the  temporal  lohe  or  in  the  crehellum, 
and  tile  oi.eratioii  should  be  perl'ormed  at  the  jioints  most  accessiiile  to  thes- 
rejiions.  .And,  histlv,  a  ni()st  importiint:.  one  might  almost  say  essential, 
lartor  in  the  siiccess'lul  trea'tmeiit  of  intracianial  suppuration  is  an  intelli- 
gent knowledge  on  tlie  part  of  the  surgeon  of  the  work  aud  works  of  William 
Macewen. 


VI.     HYDROCEPHALUS. 

Definition.— A  condition,  congenital  or  ac(iuirt'd,  in  which  there  is 
a  great  accumulation  of  fluid  within  the  ventricles  of  the  lirain. 

'"'riie  term  hyilrocephalns  lias  also  been  api)lied  t;)  the  ctdlection  of  tlnid 
betwe.'ii  the  cortex  of  the  brain  and  the  skull,  known  in  this  situati(Ui  as 
//.  c.rlt'rniis  or  li.  ex  fdftio,  a  condition  common  in  cases  of  atrophy  of  the 
brain  substance,  met  with  in  old  age,  after  luvniorrhages,  softenings,  or 
scleroses,  in  lingering  and  cachectic  diseases,  as  cancer,  chronic  nephritis, 
(■hronic  alcoiioirsm,  and  sometimes  in  rickets.  Occasionally  the  disease  is 
caused  by  meningeal  cysts.  A  true  dropsy,  however,  of  the  arachnoid  sac 
j)robal)lv  <loes  not  occur. 

The" cases  may  be  divided  into  t'lree  groups— idiopathic  internal  hydro- 
cephalus (serous  meningitis),  eongvi.ilal  or  infantile,  and  secondary  or  ac- 
quired. 

(1)  Serous  Meningitis  (Quincke)  {hUopalhir  Tnlrrnal  JI iidrorriilialu-'^ : 
Aiuiio-iiriirnlic  11  ,iJro(rji]ialiis).—T\u>^  remarkable  form,  descrilied  liv 
Quincke,  is  very  imjiortant,  since  a  knowledge  of  the  condition  may  explani 
very  iiiK'Mialous  and  puzzling  cases.  It  is  an  ependymitis  causing  a  serous 
eiVusioii  into  the  ventricles,  with  distention  and  pressure  elVects.  It  may  lie 
comi.ared  to  the  .<erous  exudates  in  the  pleura  or  in  synovial  membranes. 
It  is  n(«t  certain  that  the  process  is  inflammatory,  and  (Juineke  likens  it  to 
the  an-io-iieurotic  uMlema  of  the  skin.  In  very  acute  cases  the  ependyma 
niav  be  sm<.olh  and  natural  looking;  in  more  chronic  cases  it  may  be  thick- 
ened and  sodden.  The  exudate  does  not  dif^'r  from  tiie  normal,  and  it  mi 
lumbar  puncture  a  fluid  is  removed  of  a  specific  gravity  aliove  I.OOi),  with 
albumin  aimve  two  jht  one  thousand,  the  condition  is  more  likely  to  be 
hydroeeiihalus  from  stasis,  secondary  to  tumor,  etc. 

'  I>,oth  diil.lren  and  adults  are  atfected.  the  latter  more  freipiently.  In 
the  acute  form  the  condition  is  mistaken  for  tuberculous  or  purulent  men- 
ingitis There  are  headache,  retraction  (d'  the  neck,  and  signs  of  increased 
intracranial  i)ressure,  choked  disks,  slow  pulse,  etc.  Fever  is  usually  ab- 
sent, but  1  have  s(>en  one  case  with  recurring  iiaroxysnis  of  fever,  and  Alorton 
rrin'ce  has  described  a  similar  one.  In  both  the  exudate  was  clear  and  the 
..pendvma  not  aciitelv  inflamed.  Quincke  ha>  reimrted  cases  of  recovery. 
In  the  chronic  form  the  symptoms  are  those  of  tumor— general,  such  as 


FIYDUOCKPIIALl'S. 


Id:.".) 


Min.Iiulic.  .-li-lii  IVvcr.  xntiiiolcncc.  j,ii'l  ilclirimii:  nnd  In,.;,!.  ,.,..  (v\oi.liili,.||- 
inos,  <'i.lir  iiciiriti>.  >pa>„i.s  aiiil   rini,|ii_v  „r  musrl,-  .-iihI    piimlvsis  ..|    I'liv 

.vivl.nil  luTv.'s.     J.'niiarkiil.lc  cXiir.Tl.aiions  ocnir,  aii<l  llic  >vinj n~  varv 

111  inlniMty  rimn  ,lay  In  ,lay.  lUvnwvy  may  fullnw  al'trr  an  liliic^  .,1'  many 
\vc('ks,  and  .M.nic  cf  tliu  reported  case.-^  of  di^a]>lH•al■an<•(.  of  all  svinptoni^  oV 
iirain  tiinidr  licldii,!:-  in  this  cateii-orv. 

(■v')  Congenital  Hydrocephalus.— The  enlai-ed  h.a.I  mav  (.i,>tiurt  lah,,,- 
iiHUV  Jre<|iiently  the  ennditioii  is  iiotieed  some  lime  alter  h'irtli.  The  eaiiM. 
IS  unknown.     It  has  oeenrred  in  several  memhers  oi  the  same  family. 

The  anatomieal  e.mdition  in  these  eases  oll'ers  no  elew  to  the  nature  of 
Ihe   Irouhle.      The   Jaleral    ventrieles   are    eiiormoiislv    distend.,],    hnt    the 
opendyiua  is  iisnally  elear,  .«r,metiines  a  little  thieken'ed  „nd  -ranular   and 
Ihe  veins  lar-e.     'J'he  ehoroid  plexuses  are  vascular,  sometimes  selenUie    hut 
olten  luitiiral  lookin-      The  third   ventriele  is  enla.-ed.  the  a.iueduet   n( 
.Vlyius  (hlated.  and  the  fourth  ventriele  mav  he  distended.     The  (luantitv 
ol  fliud  may  reaeh  s..veral  litres.     It  is  limpid  an.l  ..ontains  a  traee  ..f  alhu'- 
inm  and  salts.      J  he  ehan<;vs  in  eonseipieiiee  of  this  enormous  ventrieular 
distenuon  are  remarkahle.     The  eerehral  eortex   is  ..vatlv  stret..h..d,  an.l 
over  the  mi.l.lle  re-i,m  the  thiekne.<s  mav  anu.unt  to  no  nmre  than  a  i\■^v 
millimetres  without  a  traee  of  the  .sulci  or  eonvoluti.ms.     The  has.l  .'amrli., 
are  i  Mtlened.     The  .kull  enlaroes.  and  the  cir.„mf..renee  of  the  Ima.f.d' 
a  child  ot  thnr  or  f.mr  years  may  reach  l'.")  or  even  ;50  ineh.s.    The  <nture< 
uidcn,   \\..rmian    h.mes  develop  in   them,  an.l   the  hones  of   the  cranium 
become  e.xcee.lin-ly  thin.     The  veins  are  marke.l  h.-neath  the  skin       V  llu.- 
uatum  wave  may  s.nnetimes  he  ohtain.d.  an.l   ImsIum'-s  hrain  murmur  mav 
'"■  '';■"■•''•      ""■  ""■''it"!   i.lat.'s  of  the  fn.ntal   h.,ne  are  .lepress,..|.  ,,uHin- 
oxophthalnms.  so  that  the  eyehalls  eann..t  he  covere.l  hv  th..  eveli.U      The 
sinall  sixe  ot  the  face,  wLLmin^  s.miewhat  ahove,  is  strikin-  in"  cmpari^m 
with  the  onorniously  expanded  skull. 

t'onvulsions  may  oc.ur.  The  reflexes  are  increased,  the  chil.l  I,,,rns  <., 
walk  late,  and  ultimately  in  severe  cases  the  h.irs  heconie  f,.ehl,.  an.l  ..,m.- 
times  spastic.  Sen.siti.m  is  much  less  alfected  than  motilitv.  ('hok...l  ,li<Iv 
IS  n.,t  uncomm.m.  Th..  mental  condition  is  variahle;  th'e  child  mav  he 
lin-ht.  hut,  as  a  nil...  th..re  is  some  -mde  of  imhecilitv.  The  CMn-..nital 
ca.^es  usually  die  within  the  first  f..ur  or  five  vears.  fl...  pr.H-..ss  mav  he 
arrest...!  and  the  i.ati..nt  may  reach  adult  life.  Cases  of  this  sort  ar.."  not 
very  uncominon.  Kv,..,  when  extreme,  the  mental  fac.ilties  mav  he  n'tain...! 
as  in  i.riiiht  s  eel..hrated  imtient.  Cardinal,  who  lived  to  the  a-,.  ..f  Uwuiv^. 
11.11.',  and  wlmse  head  was  translucent  wli,.,,  the  sun  was  ,.|iinin<.  hehin.l 
Inm.  (are  must  he  taken  not  to  mistake  the  rachiti..  head  for  hvdro- 
(•e])halus. 

(:5)  Acquired  Chronic  Hydrocephalus.-Th  is  is  slat..d  t..  he  .u,asi.,nallv 
primary  (.d,opatl.ic)-tliat  is  t..  say,  it  c.m,..s  on  sp.,nfan...,uslv  in  the 
-1>   t  withou    o  hservahle  lesion.     iVan  Swift  is  .siid  to 'have  died  of  hydro- 

Ih',"'']"'    M    <^;!f.;^'''"V""'^'  ^''''"^"'>'-     "   i^  •'"-'!   ^'I-n  the  statnnent 

I'.it      hi'  (Mr   ^M^teway)  open..l  the  skull  and  iound  mu.l,  water  in  the 

1'ra.n   _  a  con.hfmn  no  d.,iiht  of  /,.  ...  rnrm,  due  to  the  wastin^^  associahd 

with  Ins  prolonged  illness  and  paralyses.     In  nearlv  all  cases  there  is  either 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1030 

a  tun.or  at  tho  Imsc  uf  tl...  l.rain  or  in  Iho  thinl  v.ntri-l..  wlmU  onmprc.os 
tl  a:  <ial..ni.     Tlu.  passa,..  Inun  tl,.  thinl  to  tho  luuvth  vcntru.lo  may 

^l,...n.lio    tl>ro.|nl     whirli   th.-   vnitriclrs  conumuucato  w.tl>    tho  cr.oh.o- 
.nn        u  .i,...s:i.ec.onu.s  clusod  hy  moninj^itis.     Those  comlifons,  cn^our- 
"  It;  ,;,av  pro.luoo  tho  n.ost  oxtro.no  hy-lrooophalus  -thou    any 

,a,p.nu.nt  ol'  .1,;  hoa.l.     Kvon  .  l.on  tho  tun.or  l,o^n,.  oar  y  n.  ho     v  n 
.  ho  no  expansion  of  tho  sknU.     In  tho  oas.  of  a  -nrl  a.^.l  s.xtoon,  l,hn  1 
i      n  hor  thinl  voar,  tho  hoad  was  not  unusually  la.jro    tho  -'->  ru  -.  .. 
,„rn>onslv  .liston.lo.l,  and  in  tho  Kolandio  rog-...n  tho  hra.n  sul,.l  noo  xsa., 
d    ;^  nun.  in  thickness.    A  tun.or  oooupiod  tho  third  vonti'ulo.     In  a  oa.o 
el    1  s    at.nna  of  the  ih.or  <.f  tho  thinl  vontrielo,  in  wlneh  tho  syn.pton. 
1' 'iVo.l  at  intervals  lor  oi,ht  or  nine  years,  tho  ventrules  wore  onorn.ou>ly 
lli^t '.ndod  without  onlar,onu.nt  of  tho  skull.     In  other  .nManoes  tho  suture. 
<ei.arato  and  tho  hoad  gradually  onlargos. 

'Tho  svn.pton.s  of  hydnnophalus  in  the  adult   aro  eunously  va    a  1  . 
In  t       iir  t  case  nu-ntiom.!  there  wore  early  hoadaeiios  and  gradual  blncl- 
".then  a  pndongod  porio.l  in  which  she  was  ahlo  to  at  end  to  her  stud  os 
1  eadao  OS   a-.un    ruporvon..d,   the   gait    heeau>o    irregular   and   souiowha 

io        )eath  ooeurJed  suddenly.     In  the  other  ease  there  wore  proh.ngod 
;   ,     <;  o        na  with  a  sh.v  pulse,  and  on  one  oeeasion  the  pat.ont  ronuunod 

:;,n;;;l:s'for  n,oro  tiu.,;  thn.  --'t--  /^-'-''-^  i;-;-::;,;;!;;: 

,u,„ntis  without  foeali/.ing  ^yn>pton>s,  headaohe,  au.l  attaeks  ot  -'"'■  <^  -^ ^^^ 
,,  are  .n.-estivo  svn.pton.s.     Those  eases  of  aequ.red  ehn,n,c  hjdio- 
".Ihalus  "n^lTlK.  eortainly  diagnosed  during  life,  though  .n  eortan.  n. 
«tiinees  the  eoudition  inav  ho  suspected. 

Treatment.-Verv    ittlo  can  ho  d.n.o  to  n.lievo  hydrocephalus     Modi- 

.i, J^^^T^^  ss  to  cause  tho  absorption  of  tho  iluid.     More  rational  i. 

e  :v      n   of  gradual  con.pression,  with  or  without  the  w.thdrawal  .^  snnd 

nn  i  ie.  of  the  iluid.     The  conqnvssion  may  he  n.ado  hy  moans  of  bioa 

E   ^so  applied  as  to  on>ss  each  other  on  the  vertex,  and  anotluM-  n.y 

j;;:',!;;,:,.l  ,.,„'n'd  the  circumference.     In  tho  n>ening>t.s  serosa  Quincke  nd- 

^■'^''o;ttr:^l;';r;ui.o  of  tl.  ventrides,  an  operation  which  has  hoeu 
.,1,,  *  o  d  has  been  revived;  it  has  boon  resorted  to  >n  the  n>on.ng>  .» 
Vhon  pressure  svn,pto„,s  aro  nu.rked  (.uincko-s  F--1"- ^^^ ,^;^ 
,  .  :i  llo  roconnnonds  puncture  of  the  subarachnoul  sac  ^f ---;  -  ^l^' 
,a  ,ho  fourth  hnnbar  vertebra..  At  this  point  the  spnial  cord  cannot  be 
u:;.ied.  tL  ad^antagos  are  a  .lower  removal  uf  iluid  and  le.s  danger  of 
collapse. 


I 


NEURITIS. 


1031 


iclo  iiiiiy 
ainc'ii  nl" 
CL>i'('l)ro- 
s,  occ'ur- 
lioiit  any 

lil'o    tlV'lV 

ell,  lilind 
clcs  wort; 

illU'L'   WHS 

\]\  a  <'a^o 
iyiujitoiiH 
loi'iuou^ly 
10  iiiiturcs 

variable, 
iml  bliml- 
L'r  studios, 
sdinowhat 
l)rol(tiigoil 
,  roinaiiK'tl 
-iiifl  <)\)W 
DinnuloiR'o 
[lie  h'ydro- 
L'ortaiu  in- 
ns,   ^lodi- 
rational  is 
al  of  small 
IS  of  broad 
loliior  may 
luiucko  ad- 

h  lias  boon 
moningitis 
are  may  bo 
n  the  third 
I  cannot  bo 
s  danger  of 


YI.    DISEASES  OF  THE   PERIPHERAL   NERVES. 

I.    NEURITIS   [liitlammatiun  of  th,'  Ituudlv^  vf  Xirve  Films). 

Xonritis  may  lio  hirdliicil  in  a  single  iiorvo,  or  iinicnil,  involving  a  larire 
nnnibor  of  norvos,  in  whioh  caso  it  is  iisnaiiy  known  as  iiiKllijilc  iiciirllis  or 
jiiili/iiciirilif. 

'Etiology.— Local  I  :i'il  nnirills  arises  from  (a)  cold,  which  is  a  very  frc- 
ijnent  ciiiise.  as,  for  c\ani|>lc,  in  the  facial  nerve,  '{"his  is  sonietinus  known 
as  rlieiiniatic  neuritis.  (/;)  'I'raumatism — wounds,  blows,  t\uvv\  jircssure  on 
the  nerves,  the  tearing  and  stretching  whicli  follow  a  dislocation  or  a  frac- 
ture, and  the  hy|iodcrinic  injection  of  ether.  I'nder  this  se<'tion  come  iilso 
the  professional  palsies,  due  to  pressure  in  the  exercise  of  certain  occupa- 
tions. ((■)  Kxtensioii  of  inllammation  from  neigh l)orini.r  jiarls,  as  in  a  neuri- 
tis of  the  facial  nerve  due  to  caries  in  the  tenipiu'al  bone,  or  in  that  met 
with  in  syphilitic  disease  of  the  bone.s,  di.soaso  of  the  joints,  and  occasionally 
in  tumors. 

Miillijilc  neuritis  has  a  very  complex  etiology,  the  causes  of  which  mav 
be  classiliod  as  follows:  (a)  'I'hc  poisons  of  infectious  diseases,  as  in  leprosy, 
diphthovia,  typhoid  fever,  small-iiox,  .scarlet  fcvi'r,  and  occasionally  in  othci' 
forms;  (h)  the  organic  jjoisoiis,  comjirising  the  dilfusible  stimulants,  such 
as  alcohol  and  ether,  bisulphide  of  carbon  and  naphtha,  aiul  the  metallic 
bodies,  such  as  lead,  arsenic,  and  mercury;  (r)  cachectic  eonilitions,  such  as 
occur  in  aiuvmia,  cancer,  tuberculosis,  or  marasmus  from  any  cause;  (</)  the 
endemic  neuritis  or  beri-beri;  and  (c)  lastly,  there  are  cases  in  which  none 
of  these  factors  prevail,  but  the  disoaso  sets  in  suddenly  after  overexertion 
or  exi)osure  to  culd. 

Morbid  Anatomy.— -In  neuritis  due  to  the  extension  of  inllamma- 
tion tho  nerve  is  usually  swollen,  iidiltratcd,  aiul  ri'd  in  color.  The  iullam- 
mation  may  be  cliielly  perineural  or  it  may  ])ass  into  the  deeper  portion— 
iiitcrslilidi  neuritis— in  which  form  there  is  an  aecumidation  of  lymphoid 
elenu'nts  between  the  nerve  bundles.  The  lU'rvc  libres  themselves  may  not 
iil)|iear  involved,  but  there  is  an  increase  in  the  nuch'i  of  the  sheath  of 
Schwaini.  The  myelin  is  fragmented,  the  nuclei  of  the  interm)dal  cells  are 
swollen,  and  the  axis  cylinders  present  varii'osities  or  uiulergo  granular  de- 
generation, ritimately  the  nerve  fibres  may  be  completely  destroyed  and 
rcplac-ed  by  a  fibrous  connective  tissue  in  which  much  fat  is  sometimes  de- 
posited— the  lipiiiiKildUK  iiniritis  of  Leydeii. 

In  other  instances  the  condition  is  termed  jKn-nulnpuiiliiux  neuritis,  in 
which  the  changes  are  like  those  met  with  in  the  s-condary  or  Wallcriaii 
degeneration,  which  follows  when  the  nerve  jibre  is  cut  olf  from  the  cell 
body  of  the  neurone  to  which  it  belongs.  'I'he  medullary  substance  and  the 
axis  cylinders  are  chietly  invidve(],  the  interstitial  tissue  being  but  little 
altered  or  only  alfected  secondarily.  The  myelin  becomes  segmented  and 
divides  into  small  globules  and  granidcs.  and  the  axis  cvlinders  become 
granular,  liroken.  subdivided,  and  ultimately  disapiicar.  'I'hc  nuclei  of  the 
sheath  of  Schwann  proliferate  and  ullimatelv  tho  libres  art'  reduced  to  a 


1 


d^ 


10n2  DISEASES  OF  TITE  NERVOUS  SYSTEM. 

.tat.'  of  atrni.liic  tiil.cs  with.nit  a  tni.c  of  the  nminal  stnictun'.  Tlu'  iniis- 
,.!..<  nmiHvt.d  will.  tl...  .l.-cnrvat(..l  ihtvcs  usuallv  >\^n^^■  inark-.l  atropine 
,.h,n"v<  ainl  in  mmik'  instaiu-cs  the  .■lian-.'  in  tl...  new.'  sh..ith  ap|»':irs  to 
,.xi,.ml  .iiiv.  lly  to  tl..'  inl.'istitial  ti.s.u'  of  th.'  imiscK'.-tlio  neanUs  l^isnnns 

Symptoms.-(^/)  Localized  Neuritis.— As  a  nilc  tin;  cnn-titufonal 
,li-t.iil.ai...'s  a.v  >\hM.    TUv  n..>st  iiiiiMprtant  .^vniptum  is  i-an.  ..I  a  l.or,n;r 
i,r  <taiii>in.r  .hara.teT,  us.iaiiv  IVlt  in  the  course  oi'  tiic  lUTve  an.    iii  th.' 
part-  to  wl.i.h  it  is  .li>t.ilmt.'<l.     Tl..'  n.TV.'  itself  is  sensitive  to  pressure, 
vroi.ahlv    as  W.'ir  Mit.h.'ll  su-csts,  .-win-  to  tiie  irritati..u  ..f  its  nerv; 
m.rv..nnn.     TIh.  skin   may   I.e  sli-htly  r.'.l.leiu'.l  ..r  ev.'.i   ..•.leiiiat..us  over 
tl-o  seat  of  tl..'  inllaimnation.     Mitehell  lias  .l.'s.rili.'.i  inerease  m  tlie  teiu- 
iK'rature  and  swatin-  in  the  alV.'.'t.'.l  r.'-ion.  an.i  such  trophic  .l.sturl.aiiees 
',.HVu<ion  into  th.'  joints  an.l  herp.'S.     Th.'  fun.li.m  ..f  the  muscle  t..  which 
the  n.'rve  lihres  are  .listrilmte.l  is  iinpaire.l,  n...tion  is  pamlul,  an.l  there 
,nav  lu'  twil.'hiu-s  or  c.ntractions.     The  tactile  sensation  of  the  part  may 
lH.Vo....'\vhat  .lea.lene.l,  even  when  the  jmin  is  -r.'atly  in.'r.'as.'.).     In    iu" 
„„„.,.  c.hronic  cases  of  l.)cal  neuritis,  su.li,  f..r  insta.u-.'.  as  1..11..W  the  .l.s- 
l,„,,,i„„  „f  th.'  humerus,  the  h)cali/...><l  pain,  which  at   hrst  may  he  s.'vere, 
tira.luallv  <li>app.'ars,  th..u-h  some  sensitiveness  ..f  the  hra.h.al  pl.'xu.;  iii:iy 
Vu-i-i-t  for  a  Ion-  tin..',  aiul  the  nerve  oonls  may  ho  felt  to  he  sw.llen  ami 
iinn      The  i.ain  is  variahle— s.nnetinies  intense  an.l  .listr.'ssin.i;;  at  ..th.'i's 
not  causin-  mu.h  in.'..nv..ui.'nce.    Xumhness  an.l  formicati.m  nmy  he  pnp 
nit  an.l  th.'  tactile  s.'usation  may  he  -reatly  impaire.l.     i  he  motor  disturh- 
anc's  are  ma.k.'.l.      ritimately  there  is  .'xtrenie  atrophy  ol  the  muscles. 
Contra.'tures  mav  o.'.ur  in  the  lln.uvrs.    The  skin  may  he  re.l.lene.l  .-r  glossy, 
the  suhcutan.M.u's  tissue  .e.l.'iuat.u.s,  an.l  the  nutriti..n  ol  the  na.  s  nmy  bo 
defective,      in   the   rl...uinatic   neuritis  suhcutancus   iihroi.l   n...lules  may 

'^'"'V'n.'uritis  limit.'.l  at  first  to  a  peripheral  nerve  may  exten.l  upwar.l- 
th,.  >o-calh'.l  as,rn.li^i-  ..r  migratory  ncuritis-an.l  involve  Hu' hu'gor  nervo 
minks.  ..r  even  rea.'h  the  spinal  c.rd,  causing  suhacu  e  myelitis  (U.wors. 
TlH'  condition  is  ran'ly  seen  in  the  neuritis  fr-un  c.ld    ..r  m  that  which 
follow,  fevers:  hut  it  occurs  most  frcpientlv  in  traumatic  noun  ,s      J    K 
A     .hell,  in  his  monograph  On  Injuries  of  Nerves  (18^:3     eonclu.  es  that 
Z  lar..vr  n.'rve  trunks  are  most  snsceptihle,  and  that  the  neuritis  ma> 
;pr.'ad  either  up  or  down,  the  former  heing  th.'  nmst  coinmon.     i  he  paraly- 
s  s  s.'.',.n.larv  to  visceral  disease,  as  of  the  hladder,  n.n-  ho  due    o  an  as.-em  - 
i„.,  neuritis:    The  intlammati.m  may  extend  to  the  nerv.'s  ..f    he  other  s  de, 
citlier  through  the  spinal  ord  or  its  m.'n.hranes    or  w.th..ut  any  inv., Iv.'. 
H'nt  of  the  nervo  cntros.  the  so-calU'd  sym,.atlietic  neuritis.     Ihe  elee- 
1     .1  cl  am-s  in  localix.d  lu'.iritis  vary  a  great  deal,  dopon.ling  npon  the 
X  .^t    o  "diich  the  nerve  is  iniured.    Tho  lesi.,n  may  bo  so  sligh    tha    ^e 
lerve  and  the  muscles  to  whi.h  it  is  distributed  may  react  normally  to  1  oth 
cur    1    .:  or  it  mav  bo  so  s.'vere  that  tho  typieal  reaction  of  d.>genern  ion 
ZLw    .itlHn  a  "few  davs_i.  o..  tho  nervo  docs  not  respond  to  stimnla- 
,   b  •  either  current,  whib'  the  mnsele  r.'acts  only  to  tho  galvanic  curron 
In    in  a  peculiar  manner.    The  contraction  caused  is  slow  and  lazy,  mstead 


Thr  imir- 
iitnipliii' 

•  titiif  o'lal 
r  ;i  lioriii;: 
Ml'  ill  the 
I  pn'ssiirc, 
'  its  lu'i'v; 
itoiis  OVlT 
1   tlio   tl'lll- 

stiirhiiiu't-; 
L'  to  which 
iiiiil  thciv 
'  liart  iiiiiy 
I.  In  llic 
w  the  (lis- 
lio  severe, 
)lexii;3  iiKiV 
iVdlleii  and 
;  at  othiTs 
ay  ))e  ]ires- 
or  (listiirli- 
10  imiseles. 
il  or  jflossy, 
lils  may  be 
iduk's  may 

I  ii|i\\ar(l — 
ai'<rev  iicrvo 
s  ((iowers). 
that  wliich 
itis.    J.  K. 
eludes  that 
I'lii'itis  may 
The  iinraly- 
I  an  nseend- 
'  other  side, 
iiv  inv(dv('- 
"The  olee- 
i<T  ripon  tlio 
rlit  tliat  the 
ally  to  both 
legcnoration 
to  stimiila- 
anic  current 
lazv,  instead 


XKrUITIS. 


urns 


(if  sjiaiji  and  iiui(  k  a-  in  the  normal  mii-clc,  and  the  AnC  contraclion  i« 
usually  ^Imiiger  than  the  (('  cuntiaetiun.  Ileiucen  lhe>e  tun  ixMrMics 
there  are  many  dill'ercnt  ,uia(hs,  and  a  carerni  eh'ctrieal  examination  i-  mo-t 
iniiioitant  as  an  aid  to  dia;^iiosis  and  |pro;:iio.«is.* 

'I"he  duration  vai'ie-  tioni  a  few  days  to  weeks  or  nmnihs.  A  >li;:hl  trau- 
matic neniiti<  may  pa.-s  nil'  in  a  day  or  two.  wjiih'  tin'  severer  case-,  such  as 
rnlluw  niircdueed  di>hication  (d'  the  Inimeriis,  may  persist  I'or  niontiis  or 
never  be  com|iletcly  relie\('(|. 

(/>)  Multiple  Neuritis.— 'I'll is  |iresenls  a  complex  symptomatnluLry.  Tlic 
lidlouin;,^  are  the  most  im|)ortant  j;i'oiips  of  cases; 

(1)  Ariilc  Fchrilc.  J'uh/nnirilis. — TIh'  attack  follows  exposure  to  C(dd 
or  overexertion,  or,  in  some  instances,  comes  on  spontimcoiisly.  'I'lu'  onset 
nscmhles  that  (d'  an  acute  infectious  disease,  'i'herc  may  he  a  dclinite 
I  hill,  jiains  in  the  hack  and  liniiis  or  joints,  so  that  tlu'  case  may  be  tiioii;;ht 
to  be  acute  rheiiinati>m.  'I"he  temperature  rises  rapidly  and  mav  reach 
\o:r  or  lor.  There  aic  headache,  luss  df  appetite,  and  the  ;:eiicrai  symp- 
toms of  acute  infection.  'I'he  limhs  and  l)ack  ache.  Intense  pain  in  the 
i;ervcs.  howi'ver.  is  by  im  means  constant.  'rin;:lim:-  ami  furmieatioii  are 
J'elt  in  the  lin>rers  and  toes,  and  tlicre  is  increased  sensitiveiie>s  of  the  nerve 
trmd<s  or  of  the  entire  limi).  Loss  of  muscular  ]iowcr.  lirst  marked,  per- 
haps, in  the  Ic^s.  nradiially  comes  on  and  extends  with  the  featMr>s  of  an 
i'.sceiidiiiir  paralysis.  In  other  cases  tiii'  jiaralysis  benins  in  the  arm.-,  '{"he 
extensors  of  the  wrists  and  tlu'  llexors  of  the  ankles  iiro  early  ail'cctcd.  so 
that  there  is  foot  and  wrist  drop.  In  severe  cases  there  is  "general  loss  of 
muscular  power.  ]»rodiicin<;  a  llabby  paralysis,  which  may  extend  to  the 
muscles  (d'  the  face  and  to  the  intercostals,  and  respiration  may  be  carried 
on  by  the  dia])lirafrni  alone.  Tlu'  muscles  soften  and  waste  rapidly.  There 
may  be  only  hypera'sthcsia  with  soreness  and  stifTness  nf  the  limbs;  in  some 
cases,  increased  sensitiveness  with  ana'stliesia;  in  other  instances  the  si'ii 
sory  disturbances  are  sli'^ht.  The  (dinical  |)icture  is  not  to  be  distinLMnshed, 
in  many  cases,  from  Landry's  paralysis  in  otlu'rs.  fi'oni  the  subacute  mye- 
litis of  Dtichoune. 

The  course  is  variable.     In  tlie  most  intense  forms  the  ])atien(  may  die 

in  a  week  or  ten  days,  with  inv(dveinent  of  the  respiratory  muscles  or  fi i 

]iaralysis  of  the  heart.  As  a  rule  in  cases  of  in;)ilerate  severity,  after  per- 
sistin<r  for  five  or  six  weeks,  the  conditiou  remains  stationary  and  then  slow 
imiirovemcnt  beoiiis.  TJie  paralysis  in  some  inustdos  may  persist  for  many 
months  and  contractures  may  occur  from  shortenin,:r  oi'  the  muscles,  but 
oven  when  this  occurs  the  outlook  is,  as  a  rule,  -rood,  altlion;^h  the  paralysis 
may  have  lasted  for  a  year  or  more. 

(•2)  Rcriin-iiir}  Multiple  Xt'iirUh. — T'nder  the  term  poh/nciirilist  rrrurrcn^ 
^Fary  Sherwood  has  described  from  Kichhorst's  clinic  '2  cases  in  adults — 
in  one  case  involviuf:  tiio  nerves  of  the  rijxht  arm.  in  the  other  both  lei:s. 
Tn  one  iiatient  there  were  three  attacks,  in  the  other  two,  the  distribution 
in  the  various  attacks  bein<j  identical.  The  subject  has  recentlv  been  fully 
discussed  by  11.  'SI  Thomas  (l^hila.  :\rod.  Jour.,  'lS!)8,  i). 


lon-t 


I.ISKASKS  OF  TIIH  NKRVOl'S  SYSTKM. 


(;n  AlroUir  .Vr«n7/.s.-TI,is.  yn-hny.  <!,.«  .....st  in.p"rtnnt  form  -l  ,nul- 
tinl  >  KMiritis.  was  frra|.l.icallv  dcsrr.lM.I  in  IS-.'  I.y  .la.n.s  .la.ksun,  Sr,.  ol 
l.,n„  Wilks  nruj...'/...!  il'as  al.nl.oli..  ,>ara,.l..,'ia,  l.ut  tl,.  startM,K-lMM..t 
,,,•■,1,,  ,v...Mt  rm.a.vlu.s  on  tlu-  .lis.as..  .lat.s  ln.,n  ih.  u  ...rvat-ms  ..f 
J),mu..,il,  .>!•  Kun.-n.  Ol"  lato  yars  ..ur  loiowlnlj:..  .-1  tl..  (lis..a>..  l.as  .x- 
U,M  rapi.llv,  owinji  to  tl..  n.s.airlu.s  of  ll.is.,  Lc.y.l.M.  .lanu.  1--.  '  '  ^ 
xanl    ami  llo'nry  llun.     It  .uriirs  n.-.t  rn'Min'Mtly  m  w.m.m    i^utunla  1> 

nl.vsiVia.'  or  to  the  laM.ilv  of  l.aluts  of  ...cTct  .Innk.nj.'.    'I  l-  oM...t  .>  ..>uall. 

Ira.lual,  an.l  ...ay  h.  ,.m.e.U.,l  f..r  wooks  or  .n..ntl>s  I.y  n.uyn\^u-  ,mm.  and 

Tin-din.'  in  tho  IV.'t  an.l  Lands.     C.  -ivnlsions  ar.  not  nnc-onunon.     l.'V..    .. 

2.    Tin.  paralysis  gradually  sHs  in.  at  tirst  in  tlu-    oot  an.    I.-,s  and  th.n 

in  t],o  han.ls  an.l"  fovcarn.s.    The  cxtcnM.rs  arc  alU^t...   nw.ro  tl.an  'l'"  1<;^;    ■  • 

so  that  th..n.  is  wrist-ln.p  an.l  r-.-t-dr..,..      Pho  paralysis  '-^v  W>  in  s  1- 

it,,d  an.l  n..t  cxtm.!  hif:h..r  in  tin  lir.d,s.     In  ..tlu'r  u.stan.rs  tlu;.(.  is  paia- 

„:,,„„„  ,„,.,  i„  the  n.ost  ..xtren.o  eases  all  t  n-  extn-nutn.  are  m- 

•olvJ.|      In  rare  instances  the  fa..ial  nu.s..l..s  an.l   the  sph.n..ters  are  also 

,,r,,t,,l.    The  s..nsory  syn.|.t.Mns  are  very  yariahle.    There  are  cas.'s  ,n  ^vh..•h 

tlu.re  are  nnnd.ness  an.l  tinfrlinp  only,  withont  ^M•eat  i.un.     In  other  ease> 

tlu.re  an.  severe  hnrnin^  or  h..rin^'  pains,  the  n..rve  trunks  are  sensitive,  an.l 

,  ,„u..-l..s  are  sore  when  grasped.     The  han.ls  and  i.rt  are   lre.,nent  v 

;,r,;  an.l  <...np.ste.l.  parti..nlarly  when  hehl  down  lor  a   i-"  -;;-;  - 

The  entane..ns  rellexc'S  as  a  rule  are  preserve.l.    The  d..ep  .vlU.x..  ai.'  u.nallj 

'"^The  e.unse  of  thes..  al....holie  eases  is,  as  a  rule,  fav.>rah!e.  an-l  aft.M-  per- 
sisting...' weeks  or  n...n,hs  improvement  ,nulua!^  l.e,ins,  tl-  .m-^- 
;...ain   tlu.ir  p..wer,  an.l   even   in  the  most  .lesperate  cases  re....Ne,v 

,11    V      The  extensors  of  the  feet  may  remain  paralyzed  h.r  some  t  ine. 

S "iVe    ,1.0  patient  a  .listinetive  walk,  the  so-called  slr,„-  ,ait    ehar- 

c  h2  of  peripheral  neuritis.  It  is  s..metimes  known  as  he  l^i-'-ta  -  - 
S  '  Ithon-d,  in  reality  it  c.nld  n.,t  well  he  mistak..n  for  the  j^ait  ,.f  ataxia 
T  e  il,       ';    r  wn  f..rcil.ly  forward,  the  t,.e  lifte.l  high  in  the  air  so  as  n,.t 

.     r  .n  UThe  heel  is  hr..n,ht  d..wn  first  an.l  then  the  entire  ^.^. 

i.    n  n  1  wu  1   clnmsy  pait,  and  jiives  the  patient  the  appearance  of  con- 

;;r-c:;:r^>;s^^^^^^^ 

^'tin^  he.    and -deserihes  with  circumstantial  deta.  s  h.n,  ^ourn^s 

wldXlie  says,  he  has  recently  taken,  ,.r  tells  of  persons  wlu.m  he  has  ^ust 

%)  Mullipk  Xrvrili^  in  Ih'  Tnfcrfiovs  /);smsv..--This  has  he.ni  already 
refcrr  .1  t      partienlarlv  in  diphtheria,  in  which  it  is  most  ....mnnm.      Iho 
eri  1  I    ;    ure  of  tlie  lesh.n  in  these  instances  has  heen  shown  hy  yo  t- 
per.phcia  J  ^^  j    „^^„ii,  fayorahle  and,  except  in  diph- 

Z:S:^^^^  i-lmon.    Mnltipio  nenritis  in  tnherenlosis,  dia- 


?i 


.VKt'UITrs. 


103[ 


lict.'s,  nn.l  svpliilis  is  of  the  siiiiic  luitiiic.  licin-  pn.htiMy  <liio  to  {o\w  iii;it(<- 
liiilf  iilisorlu'd  iiiti)  the  hlndil. 

(:.)  Arsniinil  ami  Suhinniir  Xritril Is. -Thr  arsciiiral  nciiritis  is  ii„( 
•"iinnoii:  ..Illy  ji  sin-l,.  iiistiincf  ..I'  it  Ims  c..,,,,.  „i„|,.r  ,„v  ..l.scnntini, 
(tnly  oiif  ciisc  to  my  kn..vvl«'.l;r,.  has  l'uil,.\v,.,l  the  use  of  I'oulcr's  soliiliuii 
111  my  wjinl  (.r  .li.-.|.riisiiry  pni.ti.c,  alllioii-li  I  in,,  {„  H,,.  |,;,|,i(  ,,f  j,.jvi„„ 
III  clioiva  ami  aiui'inia  closer  which  mi-ht  !,.■  icnanlcl  as  uxct/ssivc.'"  Tim 
most  coiiimon  causes  arc  accidental  i.uis..iiiii;:.  as  in  the  cases  reiM,ri,.,|  hy 
Mills.  In  a  case  of  K.  (i.  Cntler  the  |>ati<'iit  .yot  the  arsenic  fn.m  k,.,.,mi- 
paper  la^'s,  wlii.li  he  was  in  the  hahit  of  putting'  in  his  month.  The  >J^-un-.i\ 
syinptonis  are  not  unlike  those  of  alcoln.lic  paralysis;  the  weakne.-s  of 
the  extensors  is  inark.il  and  the  sIvppiKic  ;rait  ehara("teristic.  'i'lie  neuritis 
due  to  lead  has  heeii  discussed  in  the  consid. ■ration  of  lca<l  poisonin;.'.  'j'|„, 
sjiecial  involvement  u\  the  motor  nerves  and  the  ^rivat  freqiien.y'"(d'  the 
occnrreiice  .d'  wrist-drop  are  the  peculiarities  cd'  this  form.  The"  chaii'^'es 
in  the  cell  h.idh.s  of  the  neurones  in  cases  of  poisonin-  with  lead  and  arsenic 
have  recently  l.ecii  studied  hy  J.nyaru  hy  means  of  the  method  of  Xissl. 

A  similar  form  (d'  neuritis  is  cau.sed'hy  the  hisulphide  of  earhon  and  hv 
the  jirotracted  use  of  tea  (M.  A.  Starr). 

(<i)  Enilnnlc  Xviirilis,  Jivri-lwri,  has  heeii  considered  under  the  Infec- 
tious Diseases. 

Anffisthesia  Paralysis.— Here  perhaps  may  most  ai)propriately  he  con- 
Mdered  the  forms  of  paralysis  following'  the  ii.-e  of  ana'sthetics.  Much  has 
heen  written  m  the  past  few  years  npon  (his  sul.ject,  which  has  heen  very 
luily  (•onsidered  hy  (iarri-nes  (American  Journal  of  the  Medical  Sciences. 
IM'T,  i).     'i'liere  are  two  jrronps  of  eases; 

1.  Pressure  jiaralysis.  in  which,  owiiifr  to  the  position,  the  nerves  have 
been  compressed,  either  the  hnmerns  a-ainst  the  hrachial  ple.xus  or  the 
musc.ulo-spiral  a-aiiist  the  tahle.  The  pressure  most  fre.piently  occurs 
when  the  arm  is  elevated  alon-'side  the  head,  as  in  laparotomy  done  in  the 
I  rendelenherjr  positn.n.  or  held  ..ut  from  the  hodv.  as  in  hroa.st  amputations 
Instances  ..f  j.aralysis  of  the  crural  hy  UohL's  l(--liolder  are  also  reported. 

..  ^1  aralysis  from  eerehral  lesions  durin^j  etherization.  In  one  of  (hir- 
ri-ues  eases  paralysis  folh.wed  the  operation,  and  at  the  autopsy,  seven 
weeks  later.  ...d'tenin-  of  (he  hrain  was  found.  Apoplexy  or  omholi'sm  may 
develop  durinjr  the  ana'sthesia.  In  Montreal  a  cataract  operation  was  per- 
iormed  on  an  old  man.  He  did  not  recover  from  the  ana'sthetic;  I  found 
post  niortem  a  eerehral  ha-niorrlia-e.  A  man  was  admitted  to  the  I»hila- 
•Iflphia  Hospital  on  the  l^Ctli  completelv  comato.^e;  the  dav  previously 
ether  had  heen  jriven  for  a  minor  operati..n.  He  never  recovered  conscions- 
ness.  hnt  remained  deeply  comatose,  with  fjreat  muscniar  rcla.Kafion  low 
iemperatnre.  !)T.r,°,  and  noisy  respirations;  he  died  on  the  -.'sth.  There  wa< 
nnlortunately.  no  autopsy.  Kpileptic  convolutions  may  occnr  durin-  (ho 
amesthesia.  and  may  even  i)rove  fatal.  The  possihilitv  has  to  he  considered 
of  ].aralysis  from  loss  of  hlood  in  jindcm^red  operations,  thouirii  I  have  no 
IKT^onal  knowledge  of  any  such  cases. 

And,  lastly,  a  j.aralysis  mi-lit  result  from  the  toxic  affects  of  the  ether 
m  a  very  jirotracted  administration. 


lo;^(5 


DISKASF.S  OV  TIIK  NKUVOl'S  SYSTF.M. 


frr^'^:-i;:;;'-;c\::S;;;;vi'::;'':;:;:n:::.r::i.:li; 

::;;:;;;r,.'v.i.i:'"."'' "■!"•■•■-'' ^  ""■■■"" ""■""""""' 

^''"::;r'!;^:"':vi;v;i;z':., .i...... <,..„,.  m ;v,«..,o 

;i::; :;;     ,  ,     .1.  ti„.  ......m,.  ,..i...  ..,.1 , ■..nM™.,i.,ns ,■ .. 

;    ,  T      ,  II-  .".■lion  nl  ,l,.;.,.m.n.li *  |"v-,.l.     Hm .«' 

;:r:,'::;;:r':';i..";;-.r!;Hi..iK .:  .i;;: -.■ >  -- 

, l,l;::;i.;i.':r  .*.  -■>  <•■■'>  ■"■■<'  ^  -'rr";;:;;; : ;,  r  m"'  'n  • 

«'"i''"' 17"'- '''■'"■'"";;  ;r.v:;:':r  i/;.^'^^^^^^^™^       '""^^ 

n,|.i,ll.v  .„lva„..MiK  "I".;  >  .,  „,,    ,„ ,,„  ,, ,„„„,v  ,,.,ar,l,.,l  .< 

ir -r  f;        1      ..  V    .nf.nn.lo.l  with  tlu-  suhan.to  atropine-  sp.nal 

late  clo^cl}  ai  I  .11.   "■"■'">        ,ii,,,n„.i.   from   l..roM...t<.r  ataxia   is  rarely 

„,,lvsis  ..r    Dufl.onno.        lu'        ;  fruiu  that  <.f  tal.os.     Thoro 

-;s  ,:;;;^''!n:..^^;:,;^r''n^- ;:""•" r^'!^.:i:;-'n^".^i:!- 

;,,.oyiV.oo  ,.«,i..M.j-.t ;;-■;;;;;;;,:;■:  ;;;;;;::-:n,:!^^ 

Treatment.-!!.*!  ...  l..'.l  ...  osh.,.i.,.1.      .  n,'  ■'  .       ^^    ,,„ 

n'(iuin'd.     Moat  can    im'- 1  .loccived  hv  the  s  atcmoTits 

of  tho  rolativi's.     It  i>  sonutiii  cs  C-^^^*-       -  ■  ,        ^,      stimulant-^ 

.pirit-drinkin,.  In  iho  aU-.h.  lo  ^^'^V.  <  «o  a  aW  -  .,,oul<l  bo  ...1 
.vaaually.  If  thoro  is  any  tciuloiioy  <  .^•^'^';-,;  ^J'^f,-^.^;,,,,  ,f  tho  nu,^- 
Tn-  tho  pationt  plaoo.l  ,n  a  ^""^'"7"  ^  j^f^^^^^/  ^   %,  ^.^  ,hon  tho  atro- 

r  ""^  '^-li^'S  ir;i  ns't::^  1  ;:o,:"i!':i:^;iM^rohahiy  tho  .ost 

by  passive  movements  and  extension.     Often,  AMtn 


NKl'UOMATA. 


Iti;;; 


iiiirki'tlly 

variiiii:'. 

1  ii  very 

11^.     Fiv- 

Iiltl    tn   il 

rnotnoiiii' 

S|l(lll(l     t" 

joii  until 

c-iist's  t lit- 
is {.n't'iitiT 
IS  iiiiiy  Ik' 

OIIIC  I'llf^l'^ 

:  striiiiLrt'i" 
ily  iiiiil  il 
lUTVL'  live 

uses.     'Y\u' 

S  iUlil  I'o't. 
istic-.  Th.' 
I  ri'iicli'mL; 
cpu'di'd  lis 
uiy  to  tlio 

\v!ii<-li  tlu! 
lin.tr,  siiiiu- 
|iliic  spinal 
a  is  raivly 
ln'S.  'riiero 
;l  wt'U  with 

The'  li«ht- 
ho  t'tiiihij:y, 
;  which  lias 

.■tl'S. 

witli  h'vor, 
intense  ])ain 
n   are  often 
iholic  f:irin. 
0  statements 
a  history  of 
c  stimulants 
ouhl  he  nsed 
of  the  nuis- 
lien  the  atvo- 
hly  the  most 
illy  overcome 

extreme  dc- 


forinity  from  (•oiUnicliire,  recovery  is,  in  time,  slill  |)(i>siMe.     'I'iie  iiiler- 
rii|i|e(l  iiirrent  Ik  useful  wiieii  the  acute  sta^re  is  |iasse(i. 

(»f  internal  remeilies.  strychnia  is  of  value  ami  may  he  ^^iven  In  in- 
cica.>in;,'  doses.  Arsenic  also  may  he  eni|iloycii.  and  if  tlii're  is  a  history  of 
sy|ihili.«  the  iodide  uf  |inla>^iiini  and  nicrcury  niav  he  'dven. 


II.     NEUROMATA. 

'I'uiiior-  situated  on  nerve  lihres  may  consi>t  of  iieivc  siihitaiicc  jiroper. 
the  true  neuromata,  or  id'  lihnuis  tissue,  the  false  iieiiromala.  The  true 
neuroma  usually  ontaius  nerve  lihres  (uily,  or  in  rare  inslanccs  ^'an;,dioii 
cells.  Cases  of  f.' ,i>'rl ionic  or  inciliillary  neuroma  are  extremely  rare;  some 
«\'  them,  as  Laucenaiix  su,e-;j-csts,  are  uiuhuihlcdly  instances  cd'  malforma- 
tion of  the  hrain  siihstaiice.  In  other  in.-taiices,  as  in  the  case  which  I 
re|iorted.  the  tumor  is,  in  all  prohahility,  a  j,di(Uiia  with  cells  closely  rcsciu- 
hlini:  those  of  the  central  nervous  syste/ii.  The  true  fascicular  neuroma 
occurs  in  the  lorm  <d'  the  small  suhctitaneoiis  |iainful  tumor — liihirrii'i 
(hihirosii — which  is  situated  on  the  nerves  (d'  the  skin  ahout  the  joints,  sonie- 
liiiies  on  the  face  or  (ui  the  hreast.  It  is  not  always  nuide  up  of  nerv  lihres. 
hut  may  he,  as  shown  hy  IIo^'^mu,  an  adenomatous  f,'r"wlh  cd'  the  sweat 
jrlands. 

The  true  neuromata,  as  a  rule,  are  n(d  jiaiuful,  and  occasioually  arc 
found  associated  with  the  nerve  lihres  in  various  rc,i,'ions.  Those  which 
develop  at  the  ends  and  aloii<r  the  course  of  the  nerves  (d'  the  stump  after 
amputation  consist  <d'  connective  tissue  and  of  medullateil  aiid  mui-medul- 
liited  nerve  fihres.  The  most  remarkahle  form  is  the  plcrifunn  iiniroinn, 
in  which  the  various  nerve  cords  are  occupied  hy  many  hundreds  of  tumors. 
The  cases  are  usually  c(mj:enital.  The  tumors  occur  in  all  the  nerves  of 
the  hody.  One  of  the  most  remarkahle  is  that  dcserihed  hy  I'ruddeu,  the 
specimens  (d'  which  are  in  the  medical  museum  of  Cojnmhia  ('(dli'^re,  New 
York.  There  were  over  1,1S'i  distinct  tumors  distrihuted  on  th^  nerves 
of  the  hody.  R.  W.  SniithV  splemhd  mono<rrai)li  on  neuromata  has  heeii 
reprinted  this  year  (iSilS)  hy  the  Xew  Sydenham  Society. 

Xeununata  rarely  cause  symptoms,  except  the  suhcufaneoiis  painful 
tumor  or  those  in  the  amputation  stump.  Ih're  they  may  l)e  very  painful 
and  cause  <rreat  distress.  Motor  syiu|)touis  are  .sometimes  jiresent,  |)arf;cii- 
larly  a  cimstant  twitchin;:.  K|)i' -psy  lias  sometimes  heen  associated,  and 
relief  lias  followed  removal  of  the  growths. 

The  only  availahle  treatnu'ut  is  excision.  The  suhcutaueoiis  painful 
tumor  does  not  return,  and  excision  coni]iletely  relieves  the  symptoms.  On 
the  otlier  hand,  the  amiuitation  neuromata  may  recur. 


65 


^a^ 


T 


103S 


PISEASKS   OP   THE   NERVOUS  SYSTKM. 


1 1. 


'1; 


111.    DISEASES    OF   THE   CEREBRAL   NERVES. 

(M.lACTOltY    XkUVKS    AM)    'I'liACT.S. 

Tin.  functions  of  tl-.s.  lUTVcs  n.ay  W  -listurl,..!  at  their  origin,  in  the 

„„J,    n   cons  nu.n.l.ram..  at  the  hulh,  in  the  eourse  ol  the  traet,  or  at  tne 

„    .,s  in  ti>e  hrain.     The  .li.turl.an.es  n.av  hv  nuu»i..ste.l   .n  suh  .vtu.. 

;;,;;!;,;;.,;.  or  snu.ll.  .■ou.pU.te  loss  .,r  the  s..nse,  an.l  ..e.-asu-nally  .n  hype.- 

"";;;"!<./,;,W/r.  Sn,.,!...:  /',nv..M..-llallueiuat,ons  of  ^^-^ ^f^^^^^ 
^Jj  i„  ,1  ,.  ,nsane  an.l  in  e,.nep.y.     Th..  aura  n>ay  he  represented  by  an 
,    n     ...lor.  .l..s..ihe.l  as  r.s..u.hlin,  ehi.-ri.le  ..f  lune,  hurn.ng  rags 
r    .    le^      !—   1-v  eases  with  th..se  suhj.rt.ve  sensaf.n.s  tumor,    m 
0  il  in  the  l,ipp....an,pi.     In  rare  instan.-..,  after  n,uvy  ..1    he  hea. 

h    Jn<e  is  i.Tverte.  -...l..rs  of  the  u,..st  .litVer.Mit  c^haraeter  may  he  alike, 
\   ;;,;..:, V  I,e  changed,  as  h.  a  patient  noted  hy  Morell     lacl^n^e^ 
;;,,:,  ,o,-  s.,n,e  tin,e  c.uhl  n..l  touch  e....ke.l  nu.at,  as  U  snielt  t..  h..  exactlv 

''\I)  /l;:.mii;/ ;^'.s-/n...s..  or  Iniprn..!.,  ......urs  ..hi..lly  in  nevvou.  hys- 

t.n       women,  in  .hon,  it  nn,y  son.etinus  l.e  .lev..l..p..d  ..great  y  that,  hke 
a  .i!:'.  they  .-an  rc-gnize  the  dilVerence  between  ind.vduals  by  the  odu: 

"'"'lo    \,„s,.in:  Lns.  nf  the  Sn,.'  of  S,„rU.-'Vh\^  n.ay  be  vrodu,...!  by: 
(1)^  ,•;.,. .n.  ..f  the  origin  ..f  the  nerv..  in  the  nuH...us  nunnbrane    whu  . 
perhaps  the  nu.st  fr...,u..nt  ..ause.     It  is  by  no  nu.ans  -H->n,..n  .- 

dith.n    vith  c-hr..nie  nasd  ...tarrh  and  poly,.K     In  pandys.s  .,1     1...        h 
n'ne    the  s.M.se  ..f  su,..ll  n,ay  be  lost  ..n  the  atVeeted  sule,  ow.ng  t..  nUei- 

'^■'••ir;:d:::b;n.i  wiu';;";  the ..... ..f  ^.ss  ,.f  sn>eii  foii..wing  th..  imuda. 

,io,^  :?  wIt  L.1  <.-•  strong  ..dors  should  erne  un,l..r  tins  ..r  under  the 
'^'"Zi^i  the  SO.S0  of  s.nell  the  i.-nge.t  bodies,  such  ns  nn.n,onia.  .•hich 


,  in  tliL' 
r  at  tlu' 
liji'C'tivt' 
1  liypcr- 

d  Ijy  an 
ng  ra<r^, 
Dis  have 
tlio  head 
1)0  alike, 
iickenzio, 
r  exactly 

oils,  liys- 
that,  like 
the  odor 

I  need  hy: 

lie,  which 

i\  in  asso- 

the  iil'th 

to  intcr- 

ic  inhala- 
iinder  the 

.,  in  caries 
tory  tracts 
nay  be  the 
rown  from 
le  anosmia 
smell  may 

d  cases  in 
n  reported 
1  lias  heen 
1(1  sense  of 
•rilies  (1)  a 
il  centre  in 

-inia.  which 
;s  as  cloves, 
e  matter  in 


DISEASES   OP  THE   CEREliKAL   NERVES. 


1030 


l)rnin  rapes  hy  liaviii-  (wo  or  lliree  IxitlJi's  coiitaiiiin,!;  the  essential  oils. 
Jii  all  instances  a  rJiiiioscopicul  exaniiiialioii  shoiihl  he  made,  as  the  coii- 
.lition  may  he  due  to  local,  not  central  causes,  'j'he  ImUiunil  is  un.-;itisfac- 
lory  even  in  the  cases  due  to  local  lesions  in  the  nostrils. 

Orric  Xkkvi:  and  '!"i; act. 

(1 )  Lr-'^i/iiis  (if  Ihc  h'l'liiiit. 

These  arc  of  imiiortance  to  the  pliysieiiiii,  and  inrorniation  fd  the  arcaf- 

f'st  value  may  he  ohtaiiied  hy  a  systematic  examination  of  the  eye-i^n.unds. 

Only  a  i.riei'  reference  can  here  he  made  to  the  more  important'  ol"the  ap- 

]iearaiiccs. 

('0  Retinitis.— This  occurs  in  certain  <:eneral  airections,  moiv  pnrlicu- 
larly  in  i'.ri.irht's  disease,  syphilis,  leukaemia,  and  aiaemia.  Th.'  common 
leatiirc  in  all  these  states  is  ilu'  occurrence  of  lucmorrlia-v  and  the  develop- 
ment of  op:iciti,.s.  There  may  also  !,(■  a  dilVuse  cloiidinos  due  to  eiru>i.Mi 
<d  .<eriim.  Tlie  ha'morrlia-:-es  are  in  the  layer  of  nerve  lihres.  They  vary 
^^reatly  in  size  and  form,  hut  (d'tcn  follow  the  course  of  vessels.  'Wheii 
recent  the  color  is  l,rio|i(  re.l.  hut  they  -raduallv  chan-e  and  old  ha'iuoi- 
rlia,t:es  are  almost  hlack.  The  white  spots  are  due  either  to  lihrinoiis  exudate 
"r  to  fatty  d.-cneration  nf  the  retinal  elements,  and  occasionallv  to  accumu- 
l^.tmn  <,f  leucocytes  or  (o  a  localized  sclerosis  of  the  retinal  el.'inents.  'J'he 
more  imp.n-tant  of  the  forms  (d'  retinitis  to  he  reco-nized  are: 

AllniiNiniirir  rrlinllls.  uhich  occurs  in  chronic  n'ephritis,  particiilarlv  in 
the  interstitial  or  contracted  form.     Tlie  percenta-e  <>(  cases  alfeeted  is  fro 


^r>  t 


om 


<)  :■). 


iicre  are  instances  in  which  these  retinal  chan-es  are  a-~<iciate<l 
witli  the  uranular  kidney  at  a  sta-c  when  the  amount  of'alhnnien  niav  he 
sli-ht  or  transient:  hut  in  all  such  instances  it  will  he  found  that  there 
is  a  marked  arlerio-sclerosis.  (;owers  reconnizes  a  de-enerative  fomi  (mo<t 
'"•""i"ii).  in  which,  with  tlie  retinal  chan-es,  there  niav  he  scaKcIv  aiiv 
•ilt'nition  111  til.,  disk;  a  laemoiTlia-ic  form,  with  many  ha.iiiorrha.'vs  aii.'l 
hnt  sliLdit  M-ns  of  inllammation:  and  an  inllammatc.Vv  form,  in  which 
there  is  much  swcllin-  (,f  the  retina  and  ohscnrati.m  of  th'e  .lisk.  It  is  note- 
worthy that  m  some  instances  (he  inllammation  of  the  (,ptic  nerve  pre- 
dominates .,ver  tlie  retinal  chan-vs.  and  one  mav  h..  in  doiihl  for  a  time 
whether  the  condition  is  really  associated  with  the  renal  chan-.s  or  de- 
liendent  npon  intracranial  disease. 

SiipJnIilir  l;rliHl/is.~\n  the  acjiiircd  form  this  is  less  common  than 
cliomid.tis.  In  inherited  syphilis  rdinilis  piqmcnhsa  is  .ometime<  met 
with. 

nrlinUis  in  Annn,w.-Jt  has  lon.u^  heen  known  that  a  patient  mav 
"H'mie  hlmd  after  a  lai-e  luemorrha-e.  cither  siiddenlv  or  within  two  or 
tiiree  days,  and  ,n  .me  or  hoth  eyes.  Occasionallv  the  Joss  mav  he  perma- 
nent and  complete.  In  some  of  these  instances  a  neuro-retinilis  has  heen 
l;""id_,  inv.hahly  siilhcient  to  account  for  the  svmptonis.  !„  (he  more 
chronic  anamuas.  ,,articidarly  in  the  ,.ernicioiis  form,  retinitis  is  common 
as  determined  first  l)y  (,)uincki\ 

In   malaria   retinitis  or  nenro-retinitis   may   he   present,   as   noted   hy 


mSEASES  OF  THE  NKHVOUS  SYSTEM. 

.    •  nlv  in  tho  chvoiiif  cas^cv  with  anivmia   aiul 

Stephen  Mackenzie,      t  .  ^en  .  .1)^  n.  the     ^^^^^^^.^^^^^^^^  ,,  ,,  ,,,,.,.u. 

in  niv  expenenee  i>  not  nuiux 

ana^mia.  .  .hi.  .Uleetiun  the  retinal  veins  are  largo  am 

Ln,/,.r»n-.  /.V/h./.s.-I"  »        * '  ^     ,^,  ^e^erihed  hy  Liehreich.     It 

.listended;  there  1.  also  a  ,..  ha    leun    .        ^^^^^  ^^^  ^^^^.^^^  ^  j^^^  ^ 

is  not  very  e..nnnon      ^^  ex,.te.l   n  ^.^  .^  ^^^^  l,a>nu.rrhages  and  vvh.le 

.,f  examination  ol  ;'-■-'""•,„  ^^^mpronunent.  In  one  oi  n>,  ca^s 
„r  yellow  areas,  wlnel>  n>a>  '-  '  p^'^'^'  ,  ,^^„,  „„,,1,  opaque,  white  .pot>, 
th/ retina  ,u.t  morten>  -- ! ;;'  '  ^'^^  ,,ueh  had  a  diameteyvf  near  y 
l„,Uin>r  like  little  tun>or.,  t'?'-'/;  '^\  ,;i^._,.„^,,  ,,,,.  diaf^nused  hy  ^ orris  and 

!^:irn!';;:;;;:  u;e  :::;;;.u.  o.  the  .^ron^^^^^^^^^  ^^^  ^^„^^,^^^ , ,,.,, 

(i)  Functional  ^isturbanc     of  J^^^on.       )    ^^^^^^^,  ^^^^  i.aepemlently 
„,,;,;  in  nra.mia  and  may  lolh>  v    -nuU  >    ^^  ^^^^^  ^^^  ^^^^^_     ,^,,^.^  ^^^,^^  ,, 
The  eondition,  as  a  '•"l^\l'^'^;;\;;;,^,i,,,,,a,  and  oeeasionally  hy  quinine. 

----sis  oeenrs  in  P-'-;;^  i..  act  cm  the  centres  and  not  on  the 

It  seems  more  prohalde  that  the  poi.Ai 

retina.  .        ,,,,      ,,,,,  ^f  <i>dit  is  usually  -radual,  eqtialm 

^,)  Tohnrro  -»'"'''.'/"/""- ^'''"rr'eertv'  of  the  held  of  vision.  The 
,,th  eyes,  and  alVec.ts  part.eularb  ^^J^  ,,,,,  ;,  congestion  of  the 
.ve-gronnds  may  he  '>•>-•>'"»>','", '"..i.i  Ldoma  f<n-  red  and  green  i. 
.ii,,;:.     on  testing  the  color  ;-';';  ;;-;;^';;,  ,,,,,,o  is  continued,  organic 

st:\;;"x::.op;;Uo,.hy<dt^     ^^^^^  ^^  ,„^^ ., 

(;,)   Il,,,trriral  ■^>''''^'''''  :,''\LIm  in  one  or  l-tli  eyes  may  ap- 

t::;:v:::i:^rti:^^i:^:i^^^ ..-..,........■ 

hvstevia.  _  /,w„„n/-tlie    condition    in    which    oh.iects   aic 

,|„,,|v  «■.■"  «ill,..»t  .^l^tr.■^;  "    '!■'>    7''    .,:„,,,   „„,  [,„.<  lioiiiil  a.wn.nlios  of 

:;r:^r,:;^r  ::£;;;;:.-"--   "■— 

in  epidemic  form.  .     .  .  j„  hvsterieal  women,  but 

'         )  nctimi  hipera'Mhc.ia  is  sometines  seen    n  ^^^^^^^^  ^^^^^^.^,^.^ 

is   :    found  frequently  in  'f-'^^j  ^  ^;,,,J,  "Xgree,  in  a  p.tiont  with 
n  alMuninuric  retinitis,  "-V'^jve  the      were  no  signs  other  than  the 
,„„i,  insulV.ciency,  m  who.e  Ktma 
throbbing  arteries. 

(o)  Ledums  "f  Ihr  0/./-V  ^  .-rrr.  ^    ^^^^  ^^^^^^ 

(«)  Optic  Neuritis  (Pa/H/'j/^:  'ii;^''. Je  Mu;^^^l'^  ^'^^^^'''^^ 


DISEASKS  OF  THE  CEREBRAL   NERVES. 


I(t41 


Ilia,  aiul 
rnicioU' 

.rgo  iuul 
jich.  It 
ivo  not  's 
lul  white 

ito  si)i)t>, 
[if  nearly 
oi-riri  anil 
of  failing 

n  chronic 

sfs.— This 
jjcndcntly. 
s  form  of 
ly  quinine, 
not  un  the 

1,  equal  in 
sion.  Tlio 
ion  ol!  tlie 
id  green  is 
ed,  organic 

f  acutener;^ 
•o;j  may  ap- 
icntly  under 

objects  arc 
ime  invisibh' 
:s  cannot  he 
id  light,  hut 
anouudies  of 
Lt  may  occur 

women,  hut 
lice,  however, 

patient  with 
her  than  the 


fit  stage  there 

iated.'   In  the 

increases,  the 


striatlnn  also  is  more  visil)lc.  'I'lic  physiological  ciipj)ing  (hsa]i]icars  and 
Jni'inorrliagcs  arc  not  uncominon.  'I'lie  artcrii's  jircscnt  iitlh'  cliangc.  tiie 
veins  arc  dilated,  and  the  disk  may  swell  greatly.  In  slight  grades  of  in- 
llamnndion  the  swelling  gradually  suhsidcs  and  occasionally  the  nerve  re- 
covers compl.f.iy.  In  instances  'u  which  the  swelling  and  exudate  are 
very  great,  the  suhsidencc  is  slow,  and  when  it  finally  disajipears  there  is 
complete  atroj>liy  of  the -nerve.  'J'lie  retina  not  ini'rcipicntly  participates 
in  the  inflammation,  wliich  is  then  a  nenro-rctinitis. 

This  condition  is  of  the  greatest  importance  in  diagni»sis.  It  may  exist 
in  its  early  stages  without  any  disturbance  of  vision,  and  even  with  exten- 
sive jiapillitis  the  sight  may  for  a  time  he  good. 

Oj)tic  neuritis  is  seen  occasionally  in  aiKcnda  ami  lead  ])oisoning,  more 
commonly  in  Hright's  disease  as  ncuro-rctinitis.  It  occurs  occasionally  as 
a  j)rimary  idiopathic  all'cction.  The  fre(iueiil  connection  with  intracranial 
disease,  ])articnlarly  tumor,  makes  its  |irescnce  of  great  value  to  ])racti- 
tioners.  The  nature  of  the  growth  is  without  influence.  In  over  DO  per 
cent  of  such  instances  the  papillitis  is  bilateral.  It  is  also  found  in  menin- 
gitis, either  "  luhcrculous  or  the  sim|ile  form.  In  mcinngitis  it  is  easy 
to  see  how  nllammation  may  cxti^id  down  the  nerve  sheath.     In  the 

case  of  tumor  it  was  thought  at  first  that  a  choked  disk  resulted  from  in- 
creased prcssnre  within  the  skull.  It  is  now  more  conunonly  regarded, 
however,  as  a  descending  neuritis. 

(*)  Optic  Atrophy.— This  may  be:  (1)  A  ])rimary  alfecti-ni.  There  is 
an  hereditary  foriu,  in  which  the  disease  has  developed  in  all  the  males  of 
a  family  shortly  after  ])uberty.  A  large  innnber  of  the  cases  of  primary 
atropliy  are  associated  with  spinal  disease,  ])articularly  locomotor  ataxia. 
Other  causes  which  have  been  assigned  for  the  primary  atrophy  are  cold, 
sexual  excesses,  diabetes,  the  specific  fevers,  alcoliol,  and  lead. 

(2)  Secondary  atrojdiy  results  from  cercliral  diseases,  pressure  on  the 
cliiasma  or  on  the  nerves,  or,  most  commonly  of  all,  as  a  secpience  of  pa- 
pillitis. 

The  ophthalmoscopic  ai)]iearanccs  are  different  in  the  cases  (d'  primary 
and  secondary  atrophy.  In  the  former,  the  disk  has  a  gray  tint,  the  edges 
are  well  defined,  and  the  arteries  look  almost  normal;  whereas  in  the  con- 
secutive atrophy  the  disk  has  a  staring  opacpie-white  aspect,  with  irregular 
outlines,  and  the  arteries  are  very  small. 

The  symptom  of  o])tic  atrophy  is  h^s  of  sight,  iirojiortionate  to  the 
damage  in  the  nerve.  The  cliangc  is  in  three  directions:  "(1)  Dinunishcd 
acuity  of  vision:  (2)  alteration  in  the  field  of  vision;  and  (M)  altered  per- 
ception of  color  "  (Gowers).    The  outlook  in  ])rimary  atrophy  is  bad. 

(3)  Affections  of  the  Cliiasmn  and  Tnirt. 

At  the  chiasma  the  ojitic  nerves  undergo  partial  decussation.  Each 
ojitic  tract,  as  it  leaves  tlie  chiasma.  contains  nerve  fibres  which  originate 
in  the  retiuir  of  both  eyes.  Thus,  of  the  fdtres  of  the  right  tract,  part  have 
conu'  through  the  chiasma  withoid  decussating  from  the  temiioral  half 
of  the  right  retina,  the  other  and  larger  portion  of  the  fdircs  of  the  tract 


^^ 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


„..,  uu.  nas.l  hair  of  iho  n   ma  .  M    •  ^^^^^  ,.^^^.^,^  ^^^^.  ^,„  ^,^^„,, 

,hU'.    'I'll,  fullnsvin- aiv  thr  iu(»l  luil-oHai  I  uhu  , 

of  tlio  tract  aiul  .if  tlu'  ^;1'"'^'":'-  ,,.  ,,„  ^i,^.  ,i.l,t  Mo.  this  iuxhIikh's 

1,,,  „r  funclinn  in  Uu.  t-'M'-a      a,    ol      c  Kt  ^^^^^^^  .^  ^^^^^^  ^^^^^^  ^.^.^^,^^ 

ti,,  nas.l  half  .-'•  ih..  re  lua  ..n  tin  '    ^  ■    '  •  :   ^  ,^,,,i^  ;,  ^,,,„,a  homony- 

::..  iK'nuanopia  .;  la,.-al  "--;-!:- ^J^  u  '  h!  half^.f  .ach  visual 
half  uf  ..a.h  ivtina  hnn^  '""'.'"^''  \  ;',  L  and  only  a  i.u.li-.u  of  the 
„,U1  is  hln.d.  'l-iu.  hcunanuiua  '"'»  ^  [  '  !  '  j  i,„  „„v  hal.  iho  nonual 
''^>'^  Held  ,uay  lu.  lost.      1  h.  -j'   ^^    ^^^  ^J^,  i,  ...maion.     Whou  the 

-;:;:';;:;;  ::,rid:;;d:h;::i;;;;-;^;;-.ouu 

,M  /...,..  ./■  '^f  ^  Vrr  i;7   c^'U-   i   /lil.v.s  ,.ass  .^.1,  su,n.ly  the 

'"^'  -""■'''  'Tr7^':f'l h^n.    mv      -1  'i..;  i.>  <->.-lu--loss  of  v.s.ou 
i,„„,,  „,  nasal  halves  ol  tlu  n  ini.v ,  p  temporal  hemianopia. 

-  t!H.  ou.or  half  of  each  li.ld,  or  w         >  ^^  ^^    ^;^:,,U  iot  ..nly  the  central 
^,>)  If  the  lesion  .s  """•^' ,;'-^^'">^'^'-     .  '      .  „f  tho  e..nHnissnre,  in  wlueli 

i::';;;;;:i:;:^;!;:S::ru:i:::^..::'w^---. " ' '"■' 

in  the  other.  infreiinent  from  pressnre  of  tn- 

^:5)  still  nun-e  ^-^^•■-'^■'' ;'';^'"  •  ,  ^^  ;!.  involved,  and  total  blindness 

,nors  in  this  region,  the  -••'^''^'  ^  ''         ,  '  ,„,,  often  he  traeed  in  a  suigle 

results.    The  dilVerent  stages  'l^/'  y^^,,,     ;^  kindness  in  one  eye  .ah 

,„e  fron,  Unnporal  lu;nuanop>  .  un      •  n,  L      ^^               ^^^.  ^^,_^^,^^ 

tunporal  hendanop.a  .n    lu'  "*    ^J  '  "^^    /^^  ^i^,  ,^,^U,  involves  on  y    he 
,)  A  lin.ited  lesH.n  .d  the  outer  pa  t     t  ^  ^^^^^^  ^^^^^^   .^^^^^^^  __^_^^ 

,i,.l;  iihres  passing  to  the  tenM-ond   luh  s  o^    ^  ,„„,,„,,,,,     This,  of 

"'-*^--  •''  ^"^'  ^r"'  \;:;;d  ;  na^U      n'^^nopia  n,ay  oc.ur  as  a  nmn.- 

S:::nran;i  in  tu:;;;;;sn.:olving  the  outer  t.^ 

(1)  .,/^,r/H.<.s-  of  the  Trarl  and  Centres. 

1,oav.  and  to  the  antenor  M'-  ^^^  ^  ,2,  .^fil.ves  pass  into  the  po.- 
tln^e  parts,  in  ^vhieh  the  l"*^''  1  ^  ^'^  ^^^,  „,,i,,it,l  lohe,  forming  he 
,.„,,,,  „rt  of  the  internal  -^P^  ^^^  ^  ^,  X;^  in  and  about  the  cuneus  the 
tU.res  of  the  optic  rad.atum   ^^1^'  ^  ^  "''^^^ffl,,,,,  of  the  medial  division  of 


^^ 


DISKASRS  OP  THE  CEREmJAL   NERVES. 


1043 


ila"  ni'vvo 

c  cm  oiuli 
ill  Iubkiu.s 

;    pVO(llKH>S 

lo,  cUkI  oil 

liiU'  vij^iuii, 

\  hoinoiiy- 

tlic  rifxli^ 

liou  ot  tlu! 

[lie  iioriuiil 

Wlu'U  the 

,  arc  liliiitl, 

■uU',  chiclly 
siipiily  the 

ij^s  of  vit-iou 

iiiianopia. 
tin-  I'l'iitral 

ro,  ill  wlii'li 
hoiiuanni)ia 

'ssiiro  of  tu- 

a  in  a  siiigU' 
UU'  eye  Willi 
(hu'sri. 

Ivi's  only  the 
in.l  induein.i: 
tia.  This,  of 
uv  as  a  inani- 
oach  tract. 


ic  hinder  part 
,)i'  whit'h  (the 
■ral  geniculate 
enlns).    Troiii 
:  into  the  pos- 
,0,  forming  the 
he  cnneiis,  the 
dial  division  of 
)storior  qxiadri- 
commis?nTa  in- 
action with  the 


r  V  P O H  A L-'J        ,    .      A  I 


%.i.^'^^^ 


NASAL       V   5    y  ,,,,,, 


>>J  O 


''su^^ 


Fi(!.  0. — Dinsrain  of  visual  paths.  (From  Vialot.  niinliru'd.)  OP.  N..  0|itio  iiorvo. 
Ol'.  ('..  Optic  chiasin.  Ol*.  T.,  Optic  tract.  0['.  ]{..  Optic  radiatidiis.  OKN.,  (iciiic- 
uliile  body.  Tli(^.,  Optic  tlialanuis.  C.  C^l'.,  Corpora  (|uailrip'iiiiiia.  ('.('.,  ('or|ius 
(  allosuin.  V.  S.,  Visual  s[)cccti  centre.  A.  S„  Audilorj-  speech  centre.  M,  S.,  Motor 
t^peecii  centre.  A  lesion  at  1  causes  blindness  of  that  eye;  nt  2,  bi-teniporal  heuiia- 
nopia;  at  li,  nasal  heiniunopia.  Symmetrical  lesions  at  ;i  and  Ji'  would  cause  hi-nasal 
heuiianoiiia;  at  4,  hemianopia  of  both  eyes,  with  hcmiauopic  pupillary  inaction;  at 
5  and  O,  hemianopia  of  both  eyes,  pupillary  reflexes  normal;  at  7.  amlilyopia,  espe- 
cially of  opposite  eye;  at  8,  on  left  side,  wortl-bliiulne.ss. 


^^ 


DISEASKS  OK  TlIK   NHKVOlS  SYSTEM. 


•   1    ,;  .  .  tli.it  the  corticiil  viJ^iiiU  contro 

v:::Jz:^:^^^^^^^^^^^^^^  -" -^^'- 

l,,j,„-  part  nl  ..a.l>  trart  ...U   .>.     ('    .^  ^^^^^,  ,,,,  ^.j,,,^,,  ,„  ,!>,. 

.,„U,,,s  .iu>t   Hu.n.iu>u.a  lu  tlu'  '7'1  \;V      iU.iil..vsnniH...,>tu'va.liation. 

('/)   l-->  "'   *'"■  '■':,ir"-  : .  :      •    ;   .  Hl.,uv  m  sl.uw  H.at  l.si.m  or  .iK.  an- 

;;:;;:;-;;,;-.!:!;:,l-r;:J^ni:::Jt,.^..»..«."-- ^^ 

^'^  "''•i'"'^'-  ,  ,     •  „  .  •„,  ,1,0  .n.tir  lu-n-e  in  .lillViv.it  situations  from  tlu' 

'Hu.  HVr.ts  <.!  lesions  m  the  o]  tu  ^^^,  ^^^^^  ^^       .  ,,,,,,,.^. 

,,„i,,,l  ,„..„>iuu  to  tho  bnun  ->;  -  ;^'  ^  l)^  V,,  ^.ic  .hiasnia.  eitluT 
_total  l.iindn.ss  of  tl"\-;'-'-^-l'"  >  ";;  \;,.  '  .  ;,  i,,,,,!  x.l,  or  nasal  luMni- 
,,„„,„ral  lu.n,ianopia,  ,1  the  cc.Un  ^  '..^^.....j.    3)  lesion  ot  tlu- 

.,;,,,s  lateral  henuanoiua:  (0  1  -  Ml  ^^^^^^^^  ^^^^^^.^^^  ,^^,_^^^. 

anopia;  (r.)  U's.on  ol  tlu     >" "^ J^^   ^^  ^^.^,,  i„,,„ia„opia,  ^'>nu4.mes  crosscl 

"-i;y;;^osis:^r  xlnt .  ..^^ 

Ih.  physiology  of  tho  nerve  ^'^  -  ^^  ^  ^^  ;  ;,>  I,,,..  Havin,  .leter- 
,„.  ,„„u.vtake  the  .hagnosis  of  1'"^ '"  '  ^V,;,,,  ..i.^s  as  to  the  situatum 
,ninea  the  presence  •^f.^--"'^-'!"",  Z;,  \  ,  biasma  and  the  .enieulale 
"f  tho  h.ion.  whether  m  ^1>;' ^'"'^^'V  1"  ,  ,■  letweou  these  ho.lies  and  the 
,,.,aies  or  in  the  eentral  l^f '^  ,  ,,  ^^  '  ;^.„n,  eases  by  the  lest  known 
visual  centres.  Tins  ean  ^'^  f ^^^  ^  ^^^  "  .p,,,  ^,.,,11  reilex  .le,>enas  on 
as  Wernieke's  hnmo,nr  P''/''"''^'  ,:,,!,,,,„,.  on  the  lihres  of  the  op- 
tho  integrity  of  the  v.Un.  -  ^^  j^'^^;  ,  1,,,  ,„a  the  nerve  eentre  at 
tic  nerve  and  tract  ^^huh  tumsm,    the       i  ;,,,,, ion  and  trans- 

tho  tern.ination  of  the  opt.c  trac     \1^  ^       -  ^^      .J^,  to  the  iris. 

„.its  it  to  the  third  nerve  alonjx  ;^  '  ;^\,,^.  ^  reacts,  the  integrity 
If  a  hri,ht  li^ht  is  thrown  mto  the  ^  ;<"  ^  ,J  .^  ^,,,,  ,f  lateral  henn- 
,f  this  retlex  arc  is  '  ^^  ''^  ^'^-^  "  "  ^  at  it  falls  upon  tho  blind  ha  f 
anopia  so  to  throw  the  h,jht  !"\'  \  >^^  ,,,  ,.„,traets,  the  indication  ,s 
.,f  the  retina.  If  ^vhen  tins  ^^ ;^'^ ^J^^  bv  ^vhich  we  mean  that  tho 
„,,^^  ^,„  ,,,u.x  arc  above  'f'^."^'^^^,^  \,  the  centre,  the  centre 
,i,  ,H-rve  iibres  from  the  '•^■<"?  /  .  J' 'l^  .,,,u  a  case  the  conclusion 
itself,  and  the  third  nerve  are  unnuohed.     m  aui 


'^^^^^W^^^^ 


DrsEASHS  (»F  TIIK   CHRKIMJAI-   NKIJVKS. 


104.") 


centre 
i-.gular 

roi'tii'al 
III'  situ- 

IlllllUUS, 

iih  till! 
nnii  tlu' 
•  ill  tlic 
idiatinii. 
osult  in 
'  the  aii- 
iiiaiu'iiia 
•oat  rtm- 
Icd  Willi 
le  iialuro 

I'l'diu  tla' 
ilic  lU'i'vo 
.la.  citlii'i' 
sal  lit'ini- 
i)n  of  the 
i)(ly.   iivii- 
nci've  lie- 
M'al  lienii- 
(())  U'sion 
les  (•v<t>>i  '1 
('.  9,  with 

iir  idea  of 
syniptoins 
in^f  (U'tei- 
c  situation 
jfenirulato 
ifs  and  tiie 
ti'st  known 
U'i>i'nds  on 
;  of  the  o|)- 
e  centre  at 
1  and  trans- 
,  to  the  iris, 
ho  inte.izrity 
literal  hemi- 
e  hliml  half 
indication  is 
can  that  the 
,  the  centre 
lO  conclusion 


would  1).'  jii^tilicd  that  the  cause  nl'  the  hciiiiaiio|pia  was  central;  that  is, 
situated  heyorid  the  ,<:eniciilate  liody.  either  in  the  lilires  „\'  the  (i|ilie  radi- 
iiti(Ui  or  in  the  visual  eiirlic;il  centres.  It.  on  the  utiier  h;ind.  u  hen  the 
li;:ht  is  carernliy  thrown  on  the  hemiopie  JiiiM  uf  the  retina,  the  |uiin!  re- 
mains inactive,  the  conclnsioii  is  Justilialile  thiit  ilu'iv  is  inlerni|ition  in  the 
jiatli  lietweeii  tiie  retina  and  (he  inieleiis  df  the  third  nerve,  and  that  the 
lieniianopiii  is  not  centfalrhnt  de|ieiHient  npoii  ,i  hsidu  .-itnaled  in  the  (iptic 
tract.  'J'iiis  test  of  Wernicke's  is  sometimes  dillicidt  to  ohlain.  Jl  is  best 
|ieri'ormed  a.-  fiiijow-:  " 'I'lu'  patient  heinu'  in  a  dark  or  neaily  dark  ronni 
with  the  lamp  or  ;:as-liuht  hi'liind  his  head  in  the  usual  position.  I  hid  him 
lodk  over  to  the  other  side  lA'  the  room,  so  as  to  exclude  acc(unmodalive 
iris  movenuMits  (which  are  not  necessarily  associated  with  (he  rellex).  'i'heii 
1  throw  a  faint  li^ht  from  a  plane  mirror  or  from  a  lar:;-e  concave  mirror, 
held  well  out  of  fciciis.  upon  the  eye  and  note  the  >i/e  of  the  pupil.  With 
my  other  hand  I  now  throw  a  heam  (d'  li,nhl,  focus-ed  fi'eni  the  lamp  hv  an 
ophthalmoscopic  mirror,  directly  into  the  optical  (cntiv  of  the  eve;  then 
laterally  in  various  |)ositions,  iuid  also  from  ahove  and  heh.w  the  e(piainr 
of  the  eye,  notiiijr  the  reaction  at  all  anjiles  of  incidi'iice  of  tin-  ray  of  li-lit."' 
(Sequin.) 

The  sijiiii  Ilea  lice  of  hemiauopia  varies.  There  is  a  functional  liemi- 
anopia  associated  with  iid.u'raiiie  and  hysteria,  in  a  coir-iderahle  propor- 
tion of  all  cases  there  are  sij,nis  of  orpiiiic  hi'ain-disease.  in  a  certain  num- 
ber of  instances  of  sli-ht  lesiens  of  the  occipital  lohe  hemiachroiuatopsia 
has  heeii  ohsci'ved.  The  homonymous  ^udves  (d'  the  retina  as  far  as  the 
fixation  point  are  dulled,  or  hliml  for  colors,  ilemipleni,.,  js  common,  in 
which  event  the  loss  of  |)<i\ver  and  hlindness  are  on  the  same  side.  Thus. 
a  lesion  in  the  left  hemisphci'e  involving:  the  motor  tract  produces  riuiit 
hemii.le-ia.  and  when  the  lihres  of  the  optic  radiation  are  involved  in  the 
intei'iial  capsuh'.  there  is  also  lateral  hemiaiio|)ia,  so  that  oltjects  in  the  Held 
of  vision  to  the  ri,<rht  are  not  perceived.  Ilemiaiuesthesia  is  not  uncommon 
in  such  cases,  owin,<:-  to  the  close  association  of  the  sensorv  and  visual  tracts 
at  the  po.>^terior  part  of  the  internal  capsule.  Certain' forms  ol  aphasia 
also  occur  in  many  of  the  ca.'^os. 

The  optic  aphasia  of  Freiiiid  mav  he  mentioned  here.  The  patient  after 
ao  aiioplectic  attack,  though  ahle  to  reco^niixe  ordinarv  ohjects  shown  lo 
him  is  unal)]c  to  name  them  correctly.  If  he  l)e  jiermitted  to  touch  the 
ohject  he  may  he  ahle  to  name  it  quickly  and  correctly.  Freuud's  optic 
aphasia  dill'ers  from  mind-hlindness,  since  in  the  latter  ail'ection  the  ohjects 
seen  arc  not  reco<,niized.  Optic  aj.hasia,  like  word-hlindness.  never  oc'curs 
alime.  hut  is  always  associated  with  lieiniano|.ia.  or  mind-hlindness,  and 
often  also  with  word-deafness.  In  the  cases  which  have  thus  far  come  to 
autopsy  there  has  always  heen  a  lesion  in  the  white  matter  of  the  occipital 
lohe  on  the  left  side. 

MoTuu  \i:i!vi;s  ok  Titi:   Kvi;n.\r.L. 

Third  Nerve  (Xfrnif<  (,(;iloiiinloriits).~Thv  nucleus  ,,f  oriuiii  of  this 
nerve  is  situated  in  the  floor  of  the  aipicduct  of  Sylvius;  the  nerve  passes 


■J 


msKASRS   ..F  TllK  NKUVOUS  SYSTEM. 


-''  -IM'l-s,  Uy  i.^  -M--      ',:;,.    :\,,,,,u  the  nm.nu.l  ..n.l   -n  on-, 
th..  sui-crior  nrlus.  i.iul  l.>    "■'."'     .......hIhs  puss  to  thr  nliavy  uuw  U 

-timusH.s.n.l,i..n.U.n--i;;P^^^^^ 

:l,^:::;r;;;;:r;r;:H;.;:;  v;n;.^  .. ... ..,. ;. 

,,,^,,„,     U,,ia.     Mnn.  —'•>,':„:;,,„  ,,  is  a,.a.k..l  l.y  a  ^-'-^;^^^-^ 

l,,,,,vsis  or  all  ll.v  •""^^•^;'^-,\  „,,,,■,    ana  a  little  dowuvanl  an, 

.      rd.  ■  TlH-v  is  .livc.v,c...t   ^tral-'n">.  ;    ^/^.j    ,,,,,     ,',,0  pui-il  is 

X^  ;    K.r  .yclul.  owin,  to  paralys.s  n       ^  k  .Uo>  ,  ^  1^^^    ^^^^^^^_.  ^^  ^^,,^ 

,,,,li;  ailatca.     It   .kos  -'t  .■;     .  ;  /;;  ;^,,,  .,r  tins   .aralysls  aro   tho 
,„naaUon   is  lost.      >'''V"'^V  raouM.  vision,  a.ul   tlu-  V  ;;s.s.       n 

■        i,,  ehielly  WOUU.U.  a.ul  --''-'i;;'^^      j      ^ a  .nonth;  in  otlu-vs  a  ,nmu 
,,,;,,  the  attacks  have  -•-"('^  ;    ^  ,  ,H„.i.t  throughout  liie.     Ihoy 

,„,,,  ,.n.Hl  has  .lapsch      »  ^      ^    ,    ^  J,,,.,  aua  sou^timcs  .,th  uu- 
,,0  sonu.tiu.os  associate.    vMth     a  >  literature  •^:5  eases. 

;  aine.  Mary  Sherwood  ^^  ^  ^J  ^  I,,,,  ;„  „.rvous  atVeetions.  ^^  e 
"  />/„.s;,s.  is  a  eonuuon  and  •••>!"•>  \^^^,,.  ,^,,,i,,,  it  ,nay  occur:  (a)  A 
,„,  l,ere  hrielly  ivlVr  to  ^^^  .^  ^'  :  ^^^.tK  seen:  (^)  the  fovn,  assue,- 
,.„i,enital,  ineurab  e  '"'•"^/Vira  nerve,  either  iu  its  course  or  at  it. 
•itod  with  dctinite  les.on  ot  <1'^"  "'"'";,  •  ..f  t,,,  sunerior  rectus  alone  o, 
;  il.  This  nu.y  conu-  on  -  ;  i^ ^^  ,''  ,!'i  as^oll.  (0  There  are 
,ith  varalvsis  ot  the  .uterna  ^  ^^  ;.•  ,^,a  with  eerehral  lesu.ns  w.th- 
in.t.uces  or  conqaete  orpartu     ,.t  ■>  ^^^.  „.,iv.ea.     T'he  exact  V- 

;;.;  „..  other  branch  ot  ^^^  ^^  ^  ^^^      'U  \.ukuown.     (^0  Hysterica 
sition  o\  the  cortical  centre  m  or.  ^^^^^^^_.^^^,   synipl""'-     (') 

,,tosis.  which  is  *l"»'''';/>"!\;'',;^,,„hetic  nerve,  is  as.ocudea  w.  1 
Weuao-ptosis,  due  to  ailcctHm  -^}^^^\^^^^.^^^^  ,f  the  t.n.i.erature  on  the 
.vnn.toms  or  vaso-motor  ,mls  .  ^  '       '^^  .\'  ,;  ,,.„,     Contraction  ot  the  pupd 
„V.;tea  siae  with  reaness  an     -Um  -    V^  ^^^^,^^,^  ^^,  ,^,,  ,,,„„„,, 

luoniiug. 


DISKASKS   OF  TIIK   CKlJKliUAl,   NKKVIX 


loi: 


he  wall 

>ris  ami 
inlVriipr 

•   lllUSClt' 

he  lU'i-.t' 

iscasi'  tit 
[■ral  "1>1>- 
s  L■^lUl•^e, 
.(iritis,  a-' 
ird  iKi'so 

oxtcrual 
.ward  and 
(Hiiiini:  id' 
u«  puiiil  is 
of  acfom- 
iri  are  ilu- 
itosis.      In 

Thus  the 
iier.  or  the 
u<eles  may 

Ivsis  atVeet- 
,_  111  some 
iM's  a  mma 
life.  'Hu'V 
L's  with  mi- 
■ascs. 

etions.     W*^ 
leeur:  ('0  A 
form  assoei- 
rse  or  at  its 
.•tiis  alone  or 
.)  There  are 
lesions  with- 
'lie  exaet  \w- 
d)  Hysterical 
]nlltom^.     ('') 
;soeiated  with 
■rat  lire  on  tlie 
n  of  the  I'lM'i^ 
0  slirnnk  into 
:o  nntseles  an' 
in  weak,  deli- 
icularly  iu  tho 


AnK-n;:  the  nlo^t  im|iorIaiit  id'  tiie  syniploins  (d'  the  third-nerve  |iaral\- 
sis  are  tlio^e  which  ichilr  to  the  eihary  muscle  and  iris. 

Ciirlii/ilci/iiK  |iaraly>is  of  the  I'ihary  mu-cie.  causes  joss  id'  the  power  of 
acconnnoilalion.  |)i>tant  vision  is  (dear,  iuit  near  ol.jects  cannot  lie  |iro|i- 
erlv  si'cii.  In  coiii-eiiuenci'  tiie  vision  is  indi>tinct.  luit  can  he  restored  hy 
the  n>e  id'  -cnvex  <.da->cs.  'I'his  may  occur  in  one  or  in  l)oth  eyes;  in  the 
latti'r  ea^^•  it  is  n>uallv  ii>sociated  with  (hsea.-e  in  the  nueK'i  of  the  nerve. 
Cvelople-ria  is  an  eaily  and  frciiucnt  symptoiu  in  (hohlhentic  paralysis  and 
occurs  also  in  talii'S. 

/W(A//*/r'//r/.  or  paralysis  of  the  iris,  occurs  in  three  forms  ((;(.wer>). 

((/)  ArnniiiiKiildllrr  iritloplrijid,  in  which  the  pupil  does  not  dimimsh  in 
size  durin-,'  the  act  of  accommodation.  'I'o  test  for  this  the  patient  slioidd 
look  lirst  at  a  di>tanl  and  then  at  a  near  ohjei  t  in  the  sanu'  line  id'  vision. 

(//)  J,'f/lr.r  liiih>j,l('iji(i.—'l'\\i'  path  for  the  iris  rdlex  is  alonj:'  the  optie 
nerve  and  tract  to  its  teiiuination,  then  to  the  nucleus  of  the  third  lu'rve. 
and  aloiiir  tiie  trunk  id'  this  nerve  to  the  ciliary  eaiieli,,i).  and  so  throu;;ii 
the  ciliary  nerves  to  llu'  eyis.  ivuh  eye  should  he  tested  separately,  the 
other  one  l)ein<,^  covered.  Tiie  iiatieiit  should  look  at  a  distant  ohject  in  a 
dark  part  of  the  room;  then  a  li.uht  is  hroii-ht  suddenly  in  fro.it  of  tiie 
evo  at  a  distance  id'  three  or  four  fei't.  so  as  to  avoid  the  elVect  of  at'coninio- 
d'ation.  Loss  of  this  iris  reilex  with  retention  of  the  aeciuiiinodatioii  I'on- 
traction  is  known  as  the  Ar^ryll  Hohertson  piijiil. 

{(■)  J.ds.i  (if  Ihc  >'/,■/»  li'('flr.r. —  if  the  skin  of  the  neck  is  piiuhed  or 
jiricked  the  impil  dilates  reilexly.  the  alfereiit  impulses  heiii^^  cvHiveyed 
alonji'  the  cervical  syni|)athetic.  Im'))  pointi'd  out  that  this  skin  veliex  is 
lost  usually  in  association  with  the  ndlex  contraction,  iuit  the  two  are  not 
necessarily  conjoined,  in  irido])le<,Ma  the  pupils  ari'  often  small,  particu- 
larly in  sjiinal  disease,  as  in  the  ciiaracderistie  small  pupils  of  tabe.s — spinal 
nivosis.     Jridople^da  may  coexist  with  a  [uipil  of  medium  size. 

Inequality  id'  the  ]iu])iis — aniscoria — is  not  inrre(|uent  in  |)ro;,'ressivo 
paresis  and  in  tabes.     It  may  also  occur  in  perfectly  healthy  individuals. 

Sposin. — Occasionally  in  menintrilis  and  in  hysteria  there  is  spasm  (d' 
the  muscles  supplied  hy  the  third  nerve,  pjarticiilarly  the  internal  rectus 
and  the  levator  palpel)ra'.  The  clonic  rhythmical  sjiasni  of  the  eye  museles 
is  known  as  inishKjiiiiia.  in  which  there  is  usually  a  liilateral,  rhythmical, 
involuntary  movement  of  the  eyeballs.  The  condition  is  met  with  in  many 
con;4-enital  and  acijuired  brain  lesions,  in  albinism,  and  sometimes  in  eoal- 
niiners. 

Fourth  Nerve  {Xfrnis  Irorhlcnrix). — This  snpjilies  the  sujierior  (d)li<iuo 
muscle.  In  its  course  around  the  onter  surface  of  the  crus  and  in  its 
jiassajre  into  the  orbit  it  is  liable  to  be  eomi)ressed  hy  tnmor.«.  by  aneurism, 
or  in  tlie  exudation  of  basilar  nienin<ritis.  Its  nucleus  in  the  upper  part 
of  the  fourth  ventricle  may  be  involved  by  tumors  or  iinderjro  deireneration 
with  the  other  ocular  nuclei.  The  su])erior  oblitiue  muscle  acts  in  such  a 
way  as  to  direct  the  eyeball  downward  and  rotates  it  slijrbtly.  The  paralysis 
causes  defective  downward  and  inward  movement,  often  too  .slight  to  be 


msHASKS  OP  THE  NERVOUS  SYSTEM. 


,,  ,  This  norvo  .MiuM-cs  at  tlu.  .imutiou  nl 
Sixth  Nerve  (■V'''-''"^"'"''"''''"  •"  l,,nl,  it  outers  ll^.  o.l.U  an.l  sui- 
,    the  oxtvrnal  ivrti.s  musrU'.      \    j'  ,    \,„^a.     There  is  internal 

I'V ^^-;;^i;::;'r:;ort.cr.>«.ti^.^.  i>i,.io.>.  ^eenrs  on 

,,ternal  reetv.s,inal.ilityot  the  .nte     ^     U  ^^  H^   ^^^  ^^.^^  ^^,^^^      ^^^^  i 

;.  i,nvar.l.     As  a  eonse.,uenee  <'  /  ^     ';- *  ;„,,h,  ,uio,  away  fnun  the  .we 
i  huth  are  oonjn..ately  <  ev>a  eJ    u  t       <,  ^      ^^^^  ^^^  ^^^^  ^.^^^^  ^^^^^^  ^,      ^^^^ 

iibrcB  up  i'^  *1'^-  l'""\  '       ;  ,.,    Ive  UH      We  thus  have  paralysis  of  th 

l.rvc  Nvhieh  supplies  ^l^^^'"^'''         '  't,,,   thinl   nerve  heiuj^   nnulve.l 

.  tovn-il   r.-.tus  witlu.ut  the  luuleu.   ol   tne  „H,venient  from 
;^r  o          reeeivin,  its  nervous  unpuW.      r  pu  .^  ._^  ^^ 

^hc  ^ix       n-l-'^  "f  ^^'^  "l'^'-"'';;       1-itJ^^  the  pons,  it  is  frequently 

iXliy  to  the  fanal  "--  ^    ^^^^    ^^.^^.  is\.araly.ea.  an.l  ..ves 

innul  that  the  whole  '>f  ^^^      ;^.,;^.        „  that  with  a  lesion  ot     he  /-^ 

the  eleetri<'al  reaetion  ol  ^'^^-7;\\;;  ^  ,,,,  „f  both  eyes  to  the  Uilht-u  e- 

xth  nueleus  there  is  -'>J^f  ^/^^   I't  internal  reelus,  and  sonietune, 

divides  tlie.n  into  live  groups:  ,,,ralvsis  of  the  external  rectus, 

'"'(„)  Lunilalion  of  ^/-'--;  ;"  .    ^    W   en  ihe  paralysis  is  incomplete 
the  e  eball  cannot  bo  moved  ""t^^a     ■  ^^  ^^^^  ^,,,,,, 

tbe  movement  is  deficient  in  Vr^^^^,,  ..^t  correspond.     Thus,  pa- 
A  .S/ra?.i.s«r«s.-Tho  axes  ot  the  ^^^  ■,,,^.  ,f  the  external 

raljSl  of  the  internal  -f^^^jj^^l^i'^nlv  evident  when  the  eyes  are 
^ecius,  a  -"vovgent  squint      At  h;      U>        ^^^  ^^^^^^^,^^  ,^  ""^  'J  bo 
1    „  +iw.  (lirpf'tiou  01  tne  atuiiii  vji  (loviation  ot  inc 

inarv  deviation.  ,m     ^be  patient  is  looking  iit  an  ob- 

c)  .S^cr-"?"'-.'/  ^'"•'""""•7^';        t  1      fixes  the  object  looked  at  ^^    h 
ioct     he  sound  eye  is  covered,  .0  that     c  .^^  ^^^^^  ^^^,,^    ,^,. 

;:!'Icted  eye  oiily,  the  --^;^;;^^r;:^  llie  opposite  hitornal  n«du. 
rcction-e.  g.,   outward--witl    ]  aia  ^^^,  f,,t  that,    t 

This  is  known  as  ^^^""t""^;   V  1    en  0  e  is  weak  and  an  elTort  is  made 

!:;rr;^lt'^:^^-;— ^^  .lation  of  external  ... 

Ul)  Enoneov^  ^  '■"^''''"    Trn  1  of  their  imaires  on  the  retina;  hut  ^^ <^ 


DISEASKS  OF  THE  CERERRATi  NERVES. 


1040 


10    SiiUUi 


iiution  tif 

ami  sui»- 

tlu'  l»;i^<'. 
s  inti'i'iial 
(R'l'urs  on 

^•^is  (it  tho 
)  Uirn  that 
.j)t  parallel 
m  the  side 
K'l've  seiuU 
)()site  third 
[ysis  (it  the 
II-   involved, 
■ment  from 
;  is  in  >^iieh 
s  t"re(iuently 
il.  and  giverf 
,  of  the  left 
ri<iht—\.  e.. 
.d  sometime-s 

lye.— Gowers 

tornal  rectus, 
is  incomplete 

lalsy. 

1.  "Thus,  pa- 
thc  external 
'U  tho  eyes  are 
t  may  hecome 
.'viation  of  the 
called  the  pri- 

:inir  at  an  oh- 
l„okod  at  with 
in  the  san\o  di- 
intcrnal  rectus, 
lu'  tact  that,  it 
1  ciTort  is  made 
■rfully  upon  the 

of  external  oh- 
3  retina;  hut  we 

a  of  the  eyeball 


as  indicated  <«•  us  l.y  the  innervation  we  },'ivc  to  tl\e  ocular  muscles" 
'(<i()\vcrs).  With  the  eyes  at  rest  in  the  nii(U|M>sition.  an  ol.ject  at  wiiicii 
\ve  are  Incking  is  directly  opposite  our  face.  'I'lirnin^'  liu'  eyes  to  nne^ 
side,  we  recoj;nize  that  ol.ject  in  the  middle  ol'  tiie  lield  or  to  the  side  of 
this'l'ornier  position.  \Vc  estimate  the  degree  l.y  tlie  amount  (.t  MK.vcuient 
of  the  eyes,  and  when  the  ol.ject  nw.ves  and  we  f(.llow  it  we  judge  ot  its 
position"l.y  the  amount  i.f  nK.vemeiit  of  the  cyclmlls.  Wlieii  (.ne  (.cular 
nuKcle  is  weak,  tlie  increased  iniuTvation  gives  the  impressi(.n  (.t  a  greater 
nK.vement  (4'  tlie  eve  than  has  really  taken  place.  The  mind,  at  the  same 
time  receives  the  idea  that  the  ol.ject  is  furtiuT  on  one  side  than  it  really 
i.  and  in  an  attempt  to  touch  it  the  finger  may  go  heyond  it.  As  tho 
,  '„ilil,num  ..f  the  l.(.dv  is  in  a  large  part  maintained  hy  a  knowledge  of 
the  relation  (.f  i'Xternarol.jccts  t(.  it  (.litained  l.y  the  action  of  the  eye  mus- 
des,  this  erroneous  projecti(.n  resulting  from  j.aralysis  disturhs  the  har- 
mony of  these  visual  impressions  and  nuiy  lead  to  giddiness— ocular  vertigo. 

(f)  Dniihh  ri,si,y».— This  is  one  of  the  most  disturl.ing  features  of 
paralv<i^  (.f  the  eve  muscles.  The  visual  axes  do  not  correspond,  so  that 
there"  is  a  .louhle  "inuige— diph.pia.  That  seen  hy  the  sound  eye  is  termed 
the  true  ima-e;  that  hy  the  paralyzed  eye,  the  false.  Jn  simple  (.r  lu.nK.n- 
viiH.us  dii.I(.pia  the  false  image  is  "  on  the  same  side  of  the  other  as  the  eye 
l.y  which  it  is  seen."  In  cn.ssed  diph.pia  it  is  on  the  «.ther  side.  Jn  con- 
ver"-ent  squint  the  diploiiia  is  simple;  in  divergent  it  is  crossed. 

Ophthalmople^a.— Inder  this  term  is  described  a  chronic  progressive 
jiaralysis  of  the  ocular  muscles.  Two  forms  are  rcc(.gnized— (.phthalmo- 
j.lcgia  r.iicriKi  and  onhthalmoplegia  inln-iia.  The  conditions  may  occur 
separately  (.r  t(.gether  and  are  described  hy  Gowers  under  nuclear  ocular 

palsv. 

bphlhiiliiinjilriiia  r.rlrnut.— The  condition  is  one  of  more  or  less  com- 
j.lete  palsy  (.f  tlie  external  muscles  of  the  eyeball,  due  usually  to  a  slow 
degeneration  in  the  nuclei  of  the  nerves,  but  sometimes  to  pressure  of 
tunu.rs  or  to  basilar  meningitis.  It  is  often,  but  not  necessarily,  associated 
with  ophthalmoplegia  interna.  Siemerling,  in  a  monograph  on  the  sub- 
ject, states  that  (>'i  cases  are  on  record.  In  only  11  of  these  could  syjihilis 
he  positively  determined.  Tho  levator  muscles  of  the  eyelids  and  the 
superior  recti  are  first  involved,  aiul  gradually  tho  other  muscles,  so  that 
the  eyeballs  are  fixed  ami  the  eyelids  droop.  There  is  sometimes  slight 
]ir(itrusion  of  the  eyeballs.  The  disease  is  essentially  chronic  and  may  last 
for  many  years.  It  is  found  jiarticularly  in  association  with  general  jiaraly- 
sis,  locoiiu.t(.r  ataxia,  and  in  jtrogressivo  nniscular  atroi)hy.  ^lental  dis- 
orders were  present  in  11  of  the  (y'i  cases.  With  it  may  be  associated 
atn.phy  of  the  optic  lU'rve  and  affections  of  other  cerebral  nerves.  Occa- 
sionally, as  noted  by  P.ristowe,  it  may  be  functional. 

0 {MmhmpJpgia  inlcnia. — bmathan  lhitchins(.n  applied  this  term  to 
a  prf.gressive  paralysis  <.f  the  internal  (.cular  muscles,  causing  loss  of  pupil- 
lary action  and  the  power  of  accommodation.  When  the  internal  and  ex- 
ternal muscles  are  involved  the  affection  is  known  as  total  ophthalmoplegia, 
and  in  a  majority  of  the  cases  the  tw(.  c(.nditi(.ns  are  associated.  In  some 
instances  the  internal  form  may  depend  upon  disease  of  the  ciliary  ganglion. 


i 


1(150  I.1SKASKS  OV  TIIH  NHUVelS  SYSTKM. 

Treatment  of  Ocular  Palsies       t.       \  ^^^^^^.^^  ^^_^^  ^^^^_ 

stinal.'.  aiHl  ivs,>l   ImmIum  lit.     «  .  .  ^,^^^^,^  ,,,„,,„r.l  with 

,^,\^  ,„,v  ,,a>s  away  '■l''''''''''''''':^'-\\    '    ^      ,,,„i.  ,n,l  l,„ll.ar  l-aialv- 

Al„.ll..:   ill..l    slri.l.lllil.    II"     I'll"  I     ".I  I         f,,,,,,,,,,;,,!,,,!*  iiii.l  .""11- 

»„v  ..»s.  in  .I.Ul,  II s,.n.  ».u...  »'';.,",,.    .,.,„.  ,|i,-,..l  l,v,,l- 

i.'i--i"-ii^iii ;'• ':^  »i'''';:^  ;:;,,:.■  i.H  ,M ■■■iv  «„i...,i 

r;; ,: 'u     IV  ,!!:..v.!  Ill v,,.i,.i  ,.>..,„,  .,„,..,-.'- 


Kn-Tii  Xkuvk  (.\>n'/.s  Irlnnninus). 


1.   ,•        .  ,  ,\  l)U..i<t>  of  til',  pons  iiarticiilarly  lia'in- 
...•rha,o  or  iml^h-s  ..    scl.np.      ;>,'.>,„,,,  .,,,,,,  ,,,11.1.  n,..nin,itis. 

;?r;;:;;tr:vi:'.---;Vr;;;;i;^-:;;'';w':;::;::":-^ 
:;"::;;:;';;:  ::;::;r:;;;;v;;;::riw :;".::."- ^...o^ '.»«..'. ... 

inarv  urinitis.  winch  is  fiU''-  ^  ^|      ,,|.ji,   ,„,,.vc>  may 

,,„„,  loss  ul  s...,satinn  ...  t  u      .t.         '  .j-,^.,,^  ,,,,  ,„„,„,„  ..f  th.  lij-s, 

ti,,eu..vspnnain,^suleott.    ..    1.    1     <     >  .   ^,_^.  ^^^,„^.  ^.,c..     Th. 

t.,n,.u«,  l.anl   a.ul  soft   HaU^      ^  ^   ^^     !  .„_     -n.c  ,nns..l..s  ..t  th.  facv 

,na.stlu.>ia  .nay  Ik'  p.vc....U'a  by  t'"^'  "-     J,  ,,„,,,,,      'n.o  sens,  of  smell 

,.enlsoi,.s....sil,U.a.nMl....,ov.mj...^^^^^  l;-'-^^^.   ^,   ,,,,...     ,,,,,, 

i,  intcMr..v.l    with,      llu  0   '     : 'X    !^iva.'V.  lach.vn.al.  amll.n.-al  sonr- 

"•-'''''••''''^'•'"•"■"'''T;     Tn-         t    .     u.  "US  ,m.ml..-ams  h.al  slowly. 
ti.,„s  .nay  b.  k'ss....a,  ala'as.o,..  ol      u  ^^  .  ^,,^,  ,..„.„,,,  ,„,o„u- 

„,1  i,,o  t.dl.  tn.y  1'--'-    "•;;:;:  ^,,  ^  ,,  ;  i,,,,  that  tln.so  svmptoms  only 
dniulv  a...l  may  uhv.'atc..     It  nn-.s  b"    "    >       .       ^^    ,  ^  „,•  ,,,,.  .-ears  tins 

..,,,„-rc.,l  when  the  <i'--'-^^^';"^'>"\   ;:,;"'   ^l^ia  without    .roauci... 
any  troph.e  'I'^t"'''"^"''^'',  /       jj  ^'     ,,,ii,a  l.v  the  ..ewe.  x.sually  the  ^ipper 

SI'S  tsiit ;;.:':;-  :■;•  -- -  tr:';-r ^;- 


DISKASKS  OF  TIIK  CKKIlllKAL   NKUVKS. 


li'.M 


all  lUlltL' 
111'  (nulill' 
IS    tn    llli-^ 

■crliiiii.  it 
la  ari'  nli- 
mililcU'  111' 
iiilf.l  with 
lar  1  111  rill y- 

liiic   CilStS, 

liriii'liciiil. 
li.yitl.      Ill 

Mini  (tmii- 
ircct  licat- 
ily  willioiil 

jii'ir-ins,  1)1' 
-s. 


ilarly  liivm- 
liaM-'  t'f  till! 

iii('uiii;iiti^. 

cauM'S.  ((■) 
n  l)y  tuiiK'i'^ 
I  ami  thinl 
a.     (</)   I'l'i- 

I  iicrvi'  limy 
■  dl'  tlic  fact', 
a  (if  tliL'  \\])>, 
.  silk".     Thii 
s  of  tlio  face 
msc  of  snu'll 
lastc.     Tlii'iT 
hiicial  scciT- 
iiral   slowly, 
viica'  iK'i'onie 
.iiiptdiiis  only 
ato  yoavs  this 
)iit  proiliu'iiii,' 
yet  oxiilainril. 
"illy  tlio  lipiHT 
uliiu'ly  c'lidur- 
witli  the  neu- 

mastication  on 
this  portion  of 


III''  iH'i'V"'.  It  is  tT((i;;iiiz('(l  liy  placiii::  llic  |iii;,fcr  mi  the  iiia--i'irr  and  tnn- 
jHiial  iihi.mIi-.  ami.  uli.'ii  llic  patii'iit  cIums  IIic  jaw.  llir  lVcMi'iu's>  of  their 
((iiilractiiHi  is  iiiilid.  If  paiiily/i'il,  tlic  cNlirnal  |ilriy;:oiil  (aiiih.l  iiinvc 
llic  jaw  Inwai'd  liic  iiiiall'cctcd  side;  and  uiifii  (lc|iiv>-c.|,  ijn'  jaw  di'sialrs 
In  till'  paraly/cd  side.  'I'lic  niiiicr  paralysis  of  ilic  lil'ili  ncrv.'  is  ainiost  iii- 
vai'ialily  a  it.-iiII  of  involvcinriil  nf  the  nrr\c  after  it  lias  |cf(  the  niuleiis. 
Cases,  li(i\\e\er.  have  lieenii-.-eeiated  uilli  enrtiial  le.-i.ms.  Hirl  eniiclndt.s. 
from  his  ea-e.  ilial  llie  eorlieal  niolor  eentiv  for  the  ti'i;:ciniiins  is  in  the 
iiei;:lii)orli(ioil  of  the  louer  Ihii'd  of  the  anterior  eeniial  i  iMiwiliition, 

S/xisin  (if  llif  M ii.sdis  iif  Miisliciiliiiti. — 'rrisiiiiis,  the  iiia>ti(iitorv  spasm 
of  lioiiiher;^,  may  bu  tonic  or  LJoiiii,  and  is  either  an  assoeiated  pi''H'iiome- 
iioii  in  j^ciicral  eoii\  iil>ioiis  or,  nioic  rarely,  an  indepeiideiil  alVeelion.  In 
the  tonic  form  the  jaws  are  kept  close  together— huk-jaw— or  can  he  sepa- 
rated only  for  a  short  space.  The  iiiiKeles  of  ina.-ticalioii  can  he  seen  in 
contraction  and  felt  to  he  hard;  the  spaMii  is  often  painful.  'I'lii.-  tonic 
contraclioji  is  an  early  symptom  in  t<laiiiis,  and  is  sometimes  seen  in  tetany. 
.\  form  of  this  (oiiic  spa.-ni  occurs  in  hysteria.  Occasionally  triMuns 
follows  exposure  to  <Mild,  and  is  said  to  he  due  to  rellcx  irritation  fnnii 
the  teeth,  the  iiioiith,  or  caries  (d'  the  jaw.  It  may  al^o  he  a  >ym|itoni 
of  or;:aiiic  disi'ase  due  to  irritation  near  the  motor  niiilcii>  of  tlic  tilth 
nerve. 

Cliinlr  spasm  of  the  muscles  supplied  hy  the  fifth  occurs  in  the  I'oi'ui  of 
rapidly  repeated  contractions,  as  in  "  chatlcrini,'  teeth."  Tlii-.  is  rare  apart 
from  ireiicral  conditions.  tlioii,i:ii  cases  are  on  record,  iisiiallv  in  women  late 
ill  life,  in  whom  this  isolated  clonic  spasm  of  the  muscles  of  the  jaw  has 
liccn  found,  in  another  form  cd'  clonic  spa<iii  sometimes  seen  in  chorea, 
there  are  forcihlc  sinj,de  contractions,  (lowers  mentions  an  instance  of  its 
occurrence  as  an  isolated  all'ection. 

(r)  llii.yhiliiri/. —  Loss  (d'  the  sense  of  ta<te  in  (he  anterior  (wo  (liirds  (d' 
(he  (oii;,Mie,  as  a  rule,  follows  paralysis  of  (he  lifth  nerve.  'I'lie  -ustatoiy 
llhrcs  pas-  from  the  chorda  (ympaiii  (o  (he  lin.uiial  hrancli  of  the  lifili. 
Disease  of  (he  fifth  iieive  is.  however,  ii(j(  always  associa(e(l  with  loss  of 
(as(e  in  (he  anterior  pai't  of  (he  (on.mie,  in  which  case  cither  the  (a>(c 
fihres  escape,  or  (he  disease  is  widiiii  (he  piais  where  these  filuvs  are  sepa- 
rate from  (hose  of  sensafion.  It  may  he  that  (he  nerviis  intermedins  of 
AVrisher^''  carries  (lie  (as(e  fihres. 

The  (lidi/iKisis  of  disease  ni  the  (rifacial  nerve  is  rarely  dillieult.  It 
must  he  reniemhercil  that  the  preliminary  jiain  and  liv|iei;estliesia  are 
sometimes  mistaken  for  ordinary  neiiralfiia. '  The  loss  (d"  si'usadon  and  the 
palsy  of  (he  muscles  of  masticafion  are  readily  (le(erniined. 

Treatment. — When  (he  pain  is  severe  morphia  mav  he  re(|uired  and 
local  applicadoiis  are  useful.  If  (here  is  a  suspicion  (d'  syphilis,  ap|.ropri- 
ate  (reatnieiit  should  he  given,     faradization  is  somedmcs  henelicial. 

F.vrrAT.  Xi:i{vi;. 

Paralysis  (Jlrirs  Pnls,/).—Tho  facial  or  seventh  may  he  paralyzed  hy 
(1)  lesions  of  (he  corte.x— suiiranuclear  palsy;  (•.')  lesions  of  the  nucleus 


i^^ 


1052  DISEASES  OF  THE   NERVOUS  SYSTEM. 

it.olf;  or  (.^)  involvomont  <.f  11...  n.rvo  trunk  in  its  tortuous  course  within 
the  non.  and  throUL'h  the  wiill  of  tlu>  si<ull. 

1.  .s',M.vn,.r/..r  parnh/.i.,  du.  to  lesion  of  tho  cortex  or  of  the  facia 
fihres  )n  the  corona  ra.iiata  or  internal  capsule    .s.  as  a  rule,  assoe.ate.l 
i„,  lu.nnple.na.     It  n.av  he  caused  hy  tumors,  ahseess    chronu.  .ntlanun  - 
io     or  sol,enin,  in  theVortex  or  in  the  region  o    the  -tcrna    capsule.     1 
i.  distinKui.he.1  fnnn  the  peripheral  torn,  hy  we  l-.narke<l  .harac  e..-thc 
,,.  isteme  of  the  nornud  eleetrieal  excitahility  of  hoth  nerves  and  .nusc-    . 
^,,,,1  the  a..s.  ■u.e  ,.f  involvement  of  the  upper  hranche.  ..t  the  nerve,  so  that 
il,e  orhic  daris  ,.ali.el.raruni  and  frontalis  nn.sele  are  spared      In  rare  m- 
U.C  s    hese  nicies  are  paralyzed.     A  third  diiVerence  .s  that  ,n  tins  t^rm 
the  voluntarv  nu.en.enis  are  nu.re  in>paired  than  ^l'*' ;'".'".""'^  •. ,  J.^^!^^ 
are  instaneei  .>f  cortical   facial   paralysis-numople-.a     acialis-asMHiattd 
,vith  lesions  in  the  centre  for  the  face  muscles  in  the  lower  Holandicre- 
k.,„      lsoiate.1  paralvsis,  .lue  to  iavolven>ent  of  the  nerve  td.res  m  the.r 
Trnth  to  the  nucleus/is  uncommon.     In  the  -reat  majority  of  cases  supra- 
niclear  facial  paralvsis  is  part  of  a  hemiplegia.     Paralysis  is  on  the  same 
side  as  that  of    he  a'rm  and  lejr  hecause  the  facial  niusc.les  hear  pixH-isely  the 
se  relation  to  the  cortex  as  the  spinal  muscles.     The  nuclei  o    origin  o 
either  side  of  the  middle  line  in  tho  nu;dulla  are  united  hy  d™    ng 
il!,res  with  the  crtieal  centre  on  the  opposite  side  (see  l-.g.   >  .    A  ^ ^^  ^  ^  res 
r  4ch  the  nucleus  from  the  c.-rehral  cortex  of  tho  same  side  (Melius,  Hocl    ). 
"The  .nukar  paral.si.  caused  hy  lesi.n.s  of  the  nerve  --^-  j"     ! 
inedulla  is  not  common  alone;  hut  is  seen  occasionally  m  tumors,  chumc 
"  ft         .%  and  luemorrhage.  ^Ve  have  had  one  instance  of  its  involvement  lu 
:    te    or%  lio-nivelitis.     In  diphtheria  this  centre  may  also  he  involved. 
The^Jmmolns  are  practically  Similar  to  those  of  an  atfeetion  of  the  nervo 
fihre  itself— infranuclear  jiaralysis. 

3.  I,n-olr,'n,ent  of  the  Xnrc  Tr^^^-.-Paralysis  may  result  from 
(.)  Involvement  of  the  nerve  as  it  passes  through  the  pons-that  is 
lH.t.'en    ts  nucleus  in  the  floor  of  the  fourth  ventricle  and  tho  po.ivt  of 
n  ^^ence  in  the  postero-lateral  aspect  of  tho  pons.     Tho  specially  intor- 
t  nr.   ea  .,,,  i,.  e  nnec.tion  with  involvement  of  this  part  is  tho  produc;^ion 
of  ^^nti     ailed  alternating  or  crossed  rarah/sh,  the  face  heing  involved  on 
1  ;     ne  s       as  the  leshmrand  tho  arm  and  leg  on  the  opposite  side,  since 
0  m    or  ,.ath  is  involved  ahove  the  point  of  deenssa  ion  m  the  medul  a 
(Vv?)      This  occurs  onlv  when  the  lesion  is  in  the  lower  section  of  the 
'  ;■      \  lesion  in  tho  npper  half  of  the  pons  involves  the  fibres  not  of  the 
t  m.;'    e  V     on  the  slune  side,  hnt  of  tho  fihres  from  the  lunnispheres 
;;n^  thev  have  crossed  to  the  nueieus  of  tho  opposite  side      In  tins  ease 
;       J  u  d  of  course  he.  as  in  hemiplegia,  paralysis  o    tho  face  and  liml^ 
on  [ho  side  opposite  to  the  lesion.     The  palsy,  too  won  d  rosomhle  the  cero- 
hral  form,  involving  onlv  the  louer  fihres  of  tho  facial  nerve. 
'''%  The  nerve  may  he  involved  at  its  point  of  --.'■^--^    ;>; /"l"*^  ^ 
guniinata.  meningitis,  or  occasionally  may  he  injured  in  fractuie  of  the 

'"'m  Tn  passing  through  the  Fallopian  canal  the  norvo  may  he  involved 
in  dl'se^f  thi;  ear,  particularly  by  caries  of  tho  hone  in  otitis  media. 


I 


a  within 

ic  facial 
■itiociiitcil 
illainmii- 
isule.  It 
crs — the 

iiiusclcs 
%  so  that 

rare  iii- 
tiiis  ft)rm 
.  There 
issociated 
an  (lie  re>- 
,  in  their 
les  snpra- 
tlic  same 
eisely  tlie 
origin  on 
>eu>satiniz: 
few  fibres 
S  Hoehe). 
res  in  the 
s,  chronic 
vement  in 

involved, 
the  nerve 

im: 

5 — that  is, 

e  point  of 

ally  intcr- 

produetion 

ivolved  on 

side,  since 
le  medulla 
tion  of  the 

not  of  the 
emisi)heres 
n  tills  case 
'  and  limhs 
le  the  cere- 

hy  tumors, 
turo  of  the 

bo  involved 
ititis  media. 


DISEASES  OP  TUE   CEREBRAL  NERVPLS. 


1053 


This  is  a  common  cause  in  children,     I  Jiavn  seen  two  instances  fnlhnv  otitis 
ill  puerperal  fever. 

(</)  As  the  nerve  emerges  from  the  styloid  foramen  it  is  e\|.(,sed  to 
injuries  and  blows  which  not  infreciuently  cause  ])aralysis.  Tlu-  lilnTs  mav 
lie  cut  in  the  removal  of  tumors  in  tliis  region,  or  the  p.iraUsis  mav  hi" 
laused  by  pressure  of  the  force](s  in  an  instnimental  deliverv. 

((')  ExiKisurc  to  eold  is~the  most  comi;ion  cause  of  laciai  jiaralvsis,  in- 
ducing a  neuritis  of  tiie  nerve  within  t!ie  Falloiiian  canal. 

(/')  Syjihilis  is  not  an  iiifici|uciit  lause,  and  tlie  jiaralysis  may  dcvelnp 
early  with  the  secoiulai'y  symptoms. 

(//)  It  may  (U'vcloj)  willi  Jierpes. 

FacidI  dipkijia  is  a  rare  couditiiui  occasionally  found  in  alfections  at 
the  base  of  the  brain,  lesions  in  the  p(ms.  simultaneous  involvement  of  the 
iH'rvcs  in  ear  diseasi^,  and  in  diphtheritic  iiaralysis.  Disease  of  the  nuclei 
or  symuu'trical  involvement  of  the  cortex  might  also  prodiici'  i(.  it  may 
oceur  as  a  congenital  all'ection.  II.  ,M.  Thomas  has  deseriJH'd  two  cases  iii 
one  family. 

Symptoms. — In  the  ])eri])hi'ral   facial   jiai'alysis  all   the  branches  of 
the  nerve  are  invo.ved.     The  face  on  the  alfected  side  is  imnioliilc  and  can 
neither  be  moved  at  will  nor  particijiate  in  any  emotional  movements.     The 
skin  is  smootli  and  the  wrinkles  are  etfaccd.  a  i)oint   ])articulai'ly  notice- 
able on  the  forehead  of  elderly  jiersoiis.     'J1ie  eye  cannot   be  clo-ed,  the 
lower  lid  droops,  and  the  eye  waters.     On  the  alfected  side  the  angle  of 
the  mouth  is  lowered,  and  in  drinking  the  lips  are  not  kept  in  ilose  apposi- 
tion to  the  glass,  so  that  the  licpiid  is  ajit  to  run  out.      In  smiling  or  huigh- 
ing  the  contrast  is  most  striking,  as  the  alfected  side  does  not  move,  which 
gives  a  curious  une(iual  aiiiiearance  to  the  two  sides  of  the  face.     The  eyt> 
cannot  be  closed  nor  can   the  forehead   lie   wrinkled.      In   long-standing 
cases,  when  the  reaction  of  degeneration  is  present,  if  the  ])atient  tries  to 
close  the  eyes  while  looking  lixedly  at  an  ol)Jeet  the  lids  on  the  sound  side 
close  firmly,  but  on  the  paralyzed  side  there  is  only  a  narrowing  of  the 
])alpebral  oritice,  and  the  eye  is  turned  u[)ward  and  outward  by  the  inferior 
obli(pie.     On  asking  the  jjatient  to  show  his  upper  teeth,  the  angle  of  the 
mouth  is  not  raised.     In  all  these  movements  the  face  is  drawn  to  the  sound 
side  by  the  action  of  the  muscles.     Speaking  may  be  slightly  interfered 
with,  owing  to  the  iintierfection  in   tlie  formation   of  the  laliial   sounds. 
Whistling  cannot  bo  performed.     In  chewing  the  food,  owing  to  the  jiaraly- 
sis  of  the  buccinator,  particles  collect  on  the  affected  side.     The  paralysis 
of  the  nasal  muscles  is  seen  on  asking  the  patient  to  sniif.     Owing  to  "the 
fact  that  the  lips  nie  drawn  to  the  sound  side,  the  tiuigue,  when  protruded, 
looks  as  if  it  were  pushed  to  the  paralyzed  side;  but  on  taking  its  iiosiiioii 
from  the  incisor  teeth,  it  will  be  found  to  be  in  the  middle  line.     The  reflex 
movements  are  lost  in  this  peripheral  form.     It  is  usuallv  stated  that  the 
jnilate  is  ])aralyzed  on  the  same  side  and  that  the  uvula  deviates.     I'.oth 
(lowers  and  Ilughlings  Jackson  deny  the  existence  of  this  involvement  in 
the  great  majority  of  cases,  and  Ilorsley  and  Beevor  have  shown  that  these 
parts  are  innervated  l)y  the  accessory  nerve  to  the  vagus. 

When  the  nerve  is  involved  within  the  canal  between  the  genu  and  the 


^^k 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


'        ■,           „    1.   ,„■,<■    |.„l    I..   iiu-m.-.'.l   si'iisitiviu'ss   to   musical   «'■'.'■'■ 
I!,;,";,;,.;;.  ,„"v  l,.  mn„,,l,i. o  ,.■•.     TIk.  1»,.c.  „„  (b.  ,,IU..-.c,l  .,.!,. 

:     V         'n  uMl.t  to  fn."    \Vlu.n  llu.  n.utiuu  of  .l.;z.Mu.nU>nn  ."^  l'™l- 

,„,„,.v.  a>  li>   a  Mm   on  tin   i  ^  ^^^  instance's  con- 

WiH'ii  iHTinaiiciit.  tlu'  muscles  aic  cntiK  l>  torn  „.,t„,-.l   folds 

eh:  i'Hh.i=-2':£r:::';r-S 

TIh.  .(;«./».».■.<  "t  t»"»l  V«"'l.vsi»  IS  'Win")    ■''"■■,,''„,,  „,,,„i„„,,l 

'«■•■•■"  ""■  i-'i''"'"' '"",' '"'"""  'r™,  ';■':;  Cmi.Mr^ 

Treatment.--;  n  tluyas..  wlH.1,....M  " 

«„.,,,„..,„ly  llu.  ,l„.v,„„.-..MT  ,„:,y    «.       ;    ,'         >^;         ,i     „  ,„„ 

;::l;;;:::;:'::!;':;\»;  1::';^,  f  y.V"  iTr^  ^;;:  ::i;:;;\;:;;hv.";;::= 


DISHASHS  OF  THE   CEUPIBUAL   NHUVES. 


lo'i'j 


y  to  the 
t>i(lo  the 
in  I'iU'iiil 
is  ol'  t Ile- 
al nott'S. 
I'DMiiniin, 
'ckHl  siilv; 

have  c'oii- 
I's  aro  a;i 
jtroirii'isi^ 
s.  U'  tlu' 
1(1  tliat  of 
1  i'onmila 
.vi'ly  jrooil 

oi'casion- 

]nvst'iit — 
hi'  faradic 
ity  ol"  the 
mil  if  the 
nfavorahle 
Ml  months. 
iset  in  the 
weiity-four 

have  heen 
alysis  fnan 
ay  remain, 
tanees  eon- 
.tiiral  fnhls 
on  lookini; 
:'te(l  side  i> 
U  to  smile, 
uent.     Are- 

whieli  side 

tinetinn  bc- 
inentioned. 
re  prol)a1)ly 
lid  be  made; 
[ervals  of  a 
ied.     K  the 
ained.     The 
of  the  nuis- 
iiepativo  one 
p  made  daily 
t  to  make  it 
e  face  is  also 


nsefiil.     A  ei)\ii'S(>  of  iodide  of  |iota>>iiiiii  may  lie  j^iven  even  when  tliere  is 
no  indication  of  sy|ihili>. 

Jn  some  of  the  Iranmatie  cases  tlie  ])o>siliility  of  siii'i^ical  iiitcrfcrciice 
may  be  consid'Tcd.  In  a  |iatienl  with  chronic  otitis  media  of  tweiity-thiee 
years'  duration  and  secondary  mastoid  disease  Hloodnood  o]icrated  in  May, 
IS'U).  ('om|dete  facial  |>Mraiysis  foliowid.  i-li^lit  \vecl<s  later  tlie  facial 
nerve  was  exposed  in  its  canal  and  found  to  be  almost  comiiletely  seviTed. 
The  ends  were  bronuht  toj.'ether  and  the  wonnil  ailoueil  to  till  with  blood- 
clot,  whicii  orj;anixcd.  Four  months  later  the  patient  had  improved,  and 
one  year  ami  >i.\  months  from  the  operation  the  power  had  returneil  to  all 
the  muscles  except  the  occipito-frontalis  and  the  dejinssor  of  ilie  lower  liii. 
'J"he  response  to  galvanic  and  faradic  currents  was  normal. 

Spasm. — 'i"he  spasm  may  be  limited  to  a  few  or  involve  all  the  muscles 
innervated  by  the  facial  nerve  and  may  be  unilateral  or  bilateral. 

Jt  is  known  also  by  the  name  of  mimic  spasm  or  of  convulsive  tic.  Sev- 
eral dilVerciit  alfeetions  ai'e  nsually  considered  under  the  name  of  facial 
fir  mimic  spasm,  luit  we  shall  here  speak  only  of  the  simjile  spasm  of  the 
facial  muscles,  either  luimaiT  or  followimr  paralysis,  and  shall  not  in- 
clude the  cases  of  habit  s|iasm  in  children,  or  the  lir  (■oiinilslf  ot!  the 
French. 

(lowers  recoLrnixes  two  classes — one  in  which  there  is  an  organic  lesion, 
and  an  idiopathic  form.  It  is  thought  to  be  due  also  to  rellex  causes,  such 
as  the  irritation  from  curious  ie<'th  or  the  presence  of  inti'stinal  worms. 
'J'he  disease  nsually  oc<urs  in  ailults,  wherea«  the  iiidiit  sjiasm  and  the  lir 
ciinnilsif  of  the  l''rench,  often  confounded  with  it,  are  most  common  in 
chililren.  True  mimic  spasm  occasionally  cmucs  on  in  childhood  and  per- 
sists. In  the  case  of  a  school-mate,  the  all'eetion  was  marked  as  early  as 
the  eleventh  or  twelfth  year  and  still  continues.  When  the  result  of  or- 
ganic disease,  there  has  usually  been  a  lesion  of  tlu>  centre  in  the  cortex.  a< 
in  the  ease  reported  liy  llerkeley,  or  pressure  on  the  nerve  at  the  Ijase  of 
the  brain  by  aneurism  or  tumor. 

Symptoms. — The  s|iasm  mny  invtdve  only  the  muscles  around  the 
eye — ble])harospasm — in  which  case  there  is  constant,  rajiid,  (|uick  action 
of  the  orbicnlaris  palpebrarnm,  which,  in  association  with  ]ihotophol)ia. 
may  be  tonic  in  character,  ^fnre  commonly  the  spasm  all'ects  the  lateral 
facial  mnscles  with  those  of  the  eye.  and  there  is  constant  twitching  of  th(> 
side  of  the  face  with  ])artial  closure  of  the  eye.  The  frontalis  is  rarely  in- 
volved. In  aggravated  cases  the  depressors  of  the  angle  ftf  the  mouth,  the 
levator  menti,  and  the  ])latysma  myoides  are  airected.  This  spasm  is  eon- 
fined  to  one  side  of  the  face  in  a  majority  of  eases,  tiioiigh  it  may  extend 
and  become  bilateral.  It  is  increased  by  emotional  causes  and  involuntary 
movements  of  the  face.  As  a  rule,  it  is  jtainless,  but  there  may  be  tender 
points  over  the  course  of  the  fifth  nerve,  ])artiiMdarly  the  supraorbital 
branch.  Tonic  spa>m  of  the  facial  muscle  may  follow  jiaralysis.  and  is  sai<l 
to  residt  occasionally  from  cold. 

The  outlook  in  facial  spasm  i-  always  dubious.  A  nuijorily  of  the  cases 
persist  for  years  ami  are  incurable. 


DISEASTIS  OF  THE  NERVOUS  SYSTEM. 
IO06  , 

Treatment.-Sou.ces  of  .ntat.n  ^l^^^ -^^•;;-;l,i;:,^rS!: 
^Vlu.n  a  painful  spot  ,.  pn.cut  o^   r  tl     i  ijl    "^  ^   poaenuic   i.-jections  of 

.trydnua  .nay  l.c  tnc,  but  are  j'^;  "  '^^  ^  ,^^,^^,^  aaily  or  every  .ccond 
,nends  the  freezing  of  the  cheek  to  ;  j  ;  '"  ^^^^^^^^^_  often  the  r..- 
day  ^vith  the  spray,  and  th.s,  m  ^'••''  ';  j''  ^.";;  .nnic  mav  l.e  seen  half  a 
VA  is  transient;  the  f^V^'^;'^' '  ""' .Ive  in  the  ganu>t  of  all  nuasures 
<lo-n  or  n>ore  of  such  prU^nts  .h.  un^t^ ^^^^  ^^^^^  ^^^  ^^^,^^,,,  ,, 

without  material  unprovement.      H'^i'^y^^  ,  • 

;„  severe  eases,  although  not  much  can  be  expected 

AVDITORY   NkHVE. 


the  ear  through  the  int 


.,s-the  cochlear  and  vestibular  n.ot 


These  two  roots  have 


separate  nerves-the  cochlear  '^"^^^^^     "      ;,,,  ,„,t  considered  separately. 

:;;-:;:s::sJ:;:,;:tt',::;^.u.:.:.-i «... - 

The  Corlikar  Xrnc. 
The  cortical  centre  for  hearing  is  in  ^^^ -1^-^^^^^^^^^^^^^^^ 

eate  thai  the  superior  ^^'l^i;"''',^  [.  ^  V;.  ^  the  same  situati<.n,as  destruction 
--^  the  cases  of  f '^^  ^ J^J    J     V^^^^j-deafness,  .hich  may  be  deiined 
of  this  gyms  on  the  kit  suk  ^'^'^    \^        ^       ,,f  ,,„,,,s,  though  they  may  stil 
as  an  inability  to  understand  *      '— ;  ^,^^^,„.Vn,g  to  the  ortica 

bo  heard  as  sounds.  The  ^-"^  I  ^^^^^  ,1  ,,  ,erve  may  be  involved  and 
centre  from  the  terminal  "^^  ^^  ,,;,,, vement  of  the  lateral  leinnis- 
,,,.>duce  deafness,    'llus  mav  leM.     to      1  „„lrigeinina.  especially 

■us  from  the  presence  of  a  *>;!>';  \;2-  from  a  lesion  of  the  internal 

-iS:;;x::;ir:ri:eX;:;"^^^ 

^".M /^-'^''-'M-'':'-''^. ---:;;- Sn^s^rt:^ 

p,essure  of  tumors,  meningitis  ft'"''       ^^^^^^  ,{  the  nerve  may  occur 

lu-rhage.  or  traumatism.     -^^.J'^;^^  ^V^^uinal  nuclei  of  the  cochlear 
in  k>comotor  ataxia.    I'^imarj  disca.     t  t  eochlearis  ven- 

nerve  (,n,cleus  "--vi;-'  ''^'"-'V  ^ '^^  e"  m'     >r>n  results  fron.  epidemic 
trails)  is  rare.     By  ^'>';.  ^^' ^^hkl  t    m^m-  is  frequently  inv.dved,  can^ 

V^-''^^^^"-^^'rnt'3^f '  in  vS  Snliron  the  condition  results  m  deaf- 
iiig  permanent  ueainc^s.    ^i'  j       o 

nintism. 


L>1U0VL'<1. 

e  ai)i)li- 
lions  of 
i  roconi- 
,'  second 
1  the  r'.- 
n  hiilt'  a 
llKa^U^^■ri 

sorted  to 


jipcs  i'l'oiu 
■;ls  of  two 
oots  have 
ejmvately. 
nd  i^  con- 
voi^tilndc 
uilibi'iiiiii. 


lolic.  Tii- 
1  coiu'tie  i^^ 
within  tlie 

nonts  indi- 
earin>i.    In 
destWR-tion 
r  be  doiined 
}y  may  >^tiU 
the  cortical 
nolved  and 
cral  h'ninii^- 
ii,  especially 
ilie  internal 
nternal  cap- 

ilt  from  the 
form),  luvm- 
e  may  occur 
the  cochlear 
ehlcaris  ven- 
om epidemic 
iv(dved,  caus- 
snlts  in  deaf- 


DISEASKS  (»F  THK  CKI'iEUHAL   NKUVI>'. 


ion 


{(■)  111  a  inajnrity  (if  tiie  cuscs  assdriatcd  with  aiiditdry-ncrvc  syiii|it(iiiis 
tile  lesion  is  in  tlic  iiitcrMai  ear,  eitlier  primary  or  tlie  ii'>iilt  nf  extensimi 
(if  disease  of  the  middle  ear.  Two  ^^roiips  nl'  symptoms  mny  he  |ii'(i(liiceil — 
iiy]ieiiesllnsia  and  irritalidii  and  (limiiii>lie(l  I'liiuiinn  or  iicrvdiis  deafness. 

(1)  1/ i/jirntsllicsia  iiml  I rrihiliaii. — 'I'liis  may  lie  (hie  Id  altered  fiiiie- 
tion  of  tiie  centre  as  well  as  of  the  nerve  endiiijr.  'I'nie  hypera'stiiesia— 
Jiyperacusis — is  a  condition~in  which  sounds,  sumetimes  even  tlmse  inaiidi- 
hle  to  other  persdiis,  are  iieard  with  j^ri'at  inteiifity.  it  oeeuis  in  liy.-Jeria 
and  oeeasidnally  in  cerehral  (lisea^e.  As  already  mentioned,  in  paialysis 
of  the  stapt'diiis  hiw  iidles  may  he  heard  with  iiih'iisily.  In  dy^-a'stiiesia, 
or  dysacnsis,  ordinary  sounds  eaiisi'  an  nn|)leasaiit  seiisiition,  as  eomiiidiily 
happens  in  connection  with  headai  he,  when  onlinary  noi.-es  are  hadly 
lioriie. 

'J'iiiniliis  iiiiriinii  is  a  ti'rm  eniploy(.'(l  td  desiennle  certain  siihjectivt' 
sensatidiis  of  riiieinj;',  ruarin^%  ticking,  and  whirring  noises  in  the  ear.  It  is 
a  very  cdmiiidii  and  often  a  distiessiiig  sym|itdm.  It  is  assdciated  witii  many 
fiirms  of  ear-disease  and  may  result  from  |iiessiire  of  wax  on  the  drum.  It 
is  rare  in  organic  disease  of  tiie  ei'iilral  coiiiieetions  of  the  nerve.  Sudden 
intense  stimulation  of  the  nerve  may  cause  it.  A  form  not  uncommonly 
met  with  in  medical  practice  is  that  in  which  the  patient  hears  a  continual 
hniit  in  the  ear,  ami  the  noise  has  a  systolic  iiiteiisilication,  usually  on  one 
side.  I  have  twice  heen  consulted  hy  jiliysiciaiis  for  this  condition  under 
the  liclii'f  that  they  had  an  internal  aneurism.  A  ,«ystolic  niuriiiur  may  he 
heard  occasionally  on  auscultation.  It  occurs  in  conditions  of  ameinia  and 
neurasthenia.  Suhjeetive  noises  in  the  ear  may  precede  an  epileptic  seizure 
and  are  sonu'tiines  present  in  migraine.  In  whatever  form  tinnitus  exists, 
though  slight  and  often  regarded  as  trivial,  it  occasions  great  annoyance 
and  often  mental  distress,  and  has  even  driven  patients  to  suicide. 

The  dldiiiKisis  is  rt'adily  made;  hut  it  is  often  extremely  ditliciilt  to  de- 
termine upon  what  condition  tiie  tinnitus  depends.  The  relief  of  con- 
stitutional states,  such  as  aiuemia,  neurasthenia,  or  gout,  may  rcMilt  in 
cure.  A  careful  local  I'xamiiiation  of  the  car  should  always  he  made.  One 
of  the  most  worrying  forms  is  the  constant  clicking,  sometimes  aiidihle 
many  feet  away  fi'om  the  patient,  and  due  jiroliahly  to  clonic  spasm  of  the 
muscles  connected  with  the  iMistachian  tuhe  or  of  the  levator  jialati.  Tlie 
condition  may  persist  for  years  unchanged,  and  then  disii|)pear  suddenly. 
The  pulsating  lorms  of  tinnitus,  in  which  the  sound  is  like  that  of  a  sys- 
tolic hniil.  are  almost  invariahly  ;  iihjective,  and  it  is  very  rare  to  hear  any- 
thing with  the  stethoscope.  It  is  to  he  rememhered  that  in  children  there 
is  a  systolic  hrain  murmur,  hest  heard  over  the  ear,  and  in  some  instances 
appreciahle  in  the  adult. 

i'i)  Ditiiiiiishrd  Fiiiirlioii  or  Xi'rroiis  Dcdfiu'fs. — In  testing  for  nervous 
deafness,  if  the  tuning-fork  cannot  he  heard  when  ]ilaced  near  the  meiitus, 
hut  the  vihrations  are  audihle  hy  placing  the  foot  of  tiie  tuning-fork  against 
the  temiioral  hone,  the  C(mclusion  may  he  drawn  that  the  deafness  is  not 
due  to  involvement  of  the  nerve.  The  vihrations  are  conveyed  tliroiigh 
the  temporal  hone  to  the  cochlea  and  vestihnle.  The  watch  may  he  used 
for  the  same  purjiose,  and  if  the  meatus  is  closed  and  the  watch  is  heard 
(10 


J 


n 

'A 


DISEASES  OP  THE  NERVOUS  SYSTHM. 


„„,.|,w.  II"'  ■l"^ll"'«  "  l""''»'''>     '  ,,„   ,   ,-,,,    r,v„m.l.l   *v„,|.l"m    i" 

;;;;;,:::;;::::  i;;;;:;::i'^;::7..:n;,,,:;rv: ;...'>^'' ■ -"-"^ 

ti'stcd. 

loss  ..r  .■..r.r.lination  ..f  Uu'  n.usclrs  ol  tlu  1    ad  ■  ,^     ,   .. 

Auditory Vertigo-M6niere's Disease-  n  IS  n^^..  ^^1 

.U-ian,  dosorilK.!  an  '''^.c^H.n  c  w.raH      .         J         -         ^^^.^.  ^^  ^^__^,^  .,^ 

(wl.i.l,  .uijiht  1-  assucnucd  -^  >      -;'  !     ^  ^  n  is  .^.w  n..\  to  uu.lud. 

Symptoms.— 1  lie  attack  ii>iuii}.t  I  .  ,,„„ii,:.r  or  -^ta-^i'vinj;-.     Ik' 

,„,„i,,..  or  th.   v\^.^n.un■y^   .nay  be      '  "      '  '  ,,e  l.as  tinu"  to  stoady  l.im- 
tl.at  tlK-  patient  t:d  s,  thon, h        ' ^^^J^^,,,  ,,i,ht  l.nl  transient 
,,,M;y,ras,.in,sonuMU.,,ld.onn,o^U      .^       !  l,!; Iss,  tl^-  ver.i.o  passes 
loss  of  eons..iousness.     In  a  -  "      ^ .^^^^.^^   ^^  ,,,„„„,  ,,,,1  breaks  out 

oiv  an.l  the  i)at.ent  beeon.e^  pale  an.l  naiLca 
on  the  I'a.'e,  an.l  vonnlin-  n.ay  Ldbm  ,,,„,,,t.,-.  n.ay  be  in  only 

'''""  '^"'"■"'■^^'  ^^•''"'  ^t'^V    a  r  H>    .atients  have  no  aiT..eti.>n 

one  ear  an.l  is  never  ooniplete.     As  an  ^^^  ^^  ^,^^,^^,,. 

or  the  ,ni.ldle  ear.    The  t.mutns  ^^  ^^^'^^:^:'Z..  ^,,uin:  of  the  eye- 

Lalls  .>r  nysta^nu.s  n.ay  d...'!.-!'  '1   '     ^  1  .;,        ,,^^  i,,t,,,,,s. 

Labyrinthine  vert,..>  "-l'^'''"'^;'"    ;,;';;,,„   the   attaeks;  in   other 

Sonu.tin>es  weeks  .>r   -^^f^.^.^^'^X..  disease  rarely  oc-urs  in 

-^■\c;;i:i:;:;:n;;rdU.'has.^ 

,„a„v  th..ori..s.     It  se.Mns  to   u.  <'; ''^  ;  ,   ^^^  ^^  :,,i,,,t  npon  a  distnrb- 

,„...  of  ...milibrhnn.  --l;;^:'^,^;  ,  *  ^  ^^or  ol  the  orpu.  with  whi..h 

'""•*■  "^  ^'':  ''''"'''T.1    ..        .•   n        1  V  l^u'ral  distributi.>n  or  by  H,eans  ol 

tins  nerve  ,s  ..onn..et..d.     ,  '"  «v  nptoms  often  n.^<..n.pnny.n,ir  ^    are 

;;::i:;;;::lr;;:: ":;.>  i' "- us  peripheral 

-  D;^^:.s:-The ^nation  ;^y-- -^-^Ss:' ti: 


dl«H 


DISKASKS  OF  THE  ("ERERRAI.  NERVES. 


lor.n 


\\c  open 

liUU'C    lit' 

[)t()in   ill 

■a  IV  I'll  11 V 


^0  of  the 
mis,  uml 

m\\  pliy- 
•,  vi'vtijio 
:,  ami,  in 
()  imluilt! 

(Icat'iu'Sri. 

KM)  cast's 
svin|it<)ins 

zins  ntiiso 
vinjv,  lie 
I'cm  lo  111' 
<  often   so 

oatly  liii'>- 
t  transient 
(i>io  passes 
breaks  out 

he  in  only 
10  alVeetion 
or  a  iliroli- 
of  the  eyc- 

r  intervals. 

s;  in   other 

ly  occurs  in 

more  coni- 

1(1  there  are 
the  disturh- 
,n  a  (listurh- 
,  witli  whicli 
hy  means  of 
iiiyintr  it  are 
ts  jieriplioral 

1,.=?.  witli  or 
iiosis.  There 
il.    The  form 


liiiown  as  pistrie  verti^'o,  which  is  associate<i  with  dyspepsia  and  occurs 
jiiusl  ciiiiiMioiily  in  person-  of  middle  aj;c,  is,  as  a  rule,  readdy  distiu;,Miislied 
Ijv  tiie  aliM'ncc  of  linuilns  or  eviih'uccs  of  dislurhancc  in  the  fuuctitui  of 
the  auditory  nerve.  This  variety  of  vertipi  is  much  less  ((lunuoii  than 
'J'roussean's  dcscri|ition  would  lead  us  td  helieve.  It  is  important  to  note 
the  (lose  connection  of  vertijiio  with  ocular  defects. 

The  canlio-vascular  verTi,L;-o,  one  of  the  most  common  I'ornis.  occurs  in 
ca.<os  of  valvular  di.seaso,  particularly  aortic  insutliciency,  and  as  freipii'Utly 
in  arterio-sclerosis. 

Kndvinic  I'dvnhjlir  Vcrliijo. —  In  ]iarts  of  Switzerland  and  France  there 
is  a  reinarkahle  form  of  verti.iro  descrihed  hy  (ici'lier,  which  is  cluiracterized 
liv  attacks  of  paretic  weakness  of  the  extremities,  falling  of  the  eyelids, 
remaikalile  depression,  hut  with  retention  of  couscionsnt'ss.  It  o<-curs  also 
in  uortherii  Japan,  where  Miura  says  it  develops  jiaroxysmally  aiuon.i:  the 
farm  lahorers  of  hoth  se.xes  and  all  ap's.     It  is  known  there  as  IniliisiKiari. 

Aural  vci'tif^d  must  he  carefully  (listin<.nnslied  from  attacks  of  jwlil  iintK 
or,  inileed,  of  delinite  ejiilepsv.  It  is  rare  in  ptlil  ninl  to  liave  noises  in  the 
ear  or  actual  }:iddiness,  Imt  in  the  aura  preceding"-  an  epile|iti('  attai'k  the 
patient  may  feel  jriddy.  (iidditu'ss  and  transient  loss  of  cons.'iousiiess  may 
he  associated  with  orf^anic  disease  of  the  lirain,  mor(>  particularly  with 
tumor.  A'omitinji  also  may  he  present.  A  careful  investi<;ation  of  the 
symptoms  will  usually  lead  to  a  correct  diaj^nosis. 

The  outlo<ik  in  Meniere's  disease  is  uncertain.  ^Vhile  many  cases  re- 
cover C(unpletely,  in  others  deafness  results  and  the  attacks  recur  at  shorter 
intervals.  Jn  a<rfj:ravated  cases  the  iiatient  constantly  sidl'ers  from  verti.-ro 
and  may  I'ven  lie  conliiu'd  to  Ids  hed. 

Treatment. — r.rondde  of  potassium,  in  '^0-<irain  doses  three  time-;  a 
day.  is  sometimes  ln'Ueficial.  If  thert'  is  a  history  of  syphilis,  the  iodide 
should  lie  adndnistercd.  The  salicylates  are  recommended,  and  Charcot 
advises  (pnidne  to  cinclionism.  In  cases  in  which  there  is  increase  in  the 
arterial  tension,  nitrojflycerin  may  he  <iiven,  at  first  in  very  small  doses,  hut 
iiu-reasin,ir  gradually.  It  is  not  specially  valualde  in  Meniere's  disease,  hut 
in  the  cases  of  iriddiness  in  middle-aired  men  and  women  associated  with 
arterio-sclerosis  it  sometimes  acts  very  satisfactorily.  Correction  of  errors 
of  refraction  is  somt'times  f(dlowed  hy  jirompt  relief  of  tlv  vertii^o. 

flr,osso-vnAi{Y\fii:.\i,  Xiiitvi-;  {ycvviix  iilossdjiluiri/niinis). 

The  nitdh  nerve  eontains  liotli  motor  aiul  sensory  fdircs  and  is  also  a 
nerve  of  the  special  sense  of  taste  to  the  ton.iruo.  It  supplies.  Iiy  its  motor 
hraiu'hes,  the  stylo-pharynf.'eus  and  the  middle  constrictor  of  the  pharynx. 
The  sensory  flhres  are  distrihuted  to  the  upper  ]iart  of  the  pharynx. 

Symptoms. — of  nuclear  disliirhance  we  know  very  little.  The 
]iharynireal  symptoms  of  hulhar  paralysis  are  jirohahly  asso'^iated  with  in- 
V(dvemcnt  of  the  nuclei  of  this  nerve.  Lesion  of  the  nerve  trunk  itself  is 
rare,  hut  it  may  he  comiu'cssed  hy  tumors  or  involved  in  meningitis.  Dis- 
turhance  of  the  sense  of  taste  may  result  from  loss  of  function  of  this  nerve, 
in  which  case  it  is  chiefly  in  the  posterior  part  of  the  tongue  and  soft  jial- 


^^ 


DISEASES  OF  THE  NEKVOCS  SVSTKM. 


"t »" ' H- -■■,;";'>■;;';;;;:  ;:,;:"„;■'..,:. «,.....-,...."■>".-' •■ '■ "■■ 

tifth.  ,  ,  „,,  ,,,„.e  of  taste  uuiy  lu'iv  bo  bndly  ivieir.. 

^...   ';U  „■  UK.  ..ns.  or  t-t.-l/--  -■>/;,  ,„,,.  J  .,  the  loM... 

,„•  .lnuini>h  tlu.  s..ns.  "  /^'r'", ,    '.  '   ,  •„,  tlic  cn.tns.     Di.turlKUue  m  tin 
of  tlu.  .u.rv..s  ..i.lu.r  .n  tlu.>v  <     '  -        '^  i.volvonu.nt  of  tlu.  l.Hh  .utn   , 
.,,,.0  of  tast.  is  .nost  ^■'""">"'"  >,'   ^ ",',,,.  the  funolion.     IVvvorsu-u  o 
:;;a  it  ,nay  lu-  that  tins  "--.;^-  -   ,,,„,^  ,,,,,,  ,,  an   hy^ton^tl 

,,,,  ,„„s..  of  tast.-/»M■a;^,,^^^->-^      ^^^    .ensitivcm.ss  is  st.U  .nove  u.u. 

To    0  t  the  sense  of  taste  the  patu      s  ^i  .^^,^  ^,,,,,,,^  ,„  lu.- 

.,,,,,ities  of  various  -'l'^*--;  jf  ^'l^,    l.win,  ave  tlu- tno.t  suit,^^^ 

;-;;::'";-t;;^:;s::-^^^^^^ 
::;r;:;r;;:;!;:s.nrs^;;ii-^^^^^^^^ 

well-knoNvn  metallic  taste. 


rNl-lMOdAST 


me  Xi^KVl^  (Xcrnif^  rr(;/»s). 


^    .vh.n.ive  aistvi1)ntion,  sui>l>ly- 

The  tenth  rn'rve  has  an  in,,.ortant  ^^^^^^^^^^  ,„„„,,i,.    The  tu.vve 

i„.  th      harvnx,  larynx,  l-'^-  ^ :*;,;;;'       'J, ijl  accessory  and  the  hyp-. 

;,:;,.  W   nvolve.l  at  its  nucleus  '^^""^         ';'    ,,  .-sis.     It  n.ay  he  conn.resea 

neuritis 


aistriluitiou  of  t„e  separate  nerves 


The  alTectio 


DISKASKS  OF   TIIK  (KRHnKAL   NKUVHS. 


KM'.l 


ut  llu' 
R'  root 
u'  t'niut 

niin  ill" 

rci'evro.l 

liaiu-c  ut 

t()ii;;ui'. 

limy  'lull 

olvi'llU'Mt 

te  in  Uh- 
th  ncvvo, 

VLTHUm  i>f 
hyr^tericiil 
more  viu'i'. 
ri  iin  aura 

anil  j'liiall 
Id  l>i'  IH'i'- 
,st  suitable 
^iir  or  sac- 
''salt.  O"^! 
h  givori  llie 


ion,  sui>l>ly- 
Tho  norvo 
11(1  the  liypo- 
.  coinproj^sLHl 
l)k'  or  syphi- 
,v  tumors  or 
\v,\~  l)oen  put 
ultackod  by 

tion  with  the 

^^o-phnryufical 
„in  which  tho 
yah/sis  duo  to 
yfii'c,  or  in  the 
iculty  in  f'wal- 
f  the  nerve  on 
ired.    In  these 


nisis  t!ie  jMrticlcs  ol'  I'ood  I'reiUK'iitly  pass  into  tlic  larynx,  and,  wli.n  the 
sol't  jialate  is  involved,  into  the  posterior  iiarcs. 

t<inism  ol'  tlie  pharynx  is  always  a  t'unctional  disorder,  uMially  oceiiv- 
rin"  in  liyslerical  and  liervoiis  people.  (i..wers  mentions  a  case  .d'  a  ^'iitie- 
„„u,  who"coul.l  not  eat  uid.-s  alone,  on  a.c.unt  of  the  inabdity  to  swalLuv 
in  the  presen.e  ol'  others  I'o.m  spasm  ol'  the  pharynx.  'Phis  spa.nn  i<  a  wejl- 
ini.rked  I'eature  in  liydrophol.ia,  an.)  1  have  seen  it  in  a  case  ni  ps.'udo- 
iivdroiiliohiii. 

{//)  Laryngeal  Branches.— 'I'h.'  siijierior  laryn^^al  nerve  suppius  tiu' 
MUieous  mc.n:linine  nf  the  larynx  above  the  cords  and  tlie  evien-thyn.id  nnw- 
cie  The  inl'eiini-  or  recurrent  larynj:eal  curves  around  the  arch  (d  the 
aorta  on  the  h'lt  side  ami  the  suiielavian  artery  .m  the  ri,-hl.  passes  alon;: 
the  trachea  and  su|. plies  the  mucosa  below  the  cords  and  all  the  mus.les  .,| 
tile  larynx  except  the  crico-thvroid  and  the  epi-lotti<iean.  Kx|.ernnents  have 
<ho\vn"tliat  these  motor  nerves  of  the  pneumo-astric  are  all  derived  irom 
the  spinal  accessorv.  The  r.'markable  course  of  the  recurrent  laryuL'cal 
nerves  renders  them  liable  to  pre.-sure  by  tumors  within  the  tluu-ax,  i-ar- 
ticularly  by  aneurism.     The   I'oUowin;,'  are  tlie  most   important    I'orms  .d 

^'  (i)  llihilrral  /'r/m///.s/s  of  Ihc  .\b,h,rh>rs.-]n  this  condith.n,  the  pos- 
terior crico-arvtcnoids'are  involved  and  the  jrh.ttis  is  not  oi.ened  dminj: 
inspiration.  The  cords  may  be  close  to.i:ctlier  in  the  position  of  plumation. 
and  diirin-,'  insiiiraticm  may  be  brou.irht  even  nearer  tourether  by  the  pressure 
of  air,  so  that  there  is  onl'v  a  narrow  chink  throu,i;h  wiiich  the  air  whistles 
with  a  noisv  stridor.  Th'is  dangerous  form  of  iaryn.^eal  paralysis  occurs 
occasionallv"  as  a  result  <d'  cold,  or  may  b.llow  a  larynj.^eal  catarrh.  The 
posterior  muscles  have  lieeii  found  dep'tierated  when  the  t.thers  were 
healthy.  The  condition  mav  be  produced  by  pressure  upon  both  va-i,  or 
upon  iiotli  recurrent  nerves.'  As  a  central  atVeetion  it  oc^urs  in  tabes  and 
Indbar  paralvsis.  but  may  be  seen  also  in  hysteria.  The  characteristic  symp- 
toms are  insjiiratory  stridor  with  unimimired  phonatioii.  Possibly,  as 
(lowers  sujrjzests,  many  cases  of  so-called  hysterical  spasm  of  the  ;^lotlis  arc 
in  reality  abductor  ])aralysis. 

(".')  'rinhilrral  Ahditrlor  rnnihisix.—T\m  frequently  results  Inmi  the 
pressure  of  tunmrs  or  inv(dvement  of  (me  recurrent  nerve.  Aneiirisni  is 
by  far  the  most  common  cause,  th(nij:h  on  the  rij:ht  side  the  nerve  may  be 
invcdved  in  thickeninj;  of  the  idenra.  The  symi^toms  are  iioarseiu'ss  .u- 
roufrhnesp  of  tlie  voic(>,  such  as  is  so  common  in  aneurism.  Dyspmea  is  not 
oftt^n  ])resent.  The  cord  cm  tho  afTooted  side  does  not  move  in  inspiration. 
Subse(iuently  the  adductors  may  also  liecome  involved,  in  which  case  the 
])honation  is  still  more  iin])aircd. 

(15)  Aihlitrlor  P(inihisix.—'Vh\<  results  frmn  involvement  -d"  Mie  lateral 
crico-arvtenoid  and  the  arytenoid  muscle  itself.  It  is  coinm.m  in  hysteria, 
particularly  of  women,  and  causes  the  hysterical  aphonia,  which  may  conn- 
on  sud.hniv.  It  may  result  from  catarrh  of  the  larynx  or  from  overuse  of 
the  voice.  In  hirvn;,^osco])ic  examination  it  is  seen,  on  attemid  at  i>lionation,, 
that  there  is  no  jtower  to  brin,;:  the  cords  to.tretln^r.  In  this  connection  the 
fcdlowinix  table  from  Cowers'  work  will  be  found  valuable  to  the  student: 


I 


l(t(V2 


PISKASES  OF  THE  NKRVOlS  SYSTEM. 


Symptoms. 


No  voire ;  no  oou<;li  -, 
stridor  only  on  (Ici'l*  in- 
sniration. 

Voice  low  pitclu'tl 
and  hoarse  ;  no  eou<rh  ; 
stridor  absent  or  slight 
on  deep  breathing. 

Voice  little  changed; 
congh  normal ;  inspira- 
tion diiVicult  and  long, 
with  loud  stridor. 

Symptoms  incon- 
clusive; little  alTection 
of  voice  or  cough. 

No  voice;  perfect 
cough;  no  stridor  or 
dyspna'a. 


SlONS. 

Both  I'ords  tnodcr- 
lUely  ahducti'd  and  mo- 
tionless. 

One  cord  moder- 
ately ahil-K'tcd  and  mo- 
tioidess,  the  other  mov- 
ing frcelv,  and  even 
hi.yond  the  middle  line 
in  ])honation. 

Both  cords  near  to- 
gether, and  during  in- 
spiration not  separated, 
hut  even  drawn  nearer 
together. 

One  cord  near  the 
middle  line  not  nu)ving 
during  inspiration,  the 
other  normal. 

Cords  nornud  in  po- 
sition and  moving  nor- 
mally in  respiration, 
hut  not  brought  to- 
gether on  an  attempt 
at  phonation. 


Lksiox. 


Total  bilaur:;!  palsy. 
'l',,t;ilunila;eralpal;y. 


Total  abductor  palsy. 


T^nilateral 
palsy. 


abduLlor 


Adductor  palsy. 


r,.  <1>U  Uic  adductor  muscles  are 
Sras,n  of  tl,c  ^rnscks  of  tl,e  ^7--    /  r^      a^en,  and  Inis  already 
invoU-ed.     It  is  not  an  ""^^^d  d  >  -vsnuil  atta..ks  oi  laryngwd 

,„,en  reierred  to  ««  ^'^^^"f 'J  ";;;,f  !  ",;,  .IcscTibcd  in  which  the  patien  , 
spasm  are  rnre  m  the  ''''"l^' "^^^  ,,  ^.^  ,,,,,,,  <.r  intense  dyspiuca,  winch 
,;sually  a  young  girl,  wakes    t      M|     >^  ^  ^^.^es  that  they  may 

,l„„,„„,<i.-  ...ay  .H,...r  "''"'"'"/*    ;."!„u.r  L  «i...l,il.c.     U    ' 

,„,Ll,  „r  ,l,e  va,i  ...,.1  "t  ''"■;;-'!':  'li        .ion.' 

s,,.vo  .....lor.  s™«.v,v.  .rail  fff^?  ,*"       ,°  ,„,„,   „„,]  nvM'  «.«  <-«"1'''= 

J,.„  V""  '"  ""■  "'"i-    '"■''"  ;;VS-n  lor  a- few  b«,t,  l.y  prosms 

-,:riiri".;;r:x^:«r  ;.o...„o.a.*  .0.0,  a... . .  .^.^ 


■Dm 


DISKASKS  OF  TIIK  (KUKHUAl-  NKllVKS. 


luo;} 


v,Y  \ydhy- 


ab(UiLU)i' 


alsy. 


niisclcs  are 
ms  already 
t  laryii^'t-'iil 
ho  isalient, 
ud'U,  whk'U 
it  they  may 
rm  iu  loeo- 
a  condition 
ts  to  ?pi.ak, 


ie  ucnritis: — 


pipe. 


It  is 


in  hysteria. 

lie  union  of 
lis  fibres  suh- 

c  tlie  cardiac 
iction.  Czer- 
ts  liy  prcssin.cj 
and  it  is  said 


,hal  the  sa.i.e  can  he  prudn.rd  hy  h.r.ihi..  hilal.ral  ,..vsM,r.>  uu  ihr  eaiulid 
,„,„,,l      Tlu'r..  aiv  ii.Ma.H.x  i„   vvhi.li   persons  appear  to  liaNe  IkmI   v-liin- 
,a,.y  n.ntiul  n^rr  ih.    a.t,„n  .,f  ihr  ii.art.     Cheyiie  nienlmns  tin.  .as.  u 
Cuh-nel  TownslH.n.l,  ••«!...  .unid  di.  ur  .'xpin.  when  he  piras..  ,  and  j.t 

l,v  an  elV..rt  ..r  > hnu  i-nnw  U>  lilV  a-nin.  which  it  s.nns    ,.■  h;..!  scme- 

hn's  tried  i,etnre  h.  I,ad  son,   tnr  us,"     IManln,,..,,  .,nh.  hn.r,  s  aHinn 
l.as  also  lulluwd  aendni.aT  ii.^.tuiv  ..f  un-  va,.,.     Irnlati.m  at    h.  mu  . 
„,av  alM.  h..  aecnn.imnied  with  a  n..nn,sis  nt  lliis  nnve     On  th.  utiie.  hand, 
,|-,,.  thHV  is  eunipiete  paralysis  nt  ,lu.  va,i    .h,.  iidjil.i.ury  actiun  n,^^^ 

al.nhslu.d  aii.l  the  aeecieratory  inlh.nues  hav.  Inll  sway.  liu'  h.a.  > 
a.,io„  I..  tlH.n  ^nvatly  increased.  This  is  s...!,  in  snn.e  in>taiurs  u  diph- 
,,,.,,,,,.  n..iriti>  and  in  involvement  .f  .he  iutv.  hy  tumors,  or  its  aeeidnili 
,,n,oval  or  ii^:at„.e.     (oinph'te  h.ss  of  liimtion  of  onr  vaj...s  nn.y.  hnwrvei. 

,„,t  hf  followed  hy  any  symptoms.  ,•       ,         i        ,,..,  v...v 

r>)  Srnsnni  svmptonis  on  the  part  ol  tlu-  eardia..  hran.I.e.  .  e  v..\ 
varied  N<.rniallv,  the  hearfs  action  pnu'eeds  r.-ularly  without  the  p..- 
,,,i,,tion  of  eon;eioiM,ess,  hnt  the  unpleasant  feelm.s  and  --atioi.s  o 
palpitati.m  and  pan,  are  conveyed  to  the  hram  thron,h  this  uerv...  H  u 
a,.'tho  (ihres  of 'the  pneunio,aslrie  are  involve,!  ,n  an,ina  it  '-"'i;;- '  ' 
to  .s,y.     The  various  disturhances  oi  sensation  are  .leserihed  under  the  cai- 

""(,0  Senary  Branches.-We  know  very  little  <\^Yu'1''!ZZ 
hranehes  .d"  the  va^M.  The  motor  ilhres  are  stated  to  control  the  action  t 
the  hronchial  muscles,  and  it  has  Ion,  heen  held  that  asthma  nu,y  he  a  neu- 
rosis of  these  fibres.  The  various  alterati.ms  iu  the  respiratory  rhythm  au 
prohablv  due  more  to  ehan-^.s  in  the  centre  than  in  the  nerves  themselves 

(.)  Gastric  and  (Esophageal  Branches.-Th..    muscular   movements  ot 

the'eVarts  are  j.resided  over  hy  the  va-i  an.l  vomitin,,  is  indue...!  throii^i 
them,  usually  rellexlv,  hnt  also  t,y  dinrt  irritation,  as  in  m.-niu-itis.  hpasni 
of  the  o.s<.piia-us  Generally  occurs  with  other  nerv...is  plu'imuuMia.  (,as- 
trahna  mav  sometimes  be  due  to  cramp  of  the  stomach,  but  is  more  c.un- 
monlv  a  si.ns.u'v  disturbance  of  this  nerve,  due  to  dir.rt  irritation  ol  th.. 
p..ripheral  ends",  or  is  a  n..ural^Ma  of  the  terminal  lihre..  Huiisy  is  said 
to  he  a  s..nsati.m  arons..d  bv  the  imeumo-astri-s  and  s<.me  tonus  of  nerv..,is 
dyspepsia  proi.nhlv  depend  upon  disturbed  functhm  of  this  nerve.  li.' 
.c"verc  -astri..  ci^es  which  occur  in  locomotor  ataxia  are  due  ..  .rntral 
irritation  of  the  nuclei.  Some  describe  exoi-hthalmie  yoitre  uu.ler  lesn.ns 
of  the  vagi. 

Si'iNAi.  Arcicssoin-  NKuyi-:  {Xcrru>^  (irri'ssnriiis). 

Paralysis.-Thc  smaller  or  internal  j.art  of  this  n.-rve  joins  the  yagus 
ar.d  ,s  distributed  thn-u-rh  it  to  the  laryng..al  mus.h.s.  Tlu'  ai-er  external 
nart  i<  distribut.^d  to  the  sterno-mast..id  and  trapezius  miKch's. 

The  nucl.'i  of  the  nerve,  i.iirticularly  ..f  the  accessory  part,  may  ..■  in- 
volved in  bulbar  parah-is.  The  nu,d..i  .d'  the  external  p.nlio.i  situat.'.! 
as  thev  are  in  the  eervi..al  .•ord,  may  be  attack..!  in  pr..gr.;ssive  «'<^^r"';'^^ 
tion  o'f  the  motor  nuclei  of  the  cord.  The  nerve  may  be  luv.dved  in  the 
exudation  of  meningitis,  or  be  compressed  by  tumors,  or  in  caries.      1 


^^ 


^^^(.,^  DISEASES  OF  TIIK  NKUVOCS  SYSTEM. 

.nwnlnms  uf  pi.rMlvsis  nf  ll...  nc.rssory  pnitiui.  vslml,   jnin^  tl>..  vap.^  have 

;:l^v;;l:,.n....n::..as,n...  i>i-'"- -•  •-'i'--"'-'^  i'';;:^!™  .^^ ll  1^ 

IZ'  .Z    \l  l...a.l  is  i  ..M  ul.li.,.u.ly.     A.  tin.  tra,u./n,s  ,s  Mipplu-l  u,  pari 

mv,..al  ,u.rv..s.  i.   is  n,., ,,i,..Hy  pan.lv...  .  l,ut  U.op..H>on 

Um.1.  ,.asse.s  IV..,..  ti..  n...i|>i.al  !......■  U,  ll..'  a...u„n.m  ,s  l„nH...nl.'.s.      I 

;    '        is  ..f  11...  n.,.s..l..  is  ...11  s.....  ul.-i.  tlH.  ,.....•"•  .l..aws  a  .l....p  ln.aU. 

,.u..s  .1..-  sl,.,..l.l...'s.    Ti...  ...i.iai.-  pn>'.i..n  .,!•  11...  (.•ap../...is  .s  al...  v      k- 

,;,!';. 'l.u.,l.lH.  .!.u.,ps  a  litll..,  a...!  tl...  a...'l..  .^f  .!..■  -apula  is  n^ta..! 
van    hv     h.  m.ti.m  -'f  th.  rl...u,h..i.ls  a...l  l!..>  l-a..u-  a>.,ul.   s..a,.u!a.. 

i-:;:;u;.,nh..a,....isi..,,..in..i.nMMhc.,..MH.ius.i....^ 

as  a  i...int  I'n.m  wl.i.h  the  <l..ltoi.l  •■an  w.Hv.  ,  •!  .   ,.,1    ,>..v,lvsi. 

,  ,   pn-nrssiv.  ....oscular  atn.phy  wo  s..n...t.i.u«s  s..l.  I.ila  .'n.     pa,.  l>ss 

of  i    . J.   „:.s..l..s.    Tl.,.s,  ir  tl,.  sU.>'....-n,as...i.ls  a..-  alV........  .  .1.-;  \u-..\  Wn^. 

t      1   .a   <;  wh..n  11...  InM-.^ii  an-  inv„lv..l,  it  ialls  ronvani   a  ' —^.r.  e 

;,,;,,•   he  l...a.l  in  n.any  ..a.-.s  -l'  pn,<rn.ssivo  M...s..ular  atn.phy.    (.owo  -s 

^!:X  t   at  l..ions  or  th.  a.r.ss.„-y  in  .li.li.nlt  lahor  n.ay  -•'-;"•;     ;:;;^'- 

,:.::  in  whhl.  .luni..'  tl...  ti.>t  y.ar  .-f  lif.  th.'  ..h.!.    has  ^^,.,,1  diHuH-lt     ,n 

l;;,,,!,;;  ,,.  tho  hoa.l.     m  .hil.m.n  tl.is  .ln...pin,  <.!•  th.  l...a.l  ,s  an  ,.npor- 

lant  svnu)toin  in  (•.M.vi..al  n...nin^ntis.  tl..'  n.snit  ..    c.ari.'s 

T1h>    rrnlwrnl  ..I'  th.'  .-.luiiti-n  .1..i...n.ls  n.n..h  np.ni  tl..'  oauM".     In  11... 

e..nt  ■      n  •  a  nM.l,v  '-"t  little  .an  I.  -Inn...     In  panUysis  m-.n  pr..ssuro 

i;:^"',;;;;:,!;;:  n>ay'.n>.h.ally  l..  n.li..v...l.     TU.  panUyx..!  nn.sc.U.s  shoul.l 

lw>  <tinnilat.'.l  l»v  (.l..ctricitv  aiitl  niassajic. 

i...^Zl^  n.uLlo.  arc  best  ...nsi.l..n..l  he.v,  as  th.-  '-'-1-  -P^ 
1        l>y  the  a....ss.,rv  an>  olm-ily,  th..nj:h  nut  soh.ly^  n.sp,.ns.hl.  i..i   the 

;  iti.  n.    Tl...  r..ll..vi..^'  fom.s  n,ay  l.o  .l.sc.r.lK..    in  th.s  s....t,on: 

,)  Couonnl.l  V.r/<V.//fs.-This  c-.Huliti.n.,  als..  k.u.wn  as  hx.l  t.  ,t  - 
colH^  .M;      Is  up..n  the  shovt.nin,  an.l  atn.phy  ..f  ll'^^---- j't" 

one  s.le  "Mrs  in  chil.ln.n  an.l  n.ay  n.U  !..>  n..t......l  fn    sou'ia    >.) 

on  a    o  ;  .  sh..rtn..ss  of  the  ,...  k,  th.  pan.nts  ..rton  allo,.n,  that  it 

h".  .y  c.n.e  ..n.     It  allV.c.ts  tl...  ri,.ht  si.lo  ahn.^st  -^<'l"--'l  •   .  ^ 

•0  <.in4.stan<...  i.>  conn....i..n  uith  it  is  tho  ^^f^^JJ^^ 

rv  n..to.l  hv  Wilks.  ^vhi.■h  appoars  to  l.o  an  ..ssont.al  pa  t  oi  tin. 

f,.on>  tin.  local  thickonin,^  in  tho  st.-rno-n.as...,.l  .no    ^    "^   '  ;;:J^^^';  ';^.^ 
nc.a.r  .,1  tho  tinio  of  liirtli  and  i.nuluoo  an  in.lnnit.on  oi  nuiscle  caiiu 
A  thon'h  Iho  :;o,.no-n.astoi.l  is  allnost  always  'l'^-t.l    ih^  ^o  -e  cj^- 
in  .hi.  h  .1,0  fibrous  atrophy  afToots  tho  tra,,../,.us      rius  ^'^^^^^^ 
i„    it..ir   is   unin.portant.  since   it   is   roa.l.lv   rehoyo.l   l.>    ^'^^^^J^'^ 
G..iain,-T5inl  statis  that  tho  facial  asyn.metry  pers.s  s    or  -  -^  ^ 
sho^vn  by  pbotograpbs  in  n,y  case,  become  more  ev..lont.     A\  itb  retcKn.o 


DISKASKS  OF  TIIK  rKKKFUfAr-  NKlfVKS. 


inr,:. 


i,Mi^  have 
liraiulR's 

Kirtiiiii  is 

S  (111  tlic 
tlic  Ik'UiI 
linll;^ll    ill 

(1  ill  piUt 
1}  jiiii'tiiin 
I'srt.  Tiic 
L'|)  hivath 
ilso  wt'ak- 
is  rotatt'il 
ticajiula'. 
10  seapuhi 

paralysis 
lead  tends 
iractcristie 
,'.  (luwors 
t  for  tluiso 
illii'iilly  in 
an  iiiqiDr- 

!C.  In  tlio 
m  pressure 
•k's  sliDuld 

ppasni  af- 
usclcs  sup- 
lile  for  the 
n: 

iixcil  torti- 
iiiastoid  on 
'veral  years 
iinjr  iliat  it 
Insively.    A 
vG  of  facial 
part  of  this 
<I-Uird.     In 
Rrni.  and  in 
istiii^niislied 
,  wliieli  may 
uselo  callu's. 
re  rare  cases 

of  wryiiock 
notomy,  but 
l(>ed  may,  as 
ith  reference 


In  Ihe  patiinl(i;:y  oi'  llie  alVecliuii.  (i(ildin;:-r>ird  euiirludes  that  tlie  fa<i.il 
usviiiiiii'try  and  tlie  tniiicdjlis  aiv  iiite^'i'al  parts  i>\'  one  nlVeelion  uhit  li  has 
ii  Vciitrar(iri;.'iii  and  is  the  euiintirpait  in  tlie  liead  and  iieek  ni'  iiilaiitile 
paralv.-is  w  ith  talipes  in  tlie  I'ont. 

(/*")  .'•■>(.vw/er//V  \Viiiiiirl,'.—'\\\»  varieties  of  this  spasm  occur,  the  tonic 
and  tlie  clonic,  which  niiK  alternate  in  the  same  case;  or,  ii<  i>  mo-t  coni- 
nioii,  they  are  se]mnite  and  remain  so  rmni  llie  (Hitset.  The  disea.-e  is 
most  Irecpicnt  in  adults  and.  accordiii;;  to  (lowers,  more  coiiiiiion  in  females. 
In  this  coiintiy  it  is  ci'rtainly  more  I'reipient  in  males.  Of  the  S  or  1<>  casc.-i 
which  ciimc  under  my  ohscrvation  in  .Montreal  and  Philadelpiiia.  all  were 
males,  in  females  it  may  he  an  hysterical  manifestation,  '{'here  may  he 
a  marked  neurotic  family  history.  \h:.  it  is  usually  iiiijiossihle  to  !i.\  upon 
any  dcliiiite  cti(do;iical  factor.  Siuiic  cases  have  followed  cold;  others 
a  hlow. 

'J'iie  sJiwplnins  are  well  defmcd.  In  the  tonic  form  the  contracted 
sterno-mastoid  draws  the  occiput  toward  the  shoulder  of  the  alVecled  side; 
the  chin  is  raided,  and  the  face  rotated  to  the  other  shoulder.  The  sterno- 
mastoid  may  he  all'cctcd  alone  or  in  assoc'atioii  with  the  trapezius.  When 
the  latter  is  imidicated  the  head  is  dcproscd  still  more  t>.ward  the  same 
side.  In  lon^'-standin<;  cases  these  muscles  arc  |)roiiiinent  and  very  riuid. 
There  may  he  some  curvature  of  the  siiine,  the  convexity  (d'  which  is  t(.Tvard 
the  soiiiui  side.  The  cases  in  which  the  spasm  is  clonic  are  iiiucli  iiku'c 
distressinj,'  and  serious.  The  s|)asm  is  rarely  liniite(l  to  a  sin;:ie  miisele. 
The  sterno-mastoid  is  almost  always  involved  and  rotates  the  head  so  as  to 
approximate  the  mastoid  ])rocess  to  the  inner  end  of  (he  clavicle,  tiirnin;.'' 
tlic  face  to  the  o])posite  side  and  raisin,ir  the  chin.  When  with  this  the 
trajiezius  is  affected,  the  depression  of  the  head  toward  the  same  side  is 
more  marked.  The  head  is  drawn  somewhat  hackward;  the  shoulder,  too. 
is  raiseil  hv  its  action.  Accordiiifi;  to  (iowers,  the  splenius  is  associated 
with  the  sterno-mastoid  ahout  half  as  fre(iiieiitly  as  the  trapezius.  Its  action 
is  to  incline  the  head  and  rotate  it  sli;.ditly  toward  the  same  side.  Other 
muscles  may  he  involved,  such  as  the  scalenus  and  jdatysma  myoides;  and 
in  rare  cases  the  head  may  he  rotated  hy  the  deep  cervical  muscles,  the 
rectus  and  ohliciuns.  There  are  cases  in  which  the  spasm  is  hilateral,  caus- 
ing a  backward  movement — the  rctro-cidlic  spasm.  This  may  he  either 
tonic  or  clonic,  and  in  extreme  cases  the  face  is  horizontal  and  looks  upward. 
These  clonic  contractions  may  come  on  witluuit  warninjr.  (n-  he  pre- 
ceded for  a  time  by  irregular  jjains  or  stiffness  of  the  ne<'k.  The  jerking 
movements  recnr  every  few  moments,  and  it  is  im])ossihle  to  keep  tlu'  head 
still  for  more  than  a  minute  or  two.  In  time  the  muscles  undergo  hyper- 
trophy and  may  lie  distinctly  larger  on  one  side  than  the  other.  In  some 
cases  the  pain  is  considerable:  in  others  there  is  simply  a  feeling  of  fatigue. 
The  spasms  cease  during  slcc]).  I'jnotion,  excitement,  and  fatigue  increas;; 
them,  'i'lie  sjiasm  may  extend  from  the  muscles  of  the  neck  and  involve 
those  of  the  face  or  of  the  arms. 

The  disi'ase  varii's  much  in  its  course.  Cases  occasionally  get  well,  but 
the  great  majority  oi"  them  persist,  and,  even  if  tcm]iorarily  relieved,  the 
disease  frequently  recurs.    The  alfection  is  usually  regarded  as  a  functional 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


lOCG 

nourosis.  l,ut  it  is  possibly  duo  to  Histuvbanco  ot  tl.e  cortioMl  contvos  pvcsiJ- 

"''i^ailm^lI^Tcnporavv  relief  is  somdinus  obtain..!;  a   vorn.anc.^ 

:     :,       ,:         ulil^UTitatiou  is  ...obably  useless      Fixation  o,  the  hea, 

.,       i.  1      Ti,o  la<t  does  not  eheek  the  spasm,  an,l  n>ay  a.uf^nnato 

r;^  ;;;     o Tc     po  KV  n.lief  ,nay  follow,  but,  as  a  rule,  tl-e  eou.htu.n 

'  ien   Hu-ell  thinks  that  reseeth.n  of  the  posterior  braneho.  of 

r*:;;;.-  ..e:::.:;  n:r!es  L  n.ost  nUely  to  ,ive  relief,  ana  this  has  been 

""";:;The":;:/:;;;;l  :;!:::■  -f  .hiiaren  n>ay  lu..  l.  n.en, .nea  :.  inv.,Mn. 

ehi        tlu.  n.useles  innervated  by  the  aceessory  nerve       t  nu.y  lu  a    nn,  . 

nek;a  foruv  of  halut  spasn,,  or  a  phenomenon  oi  epdep^y  (i-.  ""^■'      '  ; 

i  h  r,-e  it  1^  assoeiate.l  with  transi..nt  loss  ol  eonseiou>ne>^.     A  .nn   .  r 
\\liuli  case  11  1.   .1..ULI..  ,  I  ,.  ,.lul,lreii      In  women    t  Sometimes  ocours 

no.ldinji  spasm  may  oecurmolde.  ^'l"'''       "   ^^"    ,  "   ^  ^j,,  ,„.,,u,a  ,alaam 
as  an  hysterieal  manifestation,  commonly  as  pait  ol  tnt 
convulsion. 

JTYi'Od.ossAT,  Ntnivr.. 

This  is  the  .notor  nerve  of  the  tongue  and  for  most  ^I^IJ^^;;^;^;, 
fuhed  to  the  hvoid  bone.    Its  cortical  centre  is  probald)  the  loucr  pait 

actions  disturbed.  i,viH»rl,w<Ml  result   from 

(')\  Knclcir  and   iufm-nmknr  lesion?  oi   ti.e   hvp'>^'l'>^''i  ^^'"'^ 
(>)  i\ucicin    aiio   ill  „,:,,  i,„ii,.„.  naralvsis  or   n  locomotor  ataxia; 

slow  proL'ressve  degeneration,  a>  in  InilDai  iMiai.v..  ves^el« 

*.,11.     1.  n,»y  1.0  involvcl  in  it.  ™,,r.e  ,n  a  «,,r   ^^^^^^^^ 

:;];:r;n„u:;::;;!;,.i.;  ".'""•  »ir.,.u.,ui.|o. « i.  p.-„u.„a.a  ...^  n. 

luuiavzcd  ri.lo  ami  may  Ams  lil.rillary  '"''f""?.  ^,  ,     .,,,^.,,  .,  n,  ccnlro 
The  Si„„j,(i.».s  oJ  inv„lv™,o..l  ol  one  hyi.oglot.aI,  oitlia  at 


DISEASES   OF  THE  Sl'INAL  NERVES. 


lOCT 


or  in  its  (ouisr,  arc  those  of  iiniliitoral  ,>iiralvsis  and  atn-pliy  "f  Hif^  i""frno. 
Wlu'H  nrolnulnl.  it  is  in.slu.l  toward  tlic  alVirt.'.l  si-lc.  and  tlu'rr  arc  iImmI- 
lirv  twilihin-s.  Thr  atrophy  is  uMially  marked  and  th."  niun.ns  num  .ranc 
on  tiu'  atV.'ctc.d  side  is  tlirown  int..  folds.  Articulation  is  not  nnuh  nn- 
„air...l  in  tiic  unilateral  aiVc.-tinn.  There  is  a  ren.arkahle  triad  of  symptoms, 
to  which  lhi-hlin-s.lacks.u.1  iirst  called  attention-unilateral  henn-atrophy 
of  the  ton-ue,  loss  of  power  in  the  palate  muscle,  with  paralysis  .d  tlio 
brvnx  on 'the  same  side.  When  the  disease  is  bilateral,  th."  tonoiie  li.s 
i,l,;.ost  ni.dionl.'ss  in  the  lloor  .d'  the  month;  it  is  atropl'""'-  ;""  ^■■'"- 
r.,.t  he  i,r.>tru.le.l.  Spee.'h  and  niasticati..n  aiv  extivnu'ly  -lilheuit  ami 
dcdutition  mav  he  imi-aircd.  If  the  s.-at  -d'  th..  dis..as..  is  ah.^v..  th." 
miclei,  there  mav  he  little  ..r  no  wastin-  Tim  .■..n.lition  is  sen  m 
,„...j:r."ssive    hulhar    paralysis    an.l    .urasionally    in    lU'o-n-MV    muscular 

''  "The'jnK/m)siV  is  readily  made  and  the  situation  ol'  the  leM.ui  ."in  iisu- 
idly  he  (h't'ermincd,  since  when  >upra-nuclcar  tli."re  is  asso.Mat.'d  lu'iui- 
uk-ia  ami  m.  wastin-  of  the  muscles  ..f  the  ton-u...  M..-l..ar  diseas."  is 
,ndv  occasionally  unilateral;  most  conini.mly  hilat.ral  aiul  jmrt  ol  a  hulhar 
Virilv^i<  It  should  he  borne  in  niimi  that  the  llbr.s  ol  the  hyp..-i.issil 
may  be  inv.>lv..d  within  the  me.lulla  al'L^r  leaving  their  nu.-lei.  Jn  su.'li 
ix  c^ise  there  may  be  paralysis  .d'  the  tou.uMie  ..n  one  si.le  and  paralysis  o 
the  liudis  on  the  opposite  side,  and  the  t<.n-ue,  when  pr..lr.Hh..l,  is  pii.d,..l 

toward  the  sound  side. 

,Vp,,,,„._Tliis  rare  afTcction  may  be  unilateral  or  bilateral.  It  is  nmst 
frequently  a  part  .d'  s.mie  other  convulsive  disor.ler,  such  as  ."pilepsy, 
chorea,  or  spasm  of  the  facial  muscles.  In  some  cas.'s  of  stutterinjr,  spasm 
of  the  tonpue  ju'cccdes  the  explosive  utterance  of  the  wor.ls.  It  may  ..(•.•iir 
in  hysteria,  and  is  said  to  f..llow  reflex  irritati.m  in  the  lilth  lu'rv.-.  1  le 
uiost  remarkable  cases  are  those  .d'  ].ar..xysnial  chuuc  spasm,  m  whi.h  th." 
t.m<nie  is  raiiidlv  thrust  in  and  out,  as  many  as  r.,rty  or  lilty  tini."s  a  minut.". 
In  The  case  rep.u'tcd  by  (lowers  the  attacks  occuriv.l  durin-  sl.vp  an.  con- 
tinued for  a  V("ar  and 'a  half.  The  spasm  is  usually  bilat..ral.  W  .mdt  has 
reported  a  c:ise  in  which  it  was  unilateral.     The  pr..gnosis  is  usually  good. 

IV.    DISEASES    OF   THE    SPINAL    NERVES. 

ficnvicAi.  I'l.Kxrs. 

(1)  Occipito-cervical  Neuralgia.— This  inv.dvcs  the  nerv."  territory  sup- 
plied by  the  second,  the  occij.italis  maj.n-  an.l  miimr,  au.l  th."  auricularis 
niajrnus  nerves.  The  pains  are  chi."tly  in  the  back  of  the  h.>ad  an.l  n.'.'k 
and" in  the  ear.  The  condition  may  bdlow  .^.d.l  and  is  sonietini.s  associated 
Mith  stilTness  of  the  neck  or  b.rtic.dlis.  Unless  c.)nn."ct.".l  wiih  it  tlu"re 
exists  diseas."  of  the  hones  or  due  to  jiressure  of  tumors,  th."  .aith.ok  is  usu- 
ally go.id.  There  are  tender  jioints  midway  b.^twcn  th.'  mast.u.l  i)r.)c."ss 
and  t1i("  spill."  an.l  just  above  the  parietal  eminence,  an.l  between  th."  st."rno- 
niastoid  and  th."  trapezius.  The  atfecthm  may  be  due  tu  direct  pressure,  in 
jiersuns  who  carry  very  heavy  loads  ou  the  neck. 


^^ 


r 


^(3(58  DISEASES  OP  THE  NERVOUS  SYSTEM. 

(-2^  Affections  of  the  Phrenic  Nerve.-raralysis  may  fdlow  a  l.sion  ia 
rt'Xo  tH^ni-ion  of  the  none  „y  tu.o.  or  aneuns.n.     M.»o 

'•"''1  "'''."''TtJtrtaon^n't  m!li  n  inspinUion  and  is  forood  out 
""'  ::;  ;r  (  Ue^imr'o;;  on  atto„M.tin.  to  n.ovc  there  n>ay  be 
T  "-^5'  "'""':  t  u  ,  u,  VMS  sets  in  sud.ienly  there  n,ay  be  .lyspnu.a  and 
dyspmea.      H   ^"*    1''"  7' "^        „,„.  ,,»-    i..,Jt,.,ir^      Intereurrent  attaeks  ot 

,.o:,':Si!:  !;r  l .^ ..  •'-  •«>-  -'  r:v;;;;rk::ve;";.'';;i  ;■,';; 

p„i,.„l  ,,.o„nn,.,.  .,..1  .if.,.  0   -v.  ™.,     ;^  \       ;,  'XS'iB  or  in  interior 

torn,  oansed  b\   internuttinr,  .uu  niTorent  impress  ons  to  the 

i„g  sudden  eh,sure  as  the  air  is  rapidly  '^^\^^.  ^,„  ,vn,pton,s,  and 

"obstinate  Ineeouob  is  one  of  tl,e  ^^^^^^^\^''2^Z\ln    "W    U"^ford 
inav  tax  to  the  uttermost  the  resourees  of  the  phvu.an. 

S;:.:i;s  :::t:;:S-;i  X".  i '--  — 

particularly  tliose  associated  with  llatus. 


DISEASES  OP   THE  SPINAL  NEllVES. 


loc.y 


(r)  Spcdfic,  or,  perhaps  more  properly,  hliopalhir,  in  ^vln(■h  no  rvMlynt 
.an       =  r    pr  .  nl     in  thU  oas.s  there  is  nsnally  s..n.e  .onstm.tn.nal  ta.n, 
a     :  .u     di  >i.etes,  or  cl.ronie  i5rif.hfs  disease.     1  have  se.n  s-veral  mstane.., 
:il.ate  l,ieeun,h  iu  the  later  stages  ..r  .hronie  ,n.e,.,mal  •-!;  '^  - 
(,/)  \eiirolir,  eases  in  whieh  the  primary  eause  is  m  the'  nn   n,  >  .yUm 
hysS^e^Uepi,  ^Loek,  or^eerehral  tumors.     Ot  tliese  ea..  th.  hysterieal 
iire   nerhans,  tile  most  olislinate.  . 

"  'l^  tilaimeii,  is  often  very  unsatisfaetory.  Sometimes  in  tlie  n  d 
forms  a  sudden  rellex  irritation  will  eheek  it  at  onee.  Jeadois  ul  1  1  to 
S  "  u  iu.n  will  rememher  that  tlie  physieian  KryMma.l.us  n..oniiii.id  d 
to  K  lanes,  who  had  hie...ni,di  from  eatin,^  t.u,  mu.-h.  ..ith.r  tn  hod 
Ws  Im.  h  (  .i  h  tor  trivial  forms  of  hiec.ou.h  is  very  sat i.hulory)  or  o 
r."w^^^^^^  little  water;  hut  it  it  still  .ontiiuu.d,  Miekle  your  nose  with 
son^eUih  K  ind  sneeze;  and  it  you  sneeze  onee  or  twiee  ev.n  the  most  v.. 
1  hi.r.m.d,  is  sure  to  .o."  Tlie  atta.k  must  have  h.oii  ol  some  .-e  e  itv, 
ai^it  Is  stated  suhse.p.ently  that  the  hieeou^li  did  not  d,>a,MH.ar  until  An.- 
toi.hanes  had  resorted  to  the  sneezinji. 

^1  .0  a  teaspoontul  of  salt  and  lemon-juie..,  or  salt  and  vm.;,.ar.  or  a  t.a- 
.poolitul  ot  rlw  spirits  may  he  tried.  When  the  iiu.ou.h  .  due  o  ,  .- 
t  i.  irritation,  lava-e  is  sometimes  lU'omptly  curative.  1  sau  a  tat 
0  a  week-s  duration  eured  by  a  hy,.odermie  iujeetioii  ol  ,r.  i  ol  apon  u- 
pbia.  In  ohstinate  eases  the  various  antispasmo.lhs  have  h.vii  usrd  in  m.- 
^"  on.  I'iloearpine  has  Iu.n  reeommended.  One  has  --t'"-  ;'  ■ 
to  hvpodermic.  of  morpiiia,  or  to  inhalations  ol  cdilorotorm  ',' 
of  anivl  and  nitro.lyeerin  have  heen  henelie.al   ui  some  ;--       ;  J, 

over  tiie  i.hrenie  nerve,  .,r  pirssuie  .m  the  nerv.s.  api'lied  h.'tue,.n  th.    u  ,ul 
olViie  sterno-eleido-masloid  niuscKs  may  he  used.     In  the  very  severe  forms 
all  these  measures  may  prove  futile. 

r>u\(  iiiAi-  ri.KXfs. 

(1)  Combined  Paralysis.-The  ph'xus  may  he   involvd    in   the   .aipra- 
.lavieadar  region  hy  eompression  of  the  nerve  trunks  as  ^l-^   --e  t he       n  . 
or  hv  tumor,  and  other  morbid  processes  m  the  m.^k        .elo.   the     la 
lesions  are  more  eommou  and   result   from  injuries  tollowin^  "f 'V''    ' 
or  fracture,  .ometin.es  from  neuritis.     The  most  common  cause  "     -  ;^  ^ 
the  brachial  plexus  is  luxation  of  the  humerus,  partunilarly  tiu^  subcoi. uoid 
form.     If  the  dislocation  is  .,uiekly  reduced  the  symplmns  are  <1'''';'    ''J"- 
sient,  and  disa,.pear  in  a  few  days.     In  severe  eases  all  the  hranches  ol  the 
llcxus,  or  only  one  or  two,  may  he  involved.     The  umst  serious  case,  a  e 
Ihose  in  whicii  the  disloeathm  is  undetected  or  unreihurd  lor  some  t     . 
when  the  prolonged  pressure  on  the  nerves  may  <ansc  compU^  e  and  pe     la- 
nent  paralysis  oiMlie  anu.    The  muscles  waste,  tiie  reaction  of  dc,..ne,at mn 
is  prient,  and  trophic  changes  in  the  skin  are  apt  to  occur.      .    e  med  co- 
L.'.l  hcarin^^s  of  these  eases  are  inq.ortant,  and  may  he    l.us  hue  I      sum 
;;;^rized;  I);;eet  injury,  as  by  a  fall  or  bh.w  on  the  ^l-"'!-;--    ^  J    " 
,veat  hruisin^^  of  the  nerves  without  dislocation,  is  oecasionallv    '         -^    ^ 
complete  paralysis  of  the  arm.    A  dislocation  may  be  set  immediately  and 


^^k 


DISEASE^^  OP  THE  NETlVOL'S  SYSTEM. 


liens,  and  Hh-  Mipmator.      I  1h    hijuin   ina> 

Xnr.  (.s'nwv,/..  1  ."'^"  •-; ' '   ^.      ^^   ,„,,„;:  i„  direct  vn.sur.  in  tl.o  carry- 

,„  or  loads;  .M  .K>y  .aus  "  ;^,,  ,,  l^^^.torior.  ^Vh.n  paraly..! 
K— .  ^-->''-;;' 2  ,.;':,  '.^vin.od,  .-hlch  results  fnnn  the  pro- 
,1,0  scai">l^>  ""  tl.o  alkcU.l  .  ul  .  p.u'tu'ularly  ,...turaldo 

j^„.,.  ,„  .,,■  the  auKlc  and  I'ostcuoi  '7''  \-  /  '  ,^..^^,,  ,,„  ,„„.,v  holds  the 
ilu^u  tlu>  arn.  is  n.o..!  i---'".;;  .  ,  f  .^  ,eaddy  roeognizcd 
-'•^''^^'^''■'f  •  '^  r:^^d  s  s^K^t'd  .ith,  ..notin.os  preceded  by, 
forn.  ol  pan,  ys,s.  -^  -^  s  dnl.ions,  and  n.any  months  n,ay  elapse 
luniral-ric  pains.      1  in    toui.c 

h,ron.  there  -;'7  Jl-lj;;::!::;!;:;:  ,,,,,lies  the  deltnid  and  the  teres  nunor. 
(/,)  Cnruwlh:,-  Ann.      Hn.   ■    1  .lislocations,  bruising  by  a 

The  nerve  is  apt  t''  '-;--,      ;,,;,;;,i..n  tnnn  the  Joint.     Occa- 
orutch,  or  sonuMinio  b>  ^-^t  '^     "  j^;,  during  an  illness.    As 

.ionally  the  paralysis  arises  Iron  a  1  -^  /^j^^  ,„.,,  ;:,„,„t  be  raised. 
,  eonseqnence  of  loss  ...  l-^Y  \,J  ,  ,  fthe  shape  of  the  slunilder. 
The  v.asting  is  nsnally  marked  '''''^  ''  '-  '  .^,^  the  muscle.  The  ]oint 
Sensation  u.ay  also  be  impaired  n  ^  ;^  "  ^I^^J^t,,,,,  the  head  ot  the 
„„v  be  relaxed  and  there  ma>  be  '^  ;  ^'";;,  ;^,  ^,,,  ii,,„,nts  arc  thick- 
h„;,H.rus  and  the  acronuon.  n  f^^^^h.  produced,  but  .bich  is 
ened.  and  a  con.lition  not  unlike  ank>lo.>.  may         i 

readily  disiinguished  on  moving  ^';:'  ;;!;;•  ^,,„.,,,,;,.__This  is  one  of  the 
(,.     Mu,<ruh-xpiral   /Mn,///My     ^''''''''   ''''',,,,„  ^ho  exposed  position 
„.ost  lommon  of  penpheral  Vf^-^;^^-^^'ZL  use  If  theVrutch, 
of  the  nn.sculo-spiral  nerve.     ^\\  j^  ■,  frequently  injured  when 

l,v  injuries  of  the  arm   blows,  o,  ^'^^  '^^^  ^^  ^^,hair.  or  by  ,n'essure 

,-l,er;on  falls  asleep  with  the  arm  ^'^  ^  !^'  J  .^  •„,  ,,,  ^  i.encb  or  on  the 
oAbo  bodv  upon  the  arm  ^  ^  ^  Ij  ^:::,  :;:;V  "ntraction  of  the  triceps. 
,n-ound.     It  may  be  paraly/.cd  by  ^\'    '^^  ^  ^    ^  ^^^-^  ;,  uncomnuu.  ,n 

It  is  sometimes  involved  in  a  ncur,  .  ^  ;,  ;J  i„.,etion  of  other  the 
oon.pavis<n.  .ith  other  causes.      '^^   ^^^^    ^^^  The  paraly- 

r;n;:d^;:;::;;:;:i"-"^-- 

^^^'a  ;:;;;n  .hen  high  up  involves  the  triceps,  the  bracbialis  anticus,  and 


DISEASES  OF  THE  SPINAL  NERVES, 


1071 


iniuuMit 
oint  ill 
111'  tiiii>' 

0. 

he  arm, 
iilis  iUi- 
rii.g  de- 

Duly  tilt' 
,  iuvolv- 
>  ploxus, 

Thnrticic 
<  injured 
ho  carry- 
)  in  jiro- 
jmraly/.rd 
the  pro- 
lotireatdc 
hdldri  ll'C 
ocognized 
coded  hy, 
my  oUiiiso 

iiv  niiu'ir. 
isinji  hy  a 
nt.     Ooca- 

llllOS:*.      As 

ho  raised. 
.  shcnddor. 

The  iioint 
load  of  the 

aro  thiek- 
it  whioh  is 

one  of  the 
I'd  position 
the  crutch, 
jured  when 
hy  i)ressur(> 
h  or  on  the 
the  tricoiis. 
iconnnon  in 
of  ether  tlio 
The  iniraly- 
hranchos  of 

anticus,  and 


the  supinator  h.ULrus,  as  well  as  the  extensors  ol'  the  wrist  and  fin-ers. 
N-'iturallv  in  le^i^ns  iu>t  al)ove  the  elhow  tlie  arm  nnis.l.'s  and  tiie  supinator 
l„n>nis  lue  spared.  'I'he  most  characteristic  I'eature  of  the  paialy.is  is  tlie 
wri<t-drop  and  the  iiiahilitv  to  extend  the  tirst  plialan-es  of  tlie  Ini-ers  and 
thmiih  in  the  pressure  palsies  the  supinators  are  usually  mv.dve.l  and 
the  movements  of  supination  cannot  he  accomplished.  The  M-nsition>  may 
,„,  i,„,,„i,rd,  or  there  may  he  marked  tiii-lin-.  Imt  the  lo>s  ol  seiis.tion  is 
rari'lv  so  iiroiiouiieed  as  that  of  motion. 

Tlie  atlVetion  is  readily  reconiiiml,  hut  it  is  sometimes  dillieiilt  to  s'.y 
npon  what  it  depeii.ls.  The  sleep  ami  |..vssure  palsies  are,  a^  a  rule,  uni- 
lateral and  invlvo  the  supinator  lo,r,nis.  Tlie  paralysis  Irom  had  i>  l>i- 
lateral  and  th.'  supinators  are  unatVeeled.  I'.ilateral  wristdrop  is  a  very 
common  svmptom  in  many  forms  of  nuiltil-lo  neuritis,  parfeulary  the 
alcoholic;  'hut  the  mode  of  .mset  and  the  involvement  ot  tl:e  h-s  ami  arms 
are  features  which  make  the  diagnosis  ...sy.  The  duration  and  <ourse 
of  the  miis..ulo-spiral  paralyses  are  very  variahle.  The  pres>iiiv  palsies  may 
di^ai.lH.ar  in  a  few  davs.  JJecnvery  is  the  rule,  even  when  the  alio,  tion  lasts 
for  many  weeks.  The  electrical  examination  is  .d'  imp.nlance  in  the  prog- 
nosis, ai'.d  the  rules  lai.l  down  under  paralysis  of  the  facial  nerve  hold  -ood 

here. 

The  treatment  is  that  of  neuritis. 

(,/)  rinnr  ,Vr-nr.— The  motor  hramhcs  supidy  the  ulnar  halves  ol  the 
,hrn  ilexor  of  the  lin-ers.  the  muscles  of  the  little  lln-er,  the  mtcrossei. 
the  adduct<.r  and  the  inner  lu^id  of  the  short  tlexor  of  the  thumh,  an.  the 
nlnar  ilexor  of  the  wrist.  The  sensory  hranches  supply  the  ulnar  side  ol 
the  hand— two  and  a  half  nu-eis  on  the  hack,  an.l  one  an.l  a  hall  lin-ers 
on  the  front.  J'aralvsis  may  result  from  ].ressiire,  usually  at  the  elhow- 
ioint  alth.ui.di  the  nerve  is  hero  protected.  I'ossihly  the  neuritis  m  the 
nlnar  nerve  in  s.nne  cases  of  acute  illn.'ss  may  ho  due  to  this  cause,  (iowers 
mentions  the  case  of  a  ladv  who  twice  had  ulnar  neuritis  alter  conlinement 
Owin.^  to  paralysis  of  the  ulnar  Ilexor  of  the  wrist,  the  hand  moves  toward 
the  radial  side:  addncti.m  of  the  thumh  is  impossihle;  the  hrst  phalan-cs 
cannot  he  flexed,  and  the  others  cannot  he  e.xtcnde<l.  In  lon--standin- 
ci-e^  the  fir-t  phalanj,u's  are  oyoroxtended  and  the  others  stronoly  Hexed, 
p'roducin-  the  claw-hand;  hut  this  i  not  so  marked  as  in  the  progressive 
niuscular''atro].hy.  The  loss  of  sen>alion  corresponds  to  the  sensory  dis- 
trihuticm  just  mentioned. 

(.)  Afrdian  AVrrr.— This  suiM.lies  the  llexors  of  the  fingers  ex<rpt  the 
nlnar  half  nf  the  deep  llexors.  the  ahductor  and  the  flexors  ot  the  thumh, 
the  two  radial  lumhricales,  the  pronators,  and  the  radial  ilexor  of  th.>  wrist. 
The  .sensory  fihres  sui-idv  the  radial  side  of  the  palm  and  th..  iroiit  ..I  the 
thnml).  the  first  tw..  fingers  and  half  the  thinl  finger,  and  the  dorsal  sur- 
faces of  the  same  three  fingers.  

This  nerye  is  seldom  involved  alone.     l'araly<is  results  inun  injury  au-l 
occasionally  fnm.  neuritis.     Tin.  signs  are  iuahility  to  ,.ronate  the  forearm 
l,oy.md  tlH"  mid-position.     The  wrist  can  only  he  ilexvd  toward  the  ulnar 
side;  the  thumh  cannot  ho  opposed  to  the  tii^s  of  fingers.      '  ";;"':'^' 
phalan-es  cannot  bo  Hexed  on  the  first;  the  distal  phalanges  ot  the  first 


.^  DISEASES  OF    lUE  NERVOUS  SYSTEM. 

U.is  action  can  bcporlunnnll.       ^        ^^  ,,,,5,,^  ^.,  u,.  s.nx.ry  di.lnV.uUou 

1"-  "^  -"-^'""  1  "V  ::'  ;S  :  ^  rtli:  Uunni.  nu,.Us  .IncU  is  usually 
tS;:rT:ual.':;;;v.;.oUaeUa..a.en.a..a,...^ 

K,MUAH    AN..    SA.WA..    I'l.KXl-SKS. 

.lands  in  P^nas  aWco..,  and  ni  :''^^;  '  j,^  i,j,„,„i  ,iuvinj.  imrtuntu.n. 

^Vh.^  paralyzed  the  l'"-;^_   '„;^    oulwanl  rutatinn  is  al.o  d..  urlnd. 

^on  oi  tho  lup-,i"int,  1-^ /--"'"  '^J  l^'^i^,  .,ooud  .ynu^tom.  of  alYec- 
l,vdisc.as...rthol,n,u.sand  >;:  J'-;^  jt'^t^n.-n.  <i  the  l<n.e  with  wa.tmg 
tiun  or  this  n.Tvo  avo  l':"''''>;r;;  '  ,^^  ,al  pari,  of  the  Hugh  and  oi  the 
ol  th.  nu...l.s.  an=v.lhe.ui  u  tl.c  '^^^^ '1  f  ^^^.^^  ;,  ..nnetinu..  involved  e.ivly 
,,,,„  .iae  or  the  le,  to  the  '"I;  j'  ,^„  ,' ^"^  ^,„i,  in  it.  area  of  distrd.u- 
i„  ,,owtl>.  ahont  the  ^l"-''/    ^,  ^ '  ,„7  ,'    „.,>^h  results  ITo.n  paralysis  o 

muselos.  .     „      _,,.,.  i„,„,,,,a  in  tunu.rs  and  inilanimal.ons 

'l'"^'  r"'""J  ''Z  :X^rZL,  Partnrition.     Neurit,  .s  conr- 

:;:;;;:::;ai;:a::;^;:'.";;u7-'--:^         .thenotd. 

Of  the  l,ranehes  the  -■''''''■  '''^X^Z^l^  n.nseles  hehnv  the  knee, 
eanse.  paralysis  oi'  the  "'■-"■V^i^^^^h  involves  only  the  latter  nu.seles^^ 
1'"t  i"i^"T  helow  the  fonld      o  -  ^,_^,  ^.,,^.^  ^,„a  the  greater 

ivilient  isahlo  to  walk.  _  .        ,.  ,1,.  «,w.n     The  glniens  niaxinuis 

^""  talysis  or  the  s,.,n  -;""-;;'•';;-    ^  ti^^    -n,  a  ^.at.     There  is  a 

i.  involved  and  theve  -=^^/;^,    ;.J'    f    ,   ',  •      l^hird  of  the  Hugh. 

.trip  of  anu'sthesui  along  the  ha  k  '  '  ^^    >  ^^^^.      ,,„„,vi,  tlu>  long  ex- 

t,n..r  of  the  toes  tihml.s  an  >e  .  J  -  »  ^^^  ^,,^,  1,,.,,,  ,.  foot-drop,  and 
,,l,le  cannot  he  lU.xed,  ^-f  ^^\  V  e  >^  must  be  lifted.  ,H.ulne,ng  the 
,,  the  toes  eannot  ho  ^^^f^^^^Znu..  fonns  of  peripl>ora  n.  urit^ 
charaoteristie  ././'/'-/''  f"'  -*'  ^,  ,,,  ,^„tiv  extended  and  there  .s  wasting 
In  lo.g-standing  eases  tlu.  f"';^  ' .  [^  X^  'The  loss  of  sensation  is  ur  the 
of  the  anterior  tih.al  and  peiomal  1  >"■  ^  ^  ,,f  ^he  foot, 

^uter  half  of  iho  front  of  the  ^^^  ^  f  ^  l;,,,ntar  lU-xion  of  the  foot 

Inlernal  PopWcaJ  -^ '•'•'''■■.-^^ ''     .  '"^p  /,  f,!t  cannot  ho  addueted.  nor 

and  floxion  of  tho  toes  aiv  '-V^^^f  ^^„i!   ,„aing  cases  talipos  caloanous 

can  the  patient  rise  on  tiptoe.     In  lon„ 


1; 


DISF.ASES  OP  THE  snXAL   XKKVES. 


io:;5 


fingers 
IS.  Tho 
liliuliou 

usually 


■  Iviniih- 

i)nv.   oi: 

ilurituiii. 

anil  line 

listurl)ecl. 

;l    llisl(K-U- 

;(iinetiine3 
>  ol'  alVec- 
h  waslinf,' 
ukI  uI  llie 
.Ivetl  early 
f  distribu- 
aralysis  of 
d  miuiiiius 

animations 
ills  is  coni- 

tlie  notch, 
,v  the  knee, 
lev  muscles. 

llu-  greater 
(juently  fol- 
'  one  sciatic 
isor  an     the 

-us  maxinuis 
There  is  a 

Ihigh. 

the  long  ex- 
itorum.    The 
„,t-drop,  and 
irodueing  the 
K'val  H'uritis. 
J,,.,,  is  \vasting 
dion  is  in  the 
lot. 

m  of  the  foot 
addueted.  uor 
ipes  calcaneus 


fclh.ws  ami  tlie  toes  assume  a  claw-like  iHisitiou  from  sccdudary  (•(.uliacture, 
due  to  overe.\lcn.-i<.ii  »(  the  pruximal  and  tlcxiou  of  the  second  and  third 
jihalanges. 

SlIATlCA. 

This  is,  as  a  rule,  a  neiTi'itis  either  of  the  sciatic  lurve  or  of  its  cords 
of  oriuin.  'it  may  in  some  instances  lie  a  functional  neuro>is  or  neuralgia. 
Jt'~occurs  mo.-"t  commonly  in  adult  males.  A  hi>lury  of  rhe\imatism  or 
of  gout  is  present  in  many  cases.  Kxi)osure  to  cohl,  particularly  after 
lieavy  muscular  exertion,  (.r  a  severe  wetting  are  not  unconunon  causes. 
^Vithin  the  pelvis  the  lUTVi's  may  he  comi.re.->ed  hy  large  ovarian  or  uterine 
tunior.s  hv  Ivmi.hadcnomata,  hy  the  f<etal  lu'ad  during  lahor;  occasion- 
ally lesion's  of  the  hiii-joint  induce  a  secondary  sciatica.  Tiie  coiiditnu, 
of 'the  nerve  has  heen  examined  in  a  few  cases,  and  it  has  often  been  seen 
in  the  operation  of  stretching.  It  is,  as  a  rule,  swollen,  reddened,  and  in  a 
conditicm  of  interstitial  neuritis.  The  aiVection  may  he  most  intense  at  the 
sciatic  notch  or  in  the  nerve  about  the  middle  of  the  thigh. 

Of  the  siimptoms,  pain  is  the  most  constant  and  troiihlesome.  The 
on-et  mav  be  severe,  with  slight  pyrexia,  but,  as  a  rule,  it  is  gradual,  and 
for  a  tiiiie  there  is  (miy  slight  iiain  in  the  back  of  the  thigh,  particularly 
in  certain  positions  or  after  exertion.  Soon  the  juun  becomes  more  intense, 
and  instead  (d'  bciiii:  limited  to  the  upper  piu'tion  of  the  nerve,  extends 
down  the  thiuh,  reaching  the  foot  and  radiating  over  the  entire  distribu- 
tion of  the  nerve.  The  iiatient  can  often  point  out  the  most  sensitive  spots, 
usually  at  the  notch  or  in  the  middle  of  the  thigh;  and  on  pressure  these 
are  exquisitelv  iiainful.  The  jiain  is  described  as  gnawing  or  burning,  and 
is  usually  constant,  but  in  s(mie  instances  is  iiaroxysmal,  and  olteii  W(u-,~e 
at  ni<dit.'  On  walking  it  mav  be  very  great;  the  knee  is  bent  and  the  pa- 
tient'trcads  on  the  toes,  so  as  to  relieve  the  tension  on  the  nerve.  In  pro- 
tracted cases  there  may  be  much  wasting  of  the  muscles,  but  the  reaction  ol 
degeneration  can  seldom  be  obtained.  In  these  chronic  cases  cramii  may 
oc^ur  and  librillar  contractions.  Herpes  may  develop,  but  this  is  unusual. 
In  rare  instances  the  neuritis  ascends  and  involves  the  spinal  cord. 

The  duration  and  course  are  extremely  variable.  As  a  rule  it  is  an  ob- 
stinate affection,  lasting  for  months,  or  even,  with  slight  remissions,  for 
years  Ui'la].ses  are  not  uncommon,  and  the  disease  may  be  relieve.l  m  one 
nerve  only  to  appear  in  the  other.  In  the  severer  forms  the  patient  is  bed- 
ridden, and  such  cases  lu-ove  among  the  most  distressing  and  trying  which 
the  i)hvsician  is  called  upon  to  treat. 

In  the  diaqiiosis  it  is  imi)ortant,  in  the  first  place,  to  deternnne  whether 
the  disease  is  primary,  or  secondary  to  some  alfection  of  the  jk-Ivis  or  of 
the  spinal  cord.  A  'careful  rectal  examination  should  be  made,  and,  in 
women,  pelvic  tumor  should  be  excluded.  Lumbago  may  be  confounded 
with  it.  Affections  of  the  hip-joint  are  easily  distinguished  by  the  absence 
of  tenderness  in  the  course  of  the  nerve  and  the  sense  of  pain  on  movement 
of  the  hip-joint  or  on  pressure  in  the  region  of  the  trochanter.  There  are 
instances  of  sacro-iliac  disease  in  which  the  patient  comidains  of  pain  m 
the  upper  ])art  of  the  thigh,  which  may  sometimes  radiate;  but  careful 
•  07 


^^ 


DISEASES  OF  THE  NEIlVOrS  SYSTEM. 


„,t..ry,  .hnU  couu.  on  »-  ;;   ,;  !^,  1  ;   n'  ,!..,■.  is  a  suspicion  ol  sypluh. 

„,  „t,,.v  inslan.rs  llu.y  ''^.^^    ;  ;  ,u.lov..l,  and  .n  K">'ty  ->--  ^>>  ',"-• 
i,„li.U..  of  ,...tas.uun  si  ouhl  '  Y,     \  „,,  Uv  nu'ans  of  a  lon^'  si-linl    >  a 
H,,.l  in  lH..l  Nvith  lixatiou  ol  t' ^""   '      .  ^.,,,,,    ,,„,  upon  ^^•l^^ll  ^^i■lv 

Mit.l.ell  iK.s  ^l->''l^'."^f^ iA      tra.t...l   eas.s  ^vhn■h  had  .^-^^  '\* 
instancc-s  to  cnr.,  ol.st.nato  '"  \  ^'  ^„,,,  ..ti.factory,  pavt.cnlavly  tlu 

;,Uu.r  tv.atnH.nt.    IlyavoHu.njpy  -  '     ^  l^,,^  ,,,,  ..Ucvcl  l-y  a  prolongod 

1  .^iij;  ^^.  the  niiiu  liatn>.     ^M'1'>.> 
Smu'o  at  one  of  11..  thovnml  ^V^^^^^'  ^^,,„„f,i  u-ncHt. 

^^    Antipyrin.  antifdnin,  -'^H—         "l  ;;^,  ,^,,^  .^.,^,  ,,  ,,>  llu.n.o- 

1  .,ia    av-plieatio"^  '>''^'  "^'"'       "  ...vilv      Dci'P  inj«tions  int..  ll>f 

.,„  ;       ;  blisters  relieve  the  pa>n  t-up.   .u^V     ^  ^^  .^  ^^^^^  ^^^ 

;;;:;:;:^,..e  ,veat  relief  and  ->; ^ ^^g^    ^.l^    l..ir  of  a  .vain.    H^  e 
nH.aine  at  livst.  in  doses  ol  ^      ' .'    .  \  ^^.^^   ^^,,^  it  i,  .  danj^eron.  reniedy  m 
i,,  i,  unl-eavable  ^^^-n^f''^'\^^%  ,,.,ssil.le.    The  disease  is  so  p.  >- 
L.i.tiea  and  should  be  .nhheldj  ^^^^^.^  „,,,,,,  ,«  -f  "<'--.  '^ 
traeted.  so  liable  to  relapse    and  ^'>  ,^^,  ,-,,„,,,  „f  eontraet.n- 

:     nistant  .ovvy  and  the  ^^-j'^-J,    ^    !,    l,ai..„  .hould  the  patient 
e  morphia  habit  is  very  ^^  ;   .  ^'^^^'i^.^f.     U  is  remarkable  how 
,0  nerni  tied  to  use  the  bypodenuR  "^^  '  |  '        j  ^^.^^^.r  into  the  nerve  will 
;r;  Uly.  in  some  c.ses,  ^'^  ;J^  ;;^  ^,  ^^^l;' .1;  the  ueedles  should  be 
Ipliove  the  pain.     Aeupunetuie  may   ai.o  -,;  ^  ,,i  about  'i  inebe>, 

;';:;  deeply  mto  tl.  ^fV^^J^:.  ^'io'iuecHon  of  chlorofonu 
•md  left  for  from  lilteen  to  twenty  imnm 

;;;!/;i;ilerve  Has  also  been  r^nmend^  ^^^^^^^^^^  ^^  ^^^^^  l-'-l^-^^t 
Klectrieity  is  an  nneertan    ^^^'^>-        ;^,,„,,t  j,,,  .li^btesl  beueht      It 
i,  other  eases  it  may  Ik.  used  1       -^.  ^^^^^^  ;,  ,,,,tni,  ol  tl 

I  most  serviceable  in  the  ehro.         ■  m^^   >  ^^^.^  ,,     ,a 

l,.rs   and  should  be  combined  a    tl    i»'Y; --,•    ^.^,,  tlu>  seiatie  notch,  and  a 


ACrTK  DELlIUrM. 


lot; 


mo  on 
liii  and 
istrtiii'i'S 
ilitnin^t 

laiically 
,  ^hdulil 
(•lunatic 
1(1  iiond. 
sy|ihi!i>. 
lines, 
ilinl  is  a 
ich  Wfiv 
in  some 
r^istoil  all 
ilai'ly  the 
^imlongod 


(.  thevmo- 
s  into  tin.' 
best  to  uio 
in.    If  tlie 
remedy  in 
.  i^  so  pvo- 
rinined  hy 
L'ontraeting 
the  patient 
vkalile  how 
J  nerve  will 
5  s^honld  he 
lit  2  inches, 
ehhn-ol'onii 

•omi't  relief; 
henelU.     K 
istinir  of  the 
rrent  sho\dd 
;i()teh,  and  a 
les.    In  very 
:iracs  succoss- 
as  ever. 


VII.   (iKNERAL   AND   FUXCTIOXAL   DISEASES. 
I.    ACUTE  DELIRIUM  (H'llS  M,„u„). 

Definition. — Acute  (U'lirinii\  niiiiiiiig  a  ra|ii(liy  fatal  emirse,  with 
slii:ht  lever,  and  in  wliicli  |iiist  mortem  no  lesions  are  luund  snilicient  to 
iieciinnt  lor  tiic  disease. 

Cases  arc  reported  hy  many  old  writers  under  tiie  ter-  hiain  fever  <ir 
phrenitis.  Iiell,  at  the  time  Sn|ierintendcnt  of  the  M(  1-can  Asylimi.  de- 
Miiiied  it  *  aceiiiately  under  the  designation,  "a  form  ol'  disease  resembling 
some  advanced  stages  oi'  mania  and  I'evcr." 

'idle  disease  may  set  in  abruptly  or  l)e  preceded  hy  a  perioi)  of  irrita- 
bilitv,  restlessness,  and  in>(imnia.  The  mental  symptoms  develop  with 
rapiditv  and  may  (juJckly  reach  a  grade  ol'  the  most  intense  I'ren/.y.  'I'herc 
are  the  wilde>t  hallucinations  and  outbreaks  of  great  violence.  The  i)a- 
tient  talks  incessantly,  but  incoherently  and  unintclligihly.  Xo  sleep  is 
obtained,  and  at  last,  worn  out  with  the  intensity  of  the  muscular  move- 
ments, the  |)atient  hcconu's  utterly  ])rostrated  and  assumes  the  sitting  or 
recundjcnt  ixtstnro.  There  may  sometimes  ho  definite  salaam  movements, 
and  in  a  case  which  I  saw  at  WestphaTs  clinic  the  patient  incessantly  made 
motions  as  if  w(Mking  a  pump  handle.  After  a  jieriod  (d'  intense  hodily 
excitement,  lasting  for  fr(>ni  twenty-four  to  thirty-six  hours  or  longer,  the 
patient  can  be  examined,  and  presents  the  conditions  which  I'x'll  descril)ed 
as  tvpho-mania.  The  temperature  ranges  from  102'^  to  lot',  or  even 
higher.  The  tongue  is  dry.  the  pulse  rajiid  and  feeble;  sonu'timcs  there 
are  seen  on  the  skin  hulhe  and  jinstnles,  and  I'rcMpiently  sores  from 
abrasion  and  self-iidlicted  injuries.  Toward  the  close  or,  according  to 
S])itzka.  even  during  the  dcveloiiment  of  the  disease  there  nuiy  he  lucid 
intervals.  There  may  he  ])etcchia'  on  the  skin,  and  often  there  is  markeil 
congestion  (d'  the  face  and  extremities.  The  duration  of  tlui  disease  is 
variable.  Very  acide  cases  may  terminate  within  a  week;  others  persist 
for  two  or  even  three  weeks.  Tlio  course  of  the  disease  is  almost  uniforudy 
fatal,  'i'he  anatomical  condition  h  jiractically  Jiegative,  or  at  any  rate 
])resents  imthing  distinctive.  There  is  great  venous  engorgement  of  the 
vessels  of  the  meninges  and  of  the  gray  cortex.  In  two  cases  in  which  I 
made  a  careful  micr(isco])ical  examination  of  the  gray  matter  there  were 
]ierivascidar  exudation  and  leucocytes  in  the  lymjjli  sheaths  and  ])eri- 
gangliar  sjiaces.  In  the  inspection  of  fatal  cases  of  acute  delirium  care- 
ful examination  shoidd  l)e  made  of  the  lungs  and  ileum.  It  should  he 
home  in  nnnd  that  in  a  majority  of  the  cases  dying  in  this  manner, 
there  is  engorgement  of  the  hases  of  the  lungs  or  even  deglutition  pneu- 
monia. 

The  nature  of  the  disease  is  quite  unknown.  Some  of  the  cases  sug- 
gest acnt<>  infection.  Spitzka  thinks  that  it  is  due  to  an  autochthonous 
nerve  poison. 


*  American  Journal  of  Insanitv,  1849. 


luTti 


insEASKS  OF  TUK  NERVOrS  SYSTEM. 


,,,  ai^c..<.-  vvlm'U  may  invs.Mt  ..l.'ntu..! 
^'^■•■^"  '"'•■  '*■'"  u    r    tlK>  rust  ulaiu.'  i<>  many  .a^^^ 


I- 


Diagnosis        .-^^^  in  b.^  l'''l"';/";' ,;i,:;;t^:^,rn  al..r  tlH.  vi. 

'      0...as,onally  .uut.  ^Y^^     ,nu^  ,on.lition  of  the  u.uk.  and  the  ab 

""The  character  of  the  "'"■;:;;;;  'V'^litVerentiate  acute  ael.ruun     rum 
It   neiv  he  cxtr.Muely  (hlhci  It  to  (n  ,„,^.aion   witli   pn*'"" 

,,    ,„v    be    "'^•''i"'^^^'^'^'\;"  %r;Vt     has   ohtaineA   ..hhI    rc.u  is   1:n 
i.  almost  unil'onuly  fatal. 


U. 


PARALYSIS   AGITANS 


.  .niUon -- vl."i-^^etion  oMhe  ,mrvo.  system,  01...^^^^^^^ 

,v  ^^^^-kness,  tremors.  J-^  jj^^l^^,^^,,,  ,^,  ,  ....n.     It  rarely 
■    Etiology.-^I^^n  are  more  ^^^^^l^,,,,a  in  .hich  the  disc.,se 
occurs  unc^r  forty,  In^  -stane  .  1-  J^^^  \,,,„,  ,,  nnco.nmon  ||ffoe- 
U,,au  about  the  t^;-"^!^'*^^^:'^;;,^  ^  J  patients  often  belon,  to  fa.nO^^ 
ti.m.     Direct  heredity  is  ra,e,  '"<  J'^  J^      .^,^^,,,,j.  excitin-  causes  may  h 
Uich  there  are  other  "--^  ^^^^^a  business  ^vorries  and  nnx,ehes 
mentioned  -1--  to  c^  ^^;^^^  ,,,^^,,^  ^^^on  sevc^.  ment^^ 
In  sonuMnstancc     h    a   ea^e^^  descnhed  after  the  specdie  feveis. 
or  trauma,     ^^ascs  iui> 


PARALYSIS   AOITAN'S. 


lUTT 


iitic!\l 

0  viii- 

1  \Vl'l'l' 

(iciiir- 

MOIT- 

.  fxist- 

II     Willi 

is  vi'iy 
uiil  tl>»^' 

liii,  ami 
the  ab- 

V nil  in  " 
im  from 
h  inu'U- 
nii  I'roni 
ml  llH've 

on  ciu'ly 
in  niij;l>t 
t.  It  i^ 
in  wliicli 
;  oi'  alVou- 

(li'liviun\, 

1(1  chloi'o- 

niiiy    !'(' 

irs\ilis   liv 

he  disease 


iiiractcrizei'l 

I.  Tt  rarely 
the  disease 
innion  alTec- 
,  fiuuilies  in 
uisos  may  I'O 
nd  niixieties. 
mental  shnck 
L-vs.     ^lalaria 


m 
1 


is  helieved  l>y  H.iiie  to  he  iin  iMn.ortiuit  laetnr,  hnt  of  this  th.Te  is  no  satii?- 

Morbid  Anatomy. -No  .onstant  le-nms  hav..  h.en  fniind  Ihe 
.innhiMtv  helwe..n  eeitain  of  the  re:.t.nv>  nl'  I'arkinsun^  disease  and  those 
„r  ,,1,1  „.'.,.  Mi""v>t  tliat  the  alVeetinii  niav  depend  uiu.n  a  i.ivmntnre  seinl- 
ity  „r  e.Tlaiii'iv-ions  .d'  tlw  hraiii.     Our  oi-mik  do  hnt  a-e  iinilorndy.  hut 

in  <nnie,  uwin-'to  heivditarv  dis|.„>ilion.  the  proee.s  may   he  re  rajad 

,!,;,„  in  oth. ■:■>'.  ••  i'arkins.Mi's  disease  lias  no  eha-aeten-tie  lesions,  lail  on 
the  .>tluT  hand  it  is  not  a  neurosis.  It  lias  for  an  anatniuieal  lia-i<  the 
U..i,ms  ,d'  e.Mvhro-si.inal  senilitv,  and  xvhi.h  only  dilVer  fmin  those  .d  t.ne 
senility  in  tiioir  .'arly  onset  and  jireater  inten>ity  "  (Duhiel).  '1  he  nn- 
i.,,ilant  (  haii-es  are  .hmhtless  in  the  cerebral  cortex. 

Symptoms.— The  di.^ea^e  be.Ldns  {.'radually.  nsnally  in  one  ..r  nth.'r 
liand  and  tlie  Iren.nr  mav  he  either  con>tant  or  intermittent.  With  this 
nay  "be  a-^s..eiat.'d  w..akness  or  stillness.  At  lirst  these  symptoms  mav  be 
.resent  oidv  after  exerti.m.  Althon-h  Hie  onset  is  sluw  and  -radual  m 
nearlv  all  ea-e<.  there  are  inslanees  in  which  it  sets  in  abruptly  alter  Iri.irlit 
,,r' trauma.  When  well  ..stablisbed  the  disease  is  very  .haractenstie,  and 
tlu.  dia-nosi^  can  be  made  at  a  Ldaiice.  The  fonr  prominent  symptoms 
are  tremor,  weakness,  riuiditv,  and  the  attitude. 

V,.,,„„„._'l'lns  mav  be  in  the  four  extremities  or  ecmfined  to  bands  or 
feet  •  tiie  head  is  not  so  coninionlv  airected.  The  tremor  is  nsiially  mark.'d 
in  tiie  liamis,  and  the  thnmb  and  forelin-er  display  tlu'  motion  made  in  the 
act  <d'  rolliii"-  a  pill.  At  the  wrist  there  aiv  movements  .,1  pronation  an.l 
'.uniration,  and,  thonj:!.  less  mark.'d,  .d'  llexion  an.l  ext.a.sion.  The  iipper- 
.„,„  ,u„~clcs  are  raivlv  invoUvd.  In  the  le-s  the  movement  is  most  evident 
„  the  ankle-joint,  and  le^s  in  th.'  to.s  than  in  the  finders.  Shakiiitx  ot  the 
h,,,ul  i«  less  frequent,  but  does  oc.ur,  and  is  n<ually  vertical,  not  r.,tatory. 
The  rate  (d'  oscillation  is  ab.ait  live  per  se.-ond.  Any  emotion  .■xa--eratcs 
the  moveiiuait.  The  attemi-t  at  a  voluntary  movement  may  check  the 
tremor  (the  patient  mav  be  able  to  thread  a  nee.lh.).  but  it  re  urns  ^vlth 
i„,,rase.l  intensitv.  The  tremors  cease,  as  a  rule,  .lurinn-  sleep,  but  persist 
when  the  mnseles  are  at  repose.     The  writing-  .d'  the  patient   is  tremulous 

lV,«/,,rrN.s.-Loss  of  power  is  present  in  all  cases,  ami  may  occur  .■y.ai 
before  the  tremor,  but  is  not  very  strikin-.  as  tested  by  the  .ivnammneter 
TUitil  tl.e  late  stages.  The  weakness  is  pratest  where  the  tremor  is  most 
develoiied.     The  movements,  too,  arc  remarkably  slow.      Iheie  l^  lauly 

cinnidete  loss  of  power.  i    ...v  •     4i^,.  >i 

l^h,UII„  mav  earlv  be  expressed  in  a  slowness  and  s  ilTness  m  the  ^ol- 
untarv  mo'vements,  wbi.b  are  performed  with  some  eilor  and  dilliculty. 
and  ail  tlu.  actions  of  tbe  patient  are  d..liberate.  This  ri-idity  is  m  all  the 
nuiscles.  and  loads  nitimately  to  the  characteristic  ,      ,.,         ,         , 

MliliKlr  mid  r;«i7.-The  bead  is  bent  forward,  the  back  ,s  bo«-ed.  and 
the' arms  are  beld  awav  from  tbe  body  and  are  somewhat  il^'X'"d  '>t  the 
clbow-ioiiits.  The  face  is  expressionless,  and  the  movements  ol  the  ips 
■ire  «low  The  evcbrows  are  elevated,  and  tbe  wbol.>  expression  is  nninobile 
or  mask-like,  the  so-called  Parkinson's  mask.     Tlie  voice,  as  pointed  out 


■^^ 


luT« 


DISEASES  OP  THE  NEllVOUS  SYSTEM. 


(it't.'ii  11  lir-it:iiiiy  ill 


l,v  l',u//ar(l    is  apt  to  l.r  -lirill  mid  i>il>m^'.  and  tlu'iv  i- 

7         u".    ill  •.  In.nv      'I'liis  is  sniiu.li.iu.s  in  stiikiuf:  .nntniM  \o  ilu-  Man- 

!; :'    :  ul;;;;::'s.i.n.is.  th.  ii......  a.  .i.xe.d  ...id  i..  ti.  ,.„Mt..i 


led.     (»i(a«iiiiially   tlici' 


nvi'ivMciiMnii    (iT   til.'    trrmiiial    phalaii-c: 


:  ,  '  ,,,1,1...  .i„-,i  ..r  »,!>■ -I  "'-■'  ■"■  '■'""":' '  "•■"■""■,  .'"■  . 

!.,„..,..  ,l„.,v  „,v  ,„„1, ■„.■.„,■,-  „.  ll„.  .'1I."V..  I.,,...-.   «i„    .,„M,-         •• 
,,,,,,;,,.,,ni,,.,,,,i,..,.,.n.,l,,,r,,,.,..,».;l,vpv.,,,.    ,.,■,,,.;.    11^^^^ 


idlll    llir   fliill. 


, luulv  i.t  tin-  stuupii,.'  attit.id..  with  tl.y    i-ad   prnj...   ■>,,' 

,,.,,,.      Inatt.inpii..,  towalk.lu.st.r^<uv.l,.r,andlun,u.d.aud    as 

•,.,us..a..  .v.na.l<s.  h-  anu....  to  h.  nuu.u,  alt.r  his  .-imv  o    ,  au 
;i,is  is  l.r.iu.d  IVxinatiu.i  .„■  ,.Pi,.uNion.  ,n  iu,it.'ad,>  ....imii  t- a  ,  .      .  r 


i.rait  (iliMTVcil  will'.,  till'  patifiit  IS  |ui 


lied  luckward.  whfii  he  iiiak.-  a  iiinn- 


"„,,.  „!■  Mr,.-  and  Nvuuhl  fall  ov.t  if  imt  ,„vu...t.d-.vfnimlM>'». 

T  1.  -•  ll.'X.'s  aiv  ...nual  i..  mu.t  .as.s,  hut  i..  a  l'..w  tl-.y  aiv  ..xa,,,;.a..  I. 
;  V.  ..IT  di>tu,0.an.rs  Cha.vot  has  ....t.d  ahno.iual  al-ratiun.  n,  th. 


r  ^uhirctivt'  sensation 


ifinnrratuiv  m'Iisc.     Thr  i.ali.'iit  may  .■..mi. lam  ..i 

IX  'Lv  ....u.ral  ..r  l...al-a  i.lu.i,...n...i.,ii  whuli  may  U-  ,..vs...U  .......... 

l!;..l       Id  ass.,.-ia,..l  with  a,.  a..t..al  i..c..vas..  of  th..  s,..Ta...  t..n.,...n,t...v. 
:     m.       a<  .-  F.  «inwc.i.).     1.1  ..tlu..-  insta.uvs.  ,.ati....ts  .-...n,  a...  ..t  .-id 

i:.";!;;']  sw.ati..,  ...ay  IK.  ,,.vs.mt.    Th..  ...c.tal  ......dit,.,.i  .....ly  slmws  a..> 

'■'"IC,,//,,,.  i.  II.  N,.,/-/...s.-Th..  t.v..,.,..  „,ay  h.-  ah..nt,  h.,t  the  ..i^d- 
i,v    ^vrak....>s,  a.i.l  attit...!..  a.v  s.,irui..nt  t..  mak.  the  .haKn..s,s.      1  h.   -1  >- 

;!;;:.,  „„,  ,,.,  ,H„„i,.i..,h.  i..  .■l.......t..,'.  i..v..lvi..,^  mily  .me  s..!..  ...•  cv...  ...... 

liiul..     I's.iallv  these  are  hut  staps  ..1  the  .lisease.  _  •     i    ,.   ., 

Diagnosis.-I..    .veil-.leveh.i.e.l  eases  th..  .l.s..ase   ,s  m-..^:-n,x..'d   at   a 

.laueo.     The  attitu.le.  p.it,  stilVi...ss,  aud   uiask-like  .xi.,vsm..u  are  ,...u.^ 

:,•  as  n....-h   i,i.p...'ta,.ee  as  the  .,seillati....s.  a...l   ..sua  ly  serv..  t..  s..  ,    a te 

,lu.  .;.<..<  r.'.m,  s....ile  and  ..the.'  f...'...s  .d"  t.v.....r.      l).sse..n..a  e.l   >.-le...>.> 

!  ;,v..l..,.s  ea..lier,  ami  is  eha,-aete..ized  hy  the  nysta,.i,us.  a,..l  th,-  ........... 

s,......-h.  a,..l  d....s  lu.t  present  the  allihnir  s.i  e,...stant  ...  l';"'^''>-^;r  "^      "; 

Y,,  S..h..h/..  an.l  Sa.-hs  have  rei...rted  eas...  ,n  whi.  i  the  s,j.,.s  ,,t  mul  ., 
s..leros,<   have    he....   ass....iated   with   tl...se   ..t    ,.a.-alys,s.      1  he     ,....,,,.  ..,e 

1k>  e..nf..un.led  with  post-lu.mil.leoie  t.vm...'.  hut   th.'   hi>t...> . 


fitrin  luiLii.t 


,'  ,n...le  ..f  ..nset.  and  the  tr.vatly  iue.va<...l  retlexes  w...d.l  he  s.,nieient  t-. 
.,i.ti..-ui^h  the  tw...  The  l>arkins,.n,n..  fa.-e  is  .,f  -.rat  ,n.l...rt:u.ee  .n  the 
dia'nii.sis  ..f  the  ..hseure  and  a..<n.ial.>us  f..rm-.  i    .  x.  . 

Tlu.  di-..ns..  is  i..e...-ahle.  IV.ri.i.ls  ..!'  imp.'nvenient  n.ay  ...■e.,r.  h.it  th. 
l„„,U.u.  V  is  f..r  the  ailVeti..n  t,.  p.-..e..e.l  pi-.i-.x-ssively  d..wnwa..d.  It  is  a 
<]nw.  .l..-..ii..i'a1ive  p..nf.-.ss  and  th.'  ea^.s  last  l'..r  years. 

Treatinent.-.The.-e  is  m.  ....th...!  whi.h  .-an  he  ree..m.iiend.M  as  si  .>- 
factory  in  am-  respect.  Arsenic,  oi.ii.m.  an.l  l.y..seyam.ne  may  he  tr.ed.  hut 
,lH.  f,"i....d.  ..>  the  patient  sh....ld  h..  t..ld  f.'ankly  that  the  d,s..ase_.s  .ncu.- 
„,,,„,  „„,  that  ....thing  ca..  he  d....e  except  t..  attend  to  the  physical  cn,.- 
forts  ..f  the  j.atient. 


•^^^^K^^ 


ACUTR  cnOREA. 


liiT'.t 


tiiiii  y  111 

>  il'"tlH' 

he  m;iii- 

lin.-ilimi 

I  III'  t'\- 
lalaii^-'t's. 

1(     -.(HIU'- 

In  tlu' 
rs.     'riu- 

lie  ii»r< 
I'djfctinir 
.  iiiul,  ilS 
'  jzravity. 

|H'(iiliar 
■s  a  mim- 

L;u'<'rat>''l- 
lis  in  till' 
-atiniis  (if 
lit  <in  ('111' 
ilicratiirr, 
n  (if  cuiil. 
;li()\\s  any 

the  ri.uiil- 
Tlu'dis- 

C'VCll    dUL' 

lizcd  at  a 
are  pdiiits 
(I  sc|iarat(' 

II  ScllTdSis 

■  scaiiniiiL;' 
;is  a,i:itai!~. 
if  iiiullipic 
lu'iuiiilc,L:i(.' 
he  iiistdi'v, 
iitHciciit  til 
iiK(-'  ill  the 

iir.  lint  tin" 
(1.     It  i,<  a 

led  a?  sati^- 
0  tri('(1.  liiit 
si^  i^  im-iir- 
\Avi\\  fiiin- 


(>  III  Kit    I'olJMS    Ol'    '1'1(1;M()11. 

((/)  Sinijilr  Tinnier. — 'I'liis  is  (iccasiniially  fmiiid  in  porsniis  in  wIkhh  it 
is  iiii|i(i»ilil('  In  a.—i^ii  any  cause.  It  may  lie  traii>ieiit  m'  |iersis(  fur  an 
iiiildiiiile  liiiie.  it  is  iiftcii  exticinely  .-li;.;!!!,  aiiil  is  a.!i,urasatri|  hy  all  lause.s 
u  iiicli  lower  the  vitality.    - 

(ll)  lliriilihini  I'lrinnr.—C.  \..  Dana  has  re|i(iilcil  reiuaikalile  ea-es  nf 
hei'eilitary  trenmr.  It  (iceiiiTeil  in  all  the  hieinlier^  nf  (Hie  family,  ami  lie- 
;:iiiiiiii^'  in  infancy  centiiuieil  uithuiit   |iriiilMcimr  any  serimis  chaiit^c^. 

(( )  Stidh'  'rrciiiur. —  With  advancing;  aj;'e  ti'emuldiisness  diiriiiL;'  miiMiilar 
imncmeiits  is  extremely  ciimmnn,  hiit  is  rarely  seen  under  >eventy.  It  is 
ahva\s  a  line  treinnr,  uliieli  liej;iiis  in  the  hands  and  (ifteii  extends  to  the 
muscles  of  the  neck,  caiisin^i-  slight  iiiovemeiit  of  the  head. 

(ll)  'I'o.vic  trciiiiir  is  seen  ehietly  a>  an  elVect  of  tohaeeo.  aleoliol.  lead,  or 
inerciiry;  mme  rarely  in  arsenical  or  o]iium  poisoniii),'.  In  elderly  men 
who  smoke  much  it  may  he  entiridy  due  to  the  tnliaeco.  One  of  ilie  com- 
monest forms  of  this  is  tia'  ali'oholic  tremor,  which  occurs  only  on  mo\c- 
niciit  and  has  considerahle  raii^^c.  Lead  tremor  is  considered  under  lead 
poiMiniii;:.  of  which  it  constitutes  a  very  iiii|i(iriaiil  syni|itom. 

(r)  II i/slcriiiil  Iri'iiKii',  wliicli  usually  occurs  under  (•ircuin<iaiice<  which 
make  the  dia,i:iio.-is  ea>v,  will  he  considered  in  the  seelion  on  h\.~leria. 


111.    ACUTE    CHOREA 

(Si/di'Hham's  C/iorm  :  SI.  Vilnn'n  [htiirc). 

Definition. — .\  di>ease  chielly  all'ect ill;,''  children,  chiiraclerized  hy 
irivuular.  involuntary  contraction  of  the  muscles,  a  varialile  amount  of 
]isycliical  distiirhance,  and  a  reiiiarkahle  lialiility  to  acute  endocanlilis. 

We  shall  speak  here  only  of  Sydenliam's  chorea.  Senile  chorea,  chronic 
chorea,  the  ]ireliemiplej;ic  and  po>t  hemiplc;:ie  forms,  and  rhythmic  chorea 
are  totally  dilVereiit  aU'ectioiis. 

Etiology. — Sc.v. — (»f  ."■>:.!  ca~es  which  1  have  analyzed  tioiu  the  I'liila- 
delphia  Inlirmary  for  Diseases  of  the  Nervous  System,  Tl  per  cent  were  in 
females  and  'i'J  jier  cent  in  males.  After  pulierty  t':e  percentage  in  females 
increases. 

Ai/r. — The  disease  is  most  comi'.ion  hefween  the  aiics  of  (ivi^  and  llfteen. 
Of  'i'i'i  case-;.  liSd  occurred  in  this  period.  It  is  more  common  in  the  lower 
classes,  and  is  rare  anion<j:  the  ne,i.n'oes  and  native  races  of  this  eoutiiieiit. 
[Morris  J.  Lewis  has  shown  that  the  cases  are  most  iiumer(Uis  wiien  the 
mean  relative  liuniidity  and  liarometric  pre-'snre  are  low. 

li'liciiiiiiilistii. — A  cansal  relationship  hetween  rheiimati-m  and  chorea 
has  i)een  claimed  hy  many  since  the  time  of  llriuht.  The  hlii^li-h  and 
I'reiich  writers  maintain  the  closeness  of  this  connection;  on  the  other 
hand,  (ierman  authors,  as  a  rule,  re.irard  the  connection  as  hy  no  means  very 
close.  Of  .-).")  1  cases  which  T  have  analyzed,  in  \').~>  ]ier  cent  there  was  a 
history  of  rheumatism  in  the  family.  Li  S8  cases,  l.").S  ]icr  cent,  there 
was  a  history  of  articular  swelling,  acute  or  suhacuto.     Li  ;}:]  cases  there 


-     - 


lOSO 


DISEASES  OF  THE  XERVOUS  SYSTEM. 


us  rlu'iimnlic,  in   var 


rinus  ]iai'1s.  liut    nut 


\vi'i'(^  iniiii<.  tiouu'tiiiu's  (Icscvibcu   ..  .  . 

.  H-i      !    with  juint  truul,K..     U  .c  rcpinl  all  such  cases  a^  rlu.u.naU..  and 

':;^:^li!::l  ;;'lhL  win.  nuunlVst  ar,i.nlar  trouble,  the  piventage  .s  nusc.l 

""Ve'linltwu  ,nn,,>s   of  cases  in   which   acute  arthritis  is  present   in 
..ho      .       n  one,  the  allhritis  antedates  hy  son.e  n.onlhs  '"•  ^-•;;'';  '^ 

n,s  or  the  n.ove.nents  have  an-arcl  lirst.     It  >s  d.tlu-nl    to  d,   c  - 

^^•X;S^:.;;:^K;^:;^::';Ust  hel^  l.  .on.  .nters  to  he  the  canse 

„t  tl       l<ea<e.     ^Fhe  particles  of  iihrin  an.l  vegetations  from  the     al     . 

.      <   '  nb.li  to  the  cJrehral  vessels.     On  this  view,  which  we  shall  diseu^j 

i:;;.   .horea  is  the  result  of  an  cnholic  process  occurring  m  the  course  of 

"'  '■';r;;:rywl'^^  r^vcr  with   arthritic  nianifcations   n,ay 

h.  /^t  cedent.    Sturges  states  that  a  history  <d'  pr..-,ous  whooprng- 
■  ,      ,,curs  more  frc.,uentlv  in  choreic  than  in  other  children   hut  1  Inul 
t    d       e  oMhis  in  Ihe  Iniinnary  records.     With  the  exception  ol  rheu- 
ie  f    •  r  there  is  no  intimate  relationship  l.etween  chorea  and  the  acute 
!^e    iu^ident  to  cluldhood.     It  may  be  noted  in  contrast  to  this  that 
t>'  ::..   ed  canine  chorea  is  a  common  scmucI  of  distemper.       ' Imrcja  has 
;;;;„  ,,„,,„  u.  develop  in  the  course  of  an  acute  pyann.a.  and  to  loUo. 
.ronorrluea  and  puerperalfever.  pm,„„>„    .,„,i 

'^     Ananuia   is  le.s  often  an  antecedetit  than  a  sequence  of  a,     n 

llHUin-h  cases  develop  in  children  who  are  a.uvm.c  and  ,n  poo    health   t  u. 
W     :    cans  the  rule.     Chorea  may  develop  in  chlorotic  girls  a    p.^H.  ^ 
Pr.,nann,.-X  choreic  patient  may  hecon.e  pregnant;  more  fu 
„„  disease  occurs  during  pregnancy;  sonu>timesU  develops  post  pa,      m 
■^i.t    of  Dundee  (Trans.  Kdin.  Ohs.  Soe.,  IHt)-,),  has  tabulated  caretuU 

;■  :..orded  cases\o  that  date.  (K  ^^.;  cases,  in  G  the  chorea  prc^  cd 
,,„  nrcMuuicv;  in  lOo  it  occurred  during  the  pregnancy:  m  ,Am  lecu,- 
,t  p  ;MuuuMes;  45  cases  terminated  fatally,  and  m  U  cases  the  chorea 
ie  ell  pod  post  partum.  The  alleged  frequency  in  i  legitunate  primipan.  s 
:  rbon.0  mit  by  his  ligures.  tU.ginning  in  the  firs  three  -'-^'^  -- 
lOS  c'.^e^  in  th-  second  three  months  10  cases,  u.  the  last  tlneo  numths 
5'  cases!'   The  disease  is  often  severe,  and  matmu.al   syn^ploms  may  de- 

'''T  tendencv  to  the  disease  is  found  in  certain  families^     Tn  80  cases 

„,.;'  was  a  hiitorv  of  attacks  of  chorea  in  other  nu-iubers.     In  one  .ns  ance 

t     tu  ther  amr.ratulmother  had  been  alVeeted.     lligh-strung.  excitable, 


but  not 
alio  aiul 
iri  raist'd 

(■sent  in 
he  (iiisrt 
III  tlu' 
he  ai'uti' 
the  joint 
to  (lillVr- 
n.  U  is 
iiild  Iti'  a 
imiilaiiUs 
Jt  should 
V  1)0  the 
'that  the 

the  cause 
he  valves 
Ul  disi-ii-^s 
eouvse  of 

:i(ins  may 
,\hi)0]Mii,:x- 
hut  1  liiul 
n  of  rheu- 

the  acute 
1  this  that 
'liorea  has 

to  follow 

horea,  and 
icaltli,  this 
at  puberty. 

fiHHjuenlly 
ist  partuui. 
d  carefully 
a  preceded 
1   in  recur- 

tbe  chorea 
rinnpara^  is 
luiths  were 
ree  nuuiths 
US  may  de- 

In  SO  cases 
~)r\Q.  instance 
<r,  excitable, 


ACUTE   CHOREA. 


1081 


nervous  cluldivu  arc  especially  liahlc  b.  th,'  disca.-...  Frl^ihl  is  considered 
a  lre(iueiit  caii>e.  hut  in  a  iar-e  majority  of  tiu.  eases  n,.',h,se  connection 
exists  between  the  fright  and  the  onset  of  the  disea-e.  Oeeasionallv  the 
attack  sets  in  at  once.  .Mental  worry,  trouhlc.  a  .Middcn  i:rief.  or  a  .<coid- 
uys  may  apparently  he  tlie  exciting  cause.  The  >train  o'f  ,;h,nilion  par- 
tuuiariy  m  girls  during  t+ie  third  hemideeade,  is  a  most  important  factor 
111  the  ..tiology  of  ihe  disease.  j'.right,  intelligent,  activc-nn-ndcd  <.irN 
Ironi  ten  to  jourieen,  ambitious  to  do  well  at  school,  often  ,-timulaled  in 
their  elbirts  hy  teachers  ami  parents,  fnrm  a  large  contin-ent  of  the  ca^es 
of  chorea  in  hospital  and  private  practic.  Sturges  has  called  sp.ecial  at- 
tention to  t\u>^  ..rlnwl-iiiade  chorea  as  one  serious  evil  in  our  modern  nicllidd 
ol  iorced  education.  I nnlalimi.  which  is  nieiitioiied  as  an  exciting  caii-v 
IS  extremely  rare,  and  .I<,es  not  appear  tu  have  inliueiiccd  the  uiiK't  in  a 
single  case  in  the  Inlirinary  records. 

'I'he  discas.'  may  rapidly  follow  an  injury  or  a  sli-ht  sur-ical  operation. 
L'ellex  irritation  was  believed  to  play  an  important  roir  'in  the  diseas... 
particularly  the  |)rcsence  of  worms  or  genital  irritation:  hut  J  have  met  witl'i 
no  instance  in  which  the  disease  could  be  attributed  to  cither  of  the<e 
causes.  Local  spasm,  jiarticiilarly  .,f  the  face— the  habit  chorea  of  .Mitchell 
—may  be  a.-so.iated  with  irritation  in  the  no,<(rils  and  adenoid  growths  in 
the  vault  ol  the  ]>harynx.  as  jiointed  o  it  Ijy  Jaeohi. 

It  has  been  claimed  by  Stevens  that  onihir  dvferU  lie  at  the  basis  of 
many  ca^-s  of  chorea,  and  that  with  he  correction  of  th<.<e  the  irregular 
niovements  disappear,  'i'be  invstig.itioiis  of  De  .Schwcinil/  show 'that 
ocular  delects  do  not  occur  in  greater  proportion  in  choreic  than  in  other 
cluldren.  A  majority  of  the  cases  in  which  oiieration  has  been  followetl  bv 
relief  have  been  instances  of  lie.  ]o,al  or  n-cneral. 

Morbid  Anatomy  and  Pathology.— Xo  (onstant  lesions  have 
been  bMiiid  in  the  nervous  system  in  acute  clioiva.  A'asciilar  chann-es. 
such  as  hyaline  transformation,  exudation  of  h'licocvtes,  ininnte  laeiuor- 
rbages.  and  throinbo.sis  of  the  smaller  arti'rics.  h;,ve  been  described. 

Kmbolisiu  of  the  smaller  cerebral  vessels  has  been  found,  as  might  he 
expected  in  a  disease  with  \\\\\v\\  endocarditis  is  so  freipieiitiv  associated; 
and.  based  upon  this  fact,  Kirke.^  and  others  have  supported  wl'iat  is  known" 
as  the  embolic  the(,ry  of  the  disease.  Endocarditis  is  bv  far  the  most 
fre(|nent  lesion  in  Sydeiihanrs  chorea.  "With  no  disease,  not'exceptiim'  rlien- 
niatisin,  is  it  so  constantly  associated.  I  have  collected  from  the  literature 
(to  July,  IS!)  1)  the  records  of  T.'}  autopsies;  there  were  (:>2  with  endocarditis.* 
The  endocarditis  is  usually  of  the  simple  variety,  but  the  ulcerative  form 
lias  occasionally  been  described. 

We  are  still  far  from  a  solution  of  all  the  problems  connected  with 
chorea,  riifordinately.  the  word  has  been  used  to  cover  a  series  of  bitally 
diverse  disorders  of  movement,  so  that  there  are  still  excellent  observers 
who  liold  that  chorea  is  only  a  symptom,  and  is  not  to  be  rcirarded  as  an 
etiological  unit.  The  chorea  of  childhood,  the  disease  which  Svdenhani 
described,  jirescnis.  however,  characteristics  so  unmi^akable  (hat  it  iiiu-t 


•  Osier,  Chorea  aiui  uhorciform  Aflfoctions.  1894. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 

,,„t  only  indieat.  bru;  ly.  ^''"f '\     ,        '  ^oq.lod  viow  is  tl.at  ii  i^  «  /""<- 

/;-"/  '"•"'"  ''-';';;v'"7  ulc  ^  v""il  1^  "^i>t  about,  on.  .upp.-  '.y 

,„us,  an  instalnhty  ot  ^>>^"'     V!      ,',„.  ..^chkal  inlluonccs.  a  fourth 
l>viu'nvnua.  another  hy  anu;nua        tin    1     >   b  ^^^^^^^  ^^^  ^,^.^  ,,  „.^,„^ 

„;,„t  ,..,  know  notlnn,.  uor.  '->       ' ;  ^  !^'    \  ,;,  „  ,'H,th.r  the  iu,,.ul..s 

*'-■  '-^"'^  ••'  '  '■'^''''^'?"\h  .  r    o  wn  the  n..,or  path.     The  pre- 

,,,  ,cron.h>rily  .listurhe.l  .n  tl  en  ^  ''"'       "^  ^^^   ,',„.,,   when  the 

^1'"—"  "^  ^'" /'•""  "    r'we       ,'  'tioh.,ieal  laets  whieh 

t;t'"ln'u::Jrf::.:   o^'>e';^;.l't.>at  chorea  is  an  e.p-ion  ot 

fu;u.^onal  instability  of  the  "^;;y-;';;::^;;;';;    ,,^,  ,-i,,,„  ,,,,  ,  soli-l  basis  of 

f''- "-  ^^-  •-  r"T"'T;:;::  :;rS;a  :efl;;L:!;t  .naoeanhus  an,. 

brou^a.t  ^vith.n  .ts  hunt..      \' '       ^  ;/    i,,....;,,.  ,.f   eerebral   vessels;  au. 
without,  so  far  '^-;,  '7^!;       "     a.l'll^htis^in  whieh  the  histoh,,ieal 

tiie  earotids.  ,    ,.h,,n..i  has  been  reLTanled  as  au 

l,U.ly.  as  indeed  nu.ht  'V'!;!-^  ^.^'^  ,  ,  ternuned.  Jn  favor  of 
;„/../;..  .lis...  Notlun,  dehu.  e  V^  M  ^  ^^^^  ^,^^  ^,,,„,„^,  ,,  ,,,,,- 
this  view  it  has  been  ur^ed.  as  ^^^1      ^;;„„^^i,„,,  t,„t  both  have  their 

carditisortl>eendoeardmsrn         •  sc    1        H^  whieh  is  capable  also, 

„,i,i„  in  a  eou.uuni  eau  e,  souu     '  .  ^,,^^,  ,,,,,  i„,„  n- 

^"  I'T-^  ''T^r;::;  wUl/iulbnUet:;;!;:!:!.:::  ..  ,>uerperal  fev...  and 
ported  m  searlet  ievei  wilU  annui  suo'L^estive  at  least 

houniatisn,.  als..  after  ^•'••""•''''''-^    "    .    '      .         ....ses.     I'ossibly,  as  has 
,r  the  assoeiati.nr  of  the  '1'--;;.^        '  ;  ,':    „,itions  associated  ."ith 

W.u  su,,esled  l>y  sou>e  -••'»;; -,;';,',,  ;,  ,vphoid  and  certain  of 
,.,,„„„  ,„,v  iH.  '^'"•^"^■''"'•^ ;"'•'",,       ,,,re  are  cnulitions  extremely 

t'-  '"'■-'•"r  '"■""•        h    hN  S:-      '  t      •onnnent  ,.syebical  element 
.Hivu.ult  to  havn.onr/.e  ^^.tl    this  mcn.  1  ,^^,  ^^^,  ^,,,^^i^^ 

i^  -•^-"'>-  """  "^  '''"  '"'^'  ^- Tiri'^Jow  a      M,        Vsudden  eu.oueu. 
that  ..rdinary  chorea  ma V  ra,udh  »- I"     "^   '  -^      ,,^  reco.mzed-lhe   mild. 
Symptoms.-'riHve  ,-roups  ot   ca>cs  ma.N 

severe   and  maniacal  chorea.  i,,.  ic  cliolii    tliesiiceiU 

turbances.  such  a>  civm-  spcii  .  ,.■„..•,,.,.  ai<turbauces  and  anaM.ua 


^^ 


..>  fully. 

.  a  {liiic- 
lotor  ap- 
iposos  '»y 
a  foiu'tli 
(l/r;iu^'(- 
nary  and 
iiniiulHt> 
Tlu'  i>ir- 
wlu'U  tlu' 
;ts  whiih 
t'ossiun  of 

il  hasir^  »it' 
ciUiimt  111' 
rditis  aiiil 
?sr-L'ls;  ami 
ust(ilni:'ifal 
s  iK'piliv^'. 
animals  of 
I'ticlcs  into 

rded  as  an 
la  favor  of 
ca  to  onilo- 
1  have  their 
iipalile  also, 
vo  Ir'imi  ro- 
ll fovcr.  and 
i\v  at  least 
-ilily,  as  has 
ifiated  with 
d  ciTtain  of 
lis  cxtri'ini'ly 
ical  element 
lie  no  cloiiht 
motion. 
;1— ihe   mild. 

,i.  the  siieedi 
d.  rronioni- 
still,  a  fondi- 
■inotional  dis- 
There  may 
<  and  ana'Uiia 
■  iiotieed,  and 
r  these  symii- 


ACUTE  CnOREA. 


10S3 


toms  have  persisted  for  a  week  or  more  the  eharacterisHp  invoUuitary 
movements  he,s;in,  and  are  oflen  iirst  noticed  at  the  talih'.  wiien  the  eiiild 
spills  a  linnliK'r  of  water  or  upsets  a  [ilate.  Tlu.'re  may  he  only  awkwardness 
or  sliyid  ineciJirdiiiation  dl'  voluntary  movements,  or  constant  ii're,i;ular 
clonic  spasms.  Tlu'  jei'ky,  irre^ndar  character  of  tiic  muvements  dill'ercii- 
tiali's  tiiem  from  almost  e^ery  other  disorder  of  motion.  In  the  mild  cases 
only  one  hand,  or  the  hand  and  face,  are  alfected,  and  it  may  not  spread 
to  the  other  side. 

Jn  the  second  urade,  the  sririr  furm,  the  movenu'uts  l)econie  jreneral 
and  the  |)atienf  may  he  unal)le  to  get  ahout  or  to  feed  or  nndi'css  herscdf, 
owin.u  to  the  constant,  irre^iular,  clonic  contractions  of  the  various  muscle 
groups.  The  speech  is  also  afl'ecled,  and  for  days  the  child  may  not  he 
ahle  to  talk.  Often  with  tin-  onset  of  the  severer  sym|>toms  there  is  loss 
of  jjower  on  om-  side  or  in  the  liml)  most  alfected. 

The  third  and  most  e.\treiiu>  form,  the  so-called  maniacal  chorea,  or 
rhdira  iiisiiinriis,  is  truly  a  tei'rihle  disease,  aiul  may  develop  out  of  the 
ordinary  form.  These  cases  are  juore  common  in  adult  women  and  may 
develop  during  pregmuicy. 

Chdrea  hegins,  as  a  rule,  in  the  hands  and  arms,  then  involves  the  face, 
and  suhscipu'ntly  the  legs.  The  ujovenu/nts  may  he  cimiined  to  oiu'  side 
— hemichorea.  'J'lie  attack  hegins  oftenest  on  the  right  side,  though  oc- 
casionally it  is  general  from  the  outset.  One  arm  and  the  opj)osito  leg 
may  he  involved.  In  nearly  one  fourth  of  the  cases  speech  is  alfected; 
this  may  amount  only  to  an  cunharrassmout  or  hesitancy,  hut  iu  other  in- 
stances it  hecomes  an  incoherent  jund)le.  In  very  severe  cases  the  child 
will  make  no  attempt  to  speak.  'I'he  inahilify  is  in  articulation  rather  than 
in  phonation.  Paroxysms  of  ])anting  and  of  hard  expiration  may  occur, 
or  odd  sounds  may  he  jjroduced.  As  a  rule  the  movenu'iils  cease  during 
sleej). 

A  prominent  symptom  is  muscidar  weakness,  usually  no  m(U'e  than  a 
condition  of  paresis,  'i'he  loss  of  power  is  slight,  hut  the  wt'akness  mav 
l)e  shown  hy  an  enfeehled  gri[)  or  liy  a  dragging  of  the  leg  or  limping.  In 
his  original  acccamt  Sydenham  refei's  to  tlu-  "  unsteady  movements  of  one 
(d"  the  legs,  which  the  ]iatient  drags."  There  may  he  extreme  paresis  with 
hut  few  movements — the  jtaralytic  chorea  of  Todd.  Occasionally  a  local 
jiaralysis  or  weakness  remains  after  the  attack. 

It  is  douhtful  whether  choreic  spasms  extend  to  the  nniscles  of  organic 
life.  'I'lie  rapid  action  and  dislnrhed  rhythm  of  the  lieart  ])reseid  nothing 
lieculiar  to  the  disease,  and  there  is  no  supinu't  for  the  view  that  irregular 
contractions  occur  in  the  pa|)illary  muscles. 

Heart  Symptoms. — XcnroHr. — As  so  many  of  the  sul)jecls  of  chorea  iwo 
nervous  girls,  it  is  not  snrjirising  that  a  common  symptmn  is  a  rapidly  acting 
heart.  Irregularity,  however,  is  not  so  special  a  feature  in  choi't^a  as  ra- 
])idity.     The  patients  seldom  coinplain  of  pinn  ahout  the  heart. 

llduiir  M iiniiiirs.—\\\{\\  ana'nua  and  dehility,  not  unconunon  assoe- 
ciates  of  chori'a  in  ti"  third  or  fourth  week,  we  lind  a  corresponding 
cardiac  condition.  The  impuNe  is  dilfusi-.  ]ierliaps  wavy  in  thin  children. 
The  carotids  throh  visihly,  and  iu  the  recundjent  posture  there  may  he 


^^ 


DISEASES  OF  THE  XERVOUS  SYSTEM. 


Leurd  at  tin-  l-as.,  l-'''':'l"^-/'    jJ^l      T  i  .  clunva.  acut.  valvulit.s  nnvly 
7^„,/.,vnv///,-s.-As  ,n  '■'<-'  >f-,„,.     u  >nust  h.  snu,l„.  and  •■hn- 

•'"-:;;;r:ui:;:::':!r;i;:';;;:;;^mion.MiK.r.,uo.^    -.ay.. 

treinclv  loinnu.n  at  t!u'  l)a>u  1  au 

,„a  is'i.rol,aMy  of  no  """"^■'l'-   .^^j,,^,,,,,  i.t.nsitv  at  tho  ayvx.  ai.l  beard 
(..)  A  systolic  nu.nnur  ol  niaxnnn m  •„„,,„„„    ;„    lUiaMnu',   vn- 

J  ilon,-tlu.   Wt    ..--nal    >-,;,.      ;  ;  !;,^,^  ^,,,,,,,,tis  o.  insnt- 

feol.lnl  slates,  and  durs  not  nm..>anly  unlu 

iH'i^''"'.^-  .         •    ,„n  inion^itv  at  apox,  witli  iw-,^'»  q^'^.'^y'  ^"*^. 

(;])  A  mnrnuiv  of  niaxmunn  ''^'''''^\''\\-,^,.^  ,,n  orpmic'   lesion  of 

iirit;;:::::^:-!;-;^^^^^^^^  "- 

heart.  ,     ,      .     .  ,  ^^.^  ,,t,.r  to  trust  to  tl.e  ovidcMiee  of  oyo 

.,l(.rotir  changes  in  tho  vahe  Nslueh  P     '»  ,^  ^   f,,,,,,^  the  hoart 

normal  m  .)i ,  m  J^'    ^ 

^'^'::;;'V;:;ddi!;:t;;!ro;::;ional  .MnpUeation  of  chorea,  usually  in  cases 

with  xvell-niarked  rheumatism.  .^  ^^^^  common.     Oc- 

Sen.or,!  Di.turhiuurs.-Wnn  in  the  aU        a  ^^^^^^^^      ^^^  ^^^^^^^^_ 

c..sionally- there  is  soreness  on  pressure      J    ^^^    ,,,,-,     ^eir  Mitchell 
chorea,  in  .Inch  pain  in  the  lmib>    s  a  ,muUd_  ^^^l^^^  ^^^^  ^.  ^^^ 

-:i;::;:e:f;;;r;^^^^^^^^ 

„ii;-|n  degree.  Irritahility  "^  tomj.r  nuuUd  .'^^  ^;^  ^^^  ^,^^  ^,  .,,,_ 
outbreaks  n,ay  indicate  a  eomple  e  ^^^J^^^^^.^^^^^  ,,,e  men.ory  is  on- 
T,n.re  is  delleiency  .n  f%^'^''Z^\;Z^\,r^.  there  is  progressive 
fcehied.  and  the  aptdm  e  '^;^"^>  ^  j  ^^^  j^  ...{ual  dementia.  Aente 
impairment  of  the  i^t^'ll^VT  !•  liein^  of  sight  and  hear- 
melancholia  has  ^f '^^f  ^^  :"^  V,  ;  Z  in  an  odd  and  strange  manner  and 
in.  may  occur.  Tatients  "^'>  /^^'  '  .^^.  \  ^^^  ,,,,,t  serious  manifestation  of 
ao  Ml  sorts  of  meaningless  act^.     Lj^aMhcj 

Monograi)li  on  Choroii,  1891. 


ACUTE  CIIOUKA, 


H)s5 


rinnr  is 
111  it  y. 
is  Viircly 
111(1  ilin- 
niuirs  iit 


;  iiiiiy 


1)C" 


ity  i^;  i^x- 
c'lirtilago, 

uid  lieiU-d 
[iMiiie,  t'li- 
s  or  insul'- 

lality,  and 
•  lesion  of 

KMlt   of   tlu' 


nee  oC  eye 
oniiiil  po^i- 


ijvht  ot  the 


.'  simiile  or 
.;ul  to  those 
()£  110  pii- 
,cl  the  heart 
'I  presented 

ally  in  eases 

ininon.  Oe- 
illy  of  heiiii- 
U'ir  Mitehell 
the  linos  of 
lerves  of  the 

of  the  eases 
iiul  emotional 

of  tlie  ehild. 
leniory  is  en- 
is  progressive 
leiitia.  Acute 
.ght  and  liear- 
e  manner  and 
anilestation  of 


this  eharaeler  i--  'u'  maniacal  delirium,  oeensionally  assoeiated  uiili  the 
very  sevciv  easo — clnirrii  insdiiicns.  I'siially  the  motor  (U.-turhaiice  in 
these  eases  is  aggravated,  hut  it  lias  Iieeii  oveiiooked  and  [lalieiits  have 
heeii  sent  to  an  asylum. 

Tiie  psychical  elemi'iij  in  chorea  is  apt  to  he  neglecti'd  hy  the  ]iraeti- 
tioner.  It  is  always  a  good  plan  to  tt'U  the  paiH'iits  that  it  is  not  the 
nmseles  alone  of  the  child  which  ai'e  all'ected,  hut  that  the  general  irritu- 
hility  and  change  <d'  di>positioii,  so  often  found,  really  form  l)art  of  the 
disease. 

The  condition  of  the  rcflcirs  in  chorea  is  usually  normal.  Trophic 
lesions  rari'lv  occur  in  chorea  unless,  as  some  writers  have  done,  ue  regard 
the  joiid  trouhlcs  as  arthropathies  ucciirring  in  the  course  of  a  cerehro- 
s[)inal  disease. 

Fcri'f  is  not,  as  a  rule,  ])resent  in  chorea  uidess  c(uu|ilicatioiis  exi^t. 
There  may  he  the  most  intense  and  violent  movements  without  any  rise 
of  temperature.  1  have  seen  iiistances,  however,  in  which  without  appar- 
ently any  visct'ral  or  articular  dislurhances  there  was  slight  daily  fever. 
jr.  A.  jiare  stales  that  in  monochorea  the  temperature  on  the  ail'ected 
side  may  he  elevated;  hut  this  is  not  an  invariahle  rule.  Fever  is  found 
with  an  acute  arthritis,  when  there  is  marked  endocarditis  or  ix'ricarditis, 
though  the  former  may  certainly  occur  with  little  if  any  rise  in  tempera- 
ture, and  in  the  eases  (d'  maniacal  chorea,  in  which  the  fever  may  range 
from  lU-r  to  lOT". 

Cutaneous  Affcdions. — The  ])igineiitation,  which  is  not  nnc(unmon,  is 
due  to  the  arsenic.  Herpes  zoster  oeeasioiially  occurs.  Certain  skin  eruii- 
tions,  nsually  regarded  as  rheninatie  in  character,  are  not  uncoiiimon. 
Ervthenia  nodosum  has  heen  described  and  1  have  seen  several  eases  with 
a  purinirie  urticaria.  There  may,  indeed,  he  the  more  aggravated  eoiidi- 
tion  of  rheumatic  pur]iura.  known  as  Sehonlein's  pdiusis  rlicuniatica.  Sub- 
cutaneous lihrous  nodules,  which  have  heen  noted  by  English  observers  m 
many  cases  of  chorea,  associated  with  rheuraatisni,  are  extremely  rare  in 

this  country. 

Duration  and  Termination.— From  eight  to  ten  weeks  is  the  av- 
erage duration  of  an  attack  of  moderate  severity.  Chronic  chorea  rarely 
follows  the  minor  disease  which  we  have  been  eousidering.  The  eases  de- 
scribed under  this  designation  in  children  are  usually  instances  of  cerebral 
sclerosis  or  Friedreieh's  ataxia;  but  occasionally  an  attack  wliicli  has  come 
on  in  the  ordinary  way  jiersists  for  months  or  years,  and  recovery  ulti- 
mately takes  iilaee."  A  slight  grade  of  chorea,  particularly  noticeable  under 
exeiteinent,  may  jiersist  ior  months  in  nervous  children. 

The  tendency  of  chorea  to  recur  has  been  noticed  hy  all  writers  since 
Sydenham  first  made  the  observation.  Of  410  cases  analyzed  for  this  juir- 
l)I)se,  2U}  had  one  attack,  110  had  two  attacks,  35  three  attacks,  10  four 
attacks,  12  live  attacks,  and  3  six  attacks.     The  recurrence  is  apt  to  be 

vernal. 

Kecovery  is  the  rule  in  children.  The  gtatistics  of  out-patients'  depart- 
ments are  not  favorable  for  determining  the  mortality.  A  relialde  esti- 
mate is  that  of  the  Collective  Investigation  Committee  of  the  I'.ritish  Medi- 


lOSG 


DISEASRS  OP  TIIK  NERVOUS  SYSTEM. 


,,il  AsMKiatiiiii.  ill  whicli  !•  dciitlis  wciv  ivportcd  aiiumj,'   UV.)  cases.  al)out 

•i  uvv  cent. 

'I'lio  paralysis  rarely  i.ersists.  Mental  diiliiess  may  l)e  present  Inr  a 
time,  but  usually  pasM's  away;  iiermaiieiit   imi^airmeiit  ef  the  mind  is  au 

exceptieiial  se(|neiiee.  . 

Diagnosis.— Tlu'i-e  are  few  diseases  which  present  more  cliaraeteristie 
features,  ami  in  a  maj.iritv  ef  instances  tli.'  nature  ef  tiie  tr.uilile  is  recoj:- 
iiized  at  a  glance;  hut  there  aro  several  all'ectieiis  in  ihildren  wlurji  may 
yininlate  and  he  mistaki'ii  for  it. 

(„)  Multi|.ie  and  dilVu^e  cerehral  sclerosis.  'I'lie  cases  are  eileii  mis- 
taken for  .ordinary  eliorea,  and  have  heeii  dc>crihe<l  in  the  literature  as  chorea 

'I'll,. re  are  doulitless  chroiiie  chanj^'cs  in  the  cortt^x.  As  a  rule,  tlie 
movements  are  readilv  distinouishal>le  from  those  of  true  chorea,  hut  the 
simulation  is  s.inu'tim'es  verv  close;  the  onset  in  infancy,  the  unpaired  in- 
telligence, increased  relle.Ncs  and  kn  some  instances  rigidity,  and  the  chronic 
eoui^e  of  the  disease,  separate  them  sharply  from  true  cli(.rea. 

ih)  I'riedreith's  ataxia.  Cases  of  this  well-characterized  disease  wt'i'o 
formerly  classed  as  chorea.  The  slow,  irregular,  incoordinate  movements, 
the  scofiosis,  the  scanning  speech,  the  early  talipes,  the  nystagmus,  and  the 
family  character  of  the  disease  are  i.oints  which  should  render  the  diag- 
nosis easv.  . 

(,■)  In  rare  cases  the  paralvtic  form  of  chorea  may  he  mistaken  lor 
polio-mvelitis  or,  when  hoth  legs  are  alfected,  for  jiaraplegia  of  spinal 
origin;  "hut  this  can  only  he  the  case  when  the  choreic  movements  are  very 

slight. 

"(r/)  Hysteria  may  simulate  chm-ea  minor  most  closely,  and  uidess  there 
are  other" manifestations  it  may  l)e  impossible  to  make  a  diagnosis.  Most 
commonly,  however,  the  movements  in  the  so-called  hysterical  chorea  are 
rhythmic  and  dill'er  entirely  from  those  of  ordinary  chorea. 

'  ((')  As  mentioned  aliove,  the  mental  syiiii»toms  in  maniacal  chorea  may 
mask  the  true  nature  of  the  disease  and  patients  have  even  been  sent  to 

the  asvlum. 

Treatment.— Ahiiormally  bright,  active-minded  children  belonging 
to  families  with  ]n-onounccd  neurotic  taint  slumld  be  carefully  watched 
from  the  aires  of  eight  to  lifteen  and  not  allowed  to  overtax  their  mental 
])owers.  So  freciuently  in  children  of  this  class  does  the  attack  of  chorea 
date  from  the  worry  and  stress  incident  to  scliool  examinations  that  the 
comiietithm  for  iiriz'es  or  places  shonld  be  emphatically  forbidden. 

The  treatment  of  the  attack  consists  largely  in  attention  to  hygienic 
measures,  with  which  alone,  in  time,  a  majority  of  the  cases  recover.  Par- 
ents shonld  be  told  to  scan  gently  the  faults  and  waywardness  of  choreic 
children.  The  psvchical  element,  strongly  developed  in  so  many  cases, 
is  best  treated  bv"qniet  and  seclusion.  The  child  shonld  be  confined  to 
bed  in  the  recumbent  iiosture,  and  mental  as  well  as  bodily  quiet  enjoined. 
In  private  practice  this  is  often  impossilde,  but  with  well-to-do  patients 
the  disease  is  always  serious  enough  to  demand  the  assistance  of  a  skilled 
nurse.     Toys  and  ilolls  should  not  be  allowed  at  iirst,  for  the  child  should 


<os,  about 

cut  fnr  il 
liml  is  ill! 

I'lutcristic 
■  is  ri'(«ijj:- 
hirh  may 

)i'lt'n   inis- 
iis  churen 

rule,  Iho 
11,  Imt  tilt' 
imiriMl  in- 
lie  (.'lironic 

;oasL'   woi'o 

lovi'iiiunts, 

is,  ami  tho 

Ihu  diag- 

stakcn   for 

of   spinal 

ts  arc  very 

nlcss  there 
jsis.  Most 
chorea  are 

■horea  may 
>en  sent  to 

helonginp; 
ly  wateheil 
u'ir  mental 
:  of  ehorea 
IS  that  the 

Ml. 

lo  hygienic 
over.  I'ar- 
;  of  choreic 
nany  cases, 
confined  to 
et  enjoined, 
do  patients 
of  a  skilled 
;hild  should 


ACUTE  CFIOREA. 


10S7 


be  ke])t  amused  without  excitement.  The  rest  allays  the  hyper-excitabil- 
ity and  reiliiccs  to  a  niinimum  the  jiossihility  of  daiiiagc  tu  the  valve  seg- 
ments shdiild  ciuhuiirditis  exist.  Time  and  again  have  i  st'cii  very  severe 
cases  which  had  resiste(l  tr'eatnient  fur  wet-ks  (Hitside  a  Imspital  hectime 
(piiet  and  the  movements  suliside  after  two  or  three  days  of  aiisolute  ri'st 
in  Ited. 

The  child  should  he  kept  apart  from  other  children  and,  if  possilde, 
from  other  memliers  (d'~the  family,  and  should  see  only  tlmse  jiersons 
directly  cdiieerned  with  the  nursing  of  the  case.  Though  irksome  and 
tniui)lesiime  t(i  carry  out,  this  is  an  important  \r,irt  of  the  treatment.  In 
the  latter  jieriod  of  the  disease  daily  rui)i)iiigs  may  he  resorted  to  with 
great  heiielil. 

The  medical  treatment  of  the  disease  is  unsatisfactory;  with  the  ex- 
ception of  arscnit',  no  remedy  seems  to  have  any  intluence  in  cdntnilling 
the  progress  of  the  aU'ection.,  Without  any  specilic  action,  it  certainly 
does  good  in  many  cases,  probably  by  improving  the  geiieial  nutrition. 
It  is  conveniently  given  in  the  form  of  Fowler's  solution,  and  tlu;  good 
ell'ects  are  rarely  seen  until  maximum  doses  are  taken.  It  may  be  given 
as  Martin  originally  adviseil  {ISl.'J);  he  liegan  ''with  live  drop-  and  in- 
creased one  drop  every  day,  uniil  it  might  begin  to  disagree  with  the  stom- 
ach or  bowels."  When  the  dose  of  \'t  miniins  is  reached,  it  may  be  con- 
tiiiiu'd  for  a  week,  and  then  again  increased,  if  necessary,  eveiy  day  or  two, 
until  jihysiological  ellVcts  are  manifest.  On  the  occurrence  of  these  the 
drug  should  he  stopped  for  throe  or  four  days.  The  ])ractice  of  resuming 
the  administration  with  smaller  do.ses  is  rarely  necessary,  as  tolerance  is  usu- 
ally established  and  wo  can  begin  with  the  dose  which  the  child  was  taking 
when  the  symptoms  of  saturation  occurred.  I  have  frcMpiently  given  as 
much  as  *^5  minims  three  times  a  day.  I'sually  the  signs  of  saturation  are 
trivial  Itut  plain,  and  I  have  never  seen  any  ill  ell'ects  from  the  large  doses, 
although  I  have  heard  recently  of  a  case  of  arsenical  neuritis  due  to  the  ad- 
ministration of  Fowler's  solution  in  chorea. 

Of  other  medicines,  strychnine,  the  zinc  compounds,  nitrate  of  silver, 
bromide  of  ])otassium,  belladoni  a,  cliloral,  and  es])ecially  cimicifuga,  have 
been  recommended,  and  may  be  tried  in  olistinate  cases. 

For  its  tonic  effect  electricity  is  sometimes  useful;  but  it  is  not  neces- 
sary as  a  routine  treatment.  The  question  of  gymnastics  is  an  im])ortant 
one.  Farly  in  the  disease,  when  the  movements  are  active,  they  are  not  ad- 
visable; but  during  convalescence  carefully  graduated  exercises  are  un- 
doubtedly Ijcneficial.  It  is  not  well,  however,  to  send  a  choreic  child  to  a 
scIio(d  gymnasium,  as  the  stimulus  of  the  other  children  and  the  excite- 
ment of  the  romjiing,  violent  play  is  very  prejudicial. 

Other  ]ioints  in  treatuKMit  may  be  mentioned.  It  is  important  to  regu- 
late the  bowels  and  to  attend  carefully  to  the  digestive  functions.  For  tho 
aiiRMiiia  so  often  present  preparations  of  iron  arc  indicated. 

In  the  severe  cases  with  incessant  movements,  .sleeplessness,  dry  tongue, 
and  delirium,  tho  important  indication  is  to  procure  rest,  for  which  pur- 
pose chloral  may  bo  freely  given,  and,  if  necessary,  morphia.  Chloroform 
inhalations  may  be  necessary  to  control  the  intensity  of  the  paroxysms, 


i.« 


.1. 


li 


luss 


DISEASKS  OF  TllK  NEllVOUS  SYSTEM. 


but  \W  l.ij,'h  rat.'  ..f  innrlality  in  thi 


s  .-liiss  .if  (•a><'s  illu>tratis  liow  ofU' 


fU'ii 


but  tl.c  Wv^h  rat..  -.1   .nnna  m^   ....  ^  ,,„„,,i,„,,  v.tv  .....Um.^ 

.„„,  ,„.,  .,„.l..av..-;s  a,v    '•"'  '^'--     ';',,''    ,  ,„  ,i„k  .ai-i.llv  int..  a  l..w 


full  trial. 


In  all  cases  car.,  sh.uil.l  l.r  tak.  n  xo     ^"  ^  ,,     -^  „,,,,. 

.,,,,1,,  adV..tssh..uMlK.  i"-l).rly-,rr..l..lc.lh..   l.>   .■.> 

,.„„,   tlu.  atta.k,  tho  i.ar..nts  slu.ul.l  l.o 


-arv.  1>V  t.i).'ratiim. 

"AI'Ict  till'  cliil'l  li'i^  nri.v.'rc. 


tho  (lis.'asf  IS  hy 


„„  „„,a„s  inl'r.'.nu'nt.  ami  is  par- 


,V.    OTHER   AFFECT.ONS   DESCRIBED   AS   CHOREA. 

(„)  Chorea  Major;  Pandemic  Ch"™^!;;;';,:::;^;,':;:;."::,?;;!*: 

haviMKrurr.a  als...lurin-tl..>  cent  ny,  an    .  1  ^   Yan.U.U. 

early  settler,  in   Kentucky  have  ^-''7'  7'     '>   ,  ^'       ,    \,  ,n  allV..ti..n 

''  T^r^'f  i^iw  iS!.'rw'^>:ri: :  el';!:  :;■  ;^:i:i^  is  m  ..eauty  an 

spas^si^ssaEss i 

psychical  svini.t..ins.  a  con.lition  to  Nvhich  l-ieneii  NMitci. 

— S";;;--,-.i;.i.;... >V;;7S:;^  r,s;;; 

The  ho'i.l  is  -Mvcn  a  sndden.  <iuick  shake,  and  ,\x  inc  . 


OTIIKH   AKFRrTlONS   DKSCIURKT)   AS  CIIOHKA. 


lu.sy 


lldW    ofU'H 

,-  sdiitliin.M; 
nto  11  lii\v 
lircd  frmu 

to  nmnlh 
trciitiiii'ut. 
■lll"llt,  iiiul 
he  jiivL'U  a 

iiul  'A\nr\n'^ 
r,  if  noc'os- 

:ui(i  is  iKir- 

lllui'lU-t'S    of 

Ictihain  nd- 


OREA. 

St.  Vitiis's 
when  under 

V  syinptoius, 
■oviiu'os,  i)iir- 

of  this  sort 
m  iiinoiifi  the 
uid  YiindcU. 
)  iin  atlVc'tiou 

in  reality  an 
cnicnt. 
rcnc'h). 
ition  of  habit 
ivcnionts,  and 
iHeninces  and 
ave  <j;ivon  the 

ost  fre(|ucntly 
n  its  simplest 
facial  muscles, 
e,  ov  tlie  neck 

of  the  head. 

time  the  eyes 
;h(nildor.  The 
is  much  appra- 
?ommon  symp- 


tom. The  cnscH  are  fuiiiid  most  fn'(jn(iitly  in  ciiildrcn  who  are  "  oiil  of 
sort<,"  or  who  have  hcen  ^rowiii;,'  rapidly,  or  who  hasc  iniierited  a  tcnd- 
ciny  to  neurotic  disorders,  .\llicil  to  or  associated  wilii  thi>  are  sonic  of 
the  cnrions  tricks  of  chihh'cn.  .\  hoy  at  my  clinir  was  in  the  hahit  cvcrv 
few  inomcnls  of  pnltim;  tiii'  niiddk'  liii;:('i'  into  the  nionlli,  iiitinj^  it,  and 
at  tile  same  time  pre^sini;-  his  nose  witii  the  forelinp'r.  Ihirtlcv  Cole- 
rid;.'!'  is  said  to  have  had  a  somewhat  similar  tricl<,  only  he  hit  his  arm. 
In  all  these  ca>es  the  liahits  (d'  the  child  should  he  I'xaniiiicil  earefiilly,  the 
nose  and  vault  of  the  pharynx  tlioroii;,dily  inspected,  and  the  eyes  accurately 
testctl.  .\s  a  rule  the  condition  is  transient,  and  after  persistintr  tor  a  few 
months  or  lon^rer  ;:radually  disaitjiears.  Occasionally  a  local  spasm  persists 
— twitchintr  of  the  eyelids,  or  the  facial  ^'rimace. 

(•.*)  Tic  Coiirulsif  ((lillen  dc.  lit  TaKirllc's  JJiscfisc). — 'Hiis  remarkaiile 
alVeclion,  often  mistaken  for  chorea,  more  frecpiently  for  hahit  spasm,  is 
really  a  psychosis  allied  to  hysteria,  tluuiuh  in  certain  (d'  its  aspects  it  has 
the  features  of  monomania.  'JMie  disease  he<,Mns,  as  a  rule,  in  voiin^''  chil- 
dren, occnrriiiff  as  early  as  the  sixth  year,  thou^rh  it  may  develop  after  pu- 
herty.  'Inhere  is  usually  a  markedly  neurotic  family  history.  The  special 
features  of  the  complaint  are: 

{(i)  Involuntary  muscular  movements,  usually  aiVectinj,'  the  facial  or 
hrachial  muscles,  hut  in  a,t:,Ln'avated  cases  all  the  muscle-;  (d'  the  hody  may 
he  involved  and  the  movements  may  he  extremely  irre^nilar  and  violent. 

(h)  Kxplosive  utterances,  which  may  rcscmlih'  a  hark  or  an  inarticulate 
cry.  A  word  heard  may  he  mimicked  at  once  and  repeated  over  and  over 
again,  usually  with  the  involuntary  movements.  To  this  the  term  crhn- 
hilia  has  been  apjilied.  .\  mu(h  more  distressing;  disturliance  in  tliese 
cases  is  rnprofiilin,  or  the  \\>^v  of  had  lanijuafre.  A  (diild  of  eight  or  ten 
may  shock  its  mother  and  friends  l)y  constantly  using  the  w(M'd  lUmni 
when  making  the  involuntary  movements,  or  hy  uttering  all  sorts  of  (di- 
scene  words.     Occasionally  actions  are  mimicked — PcliokiiirsiK. 

{r)  .Associated  with  some  of  these  cases  are  curious  mental  distiirhances; 
tlie  patient  becomes  the  Mihjcct  (d'  a  form  of  obsession  or  a  fixed  idea.  In 
other  cases  the  fixed  idea  takes  the  form  of  the  impuNe  to  touch  objects, 
or  it  is  a  fixed  idea  aliout  words — onomatomania — or  the  patient  may  fe<d 
compelled  to  count  a  niiiiiher  of  times  lud'ore  doing  certain  actiiuis — arilli- 
nuimania. 

The  disease  is  well  marked  and  readily  distinguished  from  ordinary 
(diorea.  The  movements  have  a  larger  range  and  are  explosive  in  clinrac- 
ter.  Tonrette  regards  the  coprolalia  as  the  most  distinctive  feature  of  th(> 
disease.  The  prognosis  is  donlitful.  I  have,  however,  kiu)wn  recovery  to 
follow. 

{(•)  Saltatory  Spasm  (Lalali :  Mrjrhuliil ;  Jumpers). — l^amlierger  has  de- 
scribed a  disease  in  which  when  the  patient  attempted  to  stand  there  were 
strong  contractions  in  the  leg  muscles,  whiidi  caused  a  jumping  or  spring- 
ing motion.  This  occurs  only  wlien  the  patient  attempts  to  stand.  The 
affection  has  occuiTcd  in  both  men  and  women,  more  frequently  in  the 
former,  and  the  subjects  have  usually  shown  marked  neurotic  tendencies. 

In  many  eases  the  condition  has  been  transitorv:  in  others  it  has  persisted 
68 


!l 


I 


mSKASKS  OF  TllH  NEUVd'S  SYSTKM. 


.     -1       .      ti;  ■   111   icrtaiii   iH'ints  oreur 

,„,  y ,.  y- ■'<»*  »"-""'T„::.";  "u,r,  :  :;nS.; ... ' .■  --;"■' 

tain  tainilics.  ,•  ,.,„,;.,  ,ui.l  in  .lava.  wIktc  il  is 

A  very  siuulav  .lis.as.  l"''->'  ;">';,,  j,    „,.  .l.i.r  n^.tuiv  ot  wln.h  is 
Un..vn  h^lH- "auu.  oMuyna.        :    ;l    ^  ;;;^  ,^^ 

'      ,/)  -Chrome  Chorea  (//«./,.,//""  ■'-■  , ''        •    .;      ^,.,,^,,^„,,  .K.nu.Mtia.    It 

i;  r,.4U.M,lly  linvli  ary.        ''^    '  ^  ',;  ^^,,,,„  ,,,.  „,,,li...l  u.  it.     It  was  lu- 

'•'-••--  "-'  ''  "."""'"";;  ■.(-•■  at  th'  tunc  a  pnutitiunor  on 
,,nlH.(l  hy  Ihintm-tun.  ot  .1""  >:  .  ,,„,,„.,,nl,s  tlu-  salirnl  lu-mts  m 
,,„„  Island,  and  ho  ,av.  m  )  ;  ,  "  J'  ';;.dilary  natur.  the  asso.a- 
<-'>'H-ti"»  ^^-'^'^  *'>^'  ^''rr  lu   !■,      on^.t--lH.i;vc...n  tlu>  thirtieth  and 

,e..  it  in  tw..  Maryland  '->' ^ ,       '^  .!'  U;mary  form  and  th.  -s.s 

torm  chronic,  chorea  may  '"'  ^"  "I'^'V,'  '      ,ij,,,,  ,    middle  life  ..r.  more 

hich  come  on  .ithoi.t   fanuly  dis     s  t,u      <^^^  ^^.,^,,,,,  ^le  cases 

^•""""""'>--  ">  ^'"'  ''^"^-"'r      if         nmv  ments.  often  with  mental  weak- 
en children  with  chronic  ^1--    '      /"^^         ^..  ;„,,  this  category. 
,,.,,„d  <,.astic  condition  olt       ^^'^  ^  ^,,„,,  ...iuin.;  it   has  heen 

The  hereditary  character  ol  ;"'■,„,,,;„„■„,„•,  faUier  and  ^;■rand- 
^,,„^,,a  ,H,„u,h  four  or  ive  ^^^"'f  ^^j,  i„\he  familv  which  he  de- 
^.„„„,  ,,.,  physicians,  had  trc.,  ed  ^  -"  ^^-  .;,  '  .,„,  ,sth.'  is.S)  that  the 
serilH.d.  OslM.rn.  of  Kast  l>'''''i;^'''\,  ;.■'.;  i,,.aescril)e.l  hy  lluntin.uton, 
,,,.„..,  .till  continnes  to  •-•7';'>  Ij  ^  ^"^/^  i,s.  An  identical  atVecticm 
,,  U  has  done,  so  it  is  said,  for  luU>       "^^'^^  ^,j.  ^,„,,i  ,,  h.te.  rarely 

;H.eurs  without  any  hereditary  chspo    tun       1  lu  .._ 

l„f.,ve  the  thirtieth  or  the  tl»>;tT-h    J;  >     '•  ,,,,^^,  .,,,,„^„,„,  ...venuMits  are 
The  symi.toms  are  very  '■'""'^y      ;    ;  ■        ,,,,  .Hohl  dithculty  in  ,u'r- 
,.„ally  iir.t  seen  in  the  ^J^-^^';;  ^^^^  J     :)  '    when'well  estahlished  the 
r„rmin^  delic^ate  "^'^"'''^  ,      i mo     huate  rather  than  choreic,  and 

,„,ven>ents  are  disorcU.rly,  "-;;/"s^, ham's  chorea.  In  the  lac-c. 
have  not  the  ^'^-T.;--'!-'  -  ^  "\  ^^  ,vell-develo,-l  ease  the  ,a.t 
there  are  shnv.  mvohintary  f-'""'^  ,' lile  that  of  a  drunken  man.  '1  he 
I  ivre,uh>r,  swaying.  '>-/';;"'"■;  1  i-.c'  ad  v  vronounc^a  and  indis- 
sF-h  is  slow  and  ^^^^;^::>'^^r,Z^  umnurment  leads  linally  to 
tinct.  hut  not  deiinitel>  staccato. 


TN'FANTILK  ('<)N'Vri,SI()N'S. 


1091 


Us  orciir 

(l.'^criln'il 
iiiotinii  to 
(M)inniantl 

l.liliiill  of 
lis  ii\  *.•*''■- 

when'  it  it' 
t  which   lr» 

uviictorizcd 
lu'iitiii.     It 

syikMlhlllll's 

Jt  was  hi'- 
■litioner  »'i> 
it  jtdiiits  in 

I  lie  iis>iK'ia- 
ni-lii'th  and 

iiinl   iiiaiiY 
•IS.     I   havo 

rinU'V  the 
1(1  tiu>  ca^^'-* 
il'i'  or.  more 
lor  tlu"  cases 
iK'ulal  weak- 

ijory. 

it  lias  l)wi\ 
!■  juul  <iiaml- 
whiih  he  d'"- 
s'.tS)  that  the 

lluntini:toii, 
tical  atTectioii 
is  hitc,  rarely 

loveiiieiits  are 
Vieulty  in  iier- 
slahli'shed  the 

II  choreie.  ami 

In  the  I'aee 

ease  tlio  ,uait 

en  man.     Thi' 

lecd  and  indis- 

leads  iinally  to 

tit'  lesions  liiive 
jfo-eneephalitis, 
iuns  which  one 


would  e\|ie(  t  to  fiml  in  clironic  (Idiicntiii.  'I'lir  rrcnil  >liiily  <if  two  cases 
liy  l'"iici<lan  (Arch.  !'.  I'sycliiatrie,  ;'.(•)  coiitirin-  the  view  e\|ii'e-se(|  in  former 
editions  tliat  the  disease  is  a  ehroiiic  nienin;io-enee|iliaiilis  with  atro|)liy  of 
the  convuhitioiis.  The  conl  and  |iei'i|)heral  nerves  lie  Iniiiid  perfectly 
liealtliy.  'I'lic  aU'eetion  is  eviilently  a  neiiro-de;;('nerali\e  dixudcr,  and  has 
no  connection  uilh  the  siin|de  elioica  of  childiiood. 

(')  Rhythmic  or  Hysterical  Chorea. — 'I'his  is  readily  recognized  hy  the 
riiythniical  churaclcr  ol'  ihc  movements.  It  may  all'ecl  the  miisclrs  o|'  the 
alidoincn.  |iiodiuinir  the  salaam  eonvnision.  oi-  iii\ol\c  Ihe  stcrno-mastoid, 
pi'oducin^'  a  rhyllimical  mo\einent  of  the  head,  or  the  psoas,  or  any  gronp 
of  mn-cles.      In  its  ni'dcrU  ili\lhm  it  resend)lcs  the  canine  clioica. 


V.    INFANTILE    CONVULSIONS  U-:r/,iwp..ni). 

('onvnl>ive  sei/.nres  similar  to  tho-c  df  epilep~y  ai'e  not  infre(|ii('nt  in 
chililren  and  in  adults.  The  (it  may  indeed  lie  identical  with  epilepsy. 
from  which  the  cojidition  ditl'ei's  in  that  when  tin-  cause  is  removed  tiiere 
is  no  tendency  for  the  fits  to  recur.  Occasionally,  however,  the  eonvnl- 
sions  in  children  continue  and  ('evelop  into  true  epilepsy. 

Etiolog-y. — .\  convuUion  in  a  child  may  he  due  to  many  causes,  all 
(d'  which  lead  to  an  un~talile  condition  of  the  nerve-centres,  pei'mittiiij,'  of 
sudden,  excessive,  and  temporary  lu'rvous  disehai'^i'S.  The  followiii;^  are 
the  most  imi)ortant  of  them: 

(1)  Dehility.  resultinji'  usiudly  from  jrastro-intestinal  di-turhanee.  Coii- 
vnlsioiis  fre(|iu'ntly  supervene  toward  the  close  of  an  attack  of  entero- 
colitis ami  recur,  snnietimcs  iirovinj:  i'at;il.  Morris  J.  Lewis  has  shown 
that  the  death-iate  in  children  fi'om  eclampsia  rises  steadily  with  that  of 
gastro-inte~tinal  (lis<ir(lei's. 

(•.')  rcri|)lieral  irritation.  Dentition  alone  is  rarely  a  cau^e  (d'  convul- 
sions, hut  is  (d'ten  one  of  sevei'al  factors  in  a  feehle.  unhealthy  infant. 
The  ,i,n'eatest  mortality  from  convulsions  is  durinii'  the  lirst  six  months,  he- 
fore  the  teeth  have  really  cut  through  the  irums.  Other  iiTitalive  causes  art; 
the  oveiidadiuL;'  of  the  stomach  with  indiu'estihle  food,  Jt  has  lu'en  sn.ii- 
<,a'sted  that  some  of  these  cases  are  toxic,  owing'  to  the  ahsorption  of  ])oi- 
sonous  ptomaines.  Wdrms.  to  which  eonvulsidiis  are  so  lVe(piently  atti'ih- 
uted,  prohalily  have  little  inlluence.  Among  other  soiii'ccs  possihie  are 
phimosis  and  otitis. 

(.'!)  h'ickets.  The  oliservation  of  Sir  William  .lenner  upon  the  ass(jcia- 
tioii  of  rickets  and  convulsions  has  heen  amply  conllrnied.  The  s]iasms 
nniy  he  laryngeal,  the  so-called  ehild-erowing.  which,  though  eiuivulsive  i!i 
nature,  can  scarcely  lie  reckoned  under  eclampsia.  The  inlluence  of  this 
condition  is  more  ap|iarent  in  Knrope  than  in  this  country,  although  rickets 
is  a  common  disease,  particidarly  among  the  colored  people.  Spasms,  local 
or  general,  in  rickets  are  proljahiy  associated  with  the  condition  u(  delnlity 
and  malnutrition  and  with  cranio-tabes. 

{■[)  Fever.  In  young  cliildron  the  onset  of  the  infectious  diseases  is  fre- 
qnently  with  convulsions,  which  often  take  the  place  of  a  chill  in  the  adult. 


if 


^^k 


PISKASKS  OF  Tlir-  NKUVOUS  SYSTKM. 

n,... n.vi.r>...i  ,  -.VHVv..,..  n.a.o. P... 

,,...  ..nail  a  .a-t  .n-.  .anual  -"1^;';^      '         „,     „,  J„„v  ol'  ih.  ..ious  -Ijs- 

;   l,r  ,1...  n.rvons  syst.n,  m  .In  l-v   •         ,        ;^;'  ,,  .„.„:„,.,.,..    Tlwy 

,;„,s  or  innu.til.-  lH.MU,.l.'J..u  tl"";>"  ;     •;jj"'";n,„v  .....ur  .1,1.   ,nM.iM,it>s. 
U..   ln.M.untlv,Mr..d.  nspn,a      .a.U^^.^^ 

•^'''V''''^-i;<  ~'"^      i.iM-'.^.'''>- ' — - 

^      Tl,..  ino.t  i.niH.rtanl  4..-  >;»  '^  ^'   ,  ^Z  ''-„  ,,,.,„  „,■  ,,.il..,,sy.  tl..  attacks 
;„  in'  isn  .mrin,  t!.-  ilvM  tlnv.  y.  ,j  -  I       ;•        ,  ^^,.^,.„  ,,,„  ,i„, 

„„,,„,  ,,.avs.     or  tlu.  total   li>t   ttu  i,„.nui.tion  in  tlu'  .uu- 

'niious.     T!>at  convulsions  ,n  .avly   nlaiu> 

H'iin- i..  =-'■''■'• '''\;r•':;;';;^'^;;,;:;;;:■  on  su.i.u.niy  .i,hout  any  ...... 

Symptoms.- 1  1"'  i-'t.-'l^  " '•'  ,,(.  ,,,„,. .s-nos..  arc..,„i.an.ra 

i„...  „,o,v  ronunonly  it  is  l-.r.r.h.l  h     ■    '  '  <;  j     j^  ,,,„,,,,  ,„  ,n,H,.l.t. 

,V  twitclun.  ....1  I-1.;M'^  f":;:^:.H'nI;  usually  .n  th.  l-ands,  njost 
i„  its  sta,t:.s  as  tvur  .|.>l';i->'  1 1"  ;  " ; ';  ^^^,^;  ,.^^„,  ,,„.,  ,,,,in,^  or  a,v  rolU.l 
c.nnuouly  in  ilu'  n.trht  l.and       '  "      ■    ,  ^^  ,„,,„,,uUhI   I'ov  a  nio.u.nt  uv 

^,,„  i,v  tonu-  s,«asn,  ol   tl.     ^^^Y^^  ,,' „,„,,i,.„s  fullow,  tl.o  eyes  an-  vol!.-. 

*^^*^  faco  hmun...  -'"^'^"^"■'';  J,    ;    ;        tvx.l  an-l  .xtcn.!.!  in  rl.ytlnnu.a 

=.l-"<-  tl."  1">'>''^  '>'^'^  '!'''"'^  ^r        ;      ,      ,lH.  head  is  .vtra-tcl.     Tl..  attack 
,uovc.nu.Us,  tlu.  fa...  is  couto  t     .  a L  .^^^^^  ^^  ^^^^^^_  ^^^  ^,     ,,, 

.ra.luallv  subsi.l.s  au.    tluyhM  \       1\„^  i,  ,i..k.ts  an.l  intestinal 

disonlcrs  it  is  a,.t  to  h.  rcpoaU..!  .>^  '''.';  ,,  ,„„  ,,•„,  in  a  (loop  eonui. 
.vith  gvoat  va,.i.lity,  so  that  ;'>".;  ;'',;  '^^  ,  ,;,,  tluTo  n>ay  l.o  slight 
,,.  ^,,.,  ,.nuulsion  has  hm,  luu.t  -1  •  hu        to  ^„„,^,,,,i„ns  ushor  u, 

I-'"-  '^'•'"■-  '•'■'"^•"•>-  r^"  ";,":i;u:i;  m,i'       0  si.l.  is  ..o,uplotoly  vava. 

l„...l.     Duvin,  tlu.  '".  l'';;-"l^",f      ,  ;,,  •        .,.1  ..hil.ln.u  or  whon  tho  at- 
frou>  tlu.  couvulsion  .tscU.  ox.q.t    n  ^     '     ;|  i,v.lrocr,.haloi,l  state  ,n 

t,,.l<s  r.Tur  vvith  gr..at  lrequeur>.     '^  ^^^^  „,;,  ,,„,  „„.  soono. 

..ouu.rtion  .i.h  ,.rotraoto.l  'l'">-f>'  '  ,    '^^     ^^^is  in  tull  health,  the  attaek 
DiagnOSis.-Coiu.n,'  on  when    1     su  1       t  ^^^^^  .^^.^^_ 

i.  ,rohahly  due  either  to  an  "-■•'-  -^^^'^li^iAi^h  fever  an.l  vonutin,. 
ti„n,  or  .,oc.asionally  io  traun.a.  ^  ^  "^  ^^  „eeasionallv  be  tho  prnrnvy 
U  ,.ay  inai..ato  the  on..t  o,  -  ^^^;^^;^aition  is  ^vlueh  eauses  infan- 
svmvtoin  of  oucophalitis,  or  ^^hato^or  the 


EI'IliKPSY, 


lo'.t:; 


mill  pno'.i- 

llu'    l)lllOll- 

lici'lUTl'lln' 

y  indii'iitts 

i'  lit-', 
-(■riniis  ilis- 

ccnt  "I'  li"' 
i.ms.    Thry 

incnin^'iti>. 
1 1  ruin. 

and  I'l'i'sist 

ICCll     llll'llill- 

.  in  chililivii 
,  tilt'  iittink> 

s  ol'  i'liil«'l'^y 

hill  tlic  lirst 

,  in  till'  lir^t 

I  in  till'  ii>ii- 

I'olliiWCil    I'V 

ut  any  wnin- 
iiccoiniiMuit'il 

V   so   cninlilctt' 

(.  liaiiil^.  ni(t>t 
f  ov  arc  I'olU'il 

a  niniiicnt  m' 
I. nee  nl'  which 
eves  arc  I'nllcil 

in  rliythiuical 
1.  'Y\n'  attack 
tatc  di'  sluiior. 
J  and  intestinal 
11,, w  each  other 

II  a  dco])  coma. 
1  may  lie  slight 
ilsions  usher  in 
„nii)lct(>ly  I'ava- 
th  rarely  occurs 
111'  when  the  at- 
., .haloid  state  in 
1.  ilic  scene, 
oalth.  the  attack 
M'riiilH'val  irrita- 
r>r  and  vomit inir. 
:  be  the  ])rimary 
ieh  causes  infan- 


;.,   ;„ta,k    i^  as.ocial.  ,    with    dehihty   and    uilh 


tile   hciiiil'h',i:ia.      When    I 
lul 

I'll 

ln> 

ai  ins  and  arc  ml 

Willi  minor  or  w  hich 

::;„;.n  III  character.     After  the  .cc 1  year  ciis  i„-.e  >ci 

„„  nrc^nlarlv  without  apparent  canM.  and  ivcnr  ul. 

p™^;;^r';-;::;sr;:,i:':i':;:;sn^ 

,.  I     >i  I    1  .,vvi,-s  Mill.'  (d' d.aths    11  cinldrcn  nnd.'r  till.  .^.•)  l'"" 

,;,lity.     In  Morns. I.  l-eu,,->  talM.   '      '  '  ,  ,-     ,,,„,„  „r  ,l,,uhs 

'■••'"  -—•''"■''  ''''''''7  "''"i.,!^,:^      1,       i'       'to,    1.1,1,  an  esmnate 
under  one  year  are  ean>ed  hy  co.iMlMon^.  Uit     l  ^ 

•■oMhi.cnn.rv.  •" '■'-■''•'•-'''''■•;''''■'' •:''"^'''^^'';,;:!;;;^:,;:,y  i:  .a^^ 


'■   '"■"''l"":."'  dv    I     ie      'I'lie  earpo,,e.lal  spasms  and   p-cdo- 

k,.l>  ihe  dia-noM>  I.-  caMl.\  m.Hli .      im     a  .,,vn"i«mus  siri.lir 

nw  infantile  heiniph-ia  are  n-nally  at    ii.    .la.k 
,,,...nd  var  cullSlll-l^e^cl/.Mrc,  «hi.-h  conic 
t  eaiiM'"and  rccur  wliil.'  the  child  i>  api^ai- 


as- 


I'or  tin.-  c  , 

'I'i.n-^e  n-heiiii"-  in   fevers  are  rarely  serious,  am 

„„.i.„.,i  .,,1,  M„ii....,ii,i.  <....i«  ,.-„„., .; ;";*;■;',■,'.!,„. 

'i-'"-      ''"'"•   ■•'•"'■'*"'   '^  "'"T"  ;"";         !  1       I        li"d      ith  cold  watci-.     The 
iMth.and.fthcivist^.ertie    ieadma>ln   d.      Id      It  The  verv  hot 

t-UH.ratureofthchath>honl      no     hc:.o       ,K.^,^  .^^,^^,_. 

hath  is  no,  suilalde.  particular  y  .1  the  i"     '  '     '     '    '  '     .^  „„„.■„  „,„. 

^•— — --" ^.;::,jr:;n;';::';c::d!ar,i:o'U n..^..^^ 


tahilitv.   particularly    in    ri 
,„,i,i„;  will   he   found    ellicaeioiis. 


^   1„'~|    to    place   it 


When   the  convulsions   ivciir  after  tlu 
ehihl  coines  l>om  unner  nu'  i,,,,ne,u.e  ot'  Hdonih^^^^^^ 
nM-i'lly   -uh:r  the   intlucuce  ol    o,m^^^^^^^ 

mended  arc  chloral  hy  enema, 
s   passed   tln^ 


ivpoderniieallv,  in  doses -d' from  one  twen,>-u 

for  a  child  of  nne  year.    Other  n.ncdics  reeon,  ^_^^_ 

i,   ,.„.ain   doses,  and    nitrite  ,      -;>,    .^^J^         ,  r.,         in  a  day  to  a  child 

;:;--;:'^'-:;;.;;-':;;i^u;s;:.i:^^ 
:;:;;:i  :::r '''^■re,;r:i:;;;i  ^ 


.lirectcd  to  improvin-  the  general  c.mdithm 


VI.    EPILEPSY. 


Definition.— An  affccdion  of  the  nerv 


aw- 


pvstem  cliaraclerized  I'V  at- 


•lei;  .      r^^^ion^ness,  with  or  without  convulsions. 
The  t'nsient  loss  of  eonscionsness  without  convul.ve  se 


azures  is  known 


^^hi 


lOU'i 


i)isr,ASKs  OF  Tin:  nervous  system. 


ii<  pi'lil  iinil:  Ihc  lo^s  (.i 


,.onsri..usnoHS  witli  jzrnenil  convulsive  scizuiys  is 

l;;r .;;  ::.n';'i::l:;-:  .■,.   known   ,.  .,.,h.p.>,onn.  .>,.   n...   r.v,,u,.nny   :. 
,liu-ks(iniiin  or  coHiciil  riiilcii>v 


Etiology.—- 1,'/'.— I"  ='  '"'r''  1"'"1 


lortion  of  all  <-asc; 


the  (liscaM'  lK'i:in- 


KTtv.     or  till'  l.l">t»  eases  oiiserved  hy 


(iowers.  in    l".'-'  tlie  .liM'a>e 


:t-i.';i;;,;r;:::'r;^:;iun?'i;n:;:.::'-":- 
-->  i;;i/sr'in,^i:;::;i;\r,y;^::'::.r:;,^^^^ 

r';,    :.•,•'         U      n'  .1    n  henndeea.ie>  the  tl.nres  are  as  follows:    !•  nnn 

i:-;:;:;!;;-:.:;;:i:;:,::;;;,:';^:;;.;;^S'^ 

,...i....v  ,.,..,....i....,.Mv.  if ..  I...;!--  ""...'«■'■  ,",•■:':::,:",;■  ■    „  :l. 


-"' I"""'''"' "''•■'"*"'''"' ■""■":'■   :,„v  .....1,..,.  ..* .... 


case  is  ratlu'V  m 


/    .  ;    m;      Alne h  -tre-  has  heen  lai.l  n,,on  this  hy  many  anti.ors  as  an 


(.xpeeled.  tlu'  |ieveenta,!:' 


''"'whiv '';;:,;'» St  «.i,i  n....  .ii.v.-t  M.i...ii......'  i^ «--•■'>■  i- 

v;^::;r,,:x:;lr;;:;;:;;;:^.;'^:;:u:::::n.;:f;^ 


■IZUICS    IS 
witlKUll 

lU'Utly   iis 

ic  di-iMM' 
iiu  lictun' 

,1     1     llMVC 

1 ;   Hccdiul 

vciir,  IS; 
:  flcvt'iith 
r,  -.M:  iif- 
iw.-:  Frniii 
1(1 1;  Innii 
11  sirikiii.u 

tlic  cases, 
lull.  Tor  in 
1. 
is  rclatinii, 

males  ami 
=ex.     After 

the   mules 
at   tlie  (li>- 

thors  as  an 
m  !'  t(i  over 
lave  speeial 
pilepties  in 
^iires  it  ap- 
ily  ;U  eases 

;!  in  which 
IS  n\i,uiit  be 

Tamily  his- 
jisy,  marked 
ij).  in  whieii 
only  two  in 
■  fatlier  had 
le  list  of  my 
c  iieard  this 
who  in  writ- 
tv  as  an  im- 

aratively  nn- 

n-ia,  in-anity, 

se. 

ii  jiiiteni  iH-e- 

has  analyzed 

•ee  classes,  of 


EPILEPSY.  l<J'-.'5 

whi.-h  2:u  case's  could  he  tra.-ed  directly  to  alcohol  as  a  cause;  Vlu  n.sos 
,„  ,,,,i,,,  ,1,.,,..  were  ass.u-iate.l  c<n>dmons.  such  as  syplulis  and  t^rann.at.sni; 
ISM  ca^'s  in  which  the  alcoholisu.  was  prohahly  the  result  ol  the  ..p'h'l'sy. 
Figures  equally  strong  are  ,iven  hy  Mart.n.  who  found  m  I'X";-'-'  ^V^- 
|,,Tli..s  s;{  uith  a  marked  hi.tory  -d'  parental  intemperanc.'.  Ol  the  IJ. 
Klwvn  case.,  in  which  the  fanuly  history  on  this  point  was  earelully  mves- 
ti..Mte<l.  a  delinite  stateimait  was  found  in  only  1  of  ih.'  cases. 

■"  N,./M7/...-'rhis  in  the  parents  is  prohahly  less  a  pn^hsposn,-  than  an 
,,,„al  cause  of  epile,.sy,  winch  is  the  dir.vt  outconu.  of  ocal  .-erehra  mam- 
iV<tati.ms  There  is  no  reason  for  r.rooinzmK  a  special  hu'in  n\  ssp  u  itu 
,.|,ik.psy.  On  the  other  hand,  convulsive  sei/iires  due  to  acqunv.l  syphilitic 
disease' (.f  the  lu'ain  are  very  c(mim(m. 

1/,„//o/— Severe  epileptic  convulsions  may  occur  m  steady  drinkers, 
or  excitin-  causes   fri-ht   is  helieved   to  he  important,  hut    is  h-s  s... 
think,  than   is  usually  stated.     Trauma  is  present   in  a  certain   "'-'-•'; 
in<tamrs.     .\n  imp-ulanl  onmp  depends  upon  a  local  disease  ol   the     lam 
,,,i<tin-   from  .■hihlluHuK  as  seen   in   the  p..st-hemiph-ic  ei-ilepsy.     Oeca- 
.ionallv  cas..s   follow  the  infectious  fevers.      Masturhation   has  heeu  stated 
,o  he  a  MH.cial  cause,  hut  its  inlluence  is  prohahly  overrated.     A  la,-e  -roup 
of  ..onvnlsive  seizures  allied  to  epilepsy  are  due  to  some  toxi..  ajient.  as  m 
U,,,l   noisonim,^  and  in  uraMuia.     (ireat  stress  was  laid  upon  rel  ex  ca  i.e.. 
.lud.  as  dentition  and  worms,  the  irritation  of  a  cicatrix,  some  local  alUr- 
,i„n.  such  as  a.lherent  prepuce,  or  a  forei<rn  ho.ly  in  1  -e  ...r  or  the  nose 
In  manv  of  these  cases  the  lits  cease  after  the  renun.,1  o    the  -'•-;•;''  ^'j 
there  can  he  no  .piestion  of  the  association  hetween  the  two.     In  othei.  lh 
attack-  persist,     (hmuine  cases  of  rellex  epilepsy  are.   I   helieve.  '■"■»■.     A 
marka  de  instaiu.e  of  it  occurivd  at   the  Vhiladelphia  Inlirmarv  l-u-  Ihs- 
"  ',  U  the  Nervous  Svstem  in  the  c.aso  of  a  man  with  a  testis  in  the  inguinal 
,,nal.  pressure  upon' which   wouhl   cause  a   typical   ht.     Kenioval   ol    the 

or"-au  was  followed  liy  cure.  ,       •  ,      ,■  i     i  r   ,i,,. 

Kpih  ,sv   has  heen    tlu.u.o-ht   to  he  associated    with    disturhance   ol    the 
heart's  action,  and  some  have  spoken  of  a  sp.'cial  cardiac  epilepsy,  particn- 
in  ..ases  in  which  there  is  palpitation  or  slowm,  ol   the  action  pri- 
the  on-et      Ki.ih'pt ic-  seizures  may  o.-cur  duriu-  the  passa,i:e  o    a  ^^all- 
:.;^::.:!:asi.ul.ll     clurin,  tlm  removal  cd;  pl..^^^ 
,n,l  .astric-  tnuihlc.  are  extremely  common  m  ep'l'T'^.v.  =>nd  ,n  man>    in- 
stances the  eating  cd'  indijxestihie  article's  seems  to  precapitate  an  "t'^n'l;- 
An  attempt  to  assocaate  ;:enuine  epilepsy  with  eye-strain  has  si^ualh 

"''^mptoms.-(l)   Grand  Mal.-1'recedin,  the  fits  tlmre  j;; --'llX  ^ 
locilized  sensati.u,.  known  as  an  aura,  in  some  part  of  th.^  holv.      Ih 

,  he  sonuitic.  in  which  the  feelin,  ccmies  from  some  particuhir  re^mn 
in  the  periphery,  as  from  the  lin.n.r  or  hand,  or  ,s  a  sensatum  lelt  n  the 
I  c'h  cJ  about  the  heart.  The  peripheral  sensations  preeedin,  (he  li 
are  of  ,reat  value,  particularly  those  in  which  the  aura  '^-|>-s  occur,  n, 
definite^  re-ion.  as  in  one  lln-er  nv  toe.  It  -  the  ecpuva lent  of  che  s  -nal 
1.1  Ci  a  lit  frcnn  a  brain  tunuu-.  "  .  -arieties  of  these  sej^sa^mn 
,,,    imnerons.    The  epigastric  sensation,  u-  :.ost  common.     In  these  the 


k 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1090  ,.  ,         .„ 

::;;;ti:r.i:v';:^.r;;;;;;;;:.:;;:;^  ■■.;„.. - - " ^  ^ - 

-r;:;s;[::r;;;;:;^:"-i::;^^^ 

,„„..  or  t.rrur.     Tl,.  aunv  -"      ^^^  „f  UaJus  ..f  light  or  .on.v- 

,,,„,  or  color;  U.S  -'•'-;  >^;^ '^^  a  .oiuuls  .nusiral  tonos,  or  cura- 
tory ac.nv  consist  ol  no.scs  >■  ;  ^,,„.,^,^  .npLasanl  taslos  and  odors, 
sionally  voices.    Olfac^tory  and  ou.tatoi^  .un 

i"c-  rare.  ..rcrcdcd  not  hv  an  aura,  l.nt  by  certain 

(),..a.ionally  ^1"'. 'V"'',     „ '\   und  ra,.MilV  or  run  with  great  spec-d 

,„oven,ents;  tho  i-a.u.nt   •'';;  ,^'. ;!;,,, Luriiva.     In  one  ot  the  llwyn 

'"'-^  ,Vw  >"i>>"t^''^V    'T  an     t  vi,lel  with  extraordinary  ra,.ul>ty,  so 

,a..s  the  lad  stood  on  his  t..c.  and  tN  n  ^^^^^^_^  ^^j,  ^,^^,  ^^^,^^,j. 

that  his  features  .ere  ^---'j;.,-:';;^'^       '  ,,  ^olalled  epileptic  cry.    The 

tl„  patient  n>ay  gjve  a  I-'   -  ^      ^^^^  ^     ,,,a  the  fall,     la  consecinence 
,aient  drops  as  It  shot,  n.ak.nglb^t.  ^^^^    ^^^^,^^  ^^^  ,       , 

!,  this  epileptics    -l"-^^^,^^   ^J^        loscnhed  hy  lUpp-u'rates   "     - 

or  burning  themselves      >"/'      '>  ;\;;,  ^,,,,,  i,,u,s  Iron,  the  nuu.th,  the 

,tient  loses  his  spcrch  and  ^■-' »;';'/  ,^^^  ,,,,  aistorted,  he  bcconus 

1,0th  are  lixed,  the  '•-''^'";^  ''  ^:    ^    !,  aiVecJed.     And  these  syn.pKMUS 

occur  son\e  inies  on  tl\e  icii  .  i«h,  .i„,r,.^- 

C;;:-     ...e  ht  .ay  be  desc^.  ;;•    -  -  ;^,-^,-,.^  ,,  ,,.  ,„„  and  the 

„)   Touir  .s'ym.sm.-lhe  head  '^  ''  extended.    This  tonic 

jaws  are  lixed.    The  hands  are  <'l;'-  ;  ^  ^^  \  ^  ,,„,,i,,,ti,„  i.  impeded 

..,„traction  alTects  the  muscles  ot  tl  t-  ■     ^  1^^   ^.^.  ^  ^^^^^^     ,,,,^^^ 

a-l  the  iuitial  pallor  ot  ^'>^; '-^  ""^  C, ^  .,  that  the  head  and  neck 
muscles  or  the  two  sides  are  ^- ^^^'^  ,.„  ,  ,,,  ,,,ally  ilexed  at  t  ,e 
a-  rotated  or  the  spine  -.^^-^J"^,^^'  ,:,„,,  ,,,  ti.litly  clinched  in  the 
..„„„vs.  the  hand  at  the  Y'^''/''^,  „  ^.,,„,  th,n  the 
palm.  This  stage  lasts  only  a  tew  ;  ^  ^;^^;;^;,,,,tions  become  intermit- 
(,,)  ('l„„ir  shujc  begins.  »"\">  '^^  .  „,,„,auallv  hecome  more  rai.id 
,.„;/,t   llrst    tremulous  or  Y'^^-^,,  ^^    ,i     v      The  muscles  cd  thc> 

nnd  the  limbs  are  jerked  -';  J^;!:! ,;,  the' eyelids  are  opened  and 
,.,,,  ave  in  constant  clonic  spasm,  t  h  ^   ^  ,^,.  j,,,  ■  ,,  are  very 

,,osed  convulsively.  The  -<-;;';*  ^ji:  tongue  is  apt  to  be-  caiig  t 
forcible  and  strong,  and  It  l^  /  '"^,  \,,^„„„i,,  marked  at  the  end  of  the 
,,,twcen  the  teeth  and  lacerate.b  ^ >  j';.^,^  ^^,,,i^,,^  „„,  i„  l.lood-stained, 

;:;;::t;;f;he:u:^dr'nJ..osanduri..nia.w^^^^^^ 

-:;V     The  duration  ..this  staj..^ 

one  or  two  minutes.      1  lu  *'''n''''> 

n-raduallv  sinks  into  the  condition  ol  stertorous,  the   face  con- 

'^     (,.)  r.,„a.     The  '>-f -^ ;;;;;;  ;^;^   .^10  imd-s  are  relaxed  and  the 

.nsted    but  no  longer  intensely  cyanotic. 


KPH.KI'SV. 


l()i>( 


strc?s  in 
urn  and 
s  known 

ughlings 
or  soiiio- 

(if    llR■^l• 

or  s^t-nsii- 
ho  iuidi- 
,  or  oifii- 
,nd  odor^, 

)y  certain 
I'oat  spi-H'd 
Lhe  Klwyn 
ipidity,  so 
the  attack 
cry.    Tlu- 

)llSLHlllOnCO 

•0  or  head 
rates,  "  the 
mouth,  the 
le  becomes 
'  symptoms 
metimes  on 

M,  and  tlie 

^rhis  tonic 

is  impeded 

hue.     'riH' 

id  and  neck 

exed  at   the 

iched  in  the 

lie  intermit- 
more  rapid 
uscles  of  the 
'  opened  and 
jiiw  are  very 
to  he  cauuiit 
,0  end  of  the 
dood-stained, 
rffed  in  vol  lin- 
ts more  than 
id  the  patient 

the   face  con- 
liixed  anil  the 


iiiiconscioMsiii'ss  is  i.rofoiiiui.  Aflcr  a  varialile  time  the  itatieiit  can  l)e 
iiroiised.  hut  if  left  alone  lie  sleep.-  for  some  iioiirs  and  tlien  awakes,  coin- 
|)lainiii<r  oniv  ul'  slij^ht  iieadaclie  or  mental  confusion. 

ill  some"  cases  one  attack  foll<.\vs  the  other  with  .uMvat  rai)idity  and 
coiiscioiwncss  is  not  regained.  This  is  termed  the  shiliis  rpilriilinis, 
an  e.\ce|itional  condition,  in  which  the  j.atient  may  die  of  exhanslion, 
conse(picnt    u|ion   the  repeated  atta«ks.      In  it  the  temperature   is  iisiially 

elevated. 

After  the  attack  the  reflexes  are  sometimes  ahsent;  more  frcipicntly  tiiey 
are  increased  and  the  ankle  clonus  can  usually  he  ohtaincd.  The  state  of 
the  urine  is  variahle,  particularly  as  rejrards  the  >olids.  The  ipiantity 
is    usually    iiiercased    after    the   attack,    anti    alhuinin    is    not    infrcipiently 

jiresciit. 

I'dsl-cjiilriilir  siimiiliinis  are  of  ;:reat  importaiu'c.  'I'he  jiaticnt  may  Ite 
in  a  trance-like  coiulition,  in  which  he  performs  actions  of  which  siihse- 
(luently  he  has  no  recollection.  .More  serious  are  the  attacks  of  mania,  in 
which  the  jiatient  is  often  daiificrons  and  sometimes  homicidal.  It  is  helil 
hy  o-ood  authorities  that  an  outhreak  of  mania  may  he  substituted  for  the 
lit.  ^  And.  lastly,  the  mental  condition  of  an  epileptic  patient  is  often  seri- 
ously impaired,  and  profound  defects  [UV  common. 

Paralysis,  which  rarely  follows  the  cpilciitic  lit,  is  usually  liemi|)le,ij;ic 

and  transient. 

Sli'dit  disturbances  of  siiecch  also  may  occur;  in  some  instances  forms 

of  sensorv  aphasia. 

'Ph  ittacks  may  occur  at  nif-ht,  and  a  person  may  be  epileptic  for  years 
without  knowin-r  it.  As  Trousseau  truly  remarks,  when  a  ju'r.-on  tells  us 
that  in  the  niuht  he  has  incontinence  of  urine  and  awakes  in  the  morninfjf 
with  headaclR~and  mental  confusion,  and  complains  of  ditliculty  in  speech 
owinj:  to  the  fact  that  he  has  bitten  his  ton-ue;  if,  al.<o,  there  are  on  the 
skin  of  the  face  and  neck  imrpuric  si)ots,  the  probability  is  very  strong  in- 
deed that  he  is  subject  to  nocturnal  e|)ile|)sy. 

(^')  Petit  Mai.— This  is  epilepsy  witluuit  the  convulsions.  The  attack 
consists  of  transient  unconsciousness,  which  may  come  on  at  any  time,  ac- 
companied or  unaccompanied  by  a  feelino-  oi  faintness  and  vertigo.  Sud- 
deiilv,  for  example,  at  the  dinner  table,  the  suhject  stops  talking  and  eating. 
the  eyes  l)eeonie  lixed.  and  the  face  slightly  imle.  Anything  which  uiay 
have  "been  in  the  hand  is  usually  dro])]ied.  In  a  uKuncnt  or  two  consciou.-;- 
iiess  is  regained  and  the  pati.'iit  resumes  conversation  as  if  nothing  had 
jiai.peiicd.'"  In  oth'r  instances  there  is  slight  incohercncy  or  the  i)aticnt^ 
performs  some  almost  automatic  action,  lie  may  begin  to  undress  himself 
and  on  returning  to  consciousness  find  that  he  has  ])artially  disrobed,  lie 
may  nil)  his  beard  or  face,  or  may  sjjit  about  in  a  careless  way.  In  other 
attacks  the  patient  may  fall  without  convulsive  seizures.  A  definite  aura 
is  rare.  Though  transient,  unconsciousness  and  giddiness  are  the  most 
constant  manilVstatiims  of  prtil  iind :  there  are  many  other  ecpiivalent  mani- 
festations, such  as  sudden  jerkings  in  the  limbs,  sudden  tremor,  or  a  sudden 
visual  sensation,  (lowers  mentions  no  less  than  seventeen  ditl'erent  mani- 
festations of  priil  mill.     Occasionally  there  are  cases  in  which  the  patient 


lO'.tS 


DISEASES  OV  THE   NEUV(-rS  SYSTE^I. 


,„  a  H'nsati..n  ..f  l->i"g  l'i>  1";'':"|' 


uiul  may  fvin  -rl   ivd  i 


in  the  I'lU'O.     1 


l„v.  .crn  such  attacks  also  ...  <'l'"'";;",  ^    ,  ^,  ,•  „,  ,,,,,„uls  a...l  1-.- 

An..Ml.c  attack  tlu.  ,K.t>c,,t  .>u.>laM^M-  _^^  ^^^^,,^_ 

l-"v.n  ccrtai..  auto.natic  act>.u,s.  -l'!''",'      '.,,,,  .,■  .,.,.1  actio.,.  ...ay  he 

1-^--'. -"''■;•'•;:■>;;::  ;:^;::X^  V'r 

,i„„s  arte-  a.,  attack  x  a>  n.      .^  .^^^^^.^,  ,^^,^,,^  ,.„n,mttca  a 

,,a„.ls  .>...  l.a.'t.c..la.'ly  hook.  '';;', ^,i.,„,  ,,hi,l.  co.nc  hch-.v  tl 

,\,,,,_v  the  ;/'■"'-./''",/ hcco.ncs  ucU  .IcNch.lH.l.  an  . 

iiatc. 
'(:{)  Jacksonian  Epilepsy.— '1''''"^ 


1(1 


,,„„.(,.      'Phis  coii.litioii    ha 

/(//■/•(//f( 

111  a  .iiajoiity 

slight.  Imt  iiltiui 

,„ay  then  alternate.    _^        _  ^^^  ^^^^^^^^.^^  ,.^  c.rti.ak  synii-toniatic, 

- —  '  '"'    '■  •'       ,v  liv  the 

e  attacks 
icrli  then 
a   typical 
',  a.'.).,  oi'  h'ti'. 

„,.  ,„r  insta.ice.  o.'  the  thnn. '>^'  *"* 


1  ,•,,„„  ,1h.  (..-.lina.'y  epih'l^sy  l>y  the 


OV    a;iial  opilopsy.    it  .s  disti..,u.s,ieu    n  n  .;;-.;-.,.;,^,;    ,,■• 

i..i  .o,1a..(   fact  that  conscioiM.es.    .  ^  '"  >    '  .  ,,.„,  t,,,„ 

a..\.s.u.llythe.vsultor..ntat,veleMo.n       u^^m         .^  ln> 

^„,,,     ,„,„,,iv  also  sc.son    e.i.i.va C  t>  "'/',,.  ^,„,  ,•,.,,  a.'., 
a.ta.Vthes,n,s,nhe,insinalm..U.d,,.u.c^^^^^^^ 

Tl,e  .y,o..ia.ic  ''<-■';^'"V'^h  it  li  '^  t  '  ti-^'n-ay  IVel  a  .-.satio., 
„„,  ,1,.,  l.e  .nove<l.  Vn-;:  tn  th.'  ^^  ''  -  ,.,,,.  ,„„  ...teii.ls  aiul  may 
,,,i,,„nn.esso.Min,li,.^n.the,K,.     an     t    1  -n.e  ,n.t,ent  is  coii- 

iuvolve  the  .....scles  ot  ''7^''  H  n\  1  n  'est.  the  .na.vh  of  the  s,.as... 
.,MouMlu.H,dmntan.lvvatches.ol  e.i      1  h    "      Y,,,,    as  in  a  case  which   1 

liave  .•epo.le.l.  to.'  the  pat.e..t  to  1  '  ;  '  ,,,,,^,  ,,„,  ,„ay  he  local- 
as  coniro.1ahle  as  p-.sihle  •'-'"'f     '  '\;  ^  ;'     j,  ,,  ,,ial    ,nle,,sv  ...ay  hec<nne 

■-•' '■"■■  ^^'^'r- '*'•* ;';•" r ;;r;  t '    in'i.at.ve le.:.. .. the ...oto,. 

.eneval.    The  co...!.t,o..  .>  -Lie  as  ^  '''  ,         ^^,^,,,  .,s  of  tumor,  "il 

xone.     Thus  of  1"T  ca>es  analy/e.l  1      \f    I;}        ,^,.   ^,^.,„^,   „,,   .,,,,„.,. 


i„„aiues  or   inlla...n.ato.'y  ;"""";"^    '  ;  ;;;;,;'i;i„.  insta.ues  were  due  to 
,,„in,i,is.  a,..l  S  cases  ol  t-uma.      1  h>  ^  h '-n^^  .^^^^^^^^^.^  ^^^^,^,^_,._       ,,,^.„ 

,i,al  Jacksoniai. 
in>ane.  A  coii- 
mnd  ill  chihlrei. 


:±^;;j:;;:::r;;':rr 


i.ec<m.e  ...ore  severe  a..u  ^■•.u,.,..  .„a.len..ess    of    the    attack,    the 

Diagnosis.-ln    ma.or   n'^^T^  ;        '    l',,,,.^  ^,„,  „,,„,.  „,as.i..  and 
,,,„,,  ,,.ss  of  consciousness    the  or  1  ^^^^^^^^^  ^^^^^  .listinct.ve 

^,,,  ;,,,axaiion  of  the  sphincters  at  ^^-^^^  ,,       •,    ,;,  ;„  ..,.a.'a<ter 

features.  Tho  .-.v.-lsive  -;-;'■-  '''^^i'  ],  flatly  i..c.vased  ton- 
and  ;.sually  readily  reco;:.„zed  l'>  '"  J^.  '!  „^  i,/,„„,„  ad.ilts  hystena 
.,; .,,,1  the  cmdition  ol  the  un.ie.     1-i^V"    ■,.,..;..  .,.,  „  ..nilensv.     The 


and  tiie  cmditicui  of  the  u.-i..e 


:;™;:' «::;,:;;;::;' s;;;..": >  ".«y  "'-'^  ^ '»'•■  "■ "*■''■■ 


KPILKPSV. 


lO'.t',) 


I'aro.     1 


I'ollowiiij:  tnM<'  I'min  (iowcrs'  work  draws  clciirly  tlic  cliicr  dilVrronccs  Ijc- 
Iwccii  tlu'iii: 


anil  jii'i'- 

A>  nu'U- 
is  may  Ih' 
)l'  my  \>'\- 
(■(,ul(l  lay 
liltrd  and 
ji'I'orc  tlic 

\\i\  a1  lii'^^t 
llio  attacks 

ini)tiimatic, 
psy  liy  thf 
'he  attacks 
DUjili  tlu'vo 
ti  a  typical 
ivm,  <>i'  ''',-• 

(ir  the  toes 

a  sensation 
ds  and  may 
ient  is  con- 
r  the  spasm, 
ase  whicli   1 

so  as  to  lie 
lay  lie  local- 
may  Itecome 
ill  the  n\otor 
;)1'  tumor,  ■-*! 
and   chronic 

wrre  due  to 
•reliri.  Two 
il  dacksonian 
■ane.  A  con- 
,1  in  childi'cn 
^■.  The  con- 
r  le--.  and  the 
timately  they 

V  attack,  the 
lie  spasm,  and 
are  distinctive 
ic  ill  eharai  tev 
increasod  ton- 
adults  hysteria 


Kl'M.I-.ITIC. 


ll\>iTKUlilIl. 


epilepsy. 


Tho 


AppJUVIlt     CUUSf IKHIC.  Clllnlioll. 

\\  ,,1-iiiii'.,' '  any.  ITut  ('s|ii'ciMlly  iiiiilatcral    iiiilpilal  inn,    iiialai^c   choUiiig,  lil- 

i     lir  cpi^'a^lrir  aunu.  |     laU'ral  liinl  aiiia. 

Onset '  always  mkIiIcii.  dftiai  Lrrailual. 

SrrraiM n\  (iiisi't.  iluriii.i;-  n.ui--r. 

(.•,,iiviil>inii ri,i,'i(lity    follnwi'd    liy    ••jci'U-    nj^iany  nr  -  >1imii;<;Hiii:.'"  llinivvni« 

\     ing,"" rarely  rigiilily  aloiu'.    I     alicml   nt  liialis  or  licail,  archiii.i; 

i     (if  liai'k. 
lips,  liaiuls,  (ir  (A\h-y  penple  ami 

lliiiius. 
nuvi;r. 
noviT. 
trcijueiit. 
more  lliaii  ten  miiiulr~,  iiftcii  iiiut,li 

leriirer. 
til  coiunil  vii.lriii'i'. 
spdiitaiifuus    iir    imliircil    (water, 
etc.). 


Uiiiii;,' '  tiiiii;\ie. 

Mieliirilieii freiiueiit. 

Derecatidll i.cca^ielial. 

'ralUiii!.' m'ver. 

Daration ;  a  lew  mimitfs. 

Hestraiiil  iici("->ary.  .  /  tn  prevent  areidiiit, 
'rermiiiatiiin spontaneous. 

I 


i'ccurrin.i!'  epiU'|itic  sei/.ures  in  a  pei'.-ou  o\er  thiily  who  has  not  had 
previous  allacks  is  always  sun'ucslive  <d'  orj:aiiic  disea>e.  Accordin;^-  to  11. 
('.  Wood,  whose  o|Mnion  is  supported  by  that  of  Fournier,  in  '.»  cases  out  ol' 
10  the  coiidilioii  is  (\\\v  to  syphilis. 

J'cltl  iiHil  must  he  distin,i:iiished  from  attack.s  ol'  syncope,  and  the  ver- 
tiiro  <d'  Menieri'V  disease,  of  a  cardiac  lesion,  and  of  indiuotion.  In  lliese 
cases  tlu're  is  no  actual  loss  of  consciousness,  which  foi'ms  a  characti'ristic 
thou,trh  not  an  invariahle  feature  of  /n'lil  uinl. 

.lacksonian  epilepsy  has  features  so  distinctive  and  peculiar  that  it  is 
at  once  reronnized.  It  is  liy  no  iiieans  easy,  however,  always  to  (U'ternuue 
npon  what  the  spasm  depends.  Irritalimi  in  the  motor  centres  may  he  due 
to  a  ureal  variety  of  causes,  anion.i:  which  tumors  and  localized  menin^'o- 
encephalitis  are  the  most  freipient;  Imt  it  must  not  lie  for-'oltcn  that  in 
nra'inia  localized  e|iilepsy  may  occur,  'i'lie  niosl  typical  .lacksonian  spasms 
also  are  not  infreiiueiil   in  n-eiieral  paresis  of  the  insane. 

Prognosis. — 'i'his  may  he  jriven  to-day  in  the  words  df  llippoerates: 
'■'■■ 'J1ie  in-oe'nosis  in  epilepsy  is  iinfavorahle  when  the  dir-easi'  is  conu-cidtal. 
and  when  it  endures  to  maidiood,  and  when  it  occurs  in  a  ,<:-r<>wn  person 
without  any  previous  cause.  .  .  .  The  euro  may  he  attempted  in  youn.^r 
persons,  hiil  not   in  old."" 

Death  diu'inir  the  lit  rarely  occurs,  hnt  it  may  happen  if  the  iiatient 
falls  into  Ihe  water  or  if  the  lit  comes  on  while  he  i<  eatini:-.  Occasionally 
the  Ills  seem  to  stop  spontaneously.  This  is  pailiciikirly  llie  case  in  the 
epilepsy  in  .liildren  which  has  followed  the  convulsions  of  tecthin.t;-  or  of 
the  fevers.  Kreipiency  of  the  attacks  and  marked  mental  distnrhanco  arc 
nnfavorahle  indications.  Hereditary  iireilispositinii  is  apiiareiitly  (d"  no 
moment  in  the  proirnosis.  The  ontlook  is  hetter  in  males  than  in  females. 
The  post-hemiiilepie  epilepsy  is  rarely  arre-led.     Of  the  cases  c<nning  on 


i^. 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1-  "-'^'  '"  -uU.r.tan.l    nun  tl.e  ou  .       "^^  i,"  „,,^,  ,„r,,„v  as  linU-  as 

Uvatnu.nl.     KhIuI^.u...  an-    VH'M..^  I      ^  ,^^^^,,^,   ;„  ^i,,,  ,asos. 

,,v  w.ak.nin,  of  t!,.  n.o.al  -7".  '',;,,„  ...,upanon.  It  >s  nnu.h 
-n,,  .lisras.  .I0.S  nol  .ncapantat.  a  1^  ^  ^  ''  ^^^.j,  -|,,„„  „,,  ,nany  in- 
,„Uor  for  .Til-'Pti-  t.  1.-.  -';;  \,        „,ainavy  nu.ntal  an.l  iH.Uly 

v„ov;  as,  rov.xanu.lc,  JU1U.S  (a.u  .  Na^^  ^^^^  .  ^^  ^^^.  ,^^^,„,  ^^,  ,,  ,,1. 
tvessin,'  IcaUnvs  m  qulopsy  >  lu  .  adu^^  ^^^^.^^^^^  ^^^^^^^^^^^^  ^,^^^.^,_^^^,,^.  „,,,,. 
lows  in  a  certain  nnnilu'V  ul  c-  s  •  ■         •  ^  ^^^  ^^_^^j^_^.  ^„,,,,,,i,i,„>  ,n 

<,,,,,  „,  .Low  sip.s  ol  y.olom.-  ^  !'^  ^^  '  „  ^  .icTti-.  Huvin^  tho  attack 
an  asvUnn.    Marria.o  shoul.    bo  »'     ^^^'^  ,,,  ,,,„>  and  tin.  cloUus 

-:;;xu::';:;;;;./:;^x;;^ 

">■'>■  1h' jiiven.  ^         ,    „„  n-inu-n  in  cpilopsy. 

IMrlir.-'Vh.  old  autlH.rs  1,       M        .t  ^^.^^  ^^^  j,^^^^,  ,^,,^„,^^  ^^^^ 

,p,,^.  important  point  .s  to  give  tl  0  "  ;"  -  ,^,^.,,  ^..t  slu>uld  n.d  he 
,.,  ,„  i...un.  to  1--'V--'?;:  ;^^^^  .:  •  llnc-h  anin>al  food  scvn>s 
.iv.n  n.oiv  than  on.e  a  day  '  ."^  '  ^  ,^  ^^.,,,,„,,  ,,,o,nnu.nd..d.  Tho 
■  ,Junous.     A  stnet  vo.otj   •  .  d  ;;  .-^.^^^^  ^^  ,.^,  ,„^^,^,.,, 

,Ui.nt  should  "''    .-'\  V        0    1      only    vnK'dios  uhioh  have  a  spcrial 

,/./;,  M.,/.-Tho  '-jf  -  ;  ^.  ;>  ,:"  ;;aiun>  or  potassiun.  salt  n>ay  he 
•„,„„,„,,  upon  Iho  .l.>easO.  ^^^  '  \' ^^  ivritatin-  and  is  Letter  horne  tor 
.iv.n.  Sodiun.  hronude  >s  V''"'"!  '  ^^  n  hi  irit  is  s.arcrly  taslod.  In 
a  Ion,  period,  h  n.ay  he  ,.ven  ^  ^j^^.^^^'^,,  .anlts  it  is  .ell  taken 
,U  instances  the  dilution  ^^l<-''<  ''^^  ^f  ^;;  ,  ^os.  for  an  adult  should  be 
in  soda  water  or  in  some  mineial  ^^-i^^,  ^    ^      ,•„,  recommends, 

I'-n  haU  a  draclun  to  a  ;1-lnn  am  ;  ;!■  "^  ^;,^  ,^„,,  (;,  ,;,  „,„,  before 
it  is  often  best  to  .unve  bu  a  sn.ule  '^-  '  ^  ',  ;.^,  j,^  ^,,.,  ,,,,  of  nocturnal 
th.  attacks  are  nu.st  likely  to  -•--.^,  '  ^^^  '^  ^  ,r,er  the  evening  meal. 
,,,l,psy  a  draelnn  should  be  ^ven  an     om    nU  ^^^^^^^^^^  ^^^^^^^  ^^  ^ ^^^ 

H  the  attack  <-euvs  ear^^  |n  '  -.„,^,  J  ,,,  ,  is  best  given  aitc. 

.lose  when  be  awakes  ^y'^^^  -  '  .  ^,^.  ,^„ai,a  to  determine  how  uuub 
tueals.  Kach  case  sboidd  Jj  '  ,  ^^  „i,  ",„,eptibility  varies  and  some 
^'-"'''^^'  ^'"''  ''  ri.n  k'  Fortunatei;,  ebildren  taki-  the  drug 
l-atients  requn;e  "'"'''^ , J  ^"^^^^  ,,,,,,  .loses  tban  adults.  Saturation  is 
,,,11  and  stand  proportioiatch  '"^^^  ^  particularly  drowsiness,  mental 
indicated  by  certain  --y^T^,^^';^^:,  palate  rellex  is  one  of  the 
^  and  gastric  and  ^•=y'^">^  f'^';  •„„;,,  „,,>  inlUunce  of  the  bromides. 

;;;;k:™;;S"'2ii;':.3™;i';!:.>.  Av..u,,,^ 


KPILEPSY. 


IIOI 


ill  iiUow  n 

nts  slioulil 
iiiiiJDrily  uf 
as  liuU'  11^ 
11  but  kiiitl 

1',.     |'(ill<l\Vi'll 

It   is  much 
I'  many  in- 

1111(1  bodily 
K'  most  <lis- 
;  whii'h  ft'l- 
liTim-ly  ini- 
])ervisiiiii  in 
jr  till'  attack 

I  till'  clothes 
posture.     As 

is  necessary, 
Vs  ot  chloro- 

II  oi  morphia 

I  in  eijilopsy. 
'd  hours,  and 
;houl(l  not  l>e 
al  food  seems 
ueuded.     The 

di.u'esliou. 
Iiave  a  special 

II  salt  may  lie 
■Iter  b(U'ne  I'or 
I'ly  tasted.     In 
t  is  well  taken 
dult  should  be 
n  rocoiiinicnds, 
ix  hours  before 
so  of  nocturnal 
>  ovcuin.ii'  meal. 
uld  take  a  full 
iiest  <iiven  after 
line   how   mucb 
aries  and  some 

take  the  drui,^ 
Saturation  i^^ 
wsiness,  uiental 
ex  is  one  of  Ibe 
:if  the  bromides, 
iplcasant  feature 


is  the  develo|'n""t  of  acne,  wliich.  Iiowever.  is  no  indication  of  bromiMii. 
Se}.niin  stales  that  the  teiKJeiicy  to  this  is  much  diminislied  by  ;:ivin,i:  the 
drujr  lar;iely  diluted  in  alkaline  waters  and  adminisleriu.u'  from  time  to  time 
fiilfdosrs  of  arsenic.  To  be  eilVctual  the  treatment  should  be  cmtinued 
for  a  pndonned  |ieriod  and  the  cases  should  be  incessantly  watched  in  order 
to  prevent  hromism.  The  niedieine  should  be  continued  for  at  lea.t  two 
years  after  ihe  cessation  of  the  iits;  indeed,  Se,i.Mnn  recommends  that  the 
reducti(m  of  the  bromides  should  not  be  be.L'un  until  the  patient  has  been 
three  years  witiiout  auv  manifestations.  Written  directiiUis  should  he  ^'iveii 
to  the  mother  or  to  tl'ie  friends  of  the  patient,  aiul  he  should  not  himself 
he  held  responsible  bir  the  administration  of  the  medicine.  A  book  should 
be  i-rovided  in  which  the  daily  number  of  attacks  and  the  amount  of  medi- 
cine taken  sluuild  he  noted.  The  addition  of  belladonna  to  the  bromide  is 
warmly  recommende.l  by  IMack,  of  (ilas<row.  In  yery  obstinate  cases  Flech- 
sitr  uses  opium,  ">  or  (i  grains,  in  three  doses  daily;  then  at  the  end  ot  six 
weeks  opium  is  stopped  and  the  bromides  in  larjj:e  amounts,  r,')  to  KIO  grains 
daily,  are  used  for  two  months. 

Among  other  remedies  wliich  have  been  recommended  as  eontrolling 
epilepsy  arc  chloral,  cannabis  indiea.  zinc,  nitronlycerin,  and  bora.v.  Nitro- 
glycerin is  sometimes  advantageous  in  petit  inaL  but  is  not  of  iiiueh  service 
in  the  major  form.  To  be  beneficial  it  must  be  given  in  full  doses,  from  •.' 
to  T)  minims  of  the  1-per-cent  s(diition.  and  increased  until  the  phy^iologu  a! 
elVeet-  are  jirodueed.  Counter-irritation  is  rarely  advisable.  When  tie' 
aura  is  very  definite  and  constant  in  its  onset,  as  from  the  hand  or  from  tie- 
toe  a  blister  ab<.iii  the  ].art  or  a  ligature  tiglitlv  applied  may  stop  the  rm- 
coiiiin-r  fit  In  children,  care  should  b.'  taken  that  there  is  no  .source  ol 
peripb'eral  irritation.  In  boys,  adherent  preimcc  may  occasionally  be  the 
,'aiise  Tlu'  irritation  of  teething,  the  presence  of  worms,  and  foreign  liodics 
in  tlu'  ears  or  nose  have  been  associated  with  epileptic  sei/.ures. 

The  -ii!>.iects  of  a  chronic  and,  in  most  eases,  a  hoiielessly  incurable 
di<ea-e  epilepti<'  patients  form  no  small  i-ortion  of  the  unfortunate  victinis 
of  charlatans  and  quacks,  who  prescribe  to-day,  as  in  tl,.'  tinu"  oi  the  father 
of  medicine,  -purifications  and  spells  and  other  illiberal  practices  ot  like 

'"".*^•»n/lVfl/.— In  Jacksonian  epiliT^y  the  propriety  of  surgical  interfer- 
ence is'uniyersallv  trranted.  It  is  (luestiouahle,  however,  whether  m  the 
,,pilcpsv  bdlowimi  hemiidegia.  considering  the  anatoniual  condition,  it  is 
likely  to  be  of  any  benefit.  Tn  idiopathic  epilei.sy.  when  the  fit  starts  in 
,,  ,.,,;,tai„  ,.,„rion— "the  thumb,  for  instance— and  the  signal  symptom  is  in- 
yiriable  the  centre  controlling  this  part  may  be  removed.  Thi<  procedure 
ha-^  been  practised  by  ^la.-ewen,  llorsloy,  Keen,  and  others,  but  time  a. me 
can  determine  its  value.     The  traumatic  epilepsy,  in  which  the  fit  follows 

fracture,  is  much  more  hopeful.  ,.        n-    ^ 

T!i(>  (M)cration,  prr  sr.  appears  in  some  cases  to  have  a  curative  elect. 
Thu«  of  :>()  cases  of  treiibinin<r  for  eiiilepsy  in  wliicli  notlung  abnormal  was 
found  to  account  lor  the  symptoms,  25  were  reported  as  cnred  and  18  as  im- 
proved The  operations  have  not  been  always  on  tlic  skull,  and  \\  hitc 
l,a«  collected  an  intercstin<,'  s.<ries  in  wbicb  various  surgical  procedures  have 


j^„^  DISKASKS   OK  TilK   NEUVOUS  SYSTEM. 

■  1  I-,.,  .,iv,.,.i    ^iicli  ii'^  li<'iititiii  111'  tlu'  ciiroliil 

';;:;;::.;:::;:;;:,:;;:r:::::::;:':^;.-;"; ;-- ;".»."^.. ■>,..,.„. 

inci»^i..n.iltlu-HMli..  ciicuiHcisioi,,  etc. 

Vll.     MIGRAINE   (Urmkmnin:  Sick  Ih.ulavh). 

Etiology.-Ti...  .11...-  ^  ^-'1-    >,■•;,,;'  ',H,u,..tu-  nuui- 

•''^^"•■'"^r 7 "ri";    Sh,  u..i..-.u.i..  ..„t,.ut.  (■.■.iai.,iy  ..>;■ 

OtlH.vs  n-anl  tlu'  ...seas.-  a>  a  t...\,  ....a  l..  ..  ,,^.,„i,.,,,„i,i  tv,....     i'.n.n- 

ton  iTtVrs  t..  (•ar..s  ..1  t...  \vvi\x  a    a  ca  .  ,,,,,,i,„a  i„  c....iuTti.>n 

of  this  natuiv,  a.ul  Ih.^  .'Nvs  an.l  "'.7':  ,,,,,  (l.nvcTs  states  tl.at 

!;;rr:v.:v  .:;:;;;!:.      .i;.a..a..lu-s.,r_t..<;n.i...in..ty,.n.ay  ........ 

yc.a.-s  in  e..n,u;ti...>  will,  .•l.n.iuc  Ur.-.it  s  .l.s..as.. 

,„tient  ran  tdl   wl...n  an  atta.  .   .s  c.Hn.njr     n.  "^^^  '\n,K,vili..ns 

,„^,,  ai.p..av-v,si...,s  ..1  u.un.als.  .ml.  a^  "      /       ■-  ^    ^^    ,     ,^.  -,,  .nasnuxlii. 
a.'ti.u,  ..!■  tlu.  ,.n,.il  o^^    ho  aiT..et...    ;"''  /^l'  ,^.   „,^.   .listurl.aneo  ..f 

virion  is  .n.ly  a  l.luvi..,.  ..v  '   ;■';';;  ;:^^;i'    -.^l-Uun.inat^  with 
,o-caM..l  f..vtitie.at,.m  s,....t,'a  <'^'  .^•'  '  '^^    '^       '^^         ,„,,     >^,unl.nc^ss  of 


MIUKAIXK. 


im;; 


li.i 


earn 


Iiciulaclic, 

oci-uricil 
itic  I'iuui- 
inaiiy  *li^- 
.1'  the  (l;s- 
;  sliimliiril 
l)iisi'<t.  A 
l\i\?  lallt'il 
loii^'  been 

Nutritivt' 

1111(1    otlll'l'S 

■tsi'mly   tlic 
is  ri'duccil. 
I  diiiesfuHi. 
1>('.     \\nn\- 
cvcn  when 
coinu'ction 
loniial  coii- 
■hildron  are 
Willi  great 
!  statejf  that 
I'a-e.    The 
111  emotion^- 
ijri'stive  (lis- 
iie  followed 
ost  striking 
.  every  I'ort- 
i_v  recur  for 

ses,  and  the 

lirodroiiiata 

Ajiparitions 

iisient  lu'iiii- 

is  s|nisiiiodie 

iitracts  alter- 

stiirlianoe  of 

lines,  or  the 

uinated  with 

■Nuinhness  of 

vith  tingling. 


^lore  rarely  there  are  erami..-  or  ,»iM>in>  in  Hi.'  niii>.lrs  of  liie  alleeted  side. 
Transient  "ajihasia  has  also  lieeii  iiotrd.     Some  patunls  show  marked  psy- 
ciiieal  distnri.anee,  either  cxeitem.'nt  or,  more  commonly,  mental  confiiM(.n 
,,r  great  (lei)re>sion.     Dizziness  occurs  in  some  cases.     The  headache  follows 
a  short  time  after  the  iirodn.nial  symi>toms  have  apiuaicd.     it  is  cumulative 
;nid  expansile  in  ciiaracter.   hi'ginning  as  a  locaiiz.d  small  spot,  which  is 
^^cneraliy  coiotaiit  either  7m  tiu'  temi-le  or  forehead  or  in  the  .ycliall.     It 
Ts  iisualiy  de.-crilK'd  as  of  a  penetrating,  sliar|>.  iioring  character.     .\t   lirsl 
nnilaleral,  it  uiaduallv  spreads  and  in\(dvcs  the  side  of  the  head,  sometimes 
the  neck,  and  the  jiains  may  pa.s  into  the  arm.     Jn  other  cases  both  sides 
are  alVected.     Nausea  and  vomiting  are  common  symiitoiiis.     if  the  atta<k 
cujnes  on  when  the  stomach  is  full,  v.uuiting  usually  gives  relief.     \  aso- 
iiiotor  symptoms  mav  he  present.    The  face,  for  instance,  may  he  pale,  and 
there  may  he  a  marked  dilVerence  hetween  th.'  two  sides.     Suhseciueiitiy  the 
I'aee  nnd'ear  on  the  alVected  side  may  I.ecome  a  himiing  red  from  the  va-o- 
■jilat,,;.  inlUicnces.     The  pulse  may  h.'  slow.     The  t.inporal  artery  on  the 
alVected  side  mav  he  linn  and  hard,  and  in  a  condition  of  arteno-scleroMs— 
a  fact  which  ha"s  hceii  coiilirined  anatomically  hy  Thoma.     Few  alVectioiis 
are  more  prostrating  than  migraine.  an<l  during  the  paroxysm  the  patient 
may  scarcely  he  ahle  to  raise  the  heatl  from  the  pillow.     'l"he  .lightest  noiso 
or  light  aggravates  the  condition. 

Tiie  duration  of  the  entire  attack  is  variable.  The  severer  lorins  usually 
inrajiacilate  the  person  for  at  least  three  days.  In  other  instances  the  en- 
tire attack  is  over  in  a  day.  The  di.-ease  recurs  for  years,  and  in  cases  with 
a  marked  hereditary  temlency  may  persist  throughout  litV.  In  womeiMlie 
attacks  often  cca>e'aft.'r  the  climaterie,  aiul  in  men  aft.'r  the  age  ol  iitty. 
Two  of  the  greatest  sulVerers  1  have  known,  who  had  recurring  attacks 
every  few  weeks  from  early  boylKM.d.  now  have  comi.lete  freedom. 

The  nature  of  the  disease  is  unknown.  I.iveing's  view,  that  it  is  a 
nerve  .<torm  or  form  of  periodic  di>eliarge  fnuii  certain  sensory  centres  and 
is  related  to  epilepsy,  has  found  much  hivor.  Ace<u'<liiig  to  this  view,  il 
is  the  sensory  wpiivalent  of  a  true  epil.'ptic  attack.  Molhm.lorf.  Latham, 
and  others  regard  it  as  a  vaso-uiotor  neurosis,  and  hold  that  the  early  symp- 
toms are  due  to  vaso-eonstrietor  and  the  later  symptoms  to  vaso-dilator 
inllnences.  The  fact  of  (he  development  of  arterio-sclerosis  in  the  arteries 
of  the  alVected  side  is  a  point  of  interest  hearing  up(.n  this  view. 

Treatment.— The  patient  is  fully  aware  of  the  causes  which  precipi- 
tate an  attack.  Av<.idance  of  excitement,  regularity  in  the  meals,  and 
moderation  in  di.'t  are  important  rules.  1  have  known  cases  greatly  bene- 
fitted hy  a  strict  ve-etahle  diet.  The  treatment  should  be  direch-d  toward 
the  removal  of  the  conditions  upon  which  the  attacks  depend.  In  children 
much  may  be  done  hv  watchfulness  and  care  on  the  part  of  the  mother  in 
re-ulatinu'  the  bowels  and  wat.'hing  the  diet  of  the  child.  Kri^u's  ol  re- 
fraction sh.nihl  be  adjusted.  On  no  account  should  such  children  be  all<)wed 
to  coniiiete  in  scluud  for  prizes.  A  prolonged  course  n\'  bromides  sometimes 
]. roves  successful,  if  anaMuia  is  present,  iron  and  arsenic  slionld  be  given. 
^Vllell  the  arterial  tension  is  increased  a  eonrse  of  nitroglycerin  may  bo 
ivH'i].    Not  too  much,  however.  ^Iiniild  be  expected  of  the  preventive  treat- 


nt'4- 


.ASKS  (.F   TIIK   NKUVOrS  SYSTKM 

1V^^(.(I  that  in 


I)1S!:asi> 


,  v.rv  lar^'..  pr(.p'i''ti.>n  of 


,1,,.  .„s.s  111-  iHM.Il"-!""'  "■<■■"  "'  ''     „     (  ll„.  lULrk,  I"  »"-l'  '•"'  ""■  "'",' 


() 
\- 
II' 

H' 


■(111;!  colVcc  or  '. 
Ulllv  till'  iiiist  s\tis- 
s(.   (.1'   tlu-   <lru,ir. 
s(d  of  lilt''.    "^Vhcii 
iciiiiics  ctlVclivc. 
and  iinlil'vnn  luv 


.,ti.nt  U.U  faint  and  --  f^  ^^  „      ,  ,,,1.,,  is  pol.al.h 

faituiy   ituum1>.     ^^n""^    '  i,„n.uctin  have  hccn  mndi  used 

A„,i,,vrin,  antnVl.rn..  '">''/  "''."...^vsnu  tlu'V  a.v  son 

.iv...  .a.ly,  at  tl.c  very  <;"^-\  ^  j    „       ,,,1  „,■  antHVl-rin  a, 

Tlu.  .loses  whi.'h  have  l-een  nron.nun  j,,,,;,,,,  ,n,,,leasant  (•^lla|.^.■ 

.,   dangerous,  an.l  1  W.s.  se...  >n  a      >.        -  .  ^^  ^^^^_     1  ^.^,_^^  ,^„,  ,,,,„ 

,n,,,on.s  follow  a  .:.-^nun  'i-;"    '"^^      ,  .loses  are  n.ore  satisfactory. 

<:.>  !'-•  "-^  -spons.ln hty.     ^-'  '    ;,,  ;'X,,  ..f  „u.  eitrate.  nnx  vonu-a 

(,f  .,,her  remedies,  .alleine.  n>  j   !-''". ..jj,  ,,ues  not  appear  to  l-e  ol 

„„,  „,,.,t   l.ave  l.een  reeununended.     Idutn      . 

nnieh  service. 

Vlll.    NEURALGIA. 

-"^oio.y.-Mend,ers  of  --;;;!-' ^-^tsc  ::'r::::^iz:^^. 

disease.     It  atVects  women  ">"'%»'.'  ,^-  ^  j,  „,•„,„  the  iirst  indi.at.on 

Of  all  causes,  del.ility  .  the  most  1|        '      ;  JJ^   ,,,.„,  .,,  ,,,„,.  ..o   In- 

„f  an  oufeehled   nervous  s>>t.     .      1  »  ,,„,inent  feature  at    he 

„Uy  assoeiatcl  -th  neural,    ..t-;^  J.  ^  ,.^.^,^,,.      ,,,,„,i     j,  ,„. 

,;„,et  of  certain  acute  'l-'--;  '^j^' ,  ^  ot  1.  en  shown  that  ueural,,a  ,s 
VH.v.-d  to  he  a  potent  cause.       t    t      ^  ^^^^^    ^^^^^^^^,^,^,  ^^^.^^.,^  ,  .„„ 

"'""'  f'-l"^'"^  '"  ".^'^"'"  ,  In  f  tati..n  of  i>alndisn,.  It  occas.on- 
rejrardin,  periodicity  as  a  sp-;^l  ^^^;l  ^^,  ^J,,  ,  .,„..  in  very  sus- 
,1U.  occurs  in  inalarial  cn.'hex  a        'M^^^   '^  ,.^„.,„„  teeth,  may 

^,^,,,i,,,  persons.  Kc'tlex  irritation,  P^  '^  ^  ^,.^.,„.,  ,,„„ti,nes  in  rheu- 
i„!l.u.o  neuralgia  of  the  l.tth  nen..  -^^'>j\,,,i,,,,,  ..ural.ia  may  he 

tnatism.  s,'out,  lead  poison.nj.,  and  diahete.. 

.,  feature  of  latent  r.riL'lit  s  disease.  ,^^,  ^,,^,,,,^  .  ,,,„. 

•'  'symptomS.-lU.fore  the  <.nset  '/;.;;,  iv'^cd.  The  paiu 
,,ul.  ^.letinies  tiu.lin,  ,n  ^^^  V  .,  '  \,:  ,,  ,„„ally  alVctin,  one 
is  localized  to  a  certain  ^^'•^''V  Im  r  x v  uial.  and  is  desc-ihed  as  stah- 
side.  The  pain  is  '-^.-^r^^'t  l^  Th  skin  may  he  exquisitely  ten- 
binj:,  l.urnin.L'.  or  <lavt.nfz  m  ^;1.^"^"    IJ"  ^,,,,,^,5,,  .,„i„ts  alon-  the  course 

a.r  in  the  alfecte.l  re^i.m.  P^^''t'<'''l'"\>  ;^;'\V;,; ,,,,  ts,  as  a  rule,  arc  paiu- 
;;  the  .ervo,  the  so-called  ]<^-'-^ ^;^l^ZZ^l^^^  the  paroxysm;  the 
fnl.     Trophic  and  vnso-nu.  or  ^^''^'^'\^  ^J^^,;^,  occasionally  local 

skin  ma;  he  cool,  and  ^^-^^;^X^^  '  ^^  -'  ^^>"  ^•^^""^^'^  '\T 
,a.nia  or  erythema  occurs.    ^I<'^  '    ";^  _|^'    ,,,,,,,  foil  out.    Fortunately, 


hair,  which  may  hecom 


rM„j:;r,«;s;«^;:^";-»- •^--*'^- 


NKITUALOIA. 


11(15 


idvist'S.  so 

tllC   Stl'lll- 

■t.     II'  tlti' 


illcc  or 


•'() 


iiiisl  satis- 

tlu'  ill",!-'- 
itc.  WllfM 
■s  ctVcctivc. 
tiiiyrin  arc 

lilt   CoUillist' 

liiiil  tiik'U 
;iitisl'iictory. 
lUX  voiuicii. 
,;,!•  lo   lie  of 


0  functionil 
viti^^  in  tlK'iv 

il.jcct  tn  the 
c'ly  attiU'kcil. 
rst  indiciition 
•inii>  aro  I'rc- 
ciiturc  at  the 
yliilaria  is  Ik- 
(   iicural;lia  is 
y  arist'ii  I'roin 
It  occasion- 
:(.  in  very  sus- 
iis  teeth,  may 
times  in  rlieu- 
iraljzia  may  he 

lie  \ineasy  sen- 
:(.,!.  Tin'  liaiii 
V  alTeetinjr  one 
^(■viheil  as  stah- 
exiinisitely  ten- 
Ion^  the  course 

rule,  arc  iiain- 
!  paToxypm:  the 
•oasionally  local 

changes  in  tlu^ 
it.    Fortunately, 


Midi  alterations  are   rare.     'r\vitciiiiit:s  of   tiie  nuiscies,  or  even   spasnis, 
may  i>e  present  dnriii-  tile  paro\y>n..    After  laHtin<;  a  variahle  lime— from 
a   iVw   iniiuit.s  to  many   hoiii>-     tiie  attack  sui)si(les.     Ifccnrrence  may  lie 
ill  (Iclinile  intervals-- every  day  al   the  sanu-  hour,  or  at   inti'rvals  nf  two. 
liiree.  or  even  seven  days.  "  Oceasioiiaiiy  tiu'  paroxysms  develoi.  ciily  at  the 
eatanienia.     'I'liis  periodieity  is  ipiite  as  marked  in  non-malarial  as  m  ma- 
larial i'ej;ions,  «.    i    1  '/■  • 
Clinical  Varieties,  depending  on  the  Nerve  Groups  affected.— (1)  I  n- 
fdddl    Sniiuthjiu:    'I'ir    DdiihiKrctix :    I'l-osapalfiia. — All    the    hranches   are 
nirelv  involved  toj;etiier.     The  (.phlhalnuc  is  most  often  alVecte<l,  iuit  in 
.severe  attacks  tiu'  jiains,  though  more  intense  in  om'  division,  radiate  over 
the  otiier  hraiu'hcs.     At  the  outset  there  may  l>e  iiypera'sthesia  of  tiie  skin 
and  .sensitiveness  of  tiie  mucous  incmhrane.    Pressure  is  painful  at  the  points 
of  cmcrp'nce  of  ihe  nerve  trnids.  and  where  the  iHM'ves  enter  the  inuseles. 
Sonietimi's  in   addition,  as  Trousseau   pointed  out,  there  are  pains  at   llie 
occipital  protnlierance  and  in  the  njiper  cervical  spines.     When  the  o|ih- 
thalnnc  division  is  aiVccted  the  eye  may  weep  and  the  coiijunetiva'  are  in- 
jected and  painful.     In  the  upjier  maxillary  division  there  is  a  tender  point 
where   the   nerve  leaves  the   infraorhital   canal,  ami   the    pain   is  s|)e.ially 
marked  alonji  the  nj.per  teeth,      in  the  lower  hraiU'hcs,  which  are  more 
freipieiitly  involved,  there  are  painlul  points  along  the  anriciilo-tempnnil 
nerve  and  the  pain  radiates  in  the  region  of  the  ear  along  the  lower  jaw 
and  teeth.     The  movements  of  mastication  and  speaking  may  ho  painful. 
Salivation  is  not  uncommon.     Herpes  may  occur  al)out  the  eye  or  the  lips. 
In  protracted  cases  there  may  he  atrophy  or  induration  of  the  skin.     Some 
of  the  forms  of  hicial  neuralgia  are  ni  frightful  intensity  and  the  recnrring 
attacks  render  the  patient's  life  almost,  insupjiortahle. 

(v!)  Cenun-ocnpiUd  iicunihjin  involves  the  posterior  liranches  ol  the 
llrst  four  cervical  nerves,  particularly  the  inferhu-  occipital,  at  the  emer- 
.rence  of  which  there  is  a  iminful  iioint  ahout  half-way  between  the  mastoid 
pniccss  and  the  first  cervical  vertehra.  It  may  he  caused  hy  cold,  and  these 
nerves  are  often  aU'ectcd  in  cervical  caries. 

(;i)  Ccrrirn-hrarliial  iioirnliiin  invcdves  the  sensory  nerves  of  the  hraciual 
plexus  i>articnlarlv  in  the  cuhital  divisi.m.  When  the  circumilex  nerve  is 
involved  tlie  pain  is  in  the  deltoid.  The  pain  is  most  commonly  ahout  the 
siKHilder  and  down  the  course  of  the  ulnar  nerve.  There  is  usually  a 
marked  tender  point  upon  this  nerve  at  the  elhow.  This  form  rarely  lol- 
lows  cold,  hut   more   freipieiitly   results   from   rheumatic  allectums  oi   the 

joints,  and  trauma.  .  ^        i   ■ 

'  (1)  Xcunihiia  of  llir  phnuir  iirrrr  is  rare.  It  is  sometimes  found  m 
pleurisy  and  in  pericarditis.  The  iiain  is  chiefly  at  the  lower  part  of  the 
thorax"  on  a  line  with  the  inscrti<.n  of  the  diaphragm,  and  here  may  he 
].ainful  i.oints  on  deep  jiressure.  TmiH  insjuration  is  iiamtul.  and  there  is 
great  sensitiveness  on  coughing  or  in  the  performance  of  any  movement  by 
which  the  diaphragm  is  suddenly  de|n-esscd.  ,  .    .     ,,  i. 

(,-.)  hdcroxta]  NcHrahiiii.—^vx[  to  the  l!r  dnuhnnux  this  is  the  inost 
inuK.rtant  form.    It  is  most  frequent  in  w.Hiien  and  very  common  in  hys- 
teria and  anannia.    The  pain  in  caries  and  aneurism  is  felt  in  the  uitcrcost;U 
19 


inSKASKH  or  T,M-.  N-KUVOrS  SVSTKM. 
?".,„.  uJallv  nlon,  jl'V"-"-; ',;..,  lw,..,n  of  n,.v,vnstal  .u;un.^ 

i;!:';;;;:^;;r\;:t-J.:;;.s.>'-^^^  " 

"'■■';';;ir:::;-.v '.':•--;  :ir;;t;;::;:r;:;;n:i:-''''n:^ 

-'•-'' r;i::::;;;;;,::;;'r;;;;:;:^:v.l... ■■^-■' '^" - 

Uorvintn..lal.l..nndn.,ym.^..^aU    h^^^^  ^^  ^_^,^_,^.^,^  ..^  „,,  ,,no. 

lion  "linwrvor.  xvlucl.   is  not   ^^''>^J 

*      .    .  ,,  //,,w.-r.otl>  .n  Nvonu.n      "         '^  n^j    _u,o  ,.o.lu,lynia  ..    S. 

--r  ^•-'vi^i'niiiit'ur^irr::':!:;...  --  <-.......,  an.,  no 

;j,,i„,ssin(l»-l"i'f.  ,  ,,  ,'  1  ■■irundil  ill''""""  "' ""'  '"", 

'"     „.,„,„„./,|-— 11"*.'"'    ."'"."':    ■    „,       ,  nna  v,,v  ,v,vi,„  ,li».>v.ln', 

„„„„,„,„.|,iui,M,,...i »ri""'»""" ,:';,,,  i,, ""••  f-t-  ^1'""'" '■;*"■' 

:r;\x:r;aJ--""i;:i;:;:;:::;;;:r:MK,.^^^ 
■-r;::;;ii  ^  s:;;™u  J':,i;.  x.,,..*i»  i.  or -" *■ 

Tocfion,  pa  1  111  II  1.1 1 1,> 


^a^ 


^"^U 


.V% 


% 


w 


v<:":^>%^o^ 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


1.0 


I.I 


1.25 


'-  ilM 

■  5  0     =^ 


lii 

iL. 

a. 

I:. 


IIIIIM 
IM 


IlM 

2.2 

14    11.6 


Photographic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  NY.  14580 

(716)  872-4503 


# 


:1>^ 


,-\ 


<!^ 


A 


\ 


\ 


V 


# 


6^ 


ri> 


'<% 


w 


^^^ 


k<9 


\S0 


CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


iV 


-     *■ 


I'KOFKSSIONAL   SPASMS:   OfCri'ATlOX    NIU'ROSHS. 


lliN 


flR  Ims  iilrciiily  lu'cii   inciitiniicd.  the  syiii|itonis  iiiiiv  ( lo.-rlv  .-iimiliitc  tlin>,' 
of  stoiic 

Treatment. — ('aii.-cs  nl'  rdlcx  ii'i'ilnlidii  >iiiiuli|  lir  cnrffully  iviiiiivcil. 
'.riic  n('iii';ilL:i;u  as  a  nilc  iciiirs  imlos  llic  .Licnii'al  liralih  iiii|nn\i'>;  mp  ihal 
tiuiii'  and  livuiniic  t!ica>m'('s  tif  all  xirts  slmuld  lie  ciiiiiIuumL  ()rii'ii  a 
cliaii.izc  III'  air  nv  >[iUn\\\\i\\\\'j:>  will  rdirvr  a  mvci'c  mairaliiia.  I  lia\(! 
kiiiiwii  (ilistiiiatc  i-ast's  Id  lie  cnrcil  liv  a  |iriil(iii;:('il  ii^iilciicc  in  tlic  ninnn- 
tains.  with  an  (Hit-ol'-ilddr  life  and  plenty  (if  cxcicisc.  A  strict  vc^rlalili' 
diet  will  sdnii'tiincs  relieve  the  nenraluia  or  headaclie  of  a  ,L;nnty  person.  Of 
"■eiieral  I'enicilies,  irdii  is  dl'len  a  speeilie  in  the  eases  assdciated  wilh  ehldi'o 
sis  and  ana'niia.  Avsi'iiie,  tdd.  is^^Ncry  henelieiai  in  these  I'drnis.  and  shdnid 
lie  uiven  in  aseendini;'  duses.  'I'lie  \alne  nf  (piinine  has  lieen  mneh  dvcr- 
lated.  It  pi'dlialily  has  iid  mure  inllnenee  than  any  dther  liiltei'  Idiiie.  ex- 
cept in  the  rare  instance-^  in  which  the  neuralgia  is  (h  linitely  associated  with 
mahirial  pdisdiiinu'.  Strychnine,  cdd-livcr  dil,  and  phosplidrns  are  also  ad- 
van  taii'cous.  or  renieilies  for  the  pain,  the  new  anid,uesics  shonld  lii'st  he 
tried — aiitipiyrin,  antil'ehrin,  and  |ihenaeetin — lor  they  are  sdnielinies  df 
service.  Moi'phia  shonlil  he  uiven  witii  ^rcat  cantidii,  and  oidy  alter  other 
remedies  lia\'e  lieen  ti'ied  in  \ain.  On  no  coiisideralion  slnadd  the  patient, 
he  allowe(|  to  nse  the  liypodemnc  syrin.m'.  (ielseniiuni  i>  highly  reeoni- 
niendcd.  Of  luTvine  sliniuiants.  valerian  and  ether,  which  often  act  well 
toizcthcr.  mav  he  uiven.  Alcohol  is  a  valnahle  thoujxh  daiiii'erous  remedy, 
aiitl  shonld  not  he  oi'dcrcd  I'oi'  women,  in  tlie  trifacial  ncuralj:ia  nitro- 
i;ivi-erin  in  hw^v  doses  may  he  trieij.  Aconilia  in  doses  of  from  one  two- 
luindredth  to  one  ont'-hundied-and-liftieth  of  a  .urain  may  he  tried.  In 
ji'iinty  and  rhenmatie  snhjei-ts  cannahis  indica  and  cimicifn;.;a  :ire  recom- 
mended with  the  lithium  salts. 

Of  local  applications,  the  ihcrmo-eautery  is  invaliiahle.  paiiicnlarly  in 
zona  and  the  more  clironic  forms  of  neural,t:ia.  Acnpnnctnre  may  lie  used, 
or  a(|uapuncture,  liie  inji'ctidn  of  distilin!  water  lieiieath  the  -kin.  Chloni- 
form  liidment,  campiior  and  chloral,  menthol,  the  oleates  of  morphia,  atro- 
]iia.  and  hclladonna  used  with  hnidlin  may  he  tried,  l-'ree/.in;;-  dver  the 
tender  pdint  with  ctiier  spray  is  sometimes  successful.  'I'lie  continuous 
current  may  he  m^^v^I.  The  spon.iii's  should  he  warm,  and  the  po>itive  jiole 
sluiuld  he  placed  near  the  seat  of  the  pain.  The  stren,i:th  of  the  current 
should  he  such  as  to  cause  a  sli<-iit  tin.iilin,;,'  or  liurnin<r.  hut  not  pain. 

The  suruical  treat nu'ut  of  iiitractahle  neural.ii'ia  emhraces  nervo  strotch- 
ino-  and  excision.  The  latter  is  tiie  inoro  sitisi'aetory,  hut  too  ol'tcMi  the 
pain  returns. 


IX.    PROFESSIONAL  SPASMS;    OCCUPATION   NEUROSES. 

The  cdutiMuous  and  excessive  use  df  the  muscles  in  iierformin,!;  a  cer- 
tain movement  may  lie  followed  hy  an  irr(\irular,  involuntary  spasm  oi' 
cramji.  which  may  completely  chei'k  the  pcrforniance  of  the  actimi.  The 
comlition  is  found  most  frecpiently  in  writers,  hence  the  term  writer's  cramn 
or  scrivener's  palsy:  hut  it  is  also  I'omnion  in  piano  and  vinlii,  players  and 


51 


( 


.J. 
1: 


■■i 


ti     ■! 

k 


DISEASKS  OF  TllK  NHUVOIS  SYSTEM. 


nos 

,„  ,„,,  ,,,,,,1,  „|,,.r.„o,.     Tl,,.  s,«,s„.  ,.,....■  in  ,n.,..v  ..,I..T  V' -  -1'  ^' 

^rt.;;'::™:".:"';:';;;:;:':':: ,„ .... .  ,„.,.. 

,,„(.iit  ill  iiHU  tliiiii  in  woiHcii.     Ol' 


iiKirc    h't'- 
-,  cases  oi  iiui.ain.Ml  wntinji'  IH'Wct  re- 

UHii.      Morns  .".    i^i«'^     ''"^  ,     ,         tcU'"ni|>iv,  iirc   much 

.•ran,,.,  wmu.n,  wlu,  are  nuph^v.l  a  ,u  .        ,       n         .         .         ^^^^^^^^^^ 

tciiipcraiumt  arc  iiuuv  lial'li'  I"  ii"   <n.<a... 

arc  rarely  alUrtcd.  „  ^   vcasnnaltU'  ox- 

K„  .-I"".."  <■"».;';  ;;-,'■:,•:!,,,, ' ';i,„,,„,..a  ...i.,,  ..<  ,1,,. 

!,„  „H.  lin..s  .W  rcsistanc.0  between  'l'-'-  f'  '  j'    ^l  Ueeu.e.l  ahnos, 

„„,,,,„„ ,„ ,i,i. ™'»-'.'";7;;:;; ;' : :  t     1 1     -"*"' '-'«'-  --«"• 

::::^:;r;::',r7:';;,-;^:;::J;:":- .--. - 

'Plu.  patient   feels  a  sense  ol  -■=''^7-.    ■'';''      •;,,,,,  ,i,vu.nstan<.es  the 

'''';,.^  7',r».u.-Tl.is  is  n,ost  eonunonly  seen  in  the  forelin..^  an-l  n,ay 
,,.:;..e,;:;;;:;;,rvsv;n,.ton.  of  atrophy.  U  .  not  an  in.po>tant  sympton.. 
ami  is  rarely  sullleient  to  pr.Hlnee.l.sal..lity  ^^  , 

,n    /W„.-Al>nnr.nal   sensat.ons,   1-  -    ^    ;  /        ,  I;:;',!;,,,  ,„ay 
„n,sclcs.  are  very  constantly  rivsc.nl.     "^V^         ;     J  ,,.  ^,„.„„^.,,  ,,,,,  ,,;.,. 

'„;.;  the  ncrvos  ami  i.umbi,«s  ...'  lins-'l"'!-'  '•'  ""'  ""S"-"'- 


am 


i«« 


THT.VNV. 


11  Oil 


mis,  sm-h  n-^ 

h  nion'  Iri'- 
lo-  |ii>\v('r  rc- 
unp  wuu.:  ill 

U'U'jinil'l'^'''  '^ 
y,  lire  uiucli 
if  r,  ncv\<>>i> 
ullows  sli,uiit 

m1  of  wvitiiifi; 

as  lln'  li^<'^ 

om  llu'  L'Uiow 

I'iisnimltU'  fx- 
iicli'in  <>l'  tlif 
,■(1  in  tlu'  iul 
kncss.     "Tl.r 

(lUuT  fur  tlu' 
led  !)>•  It'ssni- 
nt.  wliicli  WHS 
cc'iitcd  aliiiiist 

tllis  U';:S('l\i'(l 
iilar  dischiirjit' 
tvrnient.  Ac- 
iiniiainiK'nt  of 
faradie  cxcita- 
i.'vvi's"'  (Gay). 
Lewis). 

iind  most  com- 
imliincd  iiiovo- 
iiuiy  Ih'  twisted 
1  has  di'scriliftl 
ictc'd   uiMin  the 

pi'.sin  or  alone, 
imist'los  of  tlu' 
ciuiistaiiccs  tlio 
sis  for  ordinary 

(inircr  and  may 
irlant  symiitom. 

feolin-x  in  tlu' 
.  Imt  tlioro  may 
eiu'ss  may  esi^^t. 
me  may  be  paiu 


((')  Viisn-woliir  Distiirhaiirrn. — 'I'lu'St'  may  occur  in  severe  eases.  Then' 
may  lie  liy|iei'a'stliesia.  Occasionally  the  .-kin  hccomes  ;;hi>sv,  or  there  i> 
a  condilioii  of  local  aspliyxia  n'sciaMin.i:  cliiliilains.  In  atte!ii|itin^'  to 
write,  the  hand  and  arm  may  hecoiiie  llii-hed  and  hot  and  the  veins  iii- 
crea.<ed  in  si/,e.  i'laiiy  in  the  disease  the  electrical  reactions  are  normal,  hin 
in  advanced  ca>es  there  may  hi'  diminution  of  faradie  and  sometimes  in- 
crease in  ihe  ^alvaiiic  ii'ritahility. 

Diagnosis. —  .\    well-marked    case   of   writer's   eram|i    or   palsy   conld 
scarcely  he  mistaken   for  any  other  airectioii.     Care  must    he  taken  to  e\- 
liide  the  existence  of  any  cereliro-s|)iiial  diM'ase,  .-iicli  as  proj;res>i\e  mn-- 

cular  atrophy   or  hemi|ile,i,da.     The   jiliysician    is  s elimes   consiilteil    hy 

nervous  persons  who  fancy  they  are  l)ecomin<r  snhjcct  to  the  disease  ami 
complain  oii  .-lilfness  or  weakness  witlnmt  di^playin^^  anv  eharaeterislic 
features. 

Prognosis.  -The  course  (d'  the  disease  is  usually  chronic.  If  taken 
in  time  and  if  the  hand  is  allowed  perfect  rest,  the  condition  may  im- 
prove rapidly,  Imt  too  id'teii  there  is  a  slroun'  tendency  to  recurrence.  The 
jiatient  may  learn  to  wi'ite  with  the  left  hand,  hut  this  also  may  after  a 
time  he  attacked. 

Treatment. — \'arious  |iropliylactic  measures  have  heen  advised.  .\s 
mentioned,  it  is  impm'tant  that  a  proper  method  of  writin;^-  he  adopted. 
(Jowers  su-Tirests  that  if  all  persons  wrote  from  the  shoulder  writer's  cramp 
would  practically  not  occur.  \'ai'ioiis  devices  have  hccii  invented  for  re- 
lieviiie;  the  fatigue,  hut  none  of  them  are  very  satisfactory.  The  nse  of  the 
tyjie-writer  has  diminished  vt'ry  much  the  freipiency  of  scrivener's  palsv. 
h'est  is  ess-'iitial.  Xo  measures  are  id'  value  without  this.  Massa^'e  and 
maiii|mlation.  when  comhined  with  systematic  fivninasties,  <>ive  the  hcsl 
I'esidts.  I'oore  recommends  the  izalvanie  current  applied  to  the  muscles, 
whicJi  are  at  the  same  time  rhythmically  exercised.  In  very  olistinate  cases 
the  condition  I'cmains  inciirahle.  1  saw  a  U'W  years  ago  a  distinjrnishcd 
fiyna'colonist  who  had  had  writer's  cramp  twenty  years  bef.ire,  and  who  had 
all  sorts  of  treatment,  inchidiiifi'  the  Wollf's  method,  without  any  avail, 
lie  still  has  it  in  a.i;jj:ravated  form,  hut  he  can  do  all  the  finer  manipiilati(uis 
id'  operative  work  without  any  ditlienlly. 

The  nutrition  of  the  patients  is  ajit  to  he  much  imjiaired,  and  cod-liver 
oil,  strychnia,  and  other  tonics  will  lie  lound  advauta.yeoiis.  Local  appli- 
cations are  of  litlie  henefit.  Tenotomy  and  nerve-stretching  have  heen 
ahandoned. 

X.    TETANY. 

Definition. — An  affect  ion  characterized  l)y  peculiar  bilateral  tonic 
spasms,  either  ])aro\ysmal  or  continued,  of  the  extremities. 

Etiology. — The  diseas(>  oeenrs  nndor  very  dill'crent  conditions,  of 
which  the  following  may  be  recognized: 

(n)  Epidemic  tetany,  also  known  as  rhenmatie  tetany.  Tn  certain 
imrts  of  the  continent  of  Knrope  the  disease  has  ])revailed  widely,  ])artieii- 
larly  in  the  winter  season.     Von  Jaksch,  who  has  described  an  epidemic 


1  ! 


': 


i  i 

'  "i 


i  : 

ill 


■  i  ! 


'f    ! 


.:   IS 


B 


IIIU 


I.ISEASKS  OF  THH   NERVOUS  SYSTEM. 


oiiictinics  Willi  ^hulii 
xA'wvz  only 


;::™;r;:;;;:^;;;.^;~-r;ir'^s^ 


1,.-   women  'rnui-M'ji'.i   en 


(/))    A    lUilJlH' 

Idwiiiij;  lartiitio 

From   its  (H'ciinvmc  in   mirsin<i 

;;;;r;;:,,,r;ri,:';:;;r;;::;;iv;::s.,!;;r::n:' - ^ 


recur   ill   siieeL--ive 


'-'•"■  '>'■"■• '•''''^";''.^;':' jrJn,;:.';,;;:;:;' .1 ■nn-,;„  .■: 


ises. 


((■)  Tetiiiiv  may 
f,.rexiimi.l.',  inllt'wed  :s<>iHTatmii 
iinil  <i  oL'  them  iirnveil   lam' 


.  ,m  eiilMP'e.l  thvn.i.l  in  r.illmtli  s  elniie. 

laiu.'s  Sleaart   has  irp'"''''!  ■'"  ''nslauee  in 

ivx(e(Uiiia.  ami  no  trace 


;    -ch  with  the  tetany  ^^^^■^^■^^^Y'T     U  ;n  ^^^^^^  •''-- 

,,/,  AmUastly.  . here  w  a    nrmo.yY,.  ,,.,,„  ,,^^^^^^^ 
„„.,„  .,,•  ,|u.  stomach.  ,.artieularl>  alte,  '''^      •"  '    ''           ^,i,,,^,^.,_     ,i,inith 
....    .1,;.  ..„ntinent    true  tetany   i>  an   extieimly    mm  


On   tins  coiitiiieiit    trm 
<  ..olleetcd  T-i  «-a>r>.  "1""".-  ^^''''■''-  • 


,„wever.  eases  of  carpo-iuMlal  spaMU 


na^  < 


'''■'v;c';;::t,.  ,,r  ,1,,.  .ii.n..  i.  ""^""«"--i-" '""" 


(li'peiu!  umlouht- 


:''^';,.:':';::,r'i,:^,n;i,:;:i':u„.;'^.i.n-«.™„. .u,.. ...... 


,.ver  the  chest.     In  ih*' 


due 
iuit 
(Ira 
ato 


rinecnes,.     .......    .  ,.,„nmonlv  involved. 

"■'••     '"-  •""^'■'r  "'   ^'•^'r    ,i    1      nVtheanolesorthemoutliaiv 

;,,,,,  ,,   ,  „,„.  „„v  ,„ss  olV  in  a  lew  hours.     In  some   ')  tin  - 


1„  ..luhlreii  the  attack  may  pi 


"  '-"l""''"  '".        ,  .       lTne<s  and  contract. iro  may  .■oiitinue  or  ev.n 

,l,r„nie  ease,  iii  adults  tlu   ->'""•   ■'  ,      ,       (,,„  ,,.,,,,!,,.     1„ 

„,n.aso  lor  many  days,  and  the  atta.^k  '"  >  "        '"  J,„       ,,,  .,„i,u..ned. 

,,,  ,,,te  cases  the  temperature  '->•  '.»  eles,  t  <      h  _^^,  ^,^^, 

„.  ^,,,  severe  ,.aroxysms  there  may    ^  ';;  ;,^        '  * .     .X.     ("ertaiu  addi- 
1 1.  .„wl  „l'  the  thorax,  induem'i  <l\si)noM  aiui   (\aii 


tl 
Ii. 

hack  and  of  tlu'  thorax. 

li 


..i.»i  (■ '"-■  >-i'-i'i"  '\t'T'',:':-.;!'Hr'di  li  i-  -t .»...  n,.  ,«r... 


vsnis  mav   m 

'i„,r   the   alVect.'d    pa-ts.   .'itlu'r    m 


their   principal   nerve 
arterial 


reproiliu-ed   at    will.     'I'ln^   >^ 

,,,1    ,n"t<    cither   in    the   direction    o 

„„,  ,„„,,e  „t  U,..  r».-.,.l  ».•.■«.  »'l      '  "  „        1„,(  tl„.  .■U..-tri..,l  irntn- 


.vitli  >li,i;!it 
r-tinti'  luily 

rliiliiy  f'll- 
(if  virkcts. 
ursi'V  vn\- 

crs,  ami   in 

I'tci'ii  ciisrs, 
DtliV  rliuic, 
iiisli\iuc  in 
no  traci'  oT 
)\  tclany. 
,1  \vili>  ilitii- 
islicd  (int. 
....     (Iritlith 
IH'dal  siia>ni 

11(1  iindonUl- 

■  in  chilitivn 
0  finjicvs  aro 
uinal  joints, 
jialni  of  the 
IS  arc  folili'd 
the  toes  ai 
Illy  involved, 
ic  nioiitli  aro 
;('  and  (I'dvm- 
•avialdo  ti;uc. 
i>t  tlic  si'viTcr 
tinuo  ov  t'vt'ii 
vo  weeks.  In 
Iso  (iiuekened. 
iiuseles  of  tiie 
("criain  addi- 

cr,  the  i>aro\-- 
|ily  conipress- 
rinciiial  nerve 
ous  or  arterial 

ISO  in  tlH>  nie- 
or  example,  in 
,liieh  it  is  dis- 
■leetrieal  irrita- 
iin  has  demon- 


IIYSTKHI.V.  1 11 1 

strated  tlie  hei^lileiied  exeitahililv  of  tlie  fjensory  nerves,  the  sliulitest 
pressure  on  which  may  caii-e  [lara'stliesia  in  liie  re<,'ion  of  distiihution. 

Diagnosis.— Tile  disease  is  I'eaihly  re  •o^nii/.ed.  ll  is  a  nn.Make  to  call 
instances  of  earpo-pedal  spasm  of  (  liihh'cn  true  tetany.  It  is  connuon  to 
find  in  I'iekety  chihh-eii  or  in  cases  of  severe  ^'astro-intestinal  catarrh  a 
transient  >\nmn  of  liie  linjzers  or  even  of  ti:e  arms.  I'.y  many  autiiurs  these 
are  considered  ca>es  of  mild  tetany,  and  there  are  all  grades  in  rickety  chil- 
dren hetween  the  simpii'  carpo-pedal  spasm  and  the  condition  in  which 
tin'  'our  extrcnuties  are  involved;  hut  it  is  well,  I  think,  to  linut  the  term 
Iviaiiy  to  till'  severer  alVcction. 

With  true  tetanus  the  disease  is  scarcely  ever  confoundeil,  as  the  eom- 
nieucenu'nt  of  tlu'  spasm  in  the  extremities,  tlu'  attitude  of  the  hands,  and 
the  (iti()l()j,ncal  hictors  ai'e  veiy  dilTeivnt.  Hysterical  contractures  are  usually 
ninlateral. 

Treatment. —  In  the  ease  of  children  the  coudilion  with  which  the 
ietaiiy  is  associated  should  hi'  treated.  P.alhs  and  c<ild  spon-iii.tx  are  recom- 
mended and  often  relieve  the  spasm  as  promjitly  as  in  eh i Id-crow iui:.  i'>ro- 
mide  of  ])otassinni  ni:iy  he  tried,  in  severe  eases  chloroform  inhalations 
may  he  ^nveii.  .Massa.Lre,  electricity,  and  the  spinal  ice-ha,Lr  have  also  heeii 
nsed  with  success.  Cases,  however,  may  resist  all  treatment,  and  the  sjiasms 
Tceiir  for  many  years.  The  thyroid  extract  should  he  trie(l.  (lotlstein  re- 
ports relied'  in  a  case  of  loiitr  standiiiLT,  and  Uramwell  repoi'ts  one  case  cd' 
operative  tetany  and  one  of  the  idiopathic  rorm  succes.-fully  treated  in 
this  way. 

XL     HYSTERIA. 

Definition.— .\  stale  in  which  ideas  eimtrol  the  hody  and  produce 
morhid  chan,s,H's  in  its  functions  (Milhins). 

Etiology. — The  all'ection  is  most  common  in  women,  and  usually  ap- 
yiears  first  ahout  the  time  (d'  puherty,  hut  the  manifestations  nuiy  continue 
until  the  menopause,  or  even  until  old  a.^c.  Men,  however,  are  hy  no  means 
exempt,  and  (d  late  years  hysteria  in  the  male  has  attracted  much  attention. 
It  oceurs  in  all  races,  luit  is  much  more  jircvaleiit,  particularly  in  its 
severer  forms,  in  nieiiihers  of  the  Latin  race.  Jn  this  country  the  milder 
ji'rades  aro  eonimon,  hut  the  uraver  forms  are  rare  in  coiuiKirison  with  the 
frequency  with  which  they  are  seen  in  France. 

Chihiron  under  twelve  years  of  a<;e  are  not  very  often  alVected,  hut  the 
disease  may  he  well  marked  as  early  as  the  fifth  or  sixth  year.  ')ne  of 
the  saddest  ehai)ters  in  the  history  of  human  deociition,  that  of  tlu; 
Salem  witches.  mi,<.dit  he  headed  lii/slcrid  in  rliihJrot,  since  the  trapnly 
resiilted  directly  from  the  hysterical  jiranks  (d'  jzirls  under  tuelve  years 
of  a, CO. 

Of  ])re''isposin,<r  causes,  two  are  important — heredity  and  education. 
The  former  acts  hy  endowiuLT  the  child  witli  a  mohile,  ahuormally  sensi- 
tive nervous  ortranizalion.  We  see  eases  most  frequently  in  families  with 
marked  neuropathic  lendoncios.  the  memhers  of  wliich  have  suffered  from 
neuroses  of  various  sorts.     I'lducation  at  home  too  often  fails  to  inculcate 


t-' 


ll- 


% 


DISKASKS   OF  TllH   NERVOUS  SYSTKM. 

habits  or  scir-cuntrul.  A  cluKl  j^nnvs  to  iiirlhund  with  nu  .nluvly  .rnm.- 
o  dc^  .!■  h.r  relation,  to  others,  a.ul  ..ccustom.l  to  have  -"■y  ^  ';  ;' 
ltno.l  and  al.undMut  svtn,.athy  h.vish.d  ou  every  woe  how.ver  nin.^ 
t;ft:.>es.on,a.>ood.,tha.,.nd. 

;i;:.n.r;j::n::i-'.^:;^.tl;^ 

:      nes      e       soH,..d   in  the  ra.n.l  .k.velopnu.nt  of  the  body,  she  .s  ollen 
c' mn   in"i'..r  exa.ninatioMS  a,ul  eoo.-ed   in  elo..  sehool-roo.ns    o-  s.x  o 
nrs  daiiv.     The  result  too  freMUontly  is  an  aeUve    l.r.,hl  nund  n. 
tiol.t    ""  -^  "'   >  J  J,,  ,i,i.serve  tlie  l'iuuti..ns  for  whieh  il  was 

,;::  r  S     a    ordL.;:!    and  prone  to  react  ahnurnudly  to  the  onlinary 
;     u   \d    ife.     Anu,n,  the  n.ore  dweet  inth.enees  are  Hnot.,.ns  jd  varu.ns 
t     is    fiht  oeeasionaHv,  n>ore  frequently  love  alfans   ,net,  and  domest.e 
t    r  ie-^      I'l.vsieal  eaus.;  U.s  often  hrin>r  on  hysLrual  outbreaks,  l.ut  they 
'■■■•.'■  ^,„  i    j„       ,,  .h.vc.lop  dur,n,  the  convaleseeneo 

'  .  n  aeute  Uhu^s  ..  be  associated  with  d.sease  of  the  ^--al|VO  -.a- 
-Ph.  nan.e  ln,sln-u,  in.licates  how  in.portant  w.s  beheve  to  be  tlu  p  . 
'  ve  bv  the  uterus  in  the  causation  cd'  the  d.sease.  Opuuons  ddle,  a 
lood  deal  on  tlds  (,uestion.  but  un.loubtedly  in  n.any  cases  there  are  o  a- 
Sn.dut.rine  .iLorders  the  rectillcation  of  which  son.et.nu.  eu,.s  he 
lli'ca^!     Sexual  excess,  particularly  nmsturbatu.n,  is  an  .n.portant  lactor, 

hi)tl\  in  'diis  and  bovs.  ,  .  i  ,i 

SymptoniS.-A  useful  division  is  int..  the  convulsive  and  non-convul- 

""convulsiveHysteria.-(a)  Mh.r  f'on»..-The  attack  most  c.unmonly 
r.,Hows  enudional  disturbance.     It  may  set  in  suddenly  or  he  preceded  by 
.vn.ptoms,  called  l,v  the  laity  "  hysterical,"  such  as  lau.trhin^^  and  crying 
•Ufrnatelv.  or  a  sensation  of  constriction  in  the  neek,  or  of  a  ball  rism-  in 
■(Ih,   throat-the   r/U»,s   Inistrrirnx.     Sonu4iines,    preceding'  the   convulsive 
niovciucnts,  there  mav  be  painful  sensations  arising  from  the  pelvic,  al.- 
.lominal,  or  thoracic'  "regions.     Kn.m  the  description  these  sensations  re- 
semble aunv.     They  hec-me   more   intense   with   the   rising   sensation   ol 
c.hokiiiL'  in  the  neck  and  dilliculty  in  getting  breath,  aiul  the  patient    al  s 
into  a  more  <.r  less  violent  convulsion.     It  will  be  noticed    hat  the  la     ,s 
not  s.uldcn.  as  in  cpile|.sy,  hut  the  sul.ject  goes  .low,,,  as  a  rule,  easily,  often 
,i,ki„,.  a  s..ft  spot,  like  a  sofa  or  an  easy-chair,  and   m  the  movements 
'    na^^tlv  ..Ncnises  care  to  d.,  herself  no  injury.     Yet  at  t  le  same  tiine 
.he  appeals  to  he  .piite  unconscious.     The  movements  arc  cl.mie  an.l  .  ,s- 
o,d..rlv    consisting  of  to-and-fro  motions  of  the  trunk  or  pelvic  m,is.' es, 
wl,ih''tlic  h.'ad  aiul  ar,„s  aiv  thrown  ahout  in  an  irregular  manner.      I  lie 
paroxvsm  after  a  few  minutes  slowly  sul.sides.  then  tl,e  patic.t  l,e(.>„ies 
',n.)tioiial,   and    iiraduallv    ivgains   con«M<Misness.      When   .,uest,..n.Hl    the 
,,„h,Mt   mav  .onfess  t.,  having  soni..  ki,..wledge  .d  the  events  wh,.'  1.  have 
taken  ,,la.e.  .ut,  as  a  rule,  has  no  accurate  rec..llect...n.     During  th.>  at- 
tack tile  alnlomen  mav  1..-  nnich  .lisiend..d  with  flatus,  and  subse.pien  ly  a 
large  amount  -d  c.h.ir' urine  may  he  passe.l.     Tlu.e  attacks  vary  greatly 
chirract.-r.     Th.M'e  mav  he  scarcely  any  movements  of  the  limhs,  hut  aftei 
a  nerve  storm  the  i.atient  sinks  into  a  t.^i-id,  semi-uneonscious  condition, 


IIY.STEIUA. 


lll.'J 


ly  crrdiic- 
cry  whim 
■r  trilling, 
willistaiul 

\V    lliJI'S    (ll' 

I  the  vital 
11'  is  ol'lru 
I'o-   six   or 

II  mind  ill 
liili  il  was 
u  ordinary 

ol'  various 
d  doiiR'slic 
s,  but  Ihoy 
iivalesienci.' 
:ivo  orj;ans. 
H>  Ihc  part 
Ills  diU'cr  a 
■ro  ai'o  ova- 
s  euros  tho 
laiit  liutor, 

iioii-convul- 

t  coMunoiily 
proccdi'd  by 
and  crying 
all  rising  in 
>   c-onviilsivo 
'  [iflvic,  ab- 
nsations  it- 
scnsation   of 
jiaticnt  falls 
it  tbe  fall  is 
oasily,  ofton 
•  movements 
e  same  time 
mie  and  dis- 
Ivic  muscles, 
lannor.     The 
ient  becomes 
estioned    the 
?  which  bave 
iiriiig  tbe  at- 
ibHe(iuently  a 
iry  greatly  in 
lbs,  but  after 
lus  condition, 


from  wliirh  she  is  rou-ed  with  great  dilliculty.  In  >o!ne  cases  from  this 
siale  the  |ialieni  passe-;  into  a  condition  dl  eatah'p^y. 

(/')  Mil  jar  Fdriiis;  Jl  i/slcni-rpilcpsii. — 'This  condition  has  been  especially 
studied  hy  Charcot  and  his  pupils.  Tyitical  instances  pa>sing  tiii'ough  tiie 
various  jihasis  are  very  rare  in  this  country.  'I'lie  attack  is  initiated  bv 
'certain  prodi'omata.  chielly  minor  hysterica!  manircstations,  either  foolisii 
or  unseemly  jjeliavinr,  excitement,  sometimes  dyspeptic  symptoms  with 
tympanites,  or  fre(pieiit  mictuiitioii.  Areas  of  hypenestliesia  may  at  this 
time  he  marked,  tiie  so-called  hysterogenic  spots  so  elahoi'atelv  (lescril)ed 
hy  b'ichet.  Tiiese  are  usually  symmetrical  and  situated  over  the  ujiper 
doi'sal  vertehra,  and  in  front  in  a  series  of  symmetrically  placed  s|)ots  on 
the  chest  and  abdomen,  the  nio.^^t  marked  l)eing  those  in  the  inguinal  re- 
gions over  tiie  ovaries.  I'ainful  .sensations  or  a  feeling  of  ujijiression  and  a 
f/liibiis  rising  in  the  throat  may  be  complained  of  prior  to  the  onset  of  tiie 
convulsion,  which,  according  to  French  writers,  has  four  distinct  stages: 
(1)  l';pile|)toid  condition,  which  closely  simulates  a  true  epileptic  attack 
with  tonic  spasm  (often  leading  to  opisthotonos),  grinding  of  the  teeth, 
congestion  of  the  face,  followed  by  .Ionic  convulsions,  gradual  relaxation, 
and  coma,  'i'liis  attack  last:'  rather  longer  than  a  true  epileptic  attack.  ("J) 
Succeeding  this  is  tJie  period  which  Charcot  has  lernied  rluiriiisin,  in  wliicii 
there  is  an  emotional  display  and  a  reiiiarkal)le  series  of  contortions  or  of 
cataleptic  po.ses.  (li)  'I'Ikmi  in  lyjiical  cases  there  is  a  stage  in  which  the 
|)atienl  assumes  certain  attitudes  expicssive  of  the  various  passions — ecstasy, 
fear,  lieatitude,  or  erotism.  (1)  Finally  consciousness  returns  and  the  pa- 
tient enters  ujion  a  stage  in  which  she  may  dis|ilay  very  varii'd  symp- 
toms, chielly  manifestations  of  ii  delirium  with  the  most  extraordinary 
hallucinations,  ^■isions  are  seen,  voices  heard,  and  conversations  held  with 
imaginary  persons.  In  this  stage  ])atients  will  relate  with  the  utmost 
solemnity  imaginary  events,  and  make  extraordinary  and  serious  charges 
against  individuals.  This  sometimes  gives  a  grave  aspect  to  these  seizures, 
for  not  only  will  the  patient  at  this  stage  make  and  lielieve  the  state- 
ments, but  when  recovery  is  complete  the  hallucinati<ui  soinetimes  per- 
sists. We  seldom  see  in  this  country  attacks  having  this  orderly  se- 
(|uencc.  ]\lucli  more  commonly  the  convulsions  succeed  each  other  at 
intervals  for  several  days  in  succession.  ]Ierc  is  a  striking  dill'erence 
between  liystero-epile])sy  and  true  epile|)sy.  In  the  latter  the  status 
epilepticns,  if  jiersistent,  is  always  serious!  associated  with  fever,  and  fre- 
(piently  fatal,  while  in  hyster()-e|)ilepsy  attacks  may  recur  for  days  with- 
out sjiecial  danger  to  life.  After  an  attack  of  hystero-e))ih'psy  the  pa- 
tient may  sink  into  a  state  of  trance  or  lethargy,  in  which  she  may  remain 
for  days. 

Non-COnvtllsive  Forms.— So  complex  and  varied  is  the  clinical  picture  of 
hysteria  that  various  manifestations  are  best  considered  according  to  the 
systems  which  are  involved. 

(1)  Disorders  of  Motion.— («)  P«/-a///.svs.— Those  may  be  hemiplegio, 
paraplegic,  or  moiioplegic.  Hysterical  diplegia  is  extremely  rare.  The 
paralysis  either  sets  in  abruj)tly  or  gradually,  and  may  take  weeks  to  attain 
its  full  development,     'flwre  is  no  type  or  form  of  onjanic  parali/aiti  vltich 


II 


5' 
1^ 


M 


t'lK-'t 


I* 


% 


^^ 


PISKASHS  OF  TIIK   NEUVOUS  SYSTEM. 


lilt  ,      ,        . 

...''<'M.. r^'':;i::^^:^^^^^^^^^^       >i" 

1,  .  .uilVrs  ,n..st.     Sensation  is  citlH..   1-'"'  !    ,„i,|,„,i,.     Tlu'  Inss  n|' 

,„„,„„1.     A  spunous  ai  kk  ^'"^  ^^J     >        ,     ,nuin<.-varu<  position.      1  lu> 

,,,  usually  oxtcnd..!  '>-V:;'''"l'^n  .■.->•'■  '«'■  **"'"^  '"'"'' 
„„,,U.s  do  not  wasto  and  th.  '  >  j,  ]  \„.  ,,„„:,,  ,,,  usually  assoca- 
f,.stations.  su.-h  as  parahsis  o    th     ''!■•;  „.,„„,,l...iaX^,nay  h.  Uu.nl 

,,,,,1  ,,„,  the  l.yst.n.al  1-"''M  :'^'''-  ;  ;"^,„inu'  u^r.^^^^^U   l-aivsis. 

'—al.  .a.  l-nu-hial.  A  7-'''''';;.;;  j'!'^  ;.;,,..,■.  aiv  usually  s,.i,s.,rv 
Tlu.  incoordination  may  iK' a  nuukcd  hatuu,ai 

manilVstations.  \n  (.slraordinarv   vari-'ly  "f  M'''^"""''*" 

<''^  ^'"""■"'•""•'■■^  :''V  •'"     t'';;^;     1  t       Host  .onnuon  a-v  tlu.   ioUow- 

''"•-^'""^  ""■""'";  '•'I'lt  a     u-k  alnu,st  any  .rou,  of   volun- 

i,„:  T,..  ln>t.ru.a    -;■";,!,.       ,,,,,,,,,1...  or   .nono,lo,i..   tv,. 

t,ry  niuscUs  and   hv  o    th*    '^'         '  d      lH.r<i  1   for  nu.ntl.s  or  yoars.  and 

•n,y  may  roiu.  on  suddenly  <''/'"^\'>'        ,' '•.  ,„,„„„u.  so.n   in   tlu'  arm. 

,,i.ai.p..ar  rapidly.     'H- /•'-'-  '';.  ^  ^  ^,  ^    !"  ^nv  tidi.ly  i^vasp  iho 

,,,i;.h  is  ll.xcd  at  ^l-';'  '^'^V'"'  •         ;  V    l>o  terminal  pludan.es  ar. 

^''-"''  -  ^"^'  '"''"  VT  \       U        V  o.         i.    one  or  in  l.oth  lo,s,  moro 

,.,,„rext.nd.d  as  ni  """;  l''  ^.^^^  ^;     „         ,  ,,,sent;  llm  foot   is  inv.rtod 

commonly  tho  lormer       1  Im  '  ^'^'^        '   U^c-  nu.v  he  mistaken  for  lateral 

,,a  the  toes  are  stron^rly  tU'X*"<l.  -   '  ^,^  ^   ;       ^„.  ,,,,,   .,,at.     The 

,.,erosis  and   the  ditlieulty   ''Y'^^-X.  ^'^  .J  ^     a  knee-jerk  and  ankle 

.pastie  j:ait  is  very  typual.  and  .,  h    I      ex.      c  f,,,     „,„„v  showed 

,  .,nus  the   picture   may  1'''  '  y''''''^^?-;   .j  •-     \,    ,  tvpical     xample  of  lat- 

such  a  case  at  the  Montreal  ^■--•'^^,^^  :';,',   .Uhteen  nlonths  and 

'-'  sclen.is.     'Phe  cond,  nm  V    J  ;     '^    ^  '  ,  \,,,„,,,tu,.  ,uav  he  h.  the 

then  disa,>peared  con  pie  elx.       '        .^^  ,.^„.^.,,  j,,  th^se  of  the  jaws- 

,,u<cles  of  the  hip.  shou  der    or  ^^'^  :;,,,,,:  ;,„,,,„,  „,  the  local  con- 

l.vsterical  tiismus-or  ,n  the  ton,n  e   ^    ;      '>         '    ,^       ,„.,„,;„,  ,  pl.antom 

tractures  in  the  diaphragm  and  :'  "  ;     '  ;    ,       „      ,  /.f  ,,.0  umhilicus  is  a 

t>'-"''  -  ^^•'^''  '  i-V  Tt^r  Wit  (lowers,  this  is  pro.hu-ed  by 
firm,  apparently  solid  jinn  th.  ^^**"  "-,,,.. ,^.ji„„  „f  the  diaphragm,  to- 
relaxati.m  of  the  recti  and  a  f  ^^;'"">'^^^.  "  .^^ *  „  ,,  ,rchin.  forward  of 
,.ther  .  ith  intlation  "^^^^^  -;;-:;,:;■  in  Imddle-a.ed  .omen  ahont 
^''^' ^■^■'■'^'''■'''  ^"'"''T"n.eVckmnti  associated  with  the  symptoms  ol  spn- 
the  menopause,  and  aie  1'^^!^  "V,;.  ,,.,,,„ldance  to  a  tumor  may  he  strik- 
Tious  pre-nancy-/'.vn/</<w7Ks' s.  h«  "^"l'  ''  ,  ,ie<eived.  The  ..nly 
,,.  and  1  have  known  skilful  '  "f  >"f  ^  ,  '\  ,.,  ^  ,  tumor  entirely 
safeguard  is  to  ho  found  in  ^^^^^'^'^ .^'';^^^^^  -f 

disappears.     Some  years  a,o      -"'^^>  *      '     „, !  \,,.,orof:,rm  and  the  sur- 
,  iJspital  and  found  a  patient  .,n    1     tahlm  ^^^^^_^^__   ^^^^^^   ^^^^^^_ 


IIVSTKItlA. 


II 


Iho  lu'iiii- 
iic  on  till 
1.  Im(   llu' 
•rtcd  si<l>"- 
he  loss  111' 
(it  siipiKii'l  ■ 
[•k  N  (illiMi 
Tlu;  k'A 
tidii.     Til'' 
tlu'V  uiatii- 
iiUy  iissdci- 
y  he  t'iiciiiK 
ith  imrcsis. 
lily  si'iisdi'V 

\  spiisniixlu' 

tlu'     I'olldW- 

|)  ol'  vdluii- 
l.li'L^ic  tyiu'. 
•  yt'iirs,  and 
in"  the  arm, 
ly  irrasp  ill*' 
l:alani:e:^  arc 
\\  IcL's,  move 
t  is  iiwcrtcd 
■n  I'm-  lateral 

oivat.     The 
riv  ami  aiikli; 
LMitly  showed 
aiiii>le  of  lat- 
1  nionths  aixl 
lav  he  in  the 
III'  the  jaws— 
tlu'  local  con- 
iLT  a  phantom 
iiuiliilieus  is  a 
;  produced  hy 
liaiihra^nn.  to- 
ng  forward  <d' 

women  ahout 
ptonis  id'  spu- 
r  may  he  strik- 
ed. The  oidy 
tnmor  entirely 
ratiniT-rooni  of 
m  and  the  snr- 
"vcr.  had  com- 
tcd  an  instance 


of  a  plianlmii  liinn  •■  in  thi   lei'l  pectoral  rc^idii  iii>l  aliovc  the  hrcast,  whicli 
was  tciidci',  liai'd,  and  dense 

i'liiiiir  sjiiisiiis  are  more  eonimun  in  hysteria  in  lliis  eounlry  than  lon- 
ii'actiii'es.  The  folluuini:  are  the  in.porlant  foians:  lllnjlhmir  !ii/shrit'il 
sj)iisiii.  This,  unfortunately,  is  sometimes  known  as  rhylhmie  eliorea  oi' 
Jiysterieal  chorea.  The  nio\en:ents  may  he  of  the  arm.  either  lle\ion  and 
extension,  or.  moi'e  rarely,  jironalion  and  supination.  (  loine  eonlradions 
of  the  slerno-cleido-mastoid  or  of  the  nuiscles  of  tlie  jaws  or  of  tjie  rota- 
tory muscles  of  the  head  may  produce  rhythmic  movements  of  thoe  parts. 
The  spasm  may  !ie  in  one  or  hoth  jisoas  muscles,  liftinu-  the  le^■  in  a  rhythmic 
manner  eii^hl  or  ten  times  in  a  minule.  Jn  other  inst;inces  the  muscles 
(d'  the  li'uids  are  ali'ected.  and  cTery  few  inonients  there  is  a  hiiuiii;^.-  iuo\e- 
nent — salaam  convid>ions — or  the  muscles  of  the  hack  may  contract,  caus- 
inu'  stroll:,'  arching'  of  the  vertehral  lolumii  and  retraction  of  the  head. 
These  movemeiils  may  often  alternate,  as  in  a  case  in  my  wards,  in  whicli 
tlie  patient  on  line  days  had  re.n'ular  salaam  convulsions,  while  lui  wet  days 
the  rhythmic  spasm  was  in  the  muscles  of  the  hack  and  neck.  Mitchell 
has  deserihed  a  rotatory  s|ia~m  in  wliiili  the  |iatienl  rotated  involuntarily, 
usually  to  the  left.  More  unusual  eases  are  those  in  which  the  contraclions 
closely  simulate  ]iaramyoeloiiiis  luultiple.x.  Hysterical  athetosis  is  a  rare 
form  of  spasm.  'I'ri'iiinr  my  lie  a  purely  hv>terical  manifestation,  oeciir- 
lin^  cither  alone  or  with  paraly-is  and  coiitraetiire.  It  most  coiiinioiily  in- 
volves the  hands  and  arms;  more  rarely  the  head  and  le;^s.  'i'he  iuo\(- 
iiients  are  small  and  quick.  In  the  ly|ie  liriuUi  the  tremor  may  or  ma\' 
not  persist  duriiiLT  repose,  hut  it  is  increased  or  |)ro\dked  hv  volitional  iiio\e- 
iiients.  \'olilional  or  iiiteiilioiial  tremor  may  exist,  simiilatiiii;'  closely 
the  moveiiieiits  of  insular  sclerosis.  Iliixzard  states  that  niaiiy  instances 
ef  this  disease  in  yoiiiiL;'  uirls  are  iiii>lakeii  for  hysteria. 

(••3)  Disorders  of  Sensation. — Ainrs/lirsiit  is  most  cmnmon,  and  usually 
condiied  to  one  half  of  the  hody.  II  may  not  he  noticed  hy  the  patient. 
I'siiallv  it  is  accurately  limited  to  the  middle  line  and  involves  tlu'  mucous 
-iii'faces  and  deeper  jiarts.  The  conjunctiva,  however,  is  often  sp;ired. 
There  may  he  hemianopia.  This  symptom  ni;iy  come  on  slowly  or  follow 
a  convulsive  attack.  Soiiietinies  the  various  sensations  are  dis-ocialed  ami 
the  anivsthesia  may  he  only  to  pain  and  to  ioiich.  The  skin  of  the  alfecteil 
side  is  usually  p;ile  and  cool,  and  a  pin-prick  may  iml  he  followed  hy  hlood. 
With  tlie  loss  of  feeliiiu-  there  may  lie  loss  of  miHcular  power.  Curious 
trophic  chan,u''es  may  he  present,  as  in  an  interostiiiif  ease  of  Weir  Mitcheirs, 
in  which  there  was  iinilaleral  swellin',''  of  the  ]ienii[)lei,de  side. 

A  phenomenon  to  which  much  .■itteiilion  lias  lieen  jiaid  i-^  that  of  trans- 
feri'iice.  liy  metallotlierapy,  the  apjilicatiou  of  ceiiain  iiielals.  the  aiia'-- 
ihesia  or  anal^^'sia  can  he  Iransferred  to  the  other  side  of  the  hody.  It 
has  heen  shown,  however,  that  this  phenomenon  may  he  caused  hy  the 
elect ro-ma,i:net  and  Ity  wood  and  various  other  aii'enls,  and  is  pmhahly  en- 
tirely a  mental  cfTect.  The  suhject  has  no  practical  iinporlaiice,  hut  it 
remains  an  interestine-  and  instructive  chajiter  in  (Jallic  meilical  history. 

Ifjipprrrstlii'sid. — Inci'cascil  sensitiveness  and  pains  occur  in  various  parts 
of  the  hody.     One  of  the  most   freipient  complaints  is  of  pain  in  the  liead, 


It 


I 
111. 


'    1 


''  d 


IMSKASKS   OV  TllH  NKUVOlS  SYSTKM. 

"1-..^ -.  ...-;.-:;j;;::,.:;Tr- ^^ 

ab.lnnH.n.   ,.v.-un.   upon   .huh       ;         '^  ^,^^  ,,^i^,,  ,„  „.-.  nvuruu.   .v^.'.., 
a  .n.nulMV  .>'a.k.     '-7; ;^  ^'  1      "      th.  hack   is  an    .luH.i  ."..sta.a 

,,,,;.,iu..us,,n..vss.s.or..        >  1'     '^        ,^      ,,  ^„„,  „^  ,,.,,,.■  nh-r    - 

i"  "-•  "'"'"•""'  "?■  7"         1       u'al  whh  that  nf  ,H.n.o,utis;  n.uro  rau^b 
tin-  iM.n.litioM  may  1"'  i'''""'^'  ,         „,■  ,,p,,..n.lix  .liscasc 

hoal.h.n.i.al  l-ns  .lo..ly  >vs..,uhh   t     m   <  1^  ^^^^^    ^__^^    _^^^^   ^,,,^.,       ,,,„ 

„.nal  ^""--yr'T   f  ai -Uv         <       :  ula.  .y.nplou..  retina    hy,-;- 
^.sthcsia  i.  11-  .Kust  cmnnou    ..  1  .^  ^,^^,,^,,^„„  ^„„,  ..ually 

<lark..u.a  rn.Mu.     K.tractH.n  "    '•       "    !,.^.,^^  ,„,  ,,,,..     Th.  .,^0,.  ,..,..,,- 
foHnw.  a  c.nvul.iv.'  sc/.inv.       t  may    .  •  ,  •„,  jh,,  ...untn 

n,av  In.  mnn.al   .v.n  w,th  -"'M''        ^^j  ,  "  „  „„„„..,,    an   hy.teri.a 
;i;:\..,uomatop.aa.;.s...--J;;      --;^^^^ 

„„„irostatiun  as  .n  1^>"'"1--  '  >^  '  ,,  »;,„,  with  hysterical  hlu,a,H.->. 
„>,v  altcmato  c,r  -^^^^  ;^\^Jl  ;  area.  One-  n.ust  cuvlully  a>st,n- 
llv.tc.vi.al  a,naun.s,s  n<'  >   '>''  ^^.^.j  ,i,„uiati,.n.  .  , 

.ui.h  between  rnn.tiunal    oss  of  l'^^^  t , ,,.„•<,/ »s._-()f  d.stnrl.ance. 

'"  (:0  Visceral  Mamfestations.-/.  >■  -'  ^^  ,„  ..xa^.c-atua. 

i„  ;,.;  respiratory  H>ytlun    the  ;-  ;  ;    ,.„Vnra.  or  sixth  insp.ra- 

of  the  aeepcr  breath.  -l.-l>  -    ;  ;  !1      ;,,.,;,.  ,,:„  as  i>  seen  when  eohl 
tio".  -r  there  n>ay  he  a      -"'"  -     ^ V^.,,,  .,vs,nuea  is  rculUy  rec-o^n./ea 
,,tev  is  ponvea  over  a  i;"-"  •,,;>,        i^  ulnally  norn.al.     I  have  met 
aslheroism)s,u.c.,aia.>tre>>a,a    lu  ^,^^   ,,.,,in>t.ons  rc.e 

,,itl,  a  ren.arkable  c-ase  f"'!;'^-' ;         '      ,al  n.anirestations  a,.!>oma  ,s  the 
,,„.,ve  i;".o  in  tlH'  "'»u.te.     Am-m-  l'">    -  ^,^,,,^  ,,i,i,.,ut  other  spe- 

t.i  rrec.nent  an..  n,ay  persist  ^ ;-;;       ;;  ,;  ^^  „,,-  ueeur  with  vic^ent 
,,ial  syn.pion.s  of  the  c.seasc..     S  -"-  <     th  ^^^^^^  ^^^  ^^.^^,^^,^,        ^  ,,. 

i,„pi,atory  elVort^  and  >r.vat  ^  ;^'    :;.'     \  ,,;,„t  f„r  weeks  or  months  at  a 
,.,;,h,  or  sonncls  re..nhbn>r     .a  ..anirestat.ons  arc^ 

Ihne.     An.on-  the  most  remail.ahlc   o    t  ,  ,,„Uura  hy  animals. 

"  hvsterieal  ca-ies.     'rh-e  n,ay  nnnue  sonn  1  ^^^  ^|_^,_^^ 

!;;.b  as  barkin..  n.ewin..  or  ^J'-  -;;„;;^  ,  ^^  Z^   may   m-   P-oanca 
l,ave    heen    repeateaiv    ol.c.rvea.     >-    •7^;,;,.,,.,  ..H^ic.  at  Leipsie  a  ,.rl 
either  inspiratory  or  "^l^'f  "■> '  ,  ^,;;;,;1,  ,e.a<s  ^iven  ntterame  tc.  a  re- 
,f  thirteen  or  fonrteen.  who  hal    < '  "  '  ^^>  ,vhoop '>1'  Nvhooi'l^J^-^'""^''''  ^f 
„,arkable  inspiratory  c.y  ---^l^  J  ;',;,:!     V  .as  incessant,  ana  the 

"  -^--  ''■''  f  rV:;:;;  .      a  S<'of Vn-ln,,  yawnm,,  ana  snccng 
ifirl  was  worn  to  a  ^kclclc,n. 

inav  also  oeenr.  _  «vmntom.  partieuiarly   in  yonng 

•The  hvsterieal  eou.h  >s  a  f''^~'l"'  ^.^^  "  .In",  pcM'sistent,  croak.n^ 
.i,.l..  11  n>av  occur  in  paroxysnis,  I'^'V:  ■  t  c/l  ar  Sir  Andrew  Clark 
r  n>a>,  exlrcnu.ly  monotonous  ana  unpleasant  to  hear. 


A 


itan 


mm 


IlYSTr.KIA. 


lur 


1.     Tlii>  is 
111   iiitci  till' 
u.     lly|>.i- 
thiinix  iiii'l 
iim  (ir  I'vcu 
riaii   ri'^rii'ii. 
,;.t    (■(iiistiuil 
lilcd  to  »•*''■- 
■  11  till'  pains 
,.•„.  nicer,  nr 
mori"  nu'fly 

.    \iuc(inunt>n 

rlinal  liyi"'!'- 
f  t(.  lir  in  a 

anil  iisnally 
c(il(ir  |H'Vcoii- 

\\\\~.  I'onntry 
.,11  hystoriciil 
i.,,iui)i('to  and 
•al  blindness. 
iTl'nlly  distiu- 

f  (listiirh.inrcs 
1  cxaii^eration 

sixth  inspini- 
,.(■11  when  ecld 
ily  rccD.unizcd. 
1.'  I  iiave  n\ct 
■-piratidHS  rose 

aiiluiida  is  tin.' 
honl  other  ^w- 
•nr  with  violent 
cyanosis.     Hie- 
or  uKinths  at  a 
iiiiVstations  aro 
(■(.(1  hy  animals, 
(U'lnies  of  theni 
y    In-    produeed, 
nt  Leipsie  a  tiii'l 
tt  era  nee  to  a  re- 
)pin>;'-enu>.di.  h\\i 
icossant.  and  the 
\o,  and  sucoziug 

•uiarly  h\  y«nin,<I 
rsisteiit,  croakinii 
;iv  Andrew  CUuk 


has  called  al  lent  ion  In  a  loiid.  liarkin^r  coiiuli  ('■i/iKihr.r  lirlivlicn)  (u'ciiri'in^' 
alioiit  the  time  (if  piilicrty,  chiclly  in  hoys  hclnn^jin;,'  t<i  iiemotic  families. 
The  attacks.  «  hicii  last  almnl  a  minute,  recur  fiv(|Mcnlly. 

'riiei'e  is  !i  |)ecnliar  form  of  iKcmnplysis  which  may  he  very  deceptive 
and  I'.ad  to  the  diaunosis  of  pulmonary  disorders.  Wauiu'r  ilescrihcs  the 
sputum  as  a  pale-red  lluiil — nut  so  i)ri;;ht  in  color  as  in  ordinary  ha^mop- 
tvsis;  on  setliin.i,''  it  presents  ii  nildish-hrow  n  sediment.  It  contains  par- 
ticles of  food,  pavement  epilhelium,  red  corpu-cles,  ami  miciococci.  liut 
110  (  vlindrical  or  ciliated  epithelium.  It  pmhaiily  comes  from  the  month 
or  pharynx. 

Dhlvxliri'  Siislciii. —  l)i>tnrhe(l  or  depraved  a|ipctite.  dyspe|isia.  and  jras- 
tric  pains  are  common  in  hy:-te<'ieal  jialicnts.     'I'he  patient   may  havi    dijli- 
cnlty  in  swallowini:  the  food,  apparently  from  spasm  of  the  jiullet.     'i'licre 
are  instances  in  which  Ihe  food  seems  to  lie  ex|ielle(l  hefore  it   reaclx  .:  the 
stomach,      in   other  cases   thi>re   is   iiicessanl   jrairuin,!:.      In    the   hy.-terical 
voinitin,!:  tlie  food  is  reiiuriiitatcd  without  much  etV(U't  and  willioul   nausea. 
This  ftature  may  persist   for  years  without   ureal   di-turhanee  of  nutiitiou. 
The  most  slrikin;,^  and  remai'kalile  di;icstive  disturhatice  in  hysteria  is  the 
(i>i(;irj-!(i  iirrrosit  descrihed  hy  Sir  William  (lull.     "'I'd  call  it  io--  of  appe- 
tit(> — anorexia — hut    I'eehly    characterizes    the   symplom.      It    is   rallur   an 
annihilation  of  appetite,  so  complete  that  it  seems  in  some  cases  impossihle 
ever  to  eat  auain.     Out  of  it  ^n'ows  an  anta,irouism   to  food   which   results 
at  last  and  in  its  w(U'st  forms  in  spasm  on  the  approach  of  food,  and  this  in 
turn  ^ivcs  rise  to  some  n\'  those  remarkahle  cases  of  survival  for  Ion;:-  |)erio(ls 
without    food"  (Alilchell).     .\s  this  <xoes  on  there  may  he  an  extic  me  de- 
cree of  muscular  re-tlessness.  so  that   the  patients  wander  ahoul    unlii  ex- 
hau-lcd.      Xothinu''   niore    piliahle   is   to   he   seen    in    jn'actiee   than    an    ad- 
vanced case  id"  tliis  soi't.      It  is  usually  in  a  youn;:  e-iil.  sometiiiu's  as  early 
as  tlie  (deventli  or  twelfth,  more  coiiunoniy  helween  the  (Ifteenth  and  twen- 
tieth ye;irs.     'I'he  emaciation  is  friffhtfid.  and  scarcely  exceeded  hy  thai  of 
cancer  of  the  (esopha.uus.     The  ])atieid  finally  takes  to  hi'il.  and  in  exireine 
cases  lies  njion  one  side  with  the  thi,i:hs  and  le.irs  Hexed,  and  coniraciures 
may  occur.      i'"ood  is  either  not  taken  at  all  or  only  u|)on   urgent  c(jmpul- 
sion.     The  skin   hecomes   wasted,  dry.  and   covered   with  hran-like  scales. 
No  food  may  he  taken  for  several  weeks  at  a  time,  and  attempts  to  feed 
iiiav  ho  followed  hy  severe  spasms.      .MthouLrh  the  c(mdition  looks  so  alarm- 
in,u'.  th(>se  cases,  wlu'u  removed  from  their  home  surronndiiiLTs  and  treated 
hy  Weir  ^litcheirs  method,  sometimes  recover  in  a  remarkahle  way.      Death, 
however,  may  follow  with  extreme  emaciation.     In  a  fatal  case  uiider  my 
care  the  jrirl  weiirlied  oidy  111  pounds.     Xo  lesions  were  fouml  post  mortem. 
Amon.ir  inte-tinal  symptoms  flatulency   is  one  of  t!ie  most  distressiiiir, 
and   is  usually  associated  with   thi>  condition  of  perislaltic   unrest   (Kn-s- 
maul).     Frequent  discharges  of  fa'ces  may  he  due  to  disturlianc,'  in  either 
the  small  or  large  howel.     An  obstinate  form  of  diarrho'a  is  found  in  some 
hysterical  patients,  which  jiroves  very  intractable  and   is  associated  os]ie- 
cially  with  the  taking  of  food.     It  seems  an  aggravated  form  of  the  loose- 
ness of  bowels  to  which  so  many  nervons  ]wn])\Q  are  subject  on  emotion 
or  the  tendency  wliich  some  have  to  diarrliani  immediately  after  eating. 


i! 


niSKASKS   (.F  TUH   NKUVOUS  SYSTEM. 


IllilV    lit'   '"'*'    '"   ''    "     ■  '  ,  ,,,  .    ,1,,,   lioWf  >    11". 

„r  ,.,val  .li~tn-s.     A  Muss    -nil-     '^    '   .       .^,    „„  ,,,,u,lo-an-ina.  wIihI.  lia> 
;!,;  siniulau.  angina,  .h-  -;-;;;;>  ';>^^;;;-;,,   ,:,,  ,,.  .„.„„,  tl.   n.- 

,  ^4  .as.  ononis.  Lat.au        n    u>  - 

,,,,.  no  siuKl.'  air.c.ti..nl.a>  1  .on  -  .^^^^^  ^^^^  j^^^^^,,^  ,,  .^  ,,,„. 

f„;  the  cases  are  v.ry  ^'^  '•'^^'^      -j'     ,        h,  disease  .nay  .li-Pl-ar  at  oiu.. 

Vsually  it  allVcts  th.  ku.  -J^  !"  „.,  ,,,,„;.,.  Th.  .lura.c  may  1,. 
The  joint  is  usually  ix..l.  ^^^^^^^^  ,,  i,,„,,>..n.  To  th.  touch  it 
,„„,,  inu  sonK.tinu.s  the  l^al  tcnipca  p,,tva.t.Hl  cases  the 

\  ,v  ..nsUivv  au.l  movnuenl  .-auso.  ^  '  ">!  ;  .^  J.,,,,,,,,,,,..,  it  looks 
;,,,,.les  ahout  the  jouit  -  -;:-^:  ; ''  ^  i>;:h  tinie  the  loeal  tenM^.a- 
1,,,,,.  The  vains  are  ulten  '-.;'•  ^^,,^,_  ..un-nunielie  jo,nts  yield 
ture  nu>y  l-e  nnieh  .nereju-.  •  ^J^^^^^^.  ;,,,,,..„  i,,  the  literature  in 
to  P-l'^'r  "''^''^'^r'^^'^S^'"'  ,:  eS  he  i^netional  ai.turhan<-e.  In  lu> 
,.hieh  orpnue  ehanj^e  ^^f  ^'''^^'^^    ^AV.  lectures,  the  hysterical   tea- 

inllaunnatory  pnulucts  outsule  ^;;:;;';;;:";;,^,,„if,,tation  of  hysteria,  oecur- 

l,^j^,,,,„i„,„t  hydrarthrosis  iua>   ^^\'J^\^    ^,,,,,,i,,,t  paresis. 
,,,.,  i,  the  knee  or  "^her  jonr^   .;.-•- -;;^;/,,,,  ^„,   J,       .1   patieiU 
.1/,.,^-'/  >'//'''/'''""-'^--''*    ^.         ,    ,,.-cume<   the  ill->le(inea  territory  be- 
i^  ahvay.  ahnornjal.  ->'      '^  ,  ;7;  ,!  /        ,h.r  of  ca.es  the  vatu^nts  are 
tween  sat.ity  an.l   msan  t>        n  a  1  ^^.,,„„,,,a  i„  the  u.oral  sphe.e 

,„„v  insane,  vartic..larlyin  ^''''  l^,    '         .'    pon  their  stateuH.nts.  and 
Not    the  sli,hte^t   .Vpenaence   -^  ''     jj,,,,    ,,,1,,;,,..  an.l   l-hysican. 

"'-•   -^'    '""'  '""''u  "'■  r'hu      o    .1     Iv.  fvoni  a  nun-hhl  eravin,  for 


Is  tl\f  ii'fi- 
(liiy.  simn- 
.VCVIT,  n'.'.il 
in  till'  ali- 
cil  I'or  two 
isturl»!.i\i'i'S 

;un'. 

st  t'limlidU. 
I'll  u  SMlivrr 
t  the  hvarl 
.  whicli  hu> 

yr    tllf     inii>t 

In.  s(i-talli'il 
ill    tlic    Cflf- 
itcdly  I'nuid- 
{\\v  hyimotii' 
muv  uf  prel- 
um  I'a^ift    \v(> 
.sti'iia.     Vvv- 
ic  iirofesion, 

ids  ot  11  t'lii^i'- 
ijicar  at  once, 
lillin.u-  injury, 
it'ace  may  hv 

tilt'  toufh  it 
itcil  easis  the 
iR'Uce  it  ItHiks 
local  tcmpcra- 
ie  joints  yield 
r  literature  in 
,;,„(•,'.  In  tlu' 
livslerical   t'ea- 

tiie  disease  (d! 
ty  as  Billrotli. 
cr"  to  be  due  to 

hysteria,  occnr- 
,)aresis. 

■stcri<'al  ])atient 
cd  territory  be- 
ihc  patient;^  are 
If  moral  spbere. 
statements,  and 
and  physician, 
i-hid  eravin.L^  for 
iKiral  nature. 


HYSTFdU.\.  ^'^•' 

h,.(l.  entirely  (ihlivioiis  to  i 


mulate  that    of  ilelni 


,  ,heir  .urronndiu^s.  will:   a  dclumn.   which  n,ay 
„    „,,„„.,„.   parlicularlv    ,n    l.ci:,.   a-~oc,ated    with 


The   nutrilion    ni  ly    he    inamtamcl 


'"'''":^"";"   ""'    ''■'lt;^^dwav<'a^c^•' h.;;vv.  foul  l,r...h.     Wnh  secln- 
l,„  ,„  ,h..,c  ca.e>  then    .>  ''^^  ^^-     '        •  ;  ,,j„   ^,„,,,  „,   r„i,,   monllw. 

-'••-■■'•■''••*■  r:;'"''^uaci''ndur'^^ 

,,.,  i,H.,.ssantly  watched    a>  a  ■^"'  "','         ,,,,„,|i,i„„   ,,  ,|„.  sh,his  linslrnm^. 
1  bave  hcen  accustomed  to  >,.eak  "''"■',  „,„  .,,■  j,„i,.,  i.  the 


;;:;;;;;!;:;:;.t;:p:s;;;:;n',.  winch  they  a., ^  >a 

rdinary 
ualitative 
Ic..  there 


;;.;..:.; m»-.-.' ;;->'-'' 'i;-;-;j ;::::;;:;.  ■;,,:, :,■,■::,, 


ratio  ot   lli'^ 


;,;;;;:-;-i;:rr;:x:;-:;/"" --- - -"■" 

a  seizure.  ■     .i      <  „,,,,.,i.inirc    a-  a   rule,  is   normal. 

in,slrnral    Frrrr.--\n   by>tena   the   ^'■"  ''       '"'•,;.,„„  ,,  i,i    .vhuh 
i.s  .ith   fever  ,nay  be  ^->!-'  ^  ^l''       -.,    !'  "   „,.,  .„.„  at 
„,e  fever  is  tbe  sole  .nan.lestatuu,.        I      <    •  ■  ,  ^^,_,,..,j,,,,_ 

h,a.t  two  eases  in  wh.ch  the  chrontc  '-'■;,.,;  ,,„,   „„  ,„h..,.  dia.no.s 
and  the  entirely  '-^''''-' ;'''"'^'  ';:',,,'     ,i     1     •  ,  atient  ha~  had  for  four 

:::t::%a:;\r:f;;=;r^^^ 
:;::;,i:^:;ti:;;:\.;;r;:t;t:;t^^^^^  -■ •• 

,;M:terrupted..hin..reshn.a,,on.o.d,.  ,,,„,,.,. 

(M  Cases  of  l»-<"-'=Vr"„         ,^       The  patient   tuav  U'  suddenly 
„,,  verv  troublesotue  and  deee,.t.Ne     a     ■  ^  „.„ip..,.ature.     The 

,a.e  may  simulate  nu>n.nuiti..      "'  ""'J^^.,     ,„„„  ,vhich  may  per- 

^.,,,,,,,.U,\  pupils,  and  retraetum  ot  the  '\1'  ,„,.,„„  ,„.„valescence 

sist    for  .eeks-and   sonu>  anontahuts   •-';■'  ^^^ ,  ^^,j  ^^.„,  ,  ,,,.  „,• 

,„„v  alone  indicate  to  the  phy>.c.an    h         ''^^^     .'„,„,,„,  ,  ,,,,  .,f  ,i„.n- 

hv;teria.  and  ba<  not.  a.  he  perhaps  "="^:r  '  'l        erical  fever,  tuen- 

i,;,i,is.     ^l-Tl^;tnan..Iacob,..na,v..  t  ml,^ 

*;.,.,.   .,   ,..we     n   the  service  ot   (oinil    wnui     «  ,,,.,u-ed   to  he 

,  1'    .)(,o    (I  I  lie   (  (UU   it  OH   llioxtil    lo    1" 


tidus  a  case  in  the  servie 
sli.uht  cyauo-is.  ai 
hvsterical.     Ther 


.1 


-     " 


I>,SKASKS  OF  TllK  NKRVOI'S  SYSTEM. 


,■  n   i'  v.r   .nul  tlu.  .xiuHmvaliun  of  a  l.l.Kul-stai.u.a  nnuu..     Th^ 
,„n  doxi.al  t...n,u.ratmvs  n'I""'t<"      '    '^     >    ;'    ,,  ^„„„,,.     ,.•,,».!  has  lu^.n 

L,  ,,,,is,on..i  i.^=  to  i^u"  -;;;"  j,  ;^  ,    •    ,„  ,..,,1.1.  thou,i>  nu.- 

„n  ^m.Hl  autliorily,  provnl  a  Inim  .  ^        ,;.„,  nuuufcstaticn. 

biagnosiS.-ln.i>.uy  nUo  ^l^^  ^    ^^"      ,^j  inrl.r.uation.     Tin..  (,....- 

-'•  tlu^uental  --n^--;;;:>X       lo  l^iuu.,  wh..  <>e  all  "tju'-'s  i.  lo.. 
1i(in«   as  a  riio,  shou.>l  iiol  nt  a.  iv^^  mtii'nt  s  condition.      1  l>« 

I^kI  .ivos.ti.rac.tury  inr™.  uu.  «  ,,^  ^.^,^,„.,^  ,,, 

cKcurroru-o  of  the  globus  h  .toxia^        -    ^^^  ^^^^^^^^^^^  ^  ^he  .ou- 

fryinji,  arc-  always  su{Zf,'ostno       I  lit  1  .^^  ^,^^.,.  ,,,,,,,,,,„„„. 

vilsi^-  attacks  and   t,j.c  n»M->    --^,  ^  ^  distin.uislnn,  l.ctw.rn  to 
,,a  ,,  a  rulo  little-  cl.l  .cully  ^^  ^  -  ^.-^.j^^,,!,  ,„i  a,,t  to  he 

t.vo  conditions,    '"-/^y^^^":^^/    iJi-^.n^  may  at  ti.ncs  he  very  -icc,.- 
associatod  .itl.  an^vsthosm       U         '^^  ^j^^^,,^  ,f  ,,,,a,tinn  of  the  vsual 

;;:-;;;;d^rri;;p^^^ 

vith  lateral  sclerosis.  ,,(.„.rni/.ed  without  much  dilli- 

Tlu.  visceral  ,nan.festnt,ons  "        •  "'    >   l^^,,  S     ;,,.i  ^,,,  ,t,,.,„,  tendencv 
,ultv      The  practitioner  has  con^tantl>  to  uai 

i„  liv^terical  ,mtionts  to  practise  ^l^'^^-P^;;;  ;         ,,^^,^.  i,,  .alhered  fmu,  the 
Treatment.-'nH>  prophylaxis  ^^^^y^]^^     ry^,  successful  treat- 
n.,narks  ou  the  relation  of  ->-;'  J^  J^^    /^^w  phvsicians.     The  (irst 
„,,„t  of  hysteria  ^-"^""^^l"'^^'^  ,^^   ;;  the  uisease  on  the  part  ot 

element  is  a  due  apprectatton  f  ^  j^j^^  ^  „,,  ,f  the  tui.ery  .Inch  has 
t,,,  pbvsician  and  tru-nds.  It  'M'^^^'^^'  ''  ,^^^,.^,,  ,„a  ..ju.t  treat- 
iKvn'  tntlic.ted  on   these  ;^>;^>'M'Py     »  ^n        >>     1  ^^^  ^^^^^  ^ 

,„,nt  ^vhich  has  resulted  l-"*'""/  ^  J^  l\,,^  „,,  w,.ecki,>,^  of  mind, 
on   the   otlu-r  hand,  ^vorry   and   '    '  'f'^:.^;;',„tives  \n  the  nursin.  of  a 

'-»••  "-'  -'■''"■  7]  ^7t  'S  mu  r  "m^ifostations.  attacks  of  tlje 
protracted   case   of   hysteria.      '  "^    '"  "  j.  ,„„,,,  „„„n,nt  and  rarely 

Upors.  the  cryin-  and  weeping  f  ^'1'^.'  ••^,"    ,    j^  he  carefuUv  looke.l  into 
1      ,^,  treatn,ent.    The  phystcjd  -"'^     '  ^^  ^  J,     ,  and  <.nler  in  every- 
and  the  mode  of  lite  regnla  ed  *^''    ;;"      '     Vmnedv  for  tuany  of  these 
„,i„.      A  congenial  --^'J  '"V;      ^^     Jr^Lui  lu^  attended  to  and  a 

;:;;;:i!rStL  pr:^Hhr 

-^rS^:,asafo.daareo.^^ 

;:;^^J^:::;d  in^ilir  Sl>"  ^^-tld  he  .Uhheld.    m  ..  convulsive 


IIYSTKUIA. 


11-21 


un? 


Tli'^ 


icrnionifttT 
1,1  lias  lu't'ii 
lou^Mi  tucir 
n'Mcntnl  si 
I'lu'  Omahii 
m  iiiloiiiiL'il 

nuf'.'slatioiis 

TIU'SC    (llH'S- 

hcrs  is  least 
litiiin.  Tlu' 
wci'iiinji;  and 
ecu  thy  cdn- 

(Icscfil'tion. 

liotwccn  tho 
lul  apt  to  lie 

0  very  dcccl'- 
of  liic  visual 

s.  fj:ivi'  valua- 
4h('sia.  Spo- 
■ia  dl'  hysteria 

lit  imu'l\  (lilli- 
niiitr  teiuk'iuv 

lered  froiii  tlif 
iccossfiil  troat- 
uis.  TIk"  iivst 
on  tilt'  part  of 
scry  which  has 

1  unjust  trcat- 
of  tlie  Iruuhlc; 
•kin<;  ot'  mind, 
ic  nursiiiii:  of  ii 
atta.ks  of  t!'.'' 
ncnt  and  rarely 
ullv  Idokcd  into 

order  in  evcry- 
•  many  of  these 
leiided  to  and  a 
lid  to  the  action 

pains  in  various 
static  electricity 
[n  the  convulsive 


ii;;:-\:f  :;;-:;;■  v:;'';.ri;;-n-t:;;±.:::v 

Ihci.     s.  a,    a  HI  .  Mitchell  savs,  -fat  and  ruddy,  with 

r.therw  <c  111  irood  health,  wlio  ail',  a>  .miuiimi  ..i>  >  . 

1    ,     ,1  .,n>,..tite-:    t>ut   ever  comiihun   ol    pams  and  aelio. 

::;':l;:i;:;u,:';;;:  ^;ot;T;:::i;,.::;  .!.-"■ „.;.,„..„,.„,,,, „..!..  ...i. 

i<  <„'       H    V       ,„.nUl  an.    .■.>n...i..n„l  .„ .»lv.  .;  ""I;"";""  "  '™.""' 

ES-;;;;;;;;;:;:i;:;ri.^;.:::;'::;.rir 

■        n      i,         '^t    diet    n.assaun-,  an.l  electricity.     Separation   troni   Iru'iii^ 
!i  lon<''cr  iiciaod.     n  isc^Miinai  <i.   <i  .  luuv- 

:;?n:^:";.;":..i.K ; -. ;.; .- :;:-,-;:,:::!" ;s;:!;: 

70 


Ij 


s 


.,1* 


^^ 


ll-J-2 


LISKASKS   OV  •i-llH  NKUVOUS  SYSTEM. 

^  a  t\vo-(Ml^c<l  i^wor.l  ami 


u^t  fi'cl  lliat  It  1^ 


XII.    NEURASTHENIA. 


The  term,  nn  old  one.  l)Ut  in.i       I  ,,,.j,  .„„i  ,1,^.  ,.x- 

1^"-^.  .u.tU.y  ..-.,.  ..  7-lX^;:t    :'.''•;■  l.H.aU  li.nit.l  to  jvHain 
,,ression  of  .U.rauj:..Hu.nl  "        V       , ,,  -..anliac,  a,ul  gastric  n.urastlu.n.a. 
,rgans;  lu'iu..  the  trnus  (ru'l.ia        >'^  lu-.v-litary  and  aniunvd. 

"^Etiology.-'Hu.. .......  '-y,'-^: ''',,,  ,i,H  the  sauH.  a.uount  oi 

,„.ve  capital,     l-avcnt.  who  ^^^^^'^^^^^l,,  „,  '....vons  .onn-laints  or 
„f  various  kinds.  ..r  who  '"'-'.  '^\i;/;,i  .,,,,„  ,n  organization  winch  ,s 
of  „>ontal  tronl.U..  may  ^--'''.'t*   ^^^    \      „  ,0  nu.st  call  -  nerve  i<.rce 
dofcctive  in  what.  h,r  want  ot  ■     >^  ^^  ^\    „  ,„,oinithie  pre.iis,,osition,  and 
Sueh  individuals  start  handuappcd  yth  a  I  'patients.     A^^  van 

;„.nish  a  considerahle   V-^V^TZ^Z  c' ^  ^  -  of  the  higher  cnstella- 
(ii....n  sonorously  ,u>ts  .t.       ^^  '    ^  ,  ";,^,,,,,od  by  their  ancestors.^ 

^i,„„  of  their  assoe.at.on  -"<-'.       ,    ,  ...i.v.  whhh  ^ve  have  to  look 
j,,sides  sncl-   forms  ol  '--',.;"„  "aerived  fron.  one  or  both 
i,,,on  as  instances  ol  injury  to  th(   .i-' "  >  .,,  ;,,  ,,  -  i.li  dur.ng 

;;}  tl.e  parents,  there  have  to    -;-;;;,":,;,:,;   i,t..fere,      vith   the 
i„tra-nteriue  lite  there  have  been  "     '^  j.„  j.,,,.  as  these  indi- 

propcr  developnu.nt  and  '^''^''f""  "';    ^;  ,    ,  ,,th  their  life  capital, 

lidials  are  content  to  transact  ^  '         ',  *^      '  ;^.  ^,5^,,,;,,  of  modern  life 
,U  ,,ay  ,0  wcU.  hut  there  .s  ^     ;;,;;;,';,  ,„  ,,  bankrupts, 
these  .mall  capitalists  go  "";^^\""  '         "..vevted  most  readily  in  persons 
(.,)  ..lr</,HV.v/.-'nH'  innctions,  tl  o  g     1   m  ^^  .^^  ^^^^^^^^ 

.1.0  have  inherited  a  feeble  '-^^^^^'^^^f^UuM  is  excessive  in  pro- 
^vith  no  neuropathu.  I'Vcd-spoMtu.       >   exm   ^^^^^  ^^^^^^  ^^^^^.^^.^^  ^^^^^,^^^^^,,^^ 
,tion  to  tin.  strength-.,  c.  h>  st,a  ^^.^^^^_^^_  ,^^^^  j^^  „,,     . 

;„,..„  Uie  gaining  of  a  hvehhood  n  ^  ';,^'  ,„^„^i,,,ted  as  .'on-,.     T  u- 

,,  .,,„ns  the  strain  bcomes  exce>s,  e  "'    '     '  ,  n.n,-essentials,  tnlles 

„,.,,1,„1  ,,„.  v,u.  distinct.on  '-^--"    ^         ^  ,.    ,,  „„nocessary  readiness 
,.,,,,,,  ,,,,,,,ance.  and  the  cm  nv..g.^n^^^^^ 

to  slight  sti.nub.  and  .s  >n  a      a  >  ^^^^_    ^^^^.^^_^^  ^^^^.^,,^  ,,,t, 

vvoakness.     It  sn.h  a  condition  be  <' ^    \  ,  ,,,.    li,,,,]  a  large  pro- 

the  balan,.e  is  Muickly  restored.  ^:\^^^^\^'Z.  cJnntry,  particularly 
,,ortion  of  the  nenrasthenics  -l>-\  rn  14  Neurasthenia  may  follow 
i,nong  business  men.  t-''^--'  ^^^  a.' tvpboid  fever,  and  syphilis, 

the  infectious  dis..ases^  1^"^""^'     '     j,^!  mo  phino  may  lead  to  a  high 

The  alnise  of  certain  drngs.  f^^;^!^;;,,,  ^ore  often  a  result  rather 
,.ade  of  ---;;;--  :;;;^ifo;:;;c:nses  more  subtle,  yet  potent,  and 
than  a  cause  ot  the  neurasuituia. 


NF-rUASTIIKXIA. 


II: 


vortl  ami 

(lilUL'rV. 

luarkt'd. 


I'licy. 
an  il!-<l''- 
1(1  till'  f.\- 
lo  certain 
•ast!\t'nia. 
(■(|\rn't'<l. 
amount  nl" 
in  cxccssos 
iipliiints  or 
in  which  is 

'WO    i'olH'l'." 

)sition,  ami 
s.  As  van 
r  constella- 

iiiHOstors." 
avo  to  look 
me  or  both 
1  it'll  during 
.Ml  with  the 
;  thi'so  indi- 

lilV  caiiital. 
'  niodern  life 

ly  in  persons 
'd  in  persons 
'ssive  in  pro- 
les attendant 
.  hut  in  many 
;  worril.     TIh' 
entials,  trilles 
sary  readiness 
ailed  irritable 
■nt  given  rest, 
d  a  large  pro- 
^■,  particularly 
ia  may  I'oilow 
.  and  syiihilis. 
lead  to  a  high 
a  result  rather 
yet  potent,  and 


less  easily  dealt  with,  arc  tlie  worries  attendant  u|ion  love  alfairs,  religious 
(l(iui)ts,  and  the  sexual  passicui.  Sexual  excesses  have  undiuihledly  lii'<'ii 
exaggerated  as  a  cause  of  neMi'astiienia,  Init  that  they  are  I'espoiisihle  in  a 
iiuiuher  oi'  instances  is  certain. 

The  traumatic  I'orins.  es|iecially  those  i'ullowing  iijion  railway  accidents, 
will  he  separately  considered. 

Symptoms.— These  are  extremely  varied,  aiul  may  he  general  or 
localizt'd;  more  oi'lt'ii  a  ciunhiiiation  of  iioth.  The  apiiearami'  of  the  pa- 
tient is  suggestive,  sometimes  characteristic,  hut  dillicull  to  descrihe.  Im- 
portant information  can  he  gaiiu'd  hy  the  physician  if  he  ohserve  the 
|iaticnt  closely  as  he  enters  thej'oom — the  way  he  is  clothed,  the  maumT 
in  which  hi'  holds  his  hodv,  his  facial  expression,  aiul  the  humor  which  he 


is  in.      Loss  (d'  wciirlit  and  sli;;ht  anainia   mav 


.resent,     'i' 


le  nhvsu'al 


deliility  may  reach  a  high  grade  and  the  jwitieid  may  he  conlined  to  hcd. 
Mentally  the  patients  are  usually  low-s])iriti'd  and  despondent,  in  women 
l're(|iienlly  emotional. 

'i'he  local  symptoms  nuiy  dominate  the  situation,  and  there  have  accord- 
ingly been  descrihed  a  whole  series  (d'  types  of  the  disease — cerehral,  sjiimil, 
cardio-vasciilar,  gastric,  and  sexual.  In  all  forms  there  is  a  striking  lack  of 
accordance  between  the  sym|itoms  of  which  the  ])atient  complains  and  the 
oi)jective  changes  diseoverahle  hy  the  physician.  In  nearlyevery  clinical  type 
(d'  the  disease  the  ])redonunant  sym[)loms  are  referahle  to  patlndogical  sensa- 
tions and  the  ))syehie  ell'ects  id'  these.  Im|ierfcct  sleep  is  aNo  coin|)lained 
of  hy  a  majority  of  patients,  lu',  if  not  complained  of,  is  fouml  to  exist  on 
inquiry. 

In  the  cerebral  or  |)sychie  form  the  symptiUTis  are  chielly  connected  with 
an  inability  to  jierform  the  ordinary  tnental  work.  Thus  a  row  of  figures 
canm.t  be  corri'ctly  added,  the  dictation  or  the  writing  of  a  few  letters  is  a 
source  of  the  greatest  woi'ry,  the  transaction  of  jietty  details  in  business  is 
a  painful  elfort,  and  there  is  loss  of  power  of  ilxed  attention.  AVith  this 
condition  there  may  lie  no  headache,  the  ajipetite  may  be  good,  and  the 
]iatient  may  sleej)  well.  As  a  ride,  however,  there  are  sensations  of  fuhiess 
and  weight  or  flushes,  if  not  actual  headache.  Slee])lessness  is  a  freiiuent 
concomitant  of  the  cerehral  form,  and  may  he  the  first  manifestation. 
Some  of  these  patients  arc  good-tempered  and  cheerfid,  hut  a  majority  are 
moody,  irritable,  and  depressed. 

llypera'sthesia,  especially  to  sensations  of  pain,  is  one  of  the  main  char- 
acteristics of  almost  all  neurasthenic  individuals.  The  sensations  are  nearly 
always  referred  to  some  special  region  of  the  body — the  skin,  eye  muscles, 
the  joints,  the  blood-vessels,  or  the  viscera.  It  is  frequently  [jossible  to 
localize  a  ninidter  of  jioints  ])ainful  to  pressure  (Valleix's  jtoints).  In  some 
patients  there  is  marked  vertigo,  occasionally  even  resemhling  that  id'  ^feni- 
ere's  disease. 

Jt  such  pathological  sensations  continue  for  a  long  time  the  mood  and 
character  of  the  patient  gradually  alter.  The  so-called  "  irrital.le  humor" 
develops,  ^lany  ohnoxiously  egoistic  individuals  met  with  in  daily  life  are 
in  reality  examjdes  of  psychic  nenrasllienia.  Everything  is  complained  of. 
The  individual  demands  the  greatest  consideration  for  his  condition;  feels 


If 


n 


ii 


.■; 


^^ 


DISEASES  OV  'I  HE  M'HVu 


11-2-t  .  „„,   .,l\v;iv>  iliimO(UrttPl} 

'"1,;;:;;,!;^;;  .«„..  «■"-> -;^,;::,:"- :":'i!r:;;;;.;.;> .;  -  ;-;t 
r";::::;;'^:' u.r;£t.  r.n;..";^. ;.;:;;-::  :s;to,^:.n 

rpi,,    l'<"ir  o    IH'npli' 1111(1  "1  '"^  '     .  ,      1  .,(,,, ,li()l)iii,  <>'    >"'    '^'       ,. 

« j^;^„t  t„c  eye'*  *'i;;sr  ;>'" «:.;  -;■"«  .r'^c^^;,:"; 


NKL'RASTHHNIA. 


1125 


notVirttoly 

HIS  plcii'*- 
1'  mu'oin- 
uisiiniU"'- 

.  a  vcloir. 
.  cxistciu'i' 

linii;  ilciiVli 
soim-wlu'if 
lU'ii,  in  U\t' 

avc  ri'slU'SS, 
'I'hoy  may 
uikiiig  I'on- 
lii's  are  not 
ctually  tak'.' 

patient  (oni- 
,p  „r  control 
.jisos  tlK'Vc  is 
0(1  up  owin}!; 
uil)U!  to  form 
Son\ctimt's 

nu'loily.  oi'  ^1 
lolisli  it. 
.(1  "  ])hol)ias"' 
ihin,  in  whiili 
,pj.o<si'<l  l)y  an 
u  death,"  and 
1  of  the  tliorax 
(M'spiration  and 
liU  they  cannot 
ojien  space  can 
■vcn  by  a  t-hiUl, 
fraid  to  be  left 
lausti'ophohia)- 
li,.l)ia.     A  whole 
,„.  the  I'cav  that 
orodror.iophohia, 

fear  of  tlumder 
•lu)  are  afraid  of 
phobia, 
n      All  aching  or 

.„lH>s  of  ligbt  '1^*^ 

nervous  or  nen- 

111.     According  to 


r.in^wnncer,  t1ic  oPsonce  of  the  astheiiopie  dislnrhnnro  consi>ts  m   patho- 
lo.rieal  srnsations  of  fati-ue  in  the  eiliaiy  mu-eh's  or  llie  medial  ivdi. 

Then'  may  he  aemislu'  .li>turhanees— hypcraljiesia  and  e\.n  true  liypd'- 

(ii'ie  of  the  most  common  of  all  the  >ymploms  of  neiirasthmia  is  tlie 
pirs.inr  In  Ihr  hnul  .•omplaiiied  of  hy  these  palic.ds.  This  symptom,  vari- 
ously deserihed,  may  he  dilVuse,  imt  is  more  ire.pieiilly  lelened  to  >ome  one 
,.,,ui,"„i— frontal,  temporal,  parietal,  or  occipital.* 

When    llie   siiiiuil   si/iii plows    pred..mimite— spinal    irrilatKUi    or   spinal 
neurasthenia— in   addition   to   many   (d'   the   features  ju>t    mentioned,   the 
p..tients  complain  (d'  wearinc-s  on  the  least  exertion,  (d'  weakness,  pam   in 
Ihc  hack    intercostal  iicural^dForm  imins.  and  of  achinji  pains  in  the  h^s- 
There  mav  he  spots  of  local  tenderness  on  the  spine,     'i'iie  ra<'hial-ia  may 
he  spontaneous,  or  mav  he  notice.!  only  on   pressure  or  luovemenl.     Occa- 
si.mallv  there  mav  he'disturhanees  of  sensation,  particularly  a   ieclin-  ol 
nunihi'iess  and  tin-lin-,  and  the  retlexes  may  he  increased.     \  isceral  iieural- 
-das,  cspcciallv  in  connection  with  the  },rcnital  or^'ans,  are  frcipiently  met 
with      The  ac'hinji  imin  in  the  hack  or  in  the  hack  of  the  ne(dv  is  the  mo,-t 
constant  comidaint  in  tlie.<e  cases,     in  women  it  is  .d'ten  iinpossihlc  to  say 
whether  this  condition  is  one  of  neurasthenia  or  hysteria.     It  is  in  tlicM' 
cases  that  the  disturbances  of  mn.^cu'ar  activity  are  most  pronouiice<l.  and 
in  the   French  writin-s  amiioMhcnin  particularly  plays  an   imporlant    wh. 
The  symptoms  may  ho  irritative  or  paretic,  or  a  combination  of  both.     Dis- 
turbances of  coilniination  arc  not  nncommon  in  the  severer  f.unis.     These 
are  particularlv  |>rone  to  involve  the  associated  niovomonts  ot  the  eye  miis- 
cle<  Icadimr  to  asthenopic  lack  of  acconiniodation.     Droopinj,'  ol  one  eyehd 
i<  verv  common,  probablv  owinj^  to  insullicient  innervation  on  th.'  i^arl  ol 
the  sYmi)athetic  rather  than  to  paresis  of  the  nervns  oculoniotonus.     Oc- 
casionally Komhcr-'s  svm])tom  may  he  jiresent,  an<i  the  patient,  or  even  Ins 
i.hvsician,  mav  fear  a  hcfxinnin-  tabes.     More  randy  there  is  disturhance  ol 
such  iinely  coiinlinated  acts  as  writinj:  ami  articulation,  not  unlike  thos.- 
seen  at  the  onset  of  fieneral  pan'sis.     Such  symptoms  are  always  aarmmg, 
and  the  -reatest  care  must  he  taken  in  establishing  a  dia-n..sis.        hat  they 
may  be  the  syml.t.nns  of  pure  neurasthenia,  however,  can   no  longer  he 

'""tIk"' reflexes  in  neurasthenia   are  usually   imTcased,  the  .leep   rcilexes 
especially  never  being  absent.     The  .■on.lition  of  <h..  superli<ial  relle.xes  is 
less  constant,  though  these,  t<.o,  arc  usually  imMvas..!.    The  pupils  are  <.ltcn 
dilated,  and  the  roflexos  arc  usually  normal.    There  may  he  iiie.iual.ty  ol  the 
pupils  in  neurasthenia,  a  i.oint  which  I'clizacus  has  especially  cmphaH/.cd. 
In  another  tvpe  of  cases  the  muscular  weakness  is  extreme,  and  may  go 
on  even  to  complete  motor  helplessness.     Very  thorough  examination   ,s 
necessary  before  de(dding  as  to  the  nature  of  the  alfootion,  sinco  m  sonui 
*  For  an  oxliaustivo  oonsi.l.rntion  of  tl.o  mcnlnl  symptoms  of  „e.inistlu-nia,  spo  llu^ 
Sliattuck  Lnoture,  l,v  Cowlcs  (i5ost.m  Mo.lioal  and  Sarjiioal  Jo.mml,  IW.t).  '^^^^^'^'H  f' ^^j' 
Gorman  monograi.h's,  tliat  ot  tJinswan.n.r  (ISilOl.  aiul  that  of  r.owcnf.'R       h-   1  -'hL 
tivaUs.  of  Bouvcvt,  (180t)  is  also  valual.lc.     F.  C  M-dlor's  nandl3ucU  Jcr  Ncurastluiuo 
(Leipzig,  1893)  contains  an  excellent  bibliography  of  this  sal);ect. 


DISEASES  OK  TllK   NKUVOUS  SYSTKM. 
1120  , 

instances  .orious  n.istak.s  have     -"  nuul^       >;[;,;  ,„,„,  .,  ,,,„,, 
Ncltd.  the  ah-inrsia  nhjnv  ..I  Mnl.m.«.  and  llu 

„/,««,<,  .h.scril.e.l  >•>■   '''"'^''"^"''■;.,„.  ,  .vnn.t.Mus  are  the  nu.st   .listressii.-. 
m  otluT  eases  the  ;'"•' ^V ";,,,''   ,'n,.,  ........hro-spinal  r..neti.n,.. 

,,„,,  „„y  oec.ur  with  ..nlv  '^''^'l  V  U   v        nhine.l.     I'alpitatiun  of  the  l.avt. 
though  the  eondil.ons  are  nearly  ^  !'  ,,,,,,.,;.,ia).  and  ,.an.s  an.l 

i,,.,,ular  an.l  very  rapu    -'  "         ,    \„,.  ,,.,  ,„„.,  ..,„unun  syn.pton.s. 

organ.     Attaek^  otpsenao-anj^nan^ '>;;•- ^  ,,^,„,,   .,,    ,„,,,    eases. 

V''-''''''''^''-'''''''Xi      tin         nU  a   a   transient   hyperaMnia  of  the 
Flushes  ..f  iH.it,  esi.eeiall>  m  tin    n  a  sweatin-    n.ay    o.'enr, 

.kin   n.ay   he   very   f  ^n^sn,,  W -■«'':,,.,„,,,  ^ 

either  loeal  or  general.  ->--;-    -^         j  „,  J  ,„,,,,,,,,,  arfr.ohs. 
csting  tVatnres,  0M.no- to  the  ex  u         eu^  ^^^^^^^^^^  ^^^  ^^^^^^,,^  ^^^  „, 

The  arterial  throhhin^  n^ay    .e  ^^-^^      ^  \,,,,,^„.  j,„„„  ..in.un.stan.rs  have 
aortic  insutVeieney.     The  pulse     on,  m  >   nn  ^^^^^   ^^^^  ^^,^,^^   .,^ 

a  son.ewhat  water-hannner  'l^'^l'^y-  .  / '  ,.  "\'  .iraw..  npon  he  f-nrhea.!, 
the  nails,  on  the  lips  or  on  the  >"-|;'-  ^^j^i^^  ;  Vv.iL  ot  the  hael<  ..t 
a„d  I  have  on  several  occasions  ^^^V^^  ^^,  ;,  the  Ihmhhh,!  noriu 
the  hand.  A  ^^-^^^'f  ;;.:^";  ^  e,n^  r  un.."  as  Allan  Uurns  calls 
This  "  preternatural  l'"'^.  ^  "  'J^  ^^  t,ie  existence  of  ah.lon.inal  anen- 
it.  may  he  extremely  iore.hle  '^"''  ;-  '  J;^.;^^,  j^  n.ay  he  verv  nnpleasant, 
ri.ni     The  suhjective  sensations  associated  wun 

particnlarly  when  the  ston.ach  .s  emvty^  ,„riphoral  hlood-ves- 

1„  women  especially,  ami  ^^  >"-">.        n  1       1  ^^^  ^^^^_^__  ^^^^^^  ^^^^^ 

sels  are  eontractecl  the  -trenut^  Jn  "l^el  much  more  comtortahle 

face  has  a  pinched  expression.     ^]^^^^'^^^\,,,,^  to  various  means  to 
when  the  entaneons  vessels  '^■■f'      ;;"'',;  "i,,.n,lo  stimulants), 
favor  this  (wearing  of  heavy  <•!"      '  ^'^  '  "    ,  //,nna  have  heen  dealt 

Tho  general  features  ot  ,„.^•/^M»/^s  n  -/  '/''/^.^^.^..tion  of  these  eases 

-;rd;^:;"::r:n:l=:^St.n:^:..^ 

l^jrXeL.,..^  m.  alreinly  ^^l^^^;^'^  au  irritahle  weaK- 

easv  prev  to  qna<d<s  and  charlatans  "^^ ;^1\ 5;'   '^;.  ,,,      ,,,,,;„  of  c<m- 

■Spermatorrluva  is  the  hnghear  ot  the  "^^  ^     :^„.  ,    ,\,„  Jions.     After 

ti,.ull  losses,  nsually  witliont  ---;i;-;;2';:;:t," Microscopic  ex- 

,.f..ation  or  mi.;tur,t.on  ^  ;:'';;  ^      ';  ,^::;;':!,';:„,to.oa.     A.^tual  nervous 

•:;:::;;:  ;r;;;::n:o:;;:::;'.'n>'  -  .-^^-^  ^-^'^■^^"  '^  -  ^-'^-^^""^^"  "^"• 

"1;:  thJ'l^or"::;.  especially  those  hearing  the  .tigmata  of  degenera- 


NKl'UASTllRNIA. 


112; 


'rcDiiif  of 
)!'  asldsiii 

sti'i'ssiiij:. 

llu'  111  art, 
|)iuns  iiiui 
.viiijttonis. 
ilic  hciii't. 
Ill  till'  I'ii- 
usc  of  \\\\^ 

any  rii!^o>»- 
Ilia  of  tlx' 
nay  oiriir, 
show  intiT- 
1  arti'i'iolis. 
inicli  iis  in 

aiii'i't*  hiivo 

1)1'  si'i'ii  in 
le  fori'liriul, 
till'  l)iirk  of 
hhiiiil  aorl'i. 

liiirnH  ciill^ 
niiiiiil  iiiuni- 

luipk'asant, 

\\  blood-vi's- 
)liu',  and  tlio 
conifortahlo 
Ills  mrans  to 
lilts). 

0  lu'cti  dealt 
r>f  those  cases 
dition  which 

■ritahle  weak- 
,  unusual  dc- 
of  inipotciice. 

1  they  fall  an 

iiplain  of  con- 
lations.  After 
licroscopic  t-x- 
\ctnal  nervous 
.■ll-known  neu- 

ta  of  degenura- 


ti„ii  there  iiiav  he  evidence  of  sexual  |.erversion.  Tlie  -  daninahle  itera- 
ti„n'"  with  ul.ieh  writers  in  nur  ranks  "dish  U|.  "  this  uniileasai.l  siii.jeet 
is  proof  positive  that   not  all   pn.phets  speak  to  edilieatioii. 

ill  females  it  is  eouiinon  to  liii.l  a  tender  ovary,  and  painful  or  irregular 

ineiistruatioii.  ...  ,      , 

In  all  forms  .d'  neurasthenia  the  eouditiiui  (d'  the  urine  is  important. 
Many  cases  are  e.uuplieated  with  the  symptoms  of  the  eonditioii  known 
as  lit'luemia,  and  ,<o  marked  may  this  he  that  s(Uiie  have  iiidee.l  made  a  spc- 
eial  h.rm  of  litluemic  neurasthenia.  Polyuria  may  l.e  present,  luit  is  more 
..onunon   in   hysteria.     Willi   disturhed   di-vstion   the   urates  and   oxalates 

mav  he   in   cxee-s.  ^  ,        ,.  n 

Diagnosis.— While  in  the  majority  of  cases  the  diagnosis  eaii  readily 
he  made,  still  there  are  instances  in  which  it  is  very  dillieult.     Neurasthenia 
ovcrlai-s'livpoclumdria  and  hysteria  on  the  mie  iiand.  ami  the  psyelioses  and 
dejicnerative  diseases  of  the  nervous  system  on  the  oilier.     The  term  has 
in^the  past   heeii  alto<;etlier  too  loosely  \\^<-^\.     Simple  local   disturbances 
and  tcmporarv  ^^'ueral  disturhances  the  result  of  sudden  overexertion  should 
scarcely  he  (jia-rnoscd  as  neurasthenia.     Only  when   we  have  before  us  a 
..linicai  piiture  indicatinfr  .rcneral  weakness  of  the  nervous  system  in  addi- 
tion to  the  local  disturhances,  no  matter  how  i)ronoiinced  they  are.  is  the 
.iia.Miosis  justiliable.     Charcot  has  desijrnated  as  neurasllienic  sti.Lnuata  cer- 
tain fuiHlamental  and  tvpi.'al  symptoms,  sueli  as  the  pain  ami   pressure  m 
Ike  head,  the  di^t^lrhanees  of  sleep,  the  rhachialuia  and  spinal    hypencs- 
thesia,  the  miiseiilar  weakness,  the  nervous  dyspepsia,  the  disturbances  of 
the  'a'uital  orjiiins.  and   the  tvpical  mental   phenomena  (irritable  humor, 
iisycfiic  depression.  IVcliii.us  of  anxiety,  intellectual  fatif,nic,  incai)acity  ol 
decision,  and  the  like),     in  a.ldition  to  thc^c  cardinal  symptoms  of  the  dis- 
ease  he  described  as  secondarv  m'  accessory  symptoms  the  feelin-is  of  dizzi- 
ness'and  verti-^o.  the  iieiirast'henic  a.sthenopia,  the  eirciilatory,  respiratory, 
Hccretory,  amrmitritive  di>tiirbances.  disturbances  of  motility  and  sensa- 
tion the  fever  of  neurasthenia,  and  neurasthenic  idiosyncrasies.   The  anxiety 
..ouiiiti.ms  and  various  phobias,  as  well  as  the  dilVerent  varieli.s  ot  tic  and 
the  occupation  neuroses  when  they  accompany  neiirastnenia.  are  rejrarde.l 
„s  i.omi.lications  dependent  in  the  niaj(.rity  of  instances  upon  taulty  liend- 
itv      1  must  aj:rec  with  l',inswan,avr  in  empliasizin.u^  the  niiportance  lor  the 
di'a<rnosis  of  tlm  iieculiar  intellectual  and  emotional  e„ndition  of  the  patient, 
as  well  as  the  disturbances  of  sleep. 

Neurasthenia  is  a  disease  above  all  others  which  has  to  be  diajinosed 
from  the  subiective  statements  of  the  iiatient,  and  from  an  observati.ni  ot 
bis  ..eneral  i.ehavior  rather  than  from  the  physieal  examination  Ihc 
phvsical  examination  is  of  the  lii-hest  importance  in  excludino-  other  dis- 
eases likely  to  be  eonfouiuhd  with  it.  ^riiat  somatie  eban.u-es  oceur  ami  that 
plu-ical  sions  are  .d'ten  to  be  ma.le  out  is  very  true,  and  we  owe  to  Lowen- 
fiYd  cspeciiilly  a  careful  disiussion  of  these  jioints.  but  there  is  nothin-r 
tviiical  or  pathounonionic  in  these  objective  chan,u-es. 

'  The  hvpoch.mdriae  dilVers  frmu  the  neurasthenic  in  the  excessive  psychic 
ijistortion  of  the  imtludo-ical  sensations  to  which  he  is  subject.  lie  is 
the  victim  of  actual  de.usioiis  regard iiii.'  his  eoiidili<ni. 


v. 


lliiS 


,„SHAS,«  »1-  ■ni.-.  NKKV.'l'S  SVST,™. 


till    lU'il'l'    i'l'<''l>"'"* '•    '"' 

T -.("> '  "'■'"""'"■"r,:;';l!, ;  toi'u- ' i-  »;"■'■  "■  r;!';- 

:^;r. r\;:-j;\rz:':::J'^ ^' "ri,;:;;:*'::"."::'; 

'"^"-  "'^i;;:'ij:;;^x':-i ;»"  ;^-"' ' " --'^  '^ 

Kniluusv  is  not   hk.ly  to  1      ^'"         .      ,,-,  ,,,,/  Hu.y  iM'  iu,,7,lin-. 
.U.n     to  q.il.'pti^'  allacks.  l.ul  Hh'  -  -    '       ;'  ^„,  ,H,„n>stlu.n.. 

"'^"!!  ,  .,J,   or  c.xo,,hll.al..nr  K'U  ..  n    >  ^^^     ,      -n,.  .-noUonMl 

■  t    r.l-..lvl0lH'   COlltollI"'''''    ""    l'>"'-  •-  ,,        .l,„,j.    of     till' 

::r;;::;;;,:;r;'TJ:';;;Si"Vi;;:,.,.a,..,..^ 

veneration  ton  lato  for  -»t.slactm>    u-^nu  n  '  ^^^^^^^^^^  ^^^  ^^^^,^        tlu, 

t,.torc  tbo  oxhaust.Hl  oaintal.      I  bo  ^    ^^  j,,„„,  ^  very  early  a^a 


NEURASTIIF.NIA. 


ill'K 


ill  vfiili'y 
•riciil  l»iii'- 
tiiiil  cliiii- 
^lu)\il'l  l>nl 
livsU'rifiil 
nivstlu'sias, 
i.isis  is  iiKt 

if  \\\vyv  III' 

lin^;. 

ruvustlx'iiiii. 
^y  (Mnntiiiiial 
^,  |,l,ysic'iiiii. 
lu-nosis  fniin 

1  which  iii'ii- 
l„„rsi..    'riH' 

Iho.^i-  of   ll"' 
I'di'in  ol'  nci\- 
lu'  (liii^Miosis. 
maki'  a  thov- 
a  v',w  tliat  is 
,1'  the  sfusory 
u<  will  always 
iiiiTsis  there  is 
U'H  chanu-tei- 
(irdinavy  ncu- 
,,  u'vivvc  nature 
iv,  iierhaiis  ju-t 
•ase  oi'  j;eneral 
.,1  neurasthenia 

.It.vel.il'i"'^'  1''^' 
(if  itsyehie  ox- 
I  wluni  llie  his- 
,.  facial  or  uuis- 
lij;  „r  (if  chronic 
lianstion  shouhl. 
louia  be  sharply 
larapbariia,  facial 

ider  our  care  a 
1h'  imiiossihlc  to 
bo  taken  in  the 
a  very  early  a^o 
ing,"  every  effort 
on.  F'Vcn  in  in- 
eatest  care  sboubl 


be  exerciscil  with   re;.'anl  to   fcind.  s!i'('|).  and  scIkkiI   work.      ('oiniilaihl<  of 
children  slKiidd  not  lie  lno  -erioii-ly  considcrcil. 

MikIi  dc|peiids  n|Miii  the  cxaniiiie  set  liy  the  |iareii(-;.  A  re>t!es-,  cino- 
tionai.  cdii-lantly  e(iiii|ilaiiiinii  mother  will  rack  the  nervous  system  of  a 
delicate  child.  In  x^iiic  in-lances,  lor  the  ueHare  of  a  developing,'  boy  or 
|,Mrl.  the  |ihy>iciaii  may  lind  it  iicce-sary  to  advise  its  removal  from 
hiimc. 

Ni'uriitic  (hildreii  are  es|iecially  lialile  during'  dexelniimeiil  to  lils  of 
temper  and  of  emotional  distnrhance.  These  should  not  he  too  li;,ditly 
considereil.  .\lieve  all.  violent  ehastisemeid  in  such  cases  is  to  he  avoided, 
and  loss  of  temper  on  the  part  of  the  |)ai'ent  or  teacher  is  |iarlicularly  per- 
nici(Mis  for  the  nervous  svslem  of  the  child.  Where  pos-ihle,  in  such  in- 
stances, the  best  ti'eatmeni  is  to  |int  the  (ih>tri'|ieriuis  child  immediately  to 
hed,  and  if  the  excilemeiit  ami  temper  continue  a  warm  hath  hdlowed  iiy 
a  cool  doiich  may  lie  elVective.  Jf  he  he  pnt  to  lieil  after  the  hath  sleej)  soon 
follows. 

Sjiecial  attention  is  necessary  at  puberty  in  both  hoys  and  L;irls.  If 
there  heat  this  period  any  marked  tendeiu^y  to  emotional  distnrhance  oi'  to 
intelleclMal  weakness  the  child  shonid  he  removed  from  school  and  every 
cai'e  taken  to  avoid  iinfavoi'alile  inlluences, 

I'l'iyaiKil  lli/ijiriir. — 'riironjihont  life  individnals  of  neuropathic  predis- 
position should  ohey  sci'upulonsly  certain  hy^iieiiic  and  prophylactic  rides. 
Intellectual  work  especially  should  lie  Jiidici(Uisly  limited  and  should  alter- 
nate freiiuently  with  jieriods  of  I'epose.  Ivvcitemeiit  of  all  kimls  f-lionid  of 
course  be  avoided,  and  such  individuals  wdl  do  well  to  he  ahstennous  in 
the  use  of  tobacco,  tea.  coil'ee,  and  alcohol,  if,  indeed,  they  he  permitted  to 
use  these  substances  at  all.  The  habit,  happily  in  this  country  becoming' 
very  common,  of  takinj^  at  least  once  a  year  a  prolon.ued  holiday  away  from 
the  ordinary  environment,  in  the  woods,  in  the  mountains,  or  at  the  sea- 
shore, shoiild  he  urgently  eiijoine-d  ii|)on  every  neiiropathii'  individual.  In 
many  instances  it  is  found  to  be  the  lii'eatesl  relief  ami  rest  if  the  patient 
can  take  his  holiday  away  from  his  relatives. 

Durin^r  ordinary  life  nervous  people  should,  durinir  some  portion  of 
each  day,  pay  rational  attention  to  ilie  body.  Cold  baths,  swimming',  exer- 
cises in  the  fzymiiasium,  jrardoninfr,  j^olf,  lawn  tennis,  cricket,  liiintinjr, 
shootinir.  rowinji,  sailinir.  and  bicycling''  are  of  value  in  maintainiiiLr  the 
{Xeiieral  nutrition.  Such  exercises  are.  of  course,  to  be  recommended  only 
to  individuals  physically  eipial  to  tlu'in.  If  lu-urasthenia  lie  once  well  de- 
veloped the  trreatest  care  innst  be  observed  in  the  ordering  of  exercise. 
Many  nervous  <rirls  have  been  c()ini)letely  broken  down  by  following  injudi- 
cious advice  with  rofxard  to  long  walks. 

Trcnlntdil  of  llic  Comlllion. — The  treatmerd  of  neurasthenia  when  once 
established  ])resonts  a  varied  problem  to  the  tlioufxhtful  physician.  Every 
case  must  be  handled  u])on  its  own  merits,  no  two,  as  a  riile,  requirini,'  ex- 
actly the  same  nu'thods.  In  ^acneral  it  will  be  the  aim  of  the  medical 
adviser  to  renuive  the  ])atient  as  far  as  jiossible  from  the  influences  which 
have  led  to  his  downfall,  and  to  restore  to  normal  the  nervous  mechanisms 
which  luive  been  weakened  by  injuricnis  influences.     The  general  character 


^^ 


„f  ilic  iiiilividiKil.  hi<  I'll; 


DISKASKS  OF  'IMII",   NKItVors  SYS'I'F.M. 

.„|,v>i.;,l  ;n>a  so..i;il  statu,  .nu-1   of  .nur.r  I-  .-mm. 


,•;l;;v^;;,;';;::;v;;■:;^:;''::-rn;i:;;/':^ .> --■.i..,-'-,,. 

mill  tins  lie  \Mll  'i"'i  "I"  "  "  .  ,  1   I     ,    II   ,i„.  niiiciil    lictdit'    If  has  caiv- 

!»■  ilis^uisc.l.  ...  „i    ,1,,.  nhv.iciaii  inav  assiin- tlu>  i.atuMit 

.,r  xviU  uill  In.  n.v.l.-.l  to  fnrtluT  the  i.n.^;iv»  ul  the   urn 
,:L  or  pn.i'..ssiunal  ...n.  in  .l.un,  th.  7-';';;;.;^;  ,;!,,::;  .Uh 

cliimac  li    «i-i'"<.  iii"l  ''"''■     -^  "'I'  ."""■"'■  '  ,lv-,„.ii-ii   a  iv'i- 

li..n. , <  .I-  sr-  .Ml  ,«uii.v  ,n.v..  "'1;;;  ;„„.",.",    I,:",,,. 

r.::';;\;:T,:;;;;;:..™2;'i":;i-i™'''^- ^^^ »..■"' 


rrnni  him.     Tlir  physi.ian  wiinnakr  a  uus- 


;  1      !•  1,1    n.nilar  vi-it-     The  .•h..-uc  oi  a  nurse  is  hy  no  means  an 

"'''    ;;        ...li    n      an   'the    lirst    ..msideraiinns.      Sallow-laeea,   emu- 
;•  ;::re  e;     o      n  ea,.   only  do  haim   i.'  .letailed   to  the  cai.  of  a 


iMa 


NKIKASTIIKNIA. 


li:;i 


he  ((iil-in- 

lis  imtii'iit. 
he  indiNiil- 
if  liiis  ciin'- 
iriiulilis  iiri' 
iliciiic  thai 
ic  ('(lucalnl-. 
Mv^ii  has  In 

till'  iiatifiil 
li  till'  |>liy.-i- 

:\\\A    lit'   tiilil 
11    viji'iiriiiis 
liis   stri'iij-'tli 
1  llic  case  (if 
^  i\<  a  roiilt 
itc  rest   willi 
■  11   lllnlltll   '"' 
cji^ia.  a  rc-i- 
xcitciiiciil  "f 
disease   lias 
jrer  the  tiiin' 
y  the  Jiatiellt 
isiiiess.  under 
iiiv  dl'  cniirse 

ml   i'dP  a    IVw 
him  awav  <in 
s  n'(|iiii'(.'(l  oil 
hiiuld  not  see 
luh  he  should 
I  make  a  inis- 
lieiit    hetween 
•  III)  iiu'ans  an 
hv    no    uu'ans 
w-l'aeed.    emo- 
the  eai'c  of  a 

rammo.  uhiili 
he  need  know- 
he  nurse.  As 
•xereises,  alter- 
in;iy  he  under- 
itr,  correspond- 
nj,'  of  letters  is 
r  limited.  Cul- 
painting.  mod- 


cllin^r.  translating  fioin  a  t'ureign  hingiiage.  the  making  of  ah-traels,  etc, 
fur  sliurl  peritids  in  the  day. 

In  iii)t  a  leu  cases,  including  a  large  |iri>pnrtiiiii  df  neurasthenic  unnn  n, 
a  systematic  Weir  Mitchell  treatment  rigidly  I'arried  (Uit  shniild  he  tried 
(see  llvsliria).  I'or  (pli>timite  and  prolrai'tcil  ca--,  parlieiilarly  if  euiii- 
hined  with  the  chloral  or  morphia  lialiit.  im  uther  plan  is  so  satisl'aclory. 
The  pjitieiil  iiiii>t  he  isnjiited  from  his  friciiils.  iind  any  regiilalioiis  under- 
taken imi-t  he  .-irictly  adhered  to.  the  coiisi'iit  of  the  patient  and  his  himily 
inning  lirst  heeii  gained,  if  th  '  cax'  rcspDinls  well  to  tin'  Irealmeiil  there 
siionld  he  a  gain  nf  t'lniii  •.'  to  1  pounds  per  week,  'i'lie  heiielil  is  nl'leii 
extraordinary,  individual  increasing  in  wfig'  <  as  much  as  from  "lO  to  SO 
pounds  in  the  course  of  twelve  weeks.  'i"he  tie  itnieiil  of  the  gastric  and  in- 
testinal >ynipliini<  so  important  in  this  coniio  m  has  already  hceii  con- 
sidered, i'or  the  iri'egiiliir  paiii~.  parlicnlar  !y  in  the  hack  and  neck,  the 
tlu'riiio-caiitery  is  invaliiahle. 

Hydrotherapy  is  iiidinited  in  nearly  evi  ry  case  if  it  can  he  properly 
iipplied.  Milch  can  lie  done  at  home  or  in  an  ordinary  hospital,  hut  for 
systematic  liydrotherapeiitic  treatment  roideiice  in  a  siiitahle  sunilariiim  is 
necessary.  I  have  found  the  wei  pack  of  especial  \aliie.  i'nrlicnliiiiy  at 
iiiglit  ill  cases  of  sleeplessness  it  i»  perhaps  the  liest  remedy  against  iii- 
somniii  we  have.  Some  patients  gain  rapidly  in  weight  through  the  sys- 
tematic use  of  the  wet  pack.  Suit  hatlis  nic  more  helpful  to  some  patients. 
'I'lio  various  forms  id'  douches,  partial  packs,  foot  haths,  etc.,  may  lie  valii- 
ahlc  in  individual  cases.  The  Scotch  duuelio  is  ol'tfii  invigorating  in  Iho 
milder  cases. 

I'^lectrothcraiiy  is  of  some  value,  though  only  in  coinhiiiation  with  psy- 
chic treatment  and  hyilrotherapy.  (ieiieral  and  local  faradi/atioii,  galvanic 
electricity,  and  iManklinizatioii  may  he  u^vA;  in  every  case,  hinvover,  with 
great  caution  and  luily  hy  skilled  operators. 

'i'reatnieiit  hy  drugs  should  he  avoided  as  much  as  possihle.  'i'liey  are 
of  henellt  chieliy  in  the  comhating  of  single  symptmiis.  .\  placeho  is 
sometimes  necessary  hir  its  psyidiic  ell'ect.  .\lcohol,  morphia,  chloral,  or  co- 
caine should  never  he  given,  'i'lie  family  physician  is  often  respoiisihle  for 
the  development  (d'  a  drug  liaiiit.  i  have  lieeii  repeatedly  shoi'ki:d  hy  tlu! 
loose,  careless  way  in  which  pliy>icians  inject  nioriihia  for  a  simple  head- 
aclu'  or  a  mild  neuralgia. 

Ueneral  tonics  may  he  helpful,  esjiecially  if  the  individual  he  aiiii'mic. 
.Arsoiiic  and  more  often  iron  are  tlu  n  indicated.  'J'lie  value  uf  phospluMais 
has  licen  exaggerated.  l'"or  the  severer  pains  and  nervous  attacks  some 
sedative  may  occasionally  he  necessary.  cs|)ecially  at  the  heginning  of  tht! 
treatment,  'i'lie  hroniides.  es|)ecially  a  mixture  of  the  salts  of  ainiiKHiimii. 
potassium,  and  sodium  may  here  he  given  with  advantage.  An  occasiiuial 
dose  of  pheiiacetin.  antipyrin.  or  salipyrin  may  he  re(|>iire(l,  hut  the  le.ss  of 
these  suiistances  we  can  get  along  with  tlio  hetter.  i'or  the  relief  of  sloop- 
lessiK'SS  all  ])ossihle  measures  should  he  resorted  to  hel'ore  the  einiiloyinent  of 
drugs,  'i'lie  wet  pack  will  usually  suflico.  If  ahsoiutely  uecessary  to  givo 
a  drug,  siilphonal.  trional.  or  amylene  hydrate  may  be  omployed. 

Ill  ca.sos  in  which  the  anxietv  conditions  are  disturbing,  tho  cautious  use 


mSEASES  OF  THE  NERVOrS  SYSTEM. 

;„,.,.    .,^  in  \h<'  i-svchosos.  opnnii 

,j,„Ha  ,.,lu.v.u.r,  never  nec.e..u>  in  .u> 

XUl     THE  TRAUMATIC    NEUROSES 

,^.\.aihvay  brain"  and  ••  va,hva>^n-  _^^  i„na,nmation  of  the 

Knchsen  re.ar.le.l  tl,e  -->'    <"^,^;^ ,    ' ,,,   ,„,,,..   ...ine.     Walton    an.l 

,,,„„,..  an.l   eur.l.   and    ^a^e       ^        "       ,.,,,..,,•   ,„.  hysteri..!  natmv 

i.t.;:r:r;;;/:Utr:;;;;i;:;w::;;:r..n,n.^ 

^i^,,,  ,,  l,i,,a.es  or  the  Nervous  Syj4.a,u|  ^^^^^^^_    ^^^^^,^^    .,^    ^^    ,,,•,,,,, 

Etiology. -n.e   eun.h  >on    '  "     ^  ^J'\,,.  ^„,.^,„,a,  a  shock  or  <-...u..s- 

^-- '"  ^^"'^-'^  "T"^ "  ^;:;:; ; ;  ii  -H.t  have  smrerea  m  ms  hodv. 

sion.  fnnn  whieh  the  patH.n    n,.>>  .  M    K  ^^    .^_  ^^^  ^,^,^„^   ^^       ,,k   or 

A   n.an   n.ay  ap,H-ar  T-rfeell>  '  ,^,^j^      ,,,.,i,,    u.^k  o 

n>ore.  and  then  develop  the  ^>      't      >  ,.  ,,,^^.  ,,  ,,,,,„nd  n,en tal 

,„u.nssion  is  not  necessary.  J^J^^]^^^,^  ^/,nild.  and  received  thereby 
i,„,,ression:  thns,  an  ''f'''-^^'^X\u.h  tl>e  nx.^t  prononnceo  syn>pton>s 
,  4ry  severe  shock.  f-^^':^^^;Znin\  strain  con,bin..d  ^vith  bod.ly 
of  m-urastbenia   deve  oped.     N  ^^^^^^^^  ^^^^.^^,^  ^^.,^^,  ^^.^^^  ,,,,,,,    ,n 

.xposnre  n.ay  eanse  .t.  as  "    "^  j.''  t,,,„  .,  day   in  the  ri-inj^  belore 

,  VH>lent  storn.  '-^-j;-;;;;,;;';,';:,;  f,on.  a  carriage  or  on  the  stairs  nu.y 
he  was  rescued.     .\  .  i  ,- 

^"tl'""-  m      ,.,.,.■   Tinv  bo   divided   into  three   groups:  simp  |' 

Symptom8.-n,e  c     -      a     b.;^^^^^      n>anifestations,  and  cases  w,th 

neurasthenia,  eases    ^."'  , '  Inulatin-  organic  disease, 

severe  svn.ptonis  nul.cat.ng   n  ^"'  "'>."-      [    ^.    ^  svniptmns  usually  de- 
""(.)  ,in,plr  '/•'-'-'''•^^^^'''•"^    :?';;:;;  J\^  V  or  n!av  not   have  been 
vclop  a  few  weeks  after    be  --'  ^'•■t;    ^'  ^^^  ;^  ,„„,,ains   of   headache 
,,.oiated    with   an    actual     '•''7'^,,'/,^^,',,,,,,^  unable  to  concentrate 
luHl  tired  feelings.      He  >s  ^U'epU-    ->  '^^'  ondhion  ot  nervous  irritability 
his  attention  pn^perly  npon  ^y;  ;<    ^   Z.^^,,  manifestations,  and  the  entire 
,,,vclops.  whub  may  have  '^  ^  ^    '    ,      \'    ,,  „,  .hanged.     He  dwells  con- 
"u-"tal  attitude  oi  tl>o  P-son  nu^  b  -  ^^^^^^^^^^  ^^^^^^  h-w-spirited,  and  m 
.tantlv  upon  b.s  condition.  ^'^^        ';  '  jj^.  ,„,,.  ,„,„plain  of  numbness 

,,treme  ---'-'^-^^''t';;;    s      ^       i  some  cases  of  much  piiin  in  tl.e 
and  tingling  in  the  ^'^^  ,  I'v  be  vvell  performed,  though  such  patients 

,,,,„.     The  bodily  iunetion>    nay  be  w d  ^^^^^  ,^^^^  .^  ^^.^.,^i,^. 

usuallv  have,  for  a  tune  at  ^^  ;^'  ;^'fX\"  v  negative.  The  reflexes  are 
,,,,,  ,dn;sieal  ---^^  S^ne^^S^enia.  ^  The  pupils  may  be  un- 
plijrhtly  increased,  as  m  ouuuai. 


THE  TRAUMATIC   NEUUOSRS. 


1133 


oses.  0(1111111 
it  incut  v.ith 


presents  the 
ion  is  known 

lilt  ion  of  tlie 

Walton  iinil 
terieal  nature 
line  trauiuatie 

tin'  reader  is 
■v.  tlieir  Kela- 

in    a    railway 
ick  or  eoiu'us- 
m1  in  his  hody. 
■en   a   week   or 
odily  shock  or 
•ofound  mental 
.(■eived  thereby 
need  symptoms 
,.(1   with  bodily 
was  wreekcnl  in 

ricrffinfj;  bt'l'ore 
II  tiie  stairs  may 

groups:  simple 
,  and  cases  with 

:oms  usually  <!e- 
y  not   have  I'cen 
iins   of   headache 
,1,^>  to  concentrate 
■rvous  irritability 
s.  and  the  entire 
He  dwells  con- 
,v-s])irite(l,  and  in 
lain  of  numbness 
nueh  pain  in  the 
ufzh  such  patients 
lid  loss  in  weight. 
The   reflexes   are 
jupils  may  bo  un- 


gual-  the  ..anlio-va.eiil:ir  .han^^es  already  .leserihed  ,n  neura.then.a  may 

;J..nt   m   a  marked   decree.     Ae.-ordin,   as   the   symptoms   are   mm  > 

.pinal  or  more  cerebral,  the  comlition  is  known  as  railway  brain  o.   ,ail- 

'''>W'!;...  ,rilh  MarM  lh,slrnn,l  /.V./.n'..-  FolInwiuK  an  injury  of 
,„v  sort,  neurasthenic  symptoms,  like  tlm.e  described  above  may  deve  op- 
„.;,    ,„   „|dition    svmp.oms    repinled    a.   cliarae.eri>tH.    ol    hysteria.  e 

lotional  clemcnt-is  promineii,.  and   there  is    nil  slight  --^■•'-'  -- 
r,,,,lin.^s      The  iiatients  hav  lieadaelie,  backache,  and  vertigo.     A     loK  n 
,,,„„.';  mav  b,.  pre.ent,  ami  indeed  coiMi.ntes  the  mo.t  striking  leatnre  oi 
,!  c  <c     "l   hav..  reccntiv  seen  ^n  engineer  who  develop..!  subsequen     to 
,„  ,,',i,K.„t  a  series  of  n'ervous  phenomena,  but  the  most   marked  leaturo 
w",    excessive  t.vinor  of  the  entire  body,  which  was  special  y  man.test 
,i    .  emotional  excitement.     The  most   pronoun..ed   hysteru.al  symptoni. 
!  ,  u.  s..usorv  disturbances.     As  first  noted  by  l>ntuam  and  \\alton,  liemi- 
,   -e-  luMa   UK.v  occur  as  a  se.piem-e  of  traumatism.     This   is  a  common 
;  ,   om  in  France,  but  rare  in  Knglaud  and  in  this  country.    Achroma,.,.- 
.ia    nav  exist  on  the  ana-stlietic  side.     A  second,  more  common    manilota- 
t- >n   is  limitation  of  the  lield  of   vision,  similar  to  that    whu.h   occur<  m 

''■'Uemarkable  disturbances  may  develop  in  some  of  these  cases.     A   few- 

„on  hs  a-o  1  saw  a  man  who  had  been  stru..k  by  an  dec  ri..  car,  wl,o>e 
!  !  viiM-tom  was  an  extraordinary  increase  in  the  number  o  r..pira- 
^       He   was  a  stout,  powerfully  built  man.  and  pres.mled  practu.iUy  no 

other  svmptom  than  .lyspno.  of  the  most  extreme  ^-'-  .'^,^;:;,  7;;;; 

observation  his  respirations  were  over  VW  ].er  nnnule,  and  he  >tabd  that 

thev  bad  been  counted  at  over  l.)i>. 

,,,/    I  j_A.  a  result  of  spinal  concussion,  without  fnu^ture  or  external 
„V     her      nav  subsequently  develop  symptoms   suggestive  ol   organic 
;:,  whU-h  mav  conn-  on  rapidly  .n-  a,  a  late  date.       n  a  ease  repoH.l  by 
Lc.vden  the  symp  b.ms  following  the  commission  were  at  iirst  slight  and  t. 

i  nt  was  regarded  as  a  simulator,  but  llnally  the  '-nditim,  bec.^^^  ab- 
lated  and  death   resulted.     The   post   mortem   showed   a  cl  .on       i-adiv 
,^n   ,'   i  ,  which   had   .loubtless  result*.!    fron.   the  ac-ident.      1  uya.  > 
S^l  ,p  about  which  there  is  so  much  discussion  are  tl--  -1-         - 
hv    muked  sensory  and  nu.tor  .hangcs.     Following  an  accident  m  winch 
;  1  u>s  not- received  external  injury  a  condition  o    -■■'-";"^  ;:;;^ 

d  vcd    ,  within  a  week  or  ten  days;  he  complains  of  beadac-lie  ami  back      u 
ml  xamination  sensorv  disturbances  are  found,  either    uMnianaMheM 

;      u"  "^  o     the  skin  in  whi.h  the  sensation  is  much  benumbed:  or  pain 
a'litne  impressions  may  be  distinctly  M.   in  -|-;  .-|;;;:-;;;;;\ 
tnunerature  sense  is  absent.     The  distribution  nu.y  be  bilate.al  a  d      i 

:;:u:d  in  nmlted  regions  or  lien,iplegic  in  typ.     Lnn.t:Uion  o      he 
of  virion  is  usually  marked  in  these  cases,  and  there  may  be    "-t!"^"  "'_ 
t^u.    "i  es  of  tas  e  and  snu^ll.    Tho  supcrfi,.ial  reflexes  nuiy  be  <l"nin,  h. 
.u  llv  the  deep  reflexes  are  exaggerated.     The  pupils  may  bo  ""^'-l"  •;  ' 
m      r  LturbJnees  are   variable.     The   French   writers   doscrd.o  ea.es   of 


^^^ 


,j3,j  DISEASES  m-  Till-.  NEIlVOrs  SYSTEM. 

|„rl.v  il  m..i."|"r".  "f  ""■"".',,  „„,,|,,1  „.  ,lirfi,„tiv,.  ,.(  I,.v<vn«, 

»"",  ''"'rt;::";;;;-':-  ;■""'-''"■■- ^  '•■  ^>-i" ' »"",' >; 


jicriitctl  irllcNf^- 


^Vhc.n  death  I0IK.VS  spinal  -----,;'.;,         '  j^,    ,  ,  .hown  pnnc- 

,i,,,„  ll«"i";^r'''''^^^-.;f    ,^^J:^      ;,a  c.onc.nssi,.n  <.r  injury  of  11,0  sp.n.; 
ovation  in  llu>  pvrannda    tiacts  1"'"  ,    ,         -^.^i  .vniptonis 

l„t  in  all  these  cases  there  uas  "!'•  ':;'',",;,„,, ,t  rost-.n<lrten.s 
developed  early  or  followed  l""]^'"'l'';  f  >  :.'^^"'  ,  ^  .,  upon  a  traun.atie 
,„,on  ca.es  in  .Inch  -^--,,  ^j;  ,^^  l^:!:  ^stanel  of  a  n.an,  ^ 
neurosis  arc  extreu.ely  ra  e.  '!^'"  f  \'  f, ,,,  ,  „,,,,,  „„  ,1,,  cpi,..,striun, 
„,i,ty-lhrec,  who  in  1  H(;  --;-  ^^  j;  ,t^  :  V  f  neurasthcnil.  and  hys- 
and  suhscquently  developed  the  ;>">1'  ;'";', .,,  ,,enrcssion.  He  afterward 
t.via  with  attacks  of  v>  rt.^m  and  ^n'eat  I'f  .j'  J^  „,,„„,,i,„„„,ss.     lie 

committed  suundo  and  the  '"'"'.■'''''„,,;,,,,,  ,,,ociatcd   with  an  a.l- 
..lerosis  in  the  white  ma  ter    whu      -    1     '  ;;>^  ^  ,  ,,,,,.^,0. 

vanced  grade  of  artev.o-scleros,..     h    -'^    ""Z'  "' '  ,,,-,,,,  ,,„,iercd 

--'-'. '  ''"iz  '\  :;■  ht  l:;:;;  ;::  h!".;.H-^i.>...  i-  ^  few  wecus 

unconscious  and  had  a  slijiin  m.uix  „.,Hi.TdMrlv   "rcat   depression 

.vn.ptoms  of  traumatic  neurosis  ''*;- ? ;  ;,^  j  !  t  he  t't  and  hands, 
of  spirits,  with  headache  and  sensor>  <!'  ^       '  '•    ;   ^     J  attempted   to 

Tremor  and  grct  weakness  were  ^-^'^l'^— "I,,  !  '  ,  ",,,,,1;,,  as  an 
..,.rk.  There  was  no  increase  '^  "^l  '"ice  iv  ^-m  o  ns  'favored  this 
instance  of  simulatuui  ami   a  '^'''^V  "  '   '  " ,,,;;  ,,  ^id  not  improve, 

vi-v.     Suhscjucntly  *   -J-^;-;;"  , ^^  '';.,;;iLc  .lysi-nca.     Macro- 

Uv  died   m  .lanuary.  IN^-'.  ^^'^"  i' '1'  ..rnril     There  was  extreme  arterio- 
,,..,,,  iW  t'H.hvain  an    cor    m^^^^X.^^^  cord.     In  the  hitter 

;;;;:^:^rr:::;i:':nm^^^^ 

plo.  of  it  arc  extremely  rare.     So  fa    as  I  U n  ^^^^  ^^^^^ 

traumatic  neurosis. 


THR  TIlAUMATir   XMUROSI'X 


ii;;5 


'hiircot  lays 
Ijiimtimi  ct' 
qs,  piirticti- 
ilropliy  and 
ot  liys'oria. 
wliicli  may 
niv'  cliniijifs 
iilcd  clearly 
the  j,M'catcst 
rophy,  lilad- 
s,  and  oxaiT- 

cvy  dclinitc. 
■  may  lie  no 
ihown  pnni'- 
iidnal  (lojion- 
1)1'  the  spine; 
al  symiiloms 
"•nst  niortcms 

a   traumatic 

a  man,  ajjcd 
:■  cpijzastrium 
cilia  anil  liy>- 
11c  afterward 
ioiisncss.  lie 
lino-  multiple 

with  an   ad- 
2ed  i'(irty-t\\<>. 

was  rendered 
11  a  ft'W  weeks 
cat  deiiressioii 
'v\  and  hands. 

attempteil  to 
rc^'arded  as  an 
s  favored  this 
1  nut  imiirove. 
|iii(i'a.  ]\lacro- 
xtrenie  artcrio- 
lii  the  latter 
stance,  and  di'- 

>  of  its  eNtreine 
ons  upon  cases 
lisease.  Kxani- 
ith  autojisy  lias 
•I.  ill  which  ill*' 
"oUowcd  upon  a 


Diagnosis. — A  cmiditidn  of  frij,'lit  and  ex(  itenieiit   fullnw  iiiij  an  ai  li- 
dcnt    may   jicrsist    f(ir  days  or  even  weeks,  and   then   ixradiially   pass  away, 
'['he  symptoms  of  neurasthenia  or  of  hysteria  wiiieli  ^ull-e(|lN■ntiy  develop 
present   nothinjr  peculiar  and  are  identical  with   those  which  occur  under 
other  circumstances.     Care  must  he  taken  to  reco^niize  simulation,  and.  as  in 
these  cases  the  condition  is  largely  sniijective,  this  is  sometimes  extremely 
dillicult.      In  a  careful  examination  a   simulator  will  often   reveal  himself 
hy  exa.ii-.uvratioii  of  certain  symptoms,  particularly  scnsilivciie.-s  of  the  spine, 
ami  hy  increasing-  voluntarily  the  rellexes.     MaunkopiV  sui:\u-ests  as  a  ^ood 
test  to  take  the  pulse-rate  hefore,  duriiii;-,  ami  after  pivvMire  upon  an  area 
saiil  to  lie  painful,     if  the  rate  Is  (juiekened,  it  is  held  to  he  proof  that  the 
iiaiii  is  real.    This  is  not,  however,  always  the  case,     it  may  iiMpiire  a  careful 
study  of  the  case  to  delermine  whether  the  individual  is  hoiu'stly  snireriiii: 
froni  the  .-symptoms  of  which  he  c(miplains.     A  still  more  im|iortant  (pies- 
tion  in  these  cases  is.  Has  the  ]iatient  organic  diseaM'?    The  symptoms  given 
under  the  lir>t  two  jzroiips  of  cases  may  exist  in  a  marked  decree  and  may 
iK'rsist  for  several  years  without   the  slightest  evidence  of  organic  change, 
ilemiana'sthesia.   limitation   of  the   lieh'      ''  vision,   monoplegia   with   con- 
tracture, may  all  he  present  as  hystericf-   le   nifestatious,  from  which  recov- 
ery may  he  complete.     In  our  present  ki...      'dge  the  (liagno>i>  (d'  an  (Ugauic 
lesion  "should   he  limited   to   those  cases   in   which   optic   atrophy,   hladder 
tronhles.  and  signs  of  sclerosis  of  the  cord  arc  well    m;irked  — indicatioll^ 
either  of  degeneration  of  the  lateral  c(duiiiiis  or  of  multiple  sclerosis. 

Prognosis. — A  nia.j«u'ity  of  jiatients  with  traumatic  hysteria  recover. 
In  railway  cases,  so  long  as  litigation  is  pending  and  the  jiatieiit  is  in  the 
hands  (d'  lawyers  the  symptoms  usually  persist.  Settlement  is  often  the 
starting-p.oint  of  a  sjieedy  and  perfect  recovery.  I  have  known  return  to 
liealtli'"after  the  persistence  of  the  most  aggravated  sympt(uns  with  com- 
plete disahility  of  from  three  to  five  years"  duration.  On  the  other  hand, 
there  are  a  few  cases  in  which  the  symptoms  iicrsi.^  even  after  the  litigation 
has  heeii  closed:  the  patient  goes  from  had  to  woive  and  ii.<yelioses  develop, 
.such  as  inelanch(dia,  dementia,  or  occasionally  progressive  paresis.  And, 
lastly,  in  extremely  rare  cases,  organic  lesions  may  develo])  as  a  scipieiice 
of  the  traumatic  neurosis. 

The  function  of  the  physician  acting  as  medical  exjiert  in  these  cases 
consists  in  determining  (a)  the  existence  (d'  actual  disease,  and  (/')  its  char- 
acter, whether  simple  neurasthenia,  severe  hysteria,  or  an  organic  lesion. 
The  outlook  for  nltimate  recovery  is  good  except  in  cases  which  present  the 
more  serious  svmiiloms  ahove  mentioned.  Xevertheless,  it  must  he  home 
in  mind  that  'tranmatic  hysteria  is  one  of  the  most  intractahle  airections 
which  wo  are  called  ujion  to  treat.  In  the  treatment  of  the  traumatic 
neuroses  the  practitioner  may  ho  gnided  hy  the  ])rinciples  laid  down  in  the 
preceding  chapiter,  in  which  the  troatniont  of  neurasthenia  in  general  has 
heen  deseriliod. 


-     - 


ii;;i'. 


DISEASES   ..F  TlIK   NKUV<aS  SYSTEM. 


:,V.  OTHER  FORMS  OF 


FUNCTIONAL  PARALYSIS. 


I      I'ntlOl.K  Al.    I'AliAlVSlS. 

., -■;' ^ '■■  ::;:;z:::::;::\r:^::ir't::. :!': 

u.u.lly  ..mu.U-U.  wnlun  the  lit  t  ^^^^^^^,^,^  ,,,.  ^,,        ,,k  a.o 

,,i;i,U  in  ran.  -nstu.urs  .1   ';         >  "  y/,^,,  „,•   ,,,,  to.,uo  an.l    (.  >arynx. 

'Hu- '<-'>->  --r  '"'  r^'  "'wU     ;r  :u    Jnltu^s  an.,  .low  puU.    The 

a  :   ;  ,vlU.x.s  avc  n..Uu...l.  — V";- ^j       !    i"       .xtraonlina,  y  n..hu.liou 

,,i,,    (.n.onh.n...stv.„.u<a^-^^^^^^^ 

,„.  (.onq>lfto  al.olitu'ii  ol  tlu    lai.uiu 

nerves.  ,.  ■„  ,k,,  ,.„urse  nf  a  I'ew  hours  or  alter  a 

,,„prove,nent  hegins  -"-;'';;•        ,1  .......pl.telv.  an.l  the  patient  is  ,.er- 

,l,v  or  two.  ana  the  1--1>^';,^  j^  .j  '  „„v  mur-ev^.ry  few  .eeks.  .n  some 
iV;.tlvvveU.     As  mcntmne.1.  the  attac    .  ..  ^^^.   ^^^^^,  ^^,,  ^^^.,,   ,,„  ,. 

;,tanees  even  daily;  more  --';;;';;         l)  ,  „,  ,.„,.  dilatation  of  the 
,,,,,,.  lH.txveen  the  att..Us^e.>J;<;^^.  ^,^^  ^^^^^^^,^  ,,,,„,  .,ase. 

hoart  durinj:  tlie  altaek.     Altu 

U     Astasia;  Abasia. 
^,.Mern..indieatin.res,.etivelyinai.,,itytos,.^^ 

..ali!.  hav.  h.en  a,;,>lied  hy  7;;--;;;;  ,  '  ^    "valu^:..  -th  retention  of 
.,,teri/e.l  hv  lo^s  of  the  ,K>wri  ol  '  ■"        -  ,.,,,,-,  .lellnition  is  as  lol- 

^nsonlav  power,  ;--'"|'-""^\,:i:\;:  "l^      ^ihllitv  of  standin,  erect  and 
lows:  '-A  n.orhid  state  .n  ^^1'" 'V    "V      \,^t,,.,,itv"  of  sensation,  of  mnsen- 
alking  nornudly  is  in  contrast  wU      ^*  ^^^  ^^  , !    ,„,.,„,,nts  of  tl>e  lower 
;     str^notlK  an.l  ..f  tl,e  eoordmafo      ^  ';;„_,        „,,  ,  ,„.,,.id  entity, 

extremities.-    The  eond,t>on  '--    ;>''^         ;„  i!i.  ,nono,raph  analyzes 
.,„a  is  nrohahly  a  functional  muiosr  .     1|'  ^.f  ^,,,,,  ,vere  in  men, 

henolases  reported  inthe>  era  UK       1^^^>^^    .^  _^    ^.,^,^,,^,^^^  .„ 
,,  in  won.en.     In  '.M  cases  hv>t      a  w.  ^^^^    ^^^^.^_^^^^_  ^,,,,^,^,,  ,,  , 

U,,.v;  and  in  1.  inton  .on  V^^^^;^^^  ,  ,,..,,^  ,,,  ,it,,or  unahle  to  walk 
to  move  the  feel  and  lep^  ^f  %^  ^d Iturbanecs  have  been  very  varied, 
properly  .)V  cannot  stand  at  all.     i  l'^  ^ 


UAYNAIDS   DISKASK. 


ii;;i 


rsis. 


sis  of  iho 
rii.'iv  is  ii 
Inch    iniiy 

,11.      (ii)lli- 

l  with  this 
try   H.  \V. 

•asc's.  'Hu" 
wht'ii  tlu' 
•ten  (lurin>l 
)!!  ol"  wcari- 
iniralvsis  is 
in  the  U'f-'s. 
It'  neck  are 

III  iiharyiix. 
olvo.l.     'I'lu' 

k'xt's  miiy  I'l' 

IV  rcilui'tioii 
isrU'S  anil  <>t' 

irs  or  ai'tt'i'  a 
aticnt  is  (u'r- 
trks.  in  sonic 
)!•  two  WlH'ks 
itation  ol'  tho 
iisuallv  cL'asc. 


vl  inaliility  to 
iiulitions  char- 
li  iH'ti-ntion  of 
iliou  is  as  fol- 
linif  t-n't't  and 
ion.  of  nnisrn- 
ts  of  tlio  lower 

iuorl)iil  entity, 
ijvvapli  analyzes 
;l'  were  in  men, 
orea;  in  •.*,  epi- 
its,  thonjili  al)le 

(uialile  to  walk 
een  very  varied, 


nnd  (liircri'nt  forms  liave  lieen  rccojrnizeil.  'I'lic  eoniinonest,  ncenrdinf,'  to 
Knapp's  analysis  of  tlie  recorded  cases,  is  the  paralytic,  in  wiiich  the  lej^s 
j^ive  out  as  the  patient  attempts  to  walk  and  "  IicikI  under  him  as  if  maile 
of  cotton."'  "There  is  no  ri;:idity,  no  spasm,  no  incoiirdination.  In  iieil, 
sittiii<;',  or  e\('ti  wliile  suspended,  the  muscular  stren;;th  is  found  to  he  ^ood" 
Other  cases  are  associatiil  with  spasm  or  ataxia;  thus  there  may  he  move- 
ments which  still'eii  the  Icj^s  ami  ^dve  to  tiu'  ^'ait  a  somewhat  s|iastic  char- 
acter. In  other  instances  there  ari'  sudth'ii  llexions  of  the  Ic.us,  or  even  of 
the  arms,  (U'  a  saltat(n'y.  s|)rin^-like  spasm,  in  a  majority  of  tiie  cases  it 
is  a  manifestation  of  a  lu'iirosis  irllied  to  hysteria. 

'I'he  cases,  as  a  ride,  recover,  ])articularly  in  yoiinj.'  persons,  ifelapses 
are  not  inicoinnion.  Tlio  rest  treatmcul  and  static  electricity  should  he 
einj)loYe(l. 


VIII.   YASO-'MOTOIl   AXD   TEOPIITC   DISOIIDEIIS. 
I.     RAYNAUD'S    DISEASE. 

Definition. — A  vascnhir  disorder,  prohahly  dependent  upon  vaso- 
mot(n-  inllucnces,  ciiaracterized  hy  three  f,n'ades  of  intensity:  ('/)  ho<'al  syn- 
cope, {!))  local  asphyxia,  ami  (r)  local  or  symnu'trical  i^'an^fcne. 

Loral  Si/iicopr. — This  comlition  is  set'ii  most  freiiuently  in  the  extremi- 
ties, jn-oducin^'  the  condition  known  as  dead  fin<,fers  or  dead  toes,  it  is 
analojfous  to  tiuit  jirodnced  hy  ^n'cat  cold.  The  entire  haml  may  he  aU'ected 
with  the  linjicrs;  more  commoidy  oidy  one  or  more  of  the  linfi;ers.  This 
featnro  of  the  disease  rarely  occurs  aloiu'.  hut  is  <rem'rally  as.^ociated  with 
local  asjjhyxia.  The  common  sei|nence  is  as  follows:  On  exposure  to  slij^lit 
cold  or  in  conseiiuence  of  sonu'  emotional  disturiianee  the  linifers  heconio 
white  and  cold,  or  hoth  (in<;-crs  and  toes  are  all'ected.  The  pallor  may  con- 
tinue for  an  indelinite  time,  thoii^di  usually  not  more  than  an  hour  or  so; 
then  irradually  a  reaction  follows  and  the  iinjrers  <,ret  hnrnin^'  hot  and  red. 
This  does  not  necessarily  occur  in  all  the  lingers  t()j;-ether;  oiu'  linLjer  may 
he  as  vvliite  as  niarhle.  while  the  adjaei'iil  ones  are  of  a  deep  red  or  plum 
color. 

LdCdl  Asplii/xln. — ( 'hillilains  form  the  mildest  jrrade  of  this  condition. 
It  nsnally  iollows  the  local  synco]ie.  hut  it  may  come  on  iiide|iendcntly. 
The  liiiirers  and  toes  are  oftenest  atrectcd.  next  in  order  the  ears;  more 
rarcdy  iiortions  of  the  skin  on  the  arms  and  le^s.  Dnrin^  an  attaidc  the 
lin^fers  alone,  sometinios  the  hands,  also  swell  and  hecome  intensely  con- 
frested.  In  the  most  extreme  i^rade  the  fingers  are  ]ierfectly  livid,  and  the 
ca|)illary  circulation  is  almost  stagnant.  The  swelling  causes  stiffness  and 
nsnally  pain,  not  aente,  Imt  due  to  the  tension  and  distention  of  the  skin. 
Sometimes  there  is  marked  ana'sthesia.  I'ain  of  a  most  excruciating  kind 
may  he  ])resent.  Attacks  of  this  sort  may  recnr  for  years,  and  he  hrought 
<m  l)y  the  slightest  exposure  to  cold  or  in  conseijuence  of  disturhanees,  either 
mental  or,  in  some  instances,  gastric.  Apart  from  this  unpleasant  synip- 
71 


^^k 


DISRASKS  OP  THE  Ni:ilV(^US  SYSTEM. 


1 1  "^S 

1      Tiu'  coiK.lilion  i^  iilways  worse 
t-n  11-  ^.-H.n.l  lu.lth  •"•^  ;;;■  -:3,f  :;;i,  ,,,,„  Hu.  external  te.u,eratu,e 

■      Local  or  ;<!,nn:.rlnn,l(l.n.nr>^  J'l^^^^  ^  ^^.,,i,,,   .„„U   neerot,o 

follcvv.  the  lo.al  "^1'''>-^'"V;\  ;'.;,„•  the  ih>K'"VS.  S.nueti.nes  th^  pads 
.,n,a«  are  sometimes  seen  at  the  tips  "'  ^  •  f^.,,,„,  repeated  sli^ilit  l-.sses 
:nL  nn,..vs  an.l  of  ti>e  to.,  an- .;u^>  ->     -^  i>  ^,^,,,.„  \„^,^  „.,  .„,..aeial 

^'f  ^'-  '^'r''-  "•  f;;:  ;;  e  Th' -ever  eases,  wlueh  ternnnate  .u  es- 
1,,<<  (it  sulistanee  al  tin   to^.*^- 

t,„sive  j:anK.-ene.  ^^'^^  ;'''T'"'uU^Zy<\<i<  i"  ^l"'  ''"^'■'•"     '''>'" /"'•'";"''' 
1>^  »'^  '"^'"''^  ^^'^'  '?"'  'T    •.  MV    nef  n...rjK.o„u.ldaek,eold.and  .n- 
,,„,,,,  or  perhaps  the  ;-^;,  ^  ^  ^  *;    "^.Unal  ,an,renous  hlehs  appea. 
..M.ihU..  The  skn>  l.epns   '>  '.>^''  "    -;"         ,.  ,„„i  ,^  ,,.„1ion  of  one  ..r  more  ot 
(;ra.h,ally  a  line  of  •l-->'''^i;!;;"  ;'        ,  !'        '   f  snltanee  is  mueh  less    han 
,,,„  n,„.,.s  slou,l>s  away.       >     '^^f  ;•  ^  ;^,  j.^aieate.  an.l  a  e,.n.li,>on  whuj 
llu>  ap,.earanee  of  the  hand  m     '    ^    '  '  .,,.,^,,,,  „,  ,„ir  ..l'  a  foot  n>ay  resnlt 
U,oks\Is  if  the  pati.nl  wonld  Iom  <   1    h        .         ^  j,^  ,,verer  eases 

,,,,aps  in  only  a  sh,ht  ^I'l-    '     1      ;  ,^^,^,  „,,,  ,,,  lost.     Oeea- 

,,     ..,au.r  portion  .d  a  hnjie,  m  1  >^      1      .  ..(remities.  hnl   atVeets  sym- 
J  nnllv   tin-disease  is  m.t   eonlmed   to  ^'''      \:  ,  t,  ,,,n,U.,n-rene. 

;;:;;-::i  patem.  on  the  li-'-;^;;.;;;;  •;;,'„  l-onn,  ehiK^in,  and  death 
MM.ese  severe  types  .d  eases  .veu      '      '^ "  ^    ;  ^^^^^;,.,^^  ,,,  ,„ually  very  pa.n- 

,„v  result  within  three  -•-;';>,;,  „,!,,,.     ,n  son>e  eases  numbness 
hd.  and  the  motion  ol  the  pait  IS  mm  1        l 

and  tinizliu^  persist  for  a  lonj:  ^'"^^ ;  ^^^^  changes  is  s,-en  in  the  re- 

Tlu.  elimax  of  lh>s  senes  ol   '"  "      '  '  ,^.„,    "ry^,,,  ^-e  most  eom- 

.uarkahle  instanees  of  -^--;;r;, Sir:,  rapidity."    In  the  .ledieo 

-"-^  i"  '•''"''"■'^-  "'V'  IT-    '   7^0  ^  V r    Nil  llH've  is  an  extraordinary  ease 
Chirur^ieal  Soeiety  s  '1  ransaet     n  •  v  .^^  ^^^.^  ^^.^^^  ,,,„^  ,„,„,  ,Uove 

n'l-<"l^"l'  •"  ^^•''''•''  '^'/l"'   •,    f  knee      There  also  had  been  a  s,.ot 

11-  ^■11--  ''-'  ^''''  ';r  ^^'^         S,H    tarn         amputation  o.eurred   and  the 
of  loc.al  pu,trvene  on  the  no>e.     ^1">"    ";.     .^  J^^  „,,,,  r,...,m.nt  than  has 

;--t:.3ri;=^^^^ 

^^^'^tre  are  ren.arkahle  eoneoniitant  symptoms  ^;^J:y^::^l^::SJl 
.,,i.h  a  ,ood  deal  of  :'tlontu.n  ln>s  1-  ^  ;\,,.  ,,,.„  .,  ...  outhreid. 
,.nria  may  develop  dunn,'  an  '^^^;''  ^V  ,  !'  ;,,,,,,,,,^  on  hv  eold  weather.  In 
,n  .ueh  instances  tlu-  alleetion  •^/'^"■'">  ^  i^.vnandV  disease  oeeurred 

nse  reported  by  H-  M.  Thomas    rom  n  >    h  ,„„„o,lobinuria 

or  three  sueeessiv  winters  and  ^-^^^,^-;^'  Several  c-ases  oi  the  kind 
The  attaeks  were  son.etnnes  l>;--f^'^^>^ ;:,;:,,  „f  Kavnaud's  paper  for 
arc  fonnd  in  Harlow's  appendix    o    -^    -.    \^  ^,,,,  ,,  ,,  the  ease  jus 
the  Now  Sydenham  Soeu-ty.      11^\'    '         i,-,^,^^  ^hat  the  disease  is  m  some 

wav  associatea  wun  •ib"'-- 


\ 


ERYTIIROMELALOTA. 


11:10 


lys  worse 
Hioratiiii' 

coiidition 

lU'lM't-lU' 

til  ■  jiads 

c'!\l  Idsso? 
I"        .  •   1 

.\llHTtlfllU 

i\to  in  ex- 

.  tcnninal 
l(i.  iU\(l  in- 
■hs  ainifiir. 
or  iiKirc  "I 
h  U'ss  tlian 
lion  whit'li 
may  rcsuU 
■vorcr  casi'^ 
oA.     Ocia- 
liVccts  syni- 
a  <ran<.n'i'iu'. 
,  and  death 
,-  vi'ry  iiain- 
L>s  nuinl)ne>s 

n  in  tlio  ro- 
^.  most  com- 

tlu'  ^Icdic-o- 
)rdinary  ease 
\  arms  aUove 

liccn  a  sitol 
rrod,  and  tlie 
out  llian  has 
■ion,  Ohio,  in 

•  hlotchos  de- 
otin,  July   1. 

idV  disease  to 
lhvmoj:h)hi- 
i"  an  outlireak. 
1  weather.     In 
i<ease  ocenrred 
v.mo>;lol)iiun'ia. 
SOS  of  the  kind 
ind"s  ivaper  for 
a  the  ease  just 
case  is  in  some 

•  mental  torpor 


and  transient  loss  of  coiisc  ioiisiicss,  liave  also  hccti  noticed  in  some  eases. 
The  ease  just  mentioned  with  ha^moulohiiunia  had  e|iiie|isy  with  the  at- 
tacks. Mxposiire  on  a  cohl  day  woidd  lirinjr  on  an  e|iile|itic  seizure  with 
the  local  asjihyxia  and  iiloody  urine.  .Another  patient,  the  sulijeet  for  years 
(d'  Uaynamrs  disca-^e.  has  hail  many  attacks  of  transient  hcmi|ilci;ia  on  one 
side  or  the  other,  when  on  tiie  rijrlit  side  with  aphasia.  Since  the  second 
edition  (d'  this  work  was  issued  she  died  in  an  attack.  Occasionally  joint 
atVections  develop,  particularly  anchylosis  ami  thiekeiiinj,''  <if  the  phalan- 
<;-eal  articulations.  Soiithey  has  reported  a"  ca.-e  in  which  mania  developed, 
and  l>arlow  an  instance  in  which  the  woman  had  delusions.  Peripheral 
neiH'itis  has  lieeii  found  in  scveTal  cases. 

The  jKi/hnhiiii/  of  this  reinarkalde  di.-ease  is  still  ohsciire.  Ifaynand 
sn<r,uesteil  that  the  local  syncope  was  |iroduced  liy  contraction  of  the  vessels, 
which  seems  likely,  'i'he  asphyxia  is  ile|pen(lent  upon  dilatation  of  the 
capillaries  tind  >mall  veins,  jirohahly  with  the  peisislence  of  smne  de^ut 
of  spa.<in  of  the  smaller  arteries.  'I'liere  are  two  totally  dill'crent  forms  of 
coiifrestion.  which  may  he  shown  in  adjacent  liimcrs;  oiu'  may  he  swollen, 
of  a  vivid  red  color,  cxtremt'ly  hot,  the  capillaries  ami  all  the  vessels  fully 
distended,  and  the  ana-nna  produced  hy  pressure  may  he  iiistantaneoiisly 
ohiiterated;  the  adjacent  linirer  may  he  eipially  swollen,  ahsolutely  cyanotic, 
stone  cold,  and  the  ana'mia  produced  hy  |iressiire  takes  a  lon;f  time  to 
(lisa]i|iear.  in  the  latter  case  the  arterioles  are  |ii(ihalily  still  in  a  con<lition 
of  spasm. 

Treatment.  —  In  many  cases  the  attacks  recur  for  years  nninlhieneed 
hy  treatment.  Mild  attacks  recpiire  no  treatment.  In  the  severer  forms 
of  local  asphyxia,  if  in  the  feet,  the  ]iatient  should  he  kept  in  hed  with  the 
leys  elevated.  The  toes  should  he  wrapped  in  cotton-wool.  'l"he  i)ain  is 
oftei;  very  iidensc  and  may  reipnre  mcu'iihia.  Careftdly  applied,  systematic 
massajfe  of  the  extremities  is  somelimo  of  henelit.  (iaiviinism  may  he  tried, 
liarlow  advises  immersinfi  the  alTected  limh  in  salt  water  and  placin.ir  one 
electrode  over  the  spine  and  the  other  in  the  water.  Nitroirlycerin  has  lieeii 
wariidv  reeommended  hv  ("ates. 


II.    ERYTHROMELALGIA   (lied  XpunthiinX 

Definition. — "  A  chronie  disease  in  which  a  part  or  parts — nsnally  one 
or  more  extremities — sufTer  with  pain,  thishin<r.  and  local  fever,  made  far 
worse  if  the  parts  hantr  down  "  (Weir  Mitchell).  The  name  sijriiilies  a  pain- 
ful, red  extremity. 

Symptoms.— In  IsTv'  (Thila.  'Med.  Times,  Xovemher  -.'.Id),  in  a  lec- 
ture oti  certain  painful  atl'ections  of  the  feet,  Weir  IMitchell  deseril)ed  the 
ease  of  a  sailor,  ajred  forty,  who  after  an  African  fever  hejran  to  have  "•  dull, 
heavy  pains,  at  first  in  the  left  and  soon  after  in  the  ri^'^ht  foot.  There  was 
no  swellinir  at  first.  When  at  rest  he  was  eomi'ortahle  and  the  feet  were 
not  painfid.  After  walkin.sr  the  feet  were  swollen.  'I'hey  scarcely  i)itted 
on  pressure,  hut  were  pnrple  with  eon<festion:  the  veins  were  everywhere 
singtdarly  enlarged,  and  the  arteries  were  throbhing  visibly.     The  whole 


^^ 


f 


» 


,SKASHS  CF  Tin;  KKUVOrS  SVSTKM. 


-'will -■-"■• --'''r '':::::;;:;; -■:';--• 

:;;: '."i-Kv >  «■■»'';;?•,  :;;"i':;,;;;,:',i'u.:,.....  a i™.-  >-  '»■■■ ■ 

lie.     Ill  .1  ,..  .i;..,.„«i.  ..    ..     }),,iii,,  sugiie^ts 


„,   ;,NG.O-NEUnOT>C  CEDEMA. 

»  ,.iv..,l    1)V   tlK'   occuvrciuo   (.1    l')c.U 

;:;:;:  cannot  be  bent     ;m-at^-;--^^  .,.,re  echo,  pan. 


I-'ACIAI,   IIKMIATHOIMIY. 


iin 


lu'VO    W:l:« 

il  ho  }i"t 
I, nil  foin- 

mipt'Mi'i'ii 

h.s  t  lin- 
1   (disri'Vil- 

istiinct's  in 
n.ls.  'I'lu' 
lot  ulwiiYr'. 
s  llu'  troii- 

tio  su<2;.iicvts 
.)l'  Iho  I'oul 
IS  Ix'i'U  I'ol- 
„)l  foUowi'd 
jhiiiL;  ot  lUo 


lU'C  of  1'"'"^ 

iinsiont  lUini- 

TluTO  is  a 

Ui\Uy  cirnim- 
tiit nation;  or 
10  lojis!,  or  tlio 
issoi'iiitod  \wY- 
,„   is  of   littl'^' 
itbrcak  of  tho 
ic  attack  canio 
-  be  lu'i'oditary 
ro])oiie(l,  iiv*^ 
vs.    Tl>o  i^woU- 
iii  one  locality. 
alYcitiMl.     Itc'i- 
riH'cdi'  the  out- 
'wo  iiuMiibers  cii 
.  iiiemhev  of  this 
0  on  in  ditTevent 
•h  a  (1e>iree  that 
I'lily,  so  that  the 
four  weeks.     Ae- 
3vero  colic,  puni, 


nausea.  aTul  somelimos  vomiting'.  It  is  ,,nite  possible  Ihal  some  ..I  he  eas.s 
of  l.v.leM-s  iMterM.itte..t  von.itinjr  may  iH'h.n-  I-  this  >:ro..,..  1  he  eo  e 
is  of  Kreat  infushv  and  nsnally  reqnnrs  niornhiu.  Arthnt.s  ai-parenlly 
does  not  o.  ,ur.  l'..rio.l,r  atta.ks  of  ranlial^Ma  have  also  be...  nirt  u,th  .inr- 
,„.  the  o.itlHvak  of  the  ..■.l.nia.     lie  inojliobinuria  has  o.cnrre.l  in  several 

eases. 

The  disease 
])robably  the  same  disease 


Ikh  allinities  wilh   nrtiearin,  the  {;iant   form  of  which    is 
,„.  ,li.,.ii<e      Tlicre  is  a  form  of  severe  pnrpnra,  oft.m  with 
iirticariarmanifestations,    whici>    is   also   assoc^iate.!    with    marked   Kasiro 
iMte^^tinal  cris.'s,  and  it  is  interesting'  to  .mte  that  Schles,n^.■r  has  report.- 
.,  ,.a<e  in  whi.h  a  .•ombinati.m  of  erythromelalKiM,  IJaynaud  s  disiMs.^,  an.! 


a..„te  ....h'ma  o...nrr...l.  (^un.■ke  r.-anis  ,n..  .•-m,  ilion  as  a  vaso-moto. 
„,„,.osis.  nn.l.'r  th.«  inlluen.e  of  whi.'h  th."  p..rm..ahd.ty  ol  the  v.ss.- s  is 
su.i.h.nlv  in..r..a>..l.  Milroy,  ..f  On.aha,  has  .l.^serib.Ml  ...ses  ..  I'"''-  't^'T 
,,,,1,,,,:, 'tw..n1v-two  individuals  in  six  venerations,  in  whuh  th.'re  ..Mst..l 
,•,,„„  i,i,(h  a  soli.l  ....h.ma  -d'  ...le  ..r  .d"  both  h-s,  without  any  spee.al  nu,.n- 
v.'nience  or  any  i.ro;rrcssive  in.-rease  of  th.'  .lis.'ase. 

Son..'  v.'ar>"  a-o  1  des.rii.ed  a  remarkable  vaso-motor  neurosis  .hara.'- 
terixed  hy'swrllim,  a,nl  lum'fadwu  .f  ihc  whole  arm  on  nrrhon  My  patient 
a  a  nian,  h.^al  by  in  ....ry  other  r..sp.,ct.  U.-.'cntly  m  Mnu.h.lph.a  a 
Tinil  r  eas  has  be'en  observ...l.  On  the  snpp..siti.,n  that  tlu.re  iiu.ht  be 
,;  '11  on  the  axillary  v..ss..ls  th..se  w.-re  expos..!,  hnt  nothin,  was  oun.l. 
'  .,-|„,  ,,,„i,„rnl  is  v..rv  i...satisfM..tory.  In  the  .'ases  assoeiat..  with  ana- 
,Hia  and  t:eneral  ,iervousn..ss.  toni.-s,  ,.;.rli.'nlarly  lar-e  dos.'s  ol  stryehnia 
;i;;t:;;;i;  l,,.  t....  often  th..  .Usen..  r..sists  all  tn.tnu;nt.  1  have  seen  great 
improvement  follow  the  prol.mgcd  use  .d'  nitr..glyeerin. 

IV.    FACIAL    HEMIATROPHY. 

An  alTcction  charaet.>rix..d  by  progressive  wasting  of  J'''"  J'""*'^  ;'";'  r''''^ 
fwMies  of  <.ue  side  of  the  face.     Th."  atrophy  starts  in  .-hildhood    but  ,n  a 
f  w      se    has  not  ..on,.,  on  until  a.lult  life.     Perhaps  aft.M-  a  trilbug  .n,,nry 
or  di.ea«e  the  i-roc'ss  begins,  either  diirusely  or  more  eomnionly  at  one  spot 
irlli^'siin:    it  gradually  spn^ads.  involving  the  fat,  *>-  t'^;  ;>;;-;  -- 
mrtieularlv  tlu'  npp.T  jaw,  and  last  and  least  the  museles       1  he  wa>t  ng 
Sy  Lnit..d   d  thi  middle  line,  and  the  app.-aranee  ol  the  patien    is 
ery  ™rkabh.,  the  fa,,  looking  as  if  nuule  up  ,d  two    •^'  -    ;;-,^'»     ; 
ent"ner«ons     There  is  usually  change  in  the  color  ol  the  skin  and  tli.   hair 
f  m<     (  wi  ;<'  to  the  wasting  of  the  alvc.lar  pro,.esses  the  t..eth  beeonu.  loose 
1  .1  ul  in    elv  drop  ..ut.    The  .'ve  ..n  th..  alT.H.ted  si.le  is  sunken,  owing  to 
tt  .^^^;     1  f  t    There  is  usually  hemiatrophy  of  the  tongue  on    he  sarne 
iV      )i     irbanc-e  ..f  sensation  and  nniscle  twitching  may  preee.  e  or  a,- 
1  ui-H  y  t  e      rophy.     In  a  majority  of  the  ..ises  the  atr..phy  has  been 
X [t      n    shl  of  the  face,  but  there  are  inst^mces  on  record  .n  w^iu  i 
i«ea.e  was  bilateral,  and  a  few  eases  in  which  there  were  areas  ..f  atro- 
phv  on  ?he  haHc  ami  on  the  arm  of  the  same  side.    The  disease  is  rare;  only 
about  100  cases  are  in  the  literature  (Mobius). 


riMk 


lU-i 


1)1 


SHAKES  OK  TUK  NERVOUS  SYSTKM. 


Ol'  t 


,„.„„,.,.i.s.^l.n.l..iValonoi 


jstii'H'  lit'  all  111 


tcistitiiil  iiriiiilis  111  a 


.>,i4a..torv.    Tlinv  was  tlic  ImniMal 


,„t  maikra  ill  tlH'  siiiH'i-io 


V  iiiaxllliii'V  Imiiu'li. 


n.lnlts;  tlu-  atvopliy 


Inllnwi.iKmu'U'ail-HUisa 

siuli  a>  111  I'" 


i,s,.  rfconlcil  liy  !>■ 


llUl   11    1^  a  •  "rr-  ,,    •.   •  ,,.„i..,lilii 


the  aiuti'  iiitVctions. 


It  is*  iiu'uralik' 


V.    ACROMEGALY. 


:";;!•  foHieth.     l^'->-;;:;r;HS:^ :'   ;.  "n.l!lMy'have  no  special  conno. 
,,,„l,.l  tho  (lovolnpinLMit  of  tho  (liK.i. '-   '  ,         reiiorto.l. 

n     nth  it.     m  this  country  -;2[- ^^     ^  k,,,e  presents  most  char- 
SymptomS.-l.t  a  ^;""-"''\'';;\;:^   „  ,  .,..atly  cnargod,  hut  arc  no 
.HcrUic  features.     The  hands   uid  ^      ^   r;,,,,,],^  i,  .oneral,  involymg 
,l.rornie<l,  and  can  ho  used  treoly^  M^  l^-^^^,  ^^^  ^,^^.  ,,,^„is        he 

all  the  ti^snes,  and  ^nves  a  curious  sjudc  'J^^^  ^      ^^^^.  ,„  ,„l,u-ed    hut 

OS  on  the  palms  are  uiueU  J -P^f  .^J     ,  i,,a  like  tlie  hands  and  are 
ho  arms  arc  rarely  atrectcd.    '  ho    M^    '  ^^^^^.,^  ^.^^^,,  ;„  pvopor- 

„,f,,,iily  enlarged.    The  '^^  ^o^       --^       -  ^,^^,.^  .^  ,^,  ,       ,,,,  and    he 
tion.    The  nails  are  usually      o  d  and   a  ^^^^^^^^^  .^^  ,„        t 

terminal  phalan,cs  arc  '-*    "1  o-^^-  ^^^„^^^,,  ,,,,eh  olon,atcd  and  e   - 

S::^n;s^    T,.  latt.  in  ^:;^IZ;::J::%  ^ia^ned  ami  tl. 
nroiccts  below  the  upper  jaw.     Ih    '^l       '     ^^  ■     ^j,,.  ,„a  the  nostrils  are 
S  scpavate.1.     The  soft  Pf  ^^J  ^'  ,;^  ;  ^.'-oatlv  thickened,  and  the 
.,0  and  broad,     '^ic  cydns  a,c  ..tu  vm      .^  ^^^.^^^^  .^ 

ear^  enormously  ^^yV^'^'^^^'"']-.^^  \^,o %vm.  may  be  alTected  and  the 
LatlY  enlarged.     L=Uc  m  ^1>^\'^''^ '''"%"!?    'thorax  mav  slowly  and  pro- 
back  Lwcd-kypbosis.     Tho  1"-'Y;f  .^    jl^^^^^e  the  skin  of  the  hands 
;'ivelv  enlarge,    ^itb  this  gradua       --  -n  ^^^^^^,^^  .^ 

"In.-i  face  mav  appear  normal.   /^?'"^     "^ '    ^..^^  appearance  of  the  skin  n 
:;;L,  or  Habbv.  but  it;-  -^^-.;^   ;  ;  :t^.  ^  Vbanges  in  the  thyroid 
,„vxa-dema.    The  muscles  aie  somctim 


ItM'iniiiiil 

lUS,  lioiii 
y  bmiujli. 

ivf   I'iiciiil 
1   atropliy 

lI'lUllS  illlll 

•VI'  |)iU'aly- 
iU'.l  by  I'- 
ll rtti'di'li''' 
if  (■(iiirmi'd 
1  (loul)tliil, 
as  I'oUnwtil 


irocc:?scs 


of 


cmitK'S. 
;ho  aiVoction 
iint'L'S  as  Uilt.' 
rs  luivo  itro- 
t'lial  cuiinei'- 
rtiMl. 

s  iiioi^t  char- 
,  but  avo  not 
ral,  involving,' 
haixls.    Tbi' 
fular^oil  but 
lands  and  an' 
riT  in  vropov- 
vvinii,  and  the 
dunio,  but  not 
igated  and  on- 
.)!•  and  inferior 
size,  and  often 
(leiiod  and  the 
ho  nostrils  are 
cened,  and   the 
tanoes  beeonies 
ITected  and  the 
lowlv   and   pro- 
in  of  the  hands 
Itored  in  eoh>r, 
.  of  the  skin  in 
;  in  the  thyroid 


ACUoMKiiAl'V. 


\\r.\ 


;:;:--i;-:;::!:i:r,::;;S;bl:;:;:::;:--=;: 


,,„,,,,  ,„■  ,.nlar>:eineiit  .d'  tiie  lliyMni> 
I, ,,„■(.  lias  l»'en   noted    in   mimy  ••a.-( 
early,  i 
has"; 


McuMrual   di-tnrbancr   may  occur 

llcitc- 


.1 i.is      lbt..M.n..ralheMnano,„;MsoltenancaiU  m^m..     Wn 


III 

rarely  neuritis.     Ibtcinpora 

ni 


.iv"|.ersi>t  for  liiteeii.  Iweiily.  nr  iiioie  years. 
'r„ll,oh,„inil  .l../.-m//.-Ki'rnivai  has  '•'•ecutly  anal) 

t(.|isies,  ;ii  ill  nil' 


vx.cd  llic  recorded  an- 

„ber""('l,an-cs  in  tlu'  pituitary  ^l^'id  were  l-und  in  all. 

V, here  was  ln,,ertnrbyur,nn.n,-.     U.  -n  ....  n.^^^^;^^^ 


Miul  111  tile  majority 

it 

th\ 


=:ES5=H^=S5Bn 


the  function  of  this 


it  has  been  sng-iested  that  the  disease 

;;:r;be!;;i.;:;v':^Kisavery  e.u,de..^^^^^ 

-'•••"'"'^  f''"";"'r'  ;"ria4  i:;:-::;.  .  nc;\:^   1.;.....  i-be 

l.„K  i).     The  pitnitary  hodv  -■;;;;-;;;•.;',,;;,,,,  becomes  an 

:"r^  ^'T  ''::  on  • --T  i:i  ;  '  -l'.!  .:;  n'.  ivuphatics.  ^1.0  e.,raor- 
'uiternal  secretion.  ^^ "  '  '  .-...i,.,,,.  i<  involved  iu  this  diseas.'  l.'iids 
.n,,.ryfreM..em..,,hui     ith      a     U^  „„„,,„„„„, 


webd'it    to  the  \ie\v   that    it    is.   in   tlu 


7'""     .,        unv    o         ..    V  rat      he  proportion  regulator  nf  the  skeleton 
'"r;:.s\;;  1  ''e    ed   bv   Massah>Uo  and   others   that   ,i.anti.m  and 

It  has  iKtn  ,n_  ;  ^-  ,,„,h  i\vv  to  the  superluuelion 

,,„„H,.aly  are  one  anu     '      ;  '^"     ^^^^^  ^,  -,  .,^„,  ,,  .i„.,s.  or  who  have 

"^  ^'"  ';'"""•    '  •  :;  id    ■      i"^'     1  '  beco,i,e  acromcalic.  and  the  skulls 
lieen '*  stronjr  men      amiwiouti 


.           ,..  «,>  li.,v..  luv  eonnoetion  witli  acnmie-aly. 
not  appear  to  ha\(   an\  i.oi,,,,,,,...  noon  the  i.roore-s 


I.ISKASRS  OF  TllH  NEUVOfS  SYSTHM. 

OhTKITIS    Dl-.KOUMANS. 

1    r..  ,.l'   the  loll"  lioncs  nvo  cirH'fb' 

ii™t::;::;;;;:"i;:;:s:'^.;r:;::::::r::r..^ '> 

'Vhv  I.O.U-  striictuvo  ^1"";_;^\,;,  ,'\„„,  „,■  r„nuntiv..  ost.it.s,  w.tli  c-i- 
tain  llavcvsiaii  .anals  -'••-;^;  '  ,  !  '  ...i.is  .Lronnaiis  an.l  tl...  luima- 
1i.,n..r...ali^:.iant  tuim.iv.    Ol  »  ^"'^   ■ 

\  ,„w  the  man  fust  m  -'^I'v    V^"    ^  j  ,,  ^  i,rhoi,l.t.     His  iil.ia-  bo^ui    -. 
trcMiiilios,  liis  li-flM   IS  al.nu     .         t  ^^^^^  .^^^^^^^^^^^  ,.,  in^lu'S      11. 

uinvara;  in  n.n>.nv^'^.ly  .t  '^   ''  ";     ^^  ;;,,  I'.lll-.iioon-sliapc.l. 

,vanl;  ^^-Mo  in  inyxaMlnna  it  i    ^    ">  /^  ,,,snUiU.ly  ^H.tliin^'  is  k..<.NV... 

Ko  metliou  or  tmunu'iit  ha.  had  UK  .i>o 

,,.,.i.  has  .iv.n  01.  iiaiiu.  ''./--itV;^ ^^^ 
„  .,„.a,-l<ahU.  .lisonU-.-.  ^^-V;:;'""    o     ho"       ::r  Iho  Ion,  honos.  ehiotly 
lai-Lroniont  oV  tho  hands  ami  kd    ■'»  1  '^  ^    ^  j  Unlike  acroin.'-aly, 

the  bo.ios  .>f  tho  skull  and  "f/'^;^^   ,.,,,,,,  ,„a  h.n,.itu.linal  curves; 

.Ualangos  aro  uu.ch  ^I''->V"    .       uvv  d  o     r  the  ends  ol'  the  phalaii,es. 

ho  nails,  too.  are  lar,.n,  and  niiu.h      un*  I  ^^^^  ^^^^^_^^.^._  ^^,^^,  , 

Seoliosis  and  kyphosis  are  --  ^  J  "..^  '  .:  e  .M„-standiii,  alVeetion  .>^ 
,,,,rly  all  ease,  has  heen  "-<;  ;:^^  \  ,,^,,  /„/„:.,,„  osUo-artkropalh,). 
the  bronehi,  hm.us,  or  vleun  <^>^'"  '\,','  „;/  tuberenlosis,  and  e.ni.yonia 
of  ..lii..h  sareo.,..  eliroiue  hronehv^   ,        "    ^^  ,1  instanees  in  whieh  tho 

MTec-tion  has  developed  ^-  '^^l^^^  ,,-,irtod  i  cases  from  my  clinic 
adults  amliu  tho  male  sex.     lha>er  mu      i 


K^H 


srLKHODI'.IfMA. 


111:. 


vo  chirny 

)SC  (if  111*' 
liusP  hciiv- 
omiiH'nit'- 
liiir;  in  the 

wilh    tlif 
,  wiUi   c'l'- 

thc  roniiii- 

,vilh    'lllH'CV 

n    l'',n,irlanil. 
.  is  oiu'  r*'- 
.hinc.  lS!tf<. 
was  stniiifi 
in-  lu'^'iin  to 
I  vc,  iinil  till' 
r   V  sixty-twi) 
11(1  lower  ox- 
OS   less   than 
inclu'S.     l\\^ 
nimirod,  and 

vitli  the  hiise 

'V   iMul    (luWU- 

iiii;  is  known. 

tS  progVL's::. 


(trlhrapdlhii  to 
•toiizL'd  l)y  on- 
;  l)onos,  c'hii'tly 
icc  acrnnii'triily. 

The  torniinal 
Uidinal  cnrvi's; 

the  phahmj-H's. 
clirunir,  and  in 
no-  alVi'ction  of 
'(v-nrthropaUiii), 
,  and  cniiiyonia 
s  in  which  the 
■cuvs  usually  in 

from  my  clinic 


M„d  has  inllei  ted  T..'.  tyj-ieal  eases  from  the  lit.iaiure.  Forty-thrre  sh..\ved 
i.reeedinj;  pMlnionarv 'aiVeetion;  (.f  the  ivinainin^'.  ;i  lolluwed  syjdnlis,  ;{ 
heart-disease,  'l  eiiroiiie  diarrlnea.  I  s|.inal  caries,  and  :$  uid<nowii  caiiM's. 

The  essential  patholo,L:y  of  the  disease  is  very  nl.-^eure.  Marie  su^'^'ests 
that  the  toxinen  of  the  ii'ninionary  di.-ea>e  are  aliscrhed  into  the  eir.Mdation 
and  exercise  an  irritant  action  on  the  Ix.ny  and  arlieulur  structures,  eaiis- 
iu;,'  an  ossifviM-  periostitis.  Tiiorhurn  thinks  that  it  is  a  chronic  tulien  u- 
l,,us  alVccti/m  cif  a  laru'c  nniid.er  of  hones  and  joinis  nf  a  iicni.uii  type. 

Lkonti Asis  ()ssi:a. 

l"mally.  in  a  r(Mnarl<al)le  coiulition  known  as  lrniiliasi.<  ,,ss,'ii..  there  is 
hviierosto'sis  of  the  liones  of  the  eraniiini,  and  -oinctiincs  tliose  uf  the  face. 
'hie  description  is  larp'ly  ha<ed  np^.n  the  skulls  in  iniiseiinis.  hut  .\lleii 
Starr  has  reci'iitlv  reported  an  instance  in  a  woman,  wiio  presented  a  Mowly 
i.ro.n-essin.'  increase  in  the  si/.e  of  the  head.  face,  and  m'ck.  the  hard  and 
soft^t issues  hnth  heinn-  alVect.'d.  He  hiis  applied  to  llie  ecnditioii  the  teini 
wninh-n-plnihi.  I'ntnam  stales  that  the  disease  he-ins  in  rarly  life.  cltcM 
as  a  result  of'iniurv.  'i'h.'re  may  he  osteophylic  j:rowths  from  the  outer  or 
inner  taldcs,  whi.h'in  ihc  latter  situation  may  -iv  the  s>mptninsnf  tumor. 

MlCK()Mi:ti  Al.V. 

\  remarkahle  condition,  the  antithesis  of  acromepily.  has  heen  de- 
serihed  !)v  .)..natlian  Hutchinson  and  ilastin-rs  Cilford  (Lancet.  ISliC,  ii.  p. 
r'->7)  as  ""  mixed  premature  and  immature  development."  The  name  uiirni- 
nwiahi  is  sn^rai'sted  liv  (iilfoni,  who  .Icscril^es  it  as  a  diseas..  of  that  part  (d 
the  nervous  svstein  presidin.ir  over  nutrition,  which  manitests  itsell  m  ii 
smallness  and'  immaturity  of  some  parts  .,r  functions  and  a  relative  oc 
actual  lariTcness  or  prenialurity  <d'  others. 


VI.    SCLERODERMA. 
Definition.— A  condition  of  l-icalizcd  or  dill'usc   induration   of   the 

^  "Lewin  and  Heller  (Die  Sclerodermie,  lierlin.  IS'J.^)  have  recently  col- 
lected from  the  liti'rature  :>0S  eases. 

Two  forms  are  ivco-nized:  the  eircuuiscrihed,  which  corresponds  to 
the  keloid  <d'  .\ddis.,n.  and  to  niorpluea:  and  the  ditruse,  in  which  lar-c 

areas  are  inv(dved. 

The  di-.'ase  alfeets  females  more  frequently  than  males.  I  he  cases 
occur  most  commonlv  at  the  middle  period  of  life.  The  srlrmim  nrona- 
fnriim  is  a  ditVerent  ah-cction.  not  to  he  confounded  with  it.  i  ho  disease  is 
more  common  in  this  country  than  statistics  indicate.  J  have  roportcnl  8 
cases  (Jour,  of  Oenito-rrinary  and  rutaneous  Diseases,  January,  18J«j, 
since  which  dat(>  T  have  seen  3  additional  cases. 

In  the  drcumscrihcJ  form  there  arc  patches,  ranging  from  a  few  centi- 


^[^,.  JMSKASES  OF  THK   NKRVOUS  SYSTEM. 

,n.,n.s  in  .lianu.t.T  to  llu"  si..  .W  th.  hnn.l  or  hu-.^  in  whirl,  ll..  sl<in  l,n. 
:      XV  or  .l...i-uhi,..  ..M-nranc...  nnd  to  .1..  Unuh  -  '"•7 -^  ' ^     "  ; 
,H,l,.[i..     So„H.ti,u.s  liu.n.  is  a   luvli.ninary  hy,H.r:.>n.a  ol    tlu-  >l^  ^^  ' ' 

;.     „.n,lv  tiu.,v  an.  ..l,an,.s  in  color,  .itlu.r  arc.s  ol  l'^";;"  ;;    ;     ,  '.; 
,.„npU.t.  ano,,hv  or  ,lu.  ,,i,nu.nt-U.u..o.U.r,na.      1  In-  -^         ;'>2h^, 
v.,n.  V  inarkc.l      'VUv  Sivr.ti.n.  of  sweat  is  .hminislir.l  or  ontncl>  a hoU.  lu '.. 
'•'''•'  ,„or.  .onnnon  in  woMu.n  tlKU,  in  nu.n,  and  K<  sUuat.umoM 

•k.  soniotinu's   in   the  coi-rso  ol   tlu- 


Till'  (llsl■a^(■  I 

liTiinciitly   aiiont   the  breasts  aii( 


1    life 


,„„,,.<     Tl...  iMtch.s  niav  .ievHo,,  with  ,.Mral  rapnlily.  and  may  po.s.sl  lu, 
months  or  vars;  sonu'tinu'S  they  (lisa|MH'ar  m  a  Uw  weeks. 

Te     //)"-■  /-•'»,  lhou,h  loss  ..ennnon,  is  ..ore  -nous      1     a..elo 
,1,.,  i     ,he  extreniit,;  or  in  the  laee.  an.l  tho  patient  no  -oc;s  ";"    H';,,^ 
^■^nuisna,lyharda.aiirn.,orthatth.e,sa.^ 

;:.:^t;:t;;ri;;:;r;;:^k^ir^^^ 

nleutaneois  tissues  that   it  eannot   he  ,.ieked  up  or  l"m'l>-l.      11 

r:.;:ra-;l.;:n;;roi'::r^^ 

:  irext;     elv  limieiilt  to  feed  tlu^  patn.nt.    Th.  bauds  become  lixed  am 
he    Imrers  immobile,  on  aeeount  of  the  extreme  niduratum  of  the  skm 

er  2    oints.     Hemarkable  vaso-motor  disturbances  arc  common    as  e  - 
t    m    cvino.is  of  the  hands  and  le,s.     in  ..no  of  niy  cases  tachycanl.a  w   s 

.!  ent      Tho  disease  is  chronic,  lasting  for  months  or  years.      Ihcro  a  e 
,         s  on  rcord  of  its  persistonoo  for  more  than  tw.mty  years.     Heco^c  > 

:'      e  nr    or  the  disease  mav  be  arrested.     The  patients  are  apt  to  suc- 
;:;;;^,:;:  idmonary  eomplainls  or  to  nephritis.     Ij'--;!;;^-  ^^  ^^ 
iHHMi  n..ti cod  in  some  instances;  in  others,  endocarditis.     La>nau.   s  di.ca.e 
1^    ..oeiated  with  It.  as  in  '>  cases  described  by  Stoplum  MacKonzio. 

;-o  iJn  .n  instance  .d'  the  dilfuso  form  in  which  the  pnmaiT  symi)t<.n.s 
™;  c  ;of  local  asphvxia  of  the  fingers,  and  in  which,  with  ex  e:.s  e 
:  :roderma  of  the  amis  and  hands  and  face,  there  uerecyai^osis  a nd  s. .  - 
in,,  of  the  skin  of  the  feet  without  any  brawny  induration.     Iho  P'^™*-   ^ 

^m    f  the  skin  may  bo  as  deep  as  in  Addiscm's  dis.ise  tor  -  noh  c.«.  ha^ 
l.oen  mistake.K  scleroderma  may  cK.cur  as  a  complication  of  exophthalmic 

^'"tIio  remarkable  dvstropliv  known  as  srlnodarhiUc  belonj^s  to  this  dis- 
ord,        'here  are  svuMuetJical  involvements  of  the  ^-J^ers    which  be  o.n 
deformed,   shortened,   and   atrophied;  the   skm   becomes   tiu.kone         fa 
txv   color,   and   is   sometimes   pigmented.      lU^hv   aiid   n  cera      us   In 
been  mot  with  in  some  instanc-es,  and  a  f^-f^f  ^'"7'  >;  "^.^   r  ^i      '  w 
disease  has  usually  followed  exposure,  and  the  patie  is  ^^^^^^^^'^ 
durincr  the  winter,  and  are  curiously  sensitive  to  cold.     Thee  ma> 


Ilic  sl<in  lin? 
,-,  hunl.  and 
\i'  skill,  and 
itatidii  or  t'l' 
cliaiifi't's  aiv 
ly  aliolislK'd. 
ituatiHi  nioi^t 
:)iirs(;  of  tlio 
ly  porsist  for 

11  develops 
that  the  skill 
ss  or  tension 
iwny  indiira- 
mited  to  the 
[1.     Tlie  skin 

normal,  and 
1  observations 
e  alVeeted;  in 
•  of  the  upper 
In   80  eases 
dually  extend 
lie  face  is  ex- 
d,  and  it  may 
oine  fixed  and 
n  of  the  skin 
iiuuion,  as  ex- 
lehyearilia  was 
rs.     Til  ere  are 
ars.     IJeeoveiy 
re  ajit  to  sue- 

troubles  have 
maud's  disease 

^laekenzie.  I 
r.iry  symiitoms 
with  extensive 
losis  and  swell- 
The  pi>;iuenta- 
hieh  cases  have 
f  exophthalmic 

los  to  this  dis- 
whicli  becoinc 
iiickened,  of  a 
Icerations  have 
the  nails.  The 
re  mucli  worse 
There  may  bo 


SCLERODKRMA. 


114 


clmii^'os  in  tlie  skin  of  the  feet,  but  the  deformity  similar  to  that  which 
occurs  in  tlu'  hand  has  not  been  noted.  Some  of  the  cases  present  in  addi- 
tion dilVuse  sclcr(ider4i'.at()us  chan;,H's  of  the  skin  of  otiier  parts.  Jii  Lewin 
and  lieiler's  niniio^^q'apii  there  are  ;?.")  cases  of  isohited  scierodactylisiii,  and 
10()  cases  in  which  it  was  comi)iiicd  witli  scleroderma. 

'i'hc  pathology  of  the  disease  is  unknown.  It  is  usually  re<,rai'ded  as  a 
tropho-neurosis,  jirobably  dependent  up(Ui  chant's  in  the  arteries  of  the 
skin  leadinj;'  to  conncetivc-tissue  overjirowth.  'i'lic  thyroid  has  been  found 
atrophic  '.. 

Treatment. — 'I'he  patients  rciiuirc  to  be  warmly  clad  and  to  he 
guarded  a,uainst  ex|)osure,  as  they  are  particularly  sensitive  to  changes  in 
ihe  weather.  Warm  baths  fijllowed  liy  frictions  with  oil  should  be  sys- 
tematically used.  I  have  tried  the  thyroid  fcciliug  thoroughly  in  the  dif- 
fuse form  without  success.  In  a  recent  case  of  (juite  extensive  loealixeil 
scleroderma,  after  ten  weeks'  treatment,  the  |iatches  are  softer  and  the  ])ig- 
mentation  much  less  intense.  Salol  in  l-'j-grain  doses  three  times  a  day  is 
stated  to  have  l)cen  successful  in  several  cases. 

.\iNinM. 

Hero  a  brief  referonco  may  be  made  to  the  remarkable  tropliio  lesion 
described  by  Da  Silva  l.,iiiia,  which  is  met  with  in  negroes  in  IJrazil,  Africa, 
India,  and  occasionally  in  the  Southern  Stales.  It  is  confined  to  the  toes, 
usually  the  little  toe,  and  begins  as  a  furrow  on  the  line  of  the  digito- 
])lantar  fold.  This  gradually  decjiens,  the  end  of  the  toe  enlarges,  and, 
usually  withont  inllammation  or  pain,  the  too  falls  off.  The  process  may 
last  some  years.  Cases  have  been  rcjiorted  in  this  country  by  ILornaday, 
Pittnuui,  F.  J.  Shepherd,  and  ^lorrisun. 


i 


ft 


i 

If: 


t , 


!  : 


,tii' 


SECTION   XT. 
DISEASES  OF  THE   MCSCLES. 

1.    MYOSITIS. 

A   nrimarv  myositis  occurs  a.  an  .u  ua    J  ^,,^,^^,^^. 

leristic  cane.  Have  lu.n  <l--''''-\  [^;\,,;;,t  ..114,uilt  woman  entered 
bMakenasatyincal  exan.,lo     Ah^c    n    u.     ^^^^  ^^^^^^  ^  ^^.^^^^  ^,,,^^„^,^ 

the  hospital,  comi-laimiig  ol  f  "     'j.  "^  \^^,^^  ,,,,  para^sthes.a,  the  arms 
of  tlie  back,  of  the  hamls  and  for      n         Ik  ^,^^^^^^^^,|y 

h.can>e  swoHen,  the  skin  tense^  .^nd^^  ^^ahout  thr.;;  months.  The 
the  thighs  hecame  allected  ^^'^^^'J'^^^,^,,  „U  the  muscles  except 
post  mortem  showed  slight  pulmonaij  ^"' '"  '  '  .  ^  ^^,^  ^-  ,,,,t  fragile, 
Ihe  glutei,  the  calf,  and  j;;;  -i;-;  --  r;:^:;:^:^^  tli;  interstUial 
and  there  were  serous  ml  Uiati.m.  r'    '     1  reported  hy  Vn- 

tissue,  and  fatty  degenen.tiom  J^-;!-^'^^  ^ '^j  ^  ^^..^olted  by  Jacohy 
vcrricht.  llepp,  and  .lacuby,  of  ^  ^  }  J'^-^^/^^^,^^,,,,  .lij-ht  a-dema  ..f  the 
,1,0  nniscles  were  linn,  hard,  ""'l  ^^  ^  j '7  ,,  '  ,  ,  to  three  months,  though 
.,in.  The  duration  of  the  eases  is  uM^al^  ^  ^;"l,;^,  ,^,,„,„,  and  t.Mider- 
tlH.re  are  instances  in  which  it  has  '^  /  ;  ;,^ti  rallv  suggest  trielun<.sis, 
„oss  of  the  muscles,  the  .edenuu  and  the  V'^^l^^^^^   .^f,^  ^.^^^e  of  the 

a.a  huleed  Ib^PP  ^^'^t;:^;:,:::;;;;:^;;  d'^lled  borders  of  sensa- 
disease  is  unknown.     Senators    a.i        '  ^    ^  ^^^^^.^,  are  not  involved 

ti„,  a.d  tlH.re  is  a  question  -beiher  f     '  ,;,  ,,,,,  ,ere  examples 

,H,,  the  nmseles.  Wagner  suggests  th  t  ^<; "^  *'J  ,^;,,,^  f,,„,  trichinosis 
„r  „,,t,  progressive  muscular  atropln.  '  ^^^^  Jt  has  not  yet  been 
,,,,  1,,  ..ade  only  by  r.-nvving  a  portion  of         -;''  ^  ;    f  .,^  v,,,  to  the 

dition  of  the  muscles  even  passing  on  to  gangrene. 
1148 


MVOTOXIA. 


1140 


ction.  and  is 
.voval  chiirao- 

NVafiiH'v  may 
oman  entered 
slight  (edema 
osia,  the  arms 
y.     Gradual  ly 
ninnths.     'I'lie 
imiHcles  exeept 
m,  hut  fragile, 
the   interstitial 
ported  hy  T'n- 
rtcd  by  Jacohy 

(edema  of  the 
nonths.  though 
iig  and  tender- 
rest  tri(^hin()sis, 
i^  nature  of  the 
)rders  of  sensa- 
ire  not  involved 
s  were  examjiles 
Tom  trichinosis 
lias  not  yot  been 
:  peculiar  to  the 
liffuse.  pundent 
iUiees  have  been 
feet  ion,  the  con- 


Mv(jsn'is  Ossiric.vNS  ruoouKssiVA. 

Of  thi-^  rare  and  reniarkalde  alTeetion  I'i  eases  have  l)een  recorded  (,Mat- 
thes).  Tiu'  process  lu'gins  within  tiie  neck  or  liack,  usually  with  swelling 
o(  the  atlVctcd  muscKs,  redness  of  the  skin,  and  slight  fever.  After 
subsiding  an  induration  remains,  which  lieconies  progre.-sively  iuirder  as 
tiie  tranriorniation  into  hone  takes  place.  The  disease  is  very  chronic,  and 
ultimatelv  mav  involve  )•,  niaj(M'ity  of  the  skeletal  muscles.  Nothing  is 
known  of  the  "etiology,  the  condition  has  often  been  associated  with  mal- 
formations. 

II.    MYOTONIA  (Tltomse7i'3  Disease), 

Definition. — An  infection  characterized  by  tonic  cramp  of  the  mus- 
cles on  attempting  voluntary  movements.  The  disease  received  its  name 
from  the  iihysician  who  lirst  descril)ed  it,  in  whose  family  it  has  existed 
for  live  generations. 

Wliile  the  disease  is  in  a  majority  of  cases  hereditary,  hence  the  name 
myotonia  rongcnita,  there  are  other  forms  of  spasm  very  similar  which  may 
be  acipiired,  and  others  still  which  are  (luite  transitory. 

Etiology.— All  the  typical  cases  have  occurred  in  family  groups;  a 
few  is(datc(l  instances  liave'l)een  described  in  which  sinnlar  symp^toms  have 
been  ])resent.    The  disease 


rare  in  this  country  and  in  Kngland;  it  seems 


more  common  in  (iermany  and  in  Scandinavia. 

Symptoms.— The  disease  comes  on  in  childhood.     It  is  noticed  that 
on  account  of  the  stitfness  the  children  are  not  able  to  take  part  in  ordi- 
nary games.    The  jjceuliarity  is  noticed  only  during  voluntary  movements. 
The  contraction  which  the  patient  wills  is  slowly  accomplished;  the  relaxa- 
tion whi(>h  the  i)atient  wills  is  also  slow.     The  crmtracti.u)  often  i)ersists  for 
a  little  time  after  he  has  droi)i)ed  an  object  which  he  has  picked  up.     In 
walking,  the  start  is  ditlicult;  one  leg  is  \nit  forward  slowly,  it  halts  trom 
stilVness  for  a  second  or  two,  and  then  after  a  few  steps  the  legs  becom(« 
limber  and  he  walks  without  any  dilliculty.     The  musctes  of  the  arms  and 
k-s  are  those  usually  implicated;  rarely  the  facial,  ocular,  or  laryngeal  nuis- 
ele<      i'lmotion  and  cold  au'^ravate  the  condition.     In  s.nne  instances  there 
is  mental  weakness.     The  sensation  and  the  rellexes  are  normal,     (i.   M. 
Hammond  has  rejiortcd  three  remarkable  cases  in  one  family,  m  which  the 
disease  began  at  the  eighth  vcar  and  was  confined  entirely  to  the  arms.     It 
was  accmipanied  with  some  slight  mental  feebleness.    The  condition  oi  the 
muscles  is  interesting.     The  i)atients  app(>ar  and  are  muscular,  and  tliere 
i.  sometimes  a  definite  hvpertroiihy  of  lh.>  mu-cles.     The  lorce  is  scarcely- 
proportionate  to  the  siz(^     V.vh  has  describ.>d  a  characteristic  redaction  ,.t 
the  nerve  and   muscle  to  the  (>lectrical   currents-the  so-called   tnyotonic 
r(>aeti(m,  the  chief  feature  of  which  is  that  normally  the  contractions  caused 
bv  either  current  attain  their  maximum  slowly  and  relax  slowly,  and  ver- 
micular, wav(>-like  contractions  iiass  from  the  erdhode  to  the  anode 

The  disease  is  incurable,  but  it  may  be  arrested  temi.orarily.      I  he  na- 
ture of  the  aiTection  is  unknown.    In  the  only  autopsy  made  Dejerine  and 


i'l 


ii:^ 


1;.  U 
;'.|  i! 

ill 


'•r! 


n 


'I: 

■  5 


!|l 


lljd 


DISEASES  OF  THE   MUSl'LES. 


Sottas  luncfcnn.n>v,K.rtn.i.hy  of  the.  i-in^ 


itivc  fibres  witli  iiuiltiplipation 


Sottas  have  Unmd   ;vi-'tn.  m>  m  u.^  diaphragm,  hut  not  the 

,f  the  nuclei  of  all  the  "J^'^'^'  '    ;    "^  "^^  ■,,^,,^,    Vrom  Jacohy's  recent 
heart.    The  spinal  eord  ami    1-   -       ;\       ^7i„  „,„,i,.  are  in  any  .ay 

studies  ^^-^^^^^^^^^^^\^^;:,X:^^^So  treatnu.nt  for  the  eondUion  . 
riiaracteristie  or  peeuliai  to  tlu  (U.uk 

known. 

HI.    PARAMYOCLONUS    MULTIPLEX 

(Myocluuia). 
,        -I    ,1  ,,v  Fric..lr<Meh.  rharac'teri/cd  hy  clonic  contvac- 

t.i'y;!:i;::rthr;::;i'^^t;::.^t.eunt..^ 

-  ^Ti;rs;:;e emeny  in  n.aie.  and  ^^;^:::;^::^-:^^;iz;. 

t'--'  ^''^'-•^'-'•%^t hf.';:;  <:::::undn  a;;;; !;;;  •  in  t..  nnnute.^  occa. 

cralandmayvaryironH.l      to  me  m  .           ,,m  ^  any  sensory 

sinnallv  tonic  spasms  occui       I  \^i J'^'  j     ^  „,,,,.  „,,v  i.e  tremors  <.t 

ai.turhanccs.    In  the  intervals  '-^w    n   1^  ■    -          ^     ^.;   ,  ^,^,,„,.  u,, 

the  nu.scles.    In  the  seve,;e  ^l-^  ^^^  ,  !     ',;  ,J.,p  the  patient  in  bed. 

:::!i;ct;s:ir;:.mi;;;n^^^^^^ 

^^■"^i:rhas  also  noted  heredity  in  four  ^;-^;-^.^:[':;S,;::  ^l^! 
author  the  essential  svn.p.o,..  a;v  -;;;;;;;;-  ^  ;;:::i;^:,herwise  nor.nal, 
tractions,  usm.Uy  ^y-'j'-^-;  '  ^\  ,'  ^^  !  ,  .vehical  nor  sensory  disturb- 
which  cease  dur.n,.^  sleep.     I  heu  '^  ^^      '^  •         ^^^^.^^  .^^^  is  nnalfeeted 

,,,,,  The  condition  >s  nu-st  -  "^^  ^  /^ '^rfibrillarv  tremors,  electric 
bv  treatment.  Raymond  ^^"^^^  ^^'^"^^^^1,.,,  and  (he  convulsive  tic, 
^■iu>rea  (llenoc-h).  !.<■  non  ^^^-^^^T^^^  i  i.  onlv  one  link  in  a  ehain 
,,nder  the  name  of  wiiochwirs.  belie\ ing  tnai  . 

;;;  pathological  manifestations  .n  the  degene.ate. 


ti  plication 
it  not  tho 
by's  recent 
n  iiny  way 
onditiou  is 


INDEX 


lie  coiitvac- 
r  cons-tanlly 

llowcd  cnio- 
svially  Itiliit- 
iiute.  Occa- 
any  sensory 
lO  tremors  of 
violent;  the 
itient  in  hed. 
rred  in  three 

rdin?  10  this 
iniseiili.r  con- 
rwise  normal, 
isory  disturb- 
is  unalfocted 
■mors,  electric 
■onvnlsive  tic, 
Ilk  in  a  chain 


Ahasin,  use,  llSfi. 

Ahdoin''  :il  tyiiliiis,  1. 

AbiliKTii.--  lurw  (see  Sixth  Xr.itvE\  liVp^. 

AbL'rnuit,  thymid  jrhiiuls,  s:!il  ;  ailiviiuls.  S'.iii. 

Aliortum,  in  rolapsinn  Ic'ver,  oo ;  in  snmll-liox, 

(i5  ;  in  sypliilin,  ii.'il. 
Ali^i-'C'ss,  atlu-nmiatous,  VVl  :  ot' lirain,  lii'2.") ;  in 

appundiiiti^   n-J-',  ,"i'JO;   in   ulamlers.   linr>;  of 

kiilney  (pyimcplirosis),  8Hi! ;  of  liver,  .")77 ;  of 

Iniii:,   C''''-i;   of  iiifdiastinuni,   fi-^d ;  of  parotid 

jrland,  4t7;  of  ton^ils,  4o-J :  porinopliric,  '."to; 

ccrfliral,  10-J.", ;  pya-iiiio,  li'iS  ;  rutro-pliarynuri'al, 

4.'io,  HTl. 
Ai'anlliooeplmla,  •'ii>">. 
Aoardia,  7i).">. 

Acarus  sonl)iei,  A.  follii'Mloruin,  37t!. 
Accentuated    aortic   second   sound,   in    dironic 

Brii,'lit's  disease,  ^''1  ;  in  artcrio-sclerosis,  77 1. 
Accessory  spnani,  Ifi'il. 
Acephnlocysta  (see  IIvriATiu  Cvsts). 
Acetoniemiu.  4'Jt'i. 
Acetone,  4'24  :  tests  for,  1'24. 
Aeetonuria,  Si;4. 
Aclii>ndroplusia.  ^41. 
Acliroinatopsia  in  liysteria,  lllii. 
Acliylia  •rii''trii'a.  odl. 
Acne,  tVoniljroniide  of  potassium,  \\0\  ;  rosacea, 

3SJ. 
Acroincjraly,  1142,  and  L'i'-'antisin.  114^. 
Actinomycosis,  'j:;.') :  pulmonary,  'jyii ;  ciitaneout, 

'J.'57 ;  cerebral,  'J^C 
Acute  bulbar  paralysis,  Si;!".. 
Acute  yellow  u^ropliy,  ri51. 
Addison's  disease,  H'JS;  pill,  -JM  ;  keloid,  1145. 
Aili-'iie,  SO'.i. 

Adenitis  in  scarlet  fever.  SI. 
Adenitis,  tulierculous.  'jsj,  sl2  ;  nialiirnant,  101. 
Adenoid  growtlis  in  ]iluiryn.\,  4ol. 
Adherent  pericardium,  liD'i. 
Adhesive  pylephlebitis,  554. 
Adrenals  in  Adilison's  disease,  8'_'9. 
.ifiirophony,  liiO,  070. 
Artcrent  system,  discuses  of.  'JiO. 
Ajjeusia.  lOfiO. 
A<rorupliobia.  1124. 
Aftraphia,  9'J2. 
Ague,  202. 


.\^rue  ctike  (sec  Esi,M!c;kii  Si'i,i;kn),  2in. 

.\inlium,  1 147. 

••  .Vir-liunu'cr'"  in  diabetes.  4'Ji!. 

.\Uinesin  al^'cra,  112ii. 

.\koria,  5(t;'>. 

.Mbini,  noiUiles  of,  7i''7. 

.\lliinism,   in   le[irosy   (lepra  albai,  "11;  of  tlie 

\w\\i,  05ii. 
.•Mliumin,  tests  for,  85(1. 
.Mbuminous  expectoration  in  pleurisy,  Cu^, 
Albuminuria,  S5l,  and  life  assurance,  .'<5,s ;  ey- 
clic,  s55  ;  felu'ile,  S55 ;  funetioiud,  ^^55  ;  in  acute 
I}ri"lit"s  disease,  870;  in  clironic  Hri^'lit's  dis- 
ease, SsO  ;  in  diabetes,  424;  in  ili]ilitlieria,  15o; 
in  epilepsy,  10'j7  ;  in  erysipelas,  151i;  in  trout, 
415;  in  pneumonia.  122;  in  scarlet  fever,  7!', 
so  ;  in  typhoid  fever,  ".1  ;  in  vari'ila,  i'.4  ;  neu- 
rotic, S55  ;    physiolo^'ical,   s55  ;    pro;.'nosis   in, 
S5s. 
.Mbiuniiuiric  retinitis,  10:!ii. 
.Mbuminuric  ulceration  of  the  bowels,  513. 
.Mliumosuria,  S57. 
.Vlcaptoimria,  si;5. 

Alcohol,  elVects  of,  on  the  diu'cstivc  system.  ^Sl  ; 
on  the  kidneys,  .'!S2;  on  the  nervous  system, 
3sl  ;  poisonous  elVects  of,  osl. 
.\lcoliolic  nem-itis,  lo:i4. 
Alcoholism,  3sO  ;   acute,  3S0 ;  and  tuberculosis, 

382;  chronic,  880. 
Alexia,  iH»2. 

.\ltrid  form  of  nuilaria,  215. 
.Mlantiasis,  o',U. 
Allocheiria,  '.t24. 
.Mlorrliythmia,  75ii. 
.\lloxuric  bodies  in  trout.  409. 
.\lopecia,  in  syphilis,  241. 

.Mtcrnatinj;  paralysis  (sec  Ckosskp  I'Ait.M.vsrsi. 
.\ltitude,  etl'ccts  of  hiu'h,  Slii. 
.Vllitude  in  tuberculosis,  25'.i,  3".4. 
Amaurosis,   liystcrical,  1040.   1110;  toxie.  lolo; 

unemic,  807,  ssi  ;  in  hicnuitcmcsis,  4'.m'p. 
.\ndilyopia.  '.040;  tobacco,  lo4ii;  crossed,  1044. 
.Vnibulatory  typhoid  fever,  14,  34. 
.Vmceha  coli  (amo'ba  dysenteriiei,  I'.iJ ;  in  liver 

abscess,  195,  577  :  in  sputa,  2ol. 
.\miebic  dysentery,  r.,i5. 
Ammoniiemia,  8^8. 

1151 


i; 


iv, 


Et-^OK,- •-»    •4<MK 


INDEX. 


1152 

A,nnosla.  au,mory,000;  taotilo,  0.0;  visual,  ^n.. 

Amvli'-ni'  iToatliiii^',  HO'.t,  ».».!• 
AiniOiorio  echo,  WJ. 

AiiiU!<ia,  001.  ,    ...      oou-  •ii\  BVi'li'ili:-, 

Amvlma  ai«.ase,  in  pMlnsis,  SViH  ,  in  hM  m 

oi->;ofkKlmy,SM;  on\vor,i.s'.. 

Aniyostlu'iiia,  ll'jn  ^ 

Amyotvophic  lateral  s.loros.-; 

1  '•vtt  •   miners,  ot»"  »    iim^i* 

*^'T  ''"':::f  t;.;  ^=  "'     'V:,n   lnanUl.m, 

r.n\  trotu  u^na,  o^. ,  ^ 

tain,  MO,  8r,0  ;   .n    malaual    ;-.>•  ,„,^i 

rh..u.«ati.n,,  170  ;  m  .ypluh..  -■*':;     '-.^,^. 
.•      ,.  VI-  Miniary  '>r  cssentiul,  .'.I2.  piof^it^    | 

^::';,  ni  ;:J'^;~»-^-r^!"^t;';'' 

;;;;l,,,;ol'si,inalcora,i>00;si,lcu,.,  NU. 

.!;;:ia;— rs  (see  11.KM.- MruMn..  I 

^Lu.e.a,aoU...;,;:o,.n.e,n,.^^ 

'•'''^~'i!i:    u  M!.rvM;saisease..7n; 

"""m    ^^ii.i'ni;"'""''"^-"^'^'^''""'"' 

ill  railway  >lHUt,  "-'■'> 

the  eonl, '."1.1.  Morvan's  ais- 

Anal!:e=*i«  in   l.^^t  na,   m 

case, '.17.-.;  in  ^vn.lgo-mJeha,  J..>. 
Anarlliria,  '.1S8. 
Anasaiva(,seel)uoi-sv). 
Anchylestomiasis  ;;n'J. 
Auehvloslomuiu  .lu.Klenale,  n„J.  _ 

Anem-ism,  770;    artrrio-veiious,    h'.,    .,;■;_ 
■1     ""r,  •  fmi"enital,    i"^-  ^.' ""  . 

di.seeUn,,770;e,nboh,..^^.;U--^._^^^, 

*"?  ;  :  :\  ;  bn  oi^s  of  Uie  abaonilnal 
'"T;''^7-  Vie  eerel.ral  arteries.  1013;  ot 
nortft,   .8.  .  0'  ^"  ,       J    .,-,;,;  of  the  he- 

^"^^"■''"r';;rc^le-"'i-'-^''^-°^ 

terio  artery.  7S7;  true,  776. 


liaravles,'ia, 
,  1117. 


siairious, 


lilt;    in  ^'ii^'tio 
nil. 
Anorexia  nervosa,  .'i' 

Anosmia,  lo38.  , 

Anterior  oerebral  artery,  en,boUs,,.._1011. 

Anterior  eriiral  nerve,  imralysis  ot,  R  , - 

AiitliHiiivla  eanieiilaris.  :178. 

Vuthraeosis.  of  Umu's,  r,r,-i  i  ot  l.ver.  o.n. 

^.xternal.  •.!•.;.•> ;  internal,  •.;-.;o. 
Anthropophol'ia,  ll-.il. 
Antil'neinii"ni''  seriiui,  11:'. 
Antii'iieuiiiotoNin,  ll'.i. 
Antitoxine    of  aiphthena,   lH,   U 

nionia,  ll■.i;<'>'t'■""""'--■^■^• 
\ntitv^>lloia  vaeeine.  -IJ 
_ 1..*,. 


155 ; 


of  imeu- 


Anuria,    8.">0 ;  eomvleti 

terical,  851. 
Anus,  iml'erforate.  533^ 

Aoita,  aneinism  of  77' 
7^^;    throbbing.'.  ~^'> 


fnmi   stone,  SoO  ;  hys- 


;  .lynaniie  pulsation  of, 
\\-y,\    tubeivulosis    of. 

7,,',i;    suaaen    a.ath    in. 


terio  artery,  7S7  ;  true,  .7o.     ^^^_  ,  „,„,ri.haf.'e 

-rs::;2'"srT;rnvi.niento.. 

r8;;unilat.:val  sweating  i'vT-;!.^ 
Aneurisni,  verminous,  m  the        .e,3^^.. 
Anuina,  LuJoviei,  450  ;  simplex,   448,. 

'''■'" ''''.,ovis7niTseuao- or  hystcrieal, 703 

A;;S;eh;:mis:Xo.iiee.Uurrhal,557;supP«ra- 

the  ana  ulcerative,  0,),. 
Ant:io-neurotie.eaema,lMO. 

\ii.'io-seU'rosis.  773. 
An;mllulastereoralis,.V.intestinalis,304. 

Animal  lymph.  7'i. 


Aortic   incompeteiiey, 

Aoltic  orifice,  couireiiital  lesions  ot;  707. 

Vortic  stenosis,  710.  -.',•.1,,- 

Aonic   valves,  bicuspia  condition  ot,    ,.>-,." 

sullicicncy  of.  70'.'. 
\iic\  pneumonia.  I'i3. 
vl.a'ia    I's^;   anatomical   locab/.at.on  ot    ',..;. ; 

P.  .en-    hemii.lcu'iu    with,    Wl  ;    ni    ni- 

fantile    hemipUL'i.i,    n^  1         ,„„•„,,     „(,.,.    hi 

£     •::;y;;:.iaL^,30;tests.,r,..;tran- 
,•,,nt,inmi,mline,llo3;\\ermcUcs,J.>.. 
Apheniia(seeAH.AsiA,  Uirvn.itis, 

i;i5;  in  alxluctor  paialjsis,  J    J    . 

tlUa  ett'usion.  O'.eJ. 
Apl,tlue(seeSTOM.vTiT,s,.V.M,Tnovs,,441. 

Aphthous  fever,  34.. 

\, oplectic /,«'<'•' «.s  IKK  ;  stroke,  1001 

Apoplexy,    cerebral.   tnC ;    ingravescent,    1001, 
pulmonary,  038  ,    ,      jntVetive, 

\ppenaicitis,    .air.    ol.l.t.ians.    .-_ 
nil ;  perforative,  5::o;reUipsm^...^,.   "1--^ 

A?;:,;,u;uh.ccj^.5.<^^ 

Appenaix  vet  m  toil  ^^^^^  ^,^^_^^,_,^_ 

ration  of,  m  typh  nd  tevu,  i- 
tionsin,r,19;foreiL'n  bodies  in,u.O,ne 

and  sUnii.'hiiig  ot'i  •''-l- 
Apraxia,  'J8'.'. 
Aprosexin.  454.  450. 
Arachnida,  parasitic,  375. 
.Vracl.nitis  (see  Meninoitis),  9,.4. 
,.     I .fv„o  of  muscular 


Arachnitis  (see  Meninoitis),  9..4. 
,L„-Z)«c/««».type  of  muscular  atrophy,  9-9, 
y41;  in  Icad-poisonini:,  388. 


INDHX. 


li:.:: 


',T  ;   si'unous, 


I  of,  \<n\. 

■r.  "0. 
aliiiiials,   '.i'ii  '< 


lo5;    cf  I'lKU- 
.tciiie,  S50  ;  liys- 

llic   li\ll?lltinll   III', 

tubfivulos'is    ot, 
kUU'Ii    a.iitli    ill. 
s  lit;  ViiT. 
il'Kjii  of,  7i>''>;  iii- 


■iiliziifK'U  of,  '.I'.i'^; 
,itli,    y.il  ;    ill    i'l- 

uiixcil  forms  of, 
uluotion,    WJ;   i" 

of,  '.lyS:  sensory, 
tests  for, '.I'.i:! ;  li-aii- 
orniolie's,  W-. 

n  lU'Uto  liiryniritis, 
s,  li'Ol ;  ill  I'l-Ticar- 


irniovsi 


441. 


oki',  lOol. 
iii.iiravcsoont,    1001 ; 

■aiis.    .VJO ;    infootive, 


uation  of,  5111;  porfo- 
:ur,  10;  fifi^ul  ooiiove- 
jdius  ill,  ii-y  ;  ii^''^'''"*''* 


is),  9r)4. 

muscular  atrophy,  0-29, 

;iS8. 


Aroli  of  ftortii,  aii<uri>iii  "l',  TT^. 

Ari'iis  sriiilis.  T'l". 

.tiyi/!l  lich.HKiiii  pupil,  I'U;  ;  in  jitii\ia,  '.'JJ. 

Aritliiiioiiiania,  losl'. 

Ann,  piriplifi-al  paralysis  of  i  >ci'  I'aum.vsis  .pf 

liUMIlIAl.  I'l.Kxrsi. 
Arrliythiiiia,  T')i!. 
Arsciiii'al  lU'iirilis,  lo:',,",. 
Arsuiiioal  pi;.'iiiiiitatioii,  ;!'.in;  in  diorca,  lo^,"i. 
Arsi'tiioal  poiwiniii'.',  ;!'■"';  Iiiirulysi>  in,  o'.il. 
Arlrrii's,  ilisua>cs  of.  TT'i;  falcili"atiori  of,  TTo; 
tk^'ciicratioM  .if,  TTii;  fatty.  77";  hyaline,  77"; 
tulierenliisis  of,  "i'J7. 
.\rterio-eapillary  lilu'osis,  77". 
Arli'i-io-elerosis,  77";  iliU'use.  77-J  ;  in  lea.l-jioi.s- 
oiiini.',  :;s'.t;  in  mii'raiiie.  II"-!;   noihilar  form, 
771;  ill  phthUis,  :;li;;  senile  form,  77-'. 
Arteritis  in  lyplioi.l  fever,  1-J,  'Jl. 
Arteritis,  ss  pliilitie,  '.'."". 
.\rtliralt,'ia  from  leail,  ".s;i. 
Arthritiiles.  ]iost-felirlle,  M.'i;  in  '.'out.  41  1. 

Arthritis,  17:!;  iieute,  in  infants,  17-1;  l' rrleeul. 

•>:A:  ill  aeiite  myelitis, ',I77 ;  in  eereliro-siiinal 
iiieninu'itis,  Im!;  in  elmrea,   I"--";  in  ilen^'iie, 
111";   in  dysentery,  •Ji.">;  in  Inemoiilnlia,  s-2"; 
in  small  pox,  il'i;  in  tn'ies  <lor,salis, '.•:!."> ;  mul- 
tiple seooiuhiry,  17:!;  in  jmrpiira,  si.'. :  rheiima- 
toiil.  ;V.if;  in  searlet  fever,  s" ;  se|itie,  17:i. 
Arthritis  Ueformans,  .'iltU;  iis  a.  elironio  infeotioii, 
41.111;  in  ehihlreii,  40:i;  elinmie  foriii.4":i;  (.'eii- 
eral  ])rou're>sive  form,  4"-J  ;    ll.h.  rd,  ii'.-<  noile> 
in,  1"1  ;  Jiartial  or  mono-arti<'uhir  form,  4o:;, 
Arthrojiathies  in  tulies,  !eJ5. 
Arthropathy,  hyiiertropliie  pulmonary,  II II, 
Aseariasis,  :i."i-J, 
Asearis  liiinhrieoides,  .'!"i-.'. 

Ascites,  0"'i,  fiM'.i ;  ehylous,  i'i"7  ;  from  eaneerous 
peritonitis,  fiO.");  from  eirrlmsis  of  the  liviT, 
.'•)7'2;  from  syphilis  of  the  liver.  -Jl;! ;  in  caneer 
of  tliu  liver,  .">s4 ;  in  tulieivulous  peritonitis, 
2s7  ;  physical  sii^ns  of,  limi ;  treatment  of,  ii07. 
Ascitic  fluid,  chylous,  (ju7;  semus,  (ju7  ;  luunior- 

rluiiric,  0"7. 
Aspergillus  in  lumr,  ""'-'. 
Asphyxia,   local,   11:57:   death    !iy.  in   phthisis, 

317. 
Aspiration,  liowditch's  ennelusions  on,  fi77 ;  in 
empyema.  1I7.S;  in  pericardial  ell'usion,  0U5 ;  in 
pleuritic  etlUsloU,  ii77. 
Aspiration  pneumonia,  iU'2. 
.Vstasia-abusia,  lI'Ji;,  U".'!, 
Asthenic  bulbar  paralysis,  '.i47. 
Asthenopia,  nervous,  1 1-J4. 

Asthma,  bronchial,  02S  ;  nasal  atlcctions  in,  i;2»  ; 
sputum  in,  <):!",  cardiac,  ii2s;  iiay,  012;  /.•.'/- 
ilcii^s  crystals  in,  0;il ;  renal,  si'o  ;  tliyinic,  ijls, 
844. 
Astrophobla.  1124. 
Atavism,  in  luemophilia,  -^Vi:  in  ,i,'out,  4"S. 


.\ta\ia.  eer.  ln'Ilar,  '.is7 ;   cerebellar  licredo,   '.i.'."; 

hereditary,  '.ir.i;   in  pro^'rc-.ssivc   pare-is,  '.ii'i2; 

1 imotnr,  i.ij";  after  small-lmx,  ii4. 

Ataxic  i.'ait,'.'2:l. 

.\taxic  paraple;.'ia,  Vts. 

Atileetasis,  piilnioiiary,  i'il2. 

Atlier i^see  .\uTKUio-s(i.i;itosis  and  I'm. 1:110- 

Si   l,K.llosl>), 

Atheto,i.s,  lop.i;  bilateral  or  double.  'r,\>. 

.\tlilete"s  heart,  71". 

Athyrea,  s:;7,  s|", 

Atniiisphcric  pre^>iire.  cM'ects  of,  lii;;!, 

Atremia.  1 1'Jil. 

.\tiiipliic  cirrhosis.  .".71. 

.\tropliy.  acute  \ellow.  of  liver,  .'i.'d  ;  of  brain, 
dilhisi',  in  (.'eiicral  parois,  '.ii;l  ;  of  brain,  uni- 
lateral, lol7;  of  mii>eles,  various  forms  of, 
;i:'.."i;  proL'rc>-.ive  muscular,  of  eciilial  orii.'in, 
lejs  ;  unilateral,  of  face,  1141. 

.\ttitude,  in  pseiido-hypcrtriipliie  mus.odar  pa- 
ralysis, li:!4  ;  in  paralysis  a^'ilaiis,  lo;;. 

.\uditory  centre,  all'cclions  of,  l".",.;;  mrvc,  dis- 
eases of.  lo,",i;;  vortiv'o,  l"'is, 

.\ura.  forms  of,  in  epilepsy,  l"'.i.'i. 

.\uto-infection  in  tuberculii>is,  -j;:;. 

Automatism,  in  jnlit  maly  l"'.i7;  in  cerebral 
;.yphilis.  24i'i. 

Auliminal  fever.  ". 
Avian  tuben-ul'isis,  •s:i'<. 

/,'(,v. ///•.<  si'.'ii.  i'i7".  i;72. 

I'.acilliis,  aiithracis,  -JJI:  of  cbolera,  17.". 

IJacillus  eiili  communis— distinction  t'roin  ty- 
phoid bacillus,  4;  in  liile-pas...a,i,'es,  .'..".^ ;  in 
t-eccs  of  sucUliliL's,  .'los  ;  in  fat  necrosis  with 
ciilitis,  "I'.d  :  in  iieritmiitis.  o'.C 

r.aeillus  diiihtheria',  M",  4.M  ;  value  of.  in  diag- 
nosis, l.'il. 

liaeilluH  gas  1 1!.  aeiM-.'i'nes  eaiisulatusi  in  peri- 
tonitis, .')!i7  ;  in  pnciimaturia,  si! I:  in  piieuim)- 
perlcardium,  li'.|'^, 

Bacillus  ieteroides.  Is;!. 

HaeiUus,  Klelis-I.oLtllcr,  140  ;  toxinc  of,  141. 

liacillus,  of  glanders,  2.13;  of  intlilenza,  HO;  of 
smc<rnia,  23S  ;  in  \vho(iping-eoiii.'li,  02  ;  of 
leprosy,  "40  ;  of  phii.'uc,  I'.i"  :  of  syphilis.  2:W; 
of  tetanus.  231  ;  pyocvaneus,  1112  ;  strepto-,  in 
typhus  fever,  o". 

Bacillus  mallei,  2.'!3. 

Bacillus  pestis.  I'.iO. 

Bacillus  iineiimoniie,  HI. 

Bacillus  imiteus  Huorescelis,  344. 

Hacillus  smegma.  2'o. 

Bacillus  tuberculo>is,  2,">1»,  000  ;  diai/nostic  value 
of,  313;  distribution  of.  201;  in  sputum.  300; 
methods  of  detection,  301  ;  outside  tlie  body, 
201 ;  products  of  growth  of,  20O. 

Bacillus  tyi>hi  abilomlnalis,  3. 

Bactcra'mia,  101. 


I, 


I' 


a   1 

i. 


II 
11 


ii:.i 


IN  UFA'. 


111  li'mrfliiiM.  •'i"^. 
IJai-teTiuiii,  o>li   oninimm.'    (Sfc  Da.  ii.i.i  s  (  <.i.i 

t'liMMiNis!;  illi■li^*  iicriiL'i'iu'>,  .■■ii>. 
I'.iiliinUis  in  <rmli<'ti'.<.  l-^.'i. 
Kiiliintiiliiiiii  ciili,  ii'il. 
l!iill-llirniHl>ii>  ill  U'l't  mini'lf.  T'j:'.. 

Ullll-Vlllvt:  >tnuc  in  CHlllllinll  lllK-t.  ^'M. 

Jliinfiii'/n  iiu'Uinil  ill  iil»»it\ ,  l"'-'. 
•>  liiirlicii  I'liolcni,"  li'.il. 
l!iirliiii„'>'"ii:.'li  I'l'l'ul-.rtv.  HIT. 

Itlflii'v'K  (li>rllM'.  >-■"'• 

liiinvl-shiil.ra.'liot  ill  ciNi.hVMiii:!, ';.-o;  ill  .11- 
liir^'i'il  tiiii>il^.  ■l•"'■''• 

li.lKiil'llc'x  lliscllSf.  ■>."■!''. 

r,:i-iliir  iiit.iv,riiil...li>iM  aii.l  tliroiiil>.isis..f.  li'l^. 
lUlis,i'nia,"iii  ivi.lic.ia  l''V.'i',  U;  ill  liMMTpv- 
iTxiu  nf  rliniiimtii-Mi,  IT.".;  in  M'urlfl  tVvfi',  '-1. 
liut.'l'li'il'iii.  n-.it. 

liuiia.-a  rii'>  ill  iiia<ris  4:;i;. 


..liuUi'ii.  IT-;  in  aiulu'ics.  4-Jl;  in  u'.m.  nx; 
in  iMrni.ii.liirm,  ^-i";  'm  l''iil<'>'"i>»-  ^"'' ^  '" 
l„.rirK'inns  iiiiii'iiiia.  T'.'T ;  in  iwii.ln  l.-nUii - 
,„•,„,  ll.«L'lviii'>  ai..'ii>r,  M-.;:  ill  purpuni,  Ml; 
in  sucunaurv  iiiuHiiiu.  T'."' ;   in  tviilioia  fcv,  r, 

I'.'- 
lUoua   s.'niin    tli.nil'.v    in    aii'lillirrin.    I.".'.;    m 
IMK.uni.iniii,  \\■^■,  m  i.tai.ii.,  ^■■■^\  in  ivi'ln'M 

iVviT,  -IT. 

IU..oa-Vf>.-ias  of  liver.  atU''li'in><  of,  .")5.'!. 

-lUiK'aiM'aM'."  71;-. 

Uliu;  lin.'  "11  >:iiiii:-  in  liaa|...i>niiiiii.',  •1'>T. 
li.nl:*.  ill  aial'.-U's.  l-"'-.  i'lt.r  tvplmia  iVvcr.  1'.': 

al'tir  >iiiiill-l"iN.  ''."i. 
linni^.  l.'^iniis  of.  ill  arroiii.'i.'iily.  Ht-J  ;  in  .■■■n- 
^..•nital  .sNi'liilis,  'Jll;  in   liuUuMiiia,  Ni>;   in 
rioUi'is, -1:14:  ill  ivplioia  Uvir,  .•;•_'. 
15(.rlpi.ry,L'iiii.  l'.'^.  .'.nT. 
l'...tlin'Vri'li.ilii^  I'l'"^'  ■'''''  '•  i'li'i'i"'!'-  •"■''"• 
ri.ituli«ii.  :'.;'!. 

I'.dtvn.ia  livi  1-  in  ^yi'liilis.  '.M'.'. 
Kovinr  uilifi->'iil">is.  'J.'iH. 


£:;::;;::';;:;r;,.,:,.u,..-::.-...,„M.i-.... ,  '--'::;»-;rr'r:;:;zT;^^ "' 


htniotion  of.  .">:!l ;  iiifiiivtion  of.  .'i-HJ, 
r.raohial  plfxiis.  alUctiniis  of.  loH'.i. 
r.nuOiVoaraiu   ,  l!>!iav.'ai-aiai,  T.V.i;    in    l\\>hnul 

ffVlT.  -.il. 

Ui-ain.  ailliisc  ana  fo.-al  aiMiiM's  of,  '.iTii;  al's,..■^s 
of,  hi-M>:  iiliswss  of.  in  ..oiiu'inital   li.-art  .ii>- 
tasi'.  Til>^ :  allV.clions  of  laoll,■l-Vl■^s(•l^  ol,  ',i'.i|; 
aniiinia    of,    W'< ;    atropliy   aii.l   scLtoms    of, 
lol7;   ..onri'stion    of,  nm ;    .■>>ts    in.    H'-Ji  ; 
i.,.liino.Mu.,.ii>  ot,  :iTI:  lia'inoiTlKi.i:^  into.  W~  : 
svpliilis  of.   '.ill,   1"-J":    L'lioiiui  of.  infill;  liv- 
liciM-niia  of. '.I'.il;  inllaniiiialioii  of,  lo-j-l ;  oau- 
nia  of.  '.I'lT  ;  iiori'iu'ii'luilu>  of.  I0I7. 
I'lrain-iuiuiinii'  in  iii'!^i-I>.  l^o. 
lirain.  so1.toh>   ot;   v:,:  ;  ailln.,..  !'>:   iiiMilar. 

li.V.i;  iniliiiry.  :>:■•<■.  tiilH.p.n>.  'MK 
r.niin,  softciiiiiL.'  of.  ml.  ydinw.aiul  wliitc  loo;., 
r.rain.  tulxivlc  of.  .-.-Jl.  lujn. 
Hraiii,  tumors   of.   U<:i'>:  incaical   treatment  of, 
lo-j'l;  snix'ieal  tivatmelit  of.   IM-Jt;  syililitoms. 
.general  ana  loealiziii;.'.  l"'.;!. 
llMiid'n  nietlioa  in  tyi'lioia  fever.  l:!. 
I5reaUl«)lie  fever  (see  I)i;noI  1. 1.  V.K 

,.l„,aer.  panilyMs  ot;  in  loooinotor  ataxia,  ...;     ^'^^'^  '^  .lial.e.ie  eoma.  -1-;:  fml.  in 
.are  .,f.  in   myelitis    .7.  •  ">'-;-'^>- .:.:    '"  '        .,:,"':',:    a.  in  enlar.ea  tonsils.  4.-1. 
aial,etesnM,.ia,ls.4:,.:.ul,eleulo.so...,..,.  ^^-j;;,-    ,_,.,,,.„,,„„,,„...,„,  4M. 

"lileeaors.M,i.      ^                  ,,    ^--,.     in   eerel.nl  /,V,  «o  r'..  I.looa  test  in  aial.etes.  4-.i7. 

r.leeaiiiL'.  in   arteno-seleros,> in..nniil  /'"'                „„.,„„•,.,    .y,o 

„a.,norrha.e,   m.:    in   en,,liy.ei,,a.  Ji^.;    in  Ur.  -aU          ";         ;  •^^^l  ^  ,„^,.,,,,  ,,„  „, 

lieart-aiseasc.   7:U;    in    ,me,unonia.    L...;    m  l.iiu'lu  >  .Hs.-.  ^,  .i^'"  • 

snii-s.roUe,  =i.S ;  in  yellow  iVver,  l^s.  j    ^.<^^^  ^^,^^^^^^_  ^^^__^^^_^._  _  ^.  ^    -.nU^rsf.tM  torni  o,; 

Btepliarospasm,  in..  ■  '"  -                                                       ■        ■ 


fever.  I'.i. 
He.r  ilrinkers.  liearl  aiMaM.'  in,  71.'.. 
j;,l!:<  I  Luthiin  mania,  I07.'.. 
//.//Vl.alsy,  Ki.'.l- 
^-oxy-l.mtyrie  aeia.  4-Ji'..  ^i'.-'.. 
r.eri'-beri,  'J-iH  ;  fni'ms  of,  -JJJ. 
liesoin  ae  resi.irer.  :>V<. 
^(■./■/idfW.f.syiiiiitoni,  w-\. 

'•  nin-,iii""  i"  *''ittle.  •-■■"''■ 
r.ile  eolorinu'  mutter,  tests  for.  .''.411. 
liiU-auets.  aeiite  eatarrh  of,  .■^.•.r. ;  asi.arMes  111. 
,m;o;  eaneer  of,  .V.'.i  ;  eoiii,'enital  obliteration  ol, 
r.iil ;  stenosis  of.  •'itiii. 
IVile-i'assa'.'es,  aiseiises  of,  •".•■'•>■ 
I'.illiarzia  lneinat.>l.iii.  ii.'.J. 
Biliary  eirrliosis  of  liver.  .'.71.'. 
Hillary  eolie.  .'.iv'.. 
r.iliary  listiiia'.  ."n'o. 

Bilious  remittent  feVer.  'JK^. 

liirth  I'lilsies.  '.i:W. 

BlaeU  aeatli.  1'."^ 

BlaeU  si.it  of  miners,  dl. 

Blaek  vomit.  l>-ii ;  in  aenu'iie.  lOo, 


Blln.lness  (soe  Amaiuosisi. 
Bl....a  and  auotless  jrlaiias.  aiseases  of,  T-'.i. 
l!|o<.a.  elmraoter.s  of,  in  nnieiiiia.  T>'.i ;  in  ''Mneer 
of  tliu   stomach,  4fc9 ;    in  eliloroois,  T'.'-.; ;    io 


s77:  eauses  of.  .s77  ;  earai.p-vaseular  ••liaiiL'.'s 
in.  sso:  liereaitary  intliieiiees  in,  t.77 ;  I'areii- 
ehymatous  form  of,  h7J. 
/livaJbt  II fd  alixn,  O'JlJ. 


INDEX. 


11').") 


1  i.'<.iit.  nil; 
liii.  >'"■•;  ill 
iii.lii  k'liUu- 
iiiri'ur:!,  ^1 1  ; 
[ilmia  t'uvi  r, 

rill.    l.''i;    ill 

;   ill    t\  I'hoi'! 

>\d  iVvcr.  I'.i; 

111--' ;  ill  i'"M- 
■luia,  >"-;    ill 


in.  -.I'l 


Ksi  ;  iiciiti.'  i>ii- 

:ai\. 

I. 

i;    ill    t\l'liiiiil 

if,  '.C',':  lll'^.■(■^s 
litiil  Ih'1111  iii>- 
,,■^Sl•l^  i.f.  '.I'.IJ  ; 
,1    scll'l-n^is     (if, 

\>ts    ill,    li'-Ji  ; 

lltlf^r   illtn,  Wi  ; 

ii  of.  lii^ii;  liy- 
1  (if,  liijl:  ii'lo- 
unr. 

0.  ',i.'i>  ;   iii,->il;ir. 

Ml. 

mill  wliitc,  li"i'.'. 

ill    tri'lltlllCllt    nf, 
lii-JI ;  .syiiilitiinis, 

•r,  t:".. 


mil.  I'-'i'i:  f'>iii.  ii> 
■d  tnnsils.  -l.')";. 
iiiiHitli,  4."i4. 
,  1-JT. 

iter.-titiiil  forir,  of. 

ntcrstitiiil  form  of, 
-viisi'iilur  I'liaiiL'i's 
\:i  in,  sTT;  imivii- 


of  liiiliirv.  ><'.iH;  of  liver,  . ".-'J;  of  ImiL'. '■''■■■'. ;  <'!' 
irMipliiiiriis,  I'll  ;  of  puiicnii^,  .'''.11;  o|  ]icrito- 
im'lliii.liiiliurv.ilol  ;of>|MiiiiiiOi.  ■I'-'' ;  lauU'.  4'.'.'!. 

('iilifrmii  ori>.  Ill;  in  iii(ii.»K>,  ^7. 

Ciiiiilii'.s.  tlu'  rc'.-iiU  of  iiriiriil,i;iii.  ll"!. 

CllMlll'il  j.'oo<ls,  |ioi.>ollilll.'  li.V,  ".'.I". 

(.'iipilhiry  puUi',  in  iiorti.'  iiisnllirii'ii.'v ,  714;  in 

niiinisilirniii.  llJi'.;  in  plitiii>i>.  "11. 
('ii|isiili',  intirniil.  '.i^- ;  l(>ioii>  ot'.  ;!>■''. 


"  Drokin-wiiidi'il."  742. 

UroiimtotoxiMiiii!',  :;;il. 

r>roiiiisiii,  llui'. 

Uroni'lii.  >'ii>l>  of.  i;:;.;:  ai>i'ii>f^  of.  iljl. 

Urollrllilll  ll>tlllllll,  ''■-^■ 

llroMi'liiiil  I'litarrli  '  liroiH'liiti>  ,  I'.-Jl. 

linmoliiiil  L'liiii.U.  tiilifiviiio,i,  of, -js:; ;  ciilinvo- 

imiit  in  \vlioopiMj-.-oii.'li,',i|,iM;  Mipinu-iuioii 

in.  iM. 

I{roni'liic'i'lu>is,  i'i-J''i;   iili.-ccss  of  I, ruin   in,  i;-.'7 :  ■  «'iiiint  .Mcdiisn',  mm. 

mliirrnital,  il'J'i ;  cyliiiiliii-iil,  '•■^'■■.  rlniiiiiutoid  j  Ciipiit  (luailrutinii,  in  rirUits.  4.".il. 

allVctions  in,  'l'J7;  .-acfular.  '■.•J'i ;   >i.miiiii   in.  Cariiolnria,  Mi.''. 

.;-J7  ;  univcrMilis,  iVl^,.  Carliuni'lc  in  .lial.it.>.  -V2\ 

r>r.iiK'liioliti>  .■xii.lativa,  I'.-J-.                     -,  '  in-'li"-  •'l'"'-"'  "l>  ■'•'■'• 

liron.'liitis.  i;-Jl  ;  amt.',  i;;;l  ;  calilllaiy,  i;ll.  <'iir.lia.'.  coinp.nsali.in,  ruptuiv  of.  711  ;  .lis.-asc 

lin.nrhiti-.  .■liroiii.'.  i!'j;i.  ;      (,,■,•  Dinka^k  of  IlKAitn. 

llroii.'hiti>.  tllirinoiis,  i;:!ii.  ;  <'arilia.'  ninrniur.i.  h.imii;  in  .■lilom^is.  7;'l;  m 

llroni'liitis  in  ni.'aM.->.  -7;  in  .-inall-pox,  I'.l;  in  cliori'a,  inM,  in  i.liopatlii.'  aniMiiia,  7'.';'.  ^ 

tvplioiil  f.'Vcr,  -1'  ;  piitri.l.  I'.-J"'.  ('ar.liiu'  riinriniirs,  or;.'ani.'.  in  aortic'  iiiMillicicn.'y, 

Uronclineelc  (s.",-  (onrin-.  .  -;l.-..  j      Tl-'i;  in  aortie  st.n...-i.s  71i;;  in  .•on-Hiital  li.art  <- 

liron.Oiopliony,  inpn.nnioiiia.  1-11.  '      all.vti.iMs,  7il'.i ;  in  mitral  in.'oinp.t.'n.'y,  7:^"; 

l{r..n.'h.i-pninimonia.   a.'iit.',   ii41  ;   elir.'uic.   r.4;i:  in  mitral  strn.iM>,  7;i:i ;  in  tri.-u.-pi.l  valvr  .lis- 

ac'iitf  tulicr.'iiluiis,  -r.^-l.  I      lasi'.  7-Jil. 

Hroni'liorrliaL'ia.  .;.;7.  I  I'ar.lia.'  lu'rvs,  tiiural-in  of,  7ia. 

HroiK'liorrliu'a,  i;-.j4 ;  s.Tons.  (i04.  j  CanliiK'  .ivcr.strain,  74l'. 

Hr.in/.i'-skin.  in   plithiriasis,  :;77  ;   in   .V.l.lisonV  i  ( 'ar.lia.' septa,  anonialics  ol.  7i;i). 

tlimise. '•:li';  in  liiiseilow's  .lisease.  >:;;i;  in.lia-  !  Canlialijia  i.-ee  (iA.<ru,\i.(ii.\i. 

botes,  4-J.'>;  in  ll.HlKliin's  .lisease,  >1-J.  I  Car.li.ieentesis,  7.'i.">. 

IJrown  atroiihy  of  li-art,  7.">n.  •  'ar.lio-respiratory  niiu'iniir,  ;',n<. 

Urown  inam-ation  of  liinir,  ii"..'>.  Caraio-selerosis.  7.'iO. 

Bi-oirn-Sf./'iiif.rs  iiaralysis,  [u\:,.  \  Caraio-vaseiaar  elianges  in  renal  disease,  s-o. 

/)V»(7.  i/V//n(('//.iis:!;  (ll  :'in'r  III  nf'.iV."':  i/'  i/i'ili/i.  '  Caries,  verteliral,  !t70. 

7114;  ,/(-//(i//'.7Msei'('uA<-Ki;i)-roT  ."^oiMi  i.:;ii;i ;  t'arinate.l  abaoiiien,  2~x. 

lit  fiiiitlli  .'D'.];  irsopliatreal.  41I11.  1  Carotid  artery,  li^'iitiire  aii.l  eompr.-ssi.'ii  ol'.  in 

liiil.o.  paroti.l  I  see  also  I'Ais.jims  1.  447.  '      eeri-liral  lueniiirrha_i.'e.  Inl'J. 

Hiil.imle  plairu.-.  Is'.i.  Carpliolo^ri;,.  ;;li. 

Hileeal  psoriasi>,  4  n;.  .  Carjio-pe.lal  spasm.  1111. 

/;»/(/■»  aiseasi'.  sis.  j   Ciiriviiii.'2hK 

Uull'iir  paraly.-is.  '.'■!>.  ',i:'.'-!;  a.Mit.'    li".:'. :  astli.iii.'  j  Caseation, 'J71. 

f.iriii. '.147  ;  .if  .•ereliral  oii'.'in. '.'■;-';  pro.'res>ive.  j  Caseous  juieiiriionia.  •J7 J. 

i,.js.  Casts,  lilood,  of  lirolieliial  tidus  in   liii'moptysis. 


liiiliiiiia.  4'J-i.  •'ill-. 

Caelu'xia.  in  .'aiin'r  of  tlie  st.>iiiai-li.  4s;i ;  mala- 
rial, '.iOV^,  "JIO;  periosteal,  s'J'i ;  saturnine,  ys7 ; 
stnimipriva,  s<4-2  ;  sypliilitie.  -Jio. 

Caisson  disease,  'jtlii. 

Calcareous  coner'.'tioiis,  in  plithisis.  ii',11;;  in  the 
tonsils,  4."ii'p. 

Caleareous    ae;.'eneration.    of   arteries.    77": 


(l.S.s;  in  tibrinoiis  lironeliiiis.  i;".'. :  ot' pelvis  of 

liiTlliev  and  ureter.  s'.i7. 
Casts  of  urinary  tiilniles.  sT'j;  .'piili.  liul,  s7I.'-7-' ; 

fatty,  b~i\;  jrraniilar,  .s7<'i,  S'-n;  hyaline,  sso. 
Casts,  tube,   in   a.'Ute   Bri;;'ht"s  disease,  s7-;   in 

ehroni.'  liri^'ht's  disease,  .s7il,  ^SU. 
Catali'p.sy  in  hysteria,  111'.'. 
Cataraet,  diabetic,  4'27  ;  after  tyi'hoid  fever.  o'K 


lieart,  7."i". 
Caleitieation.  annular,  nf  arteries,  770. 
Caleitieatioi!  in  tubercle,  'J71. 


of  ;  Catarrh,  acute  gastric  4ii:>  :  autumnal,  fiVJ; 
bronehial,0;;l ;  chronic  trns'ric.  4i;i'. ;  .Iry,  f.'.i.'i; 
nasal,  (ill  ;  simple  chronic  1  nasal  1.  'dl  ;  suH'o- 
eative.  04.". 


Calculi,  biliary,  .'iill ';  "coral."  s;i-j ;   pancreatic.     Catarrhal  broncliilis.  intlucn.'e  of.  in  tuberculo- 
I'.i,');  renal,  s'.il  ;  t.insillar,  4r)t; ;  urinary,  slU.  sis.  i;i',!i. 


Calculous  pyelitis,  ssij. 
Camp  t'cver.  4'.i. 

Cancer,  of  biU'-iiassau'cs.  ."i.'li.  ."s:', ;  of  bow. 4.  i/.V.) ; 
of  brain,  lo-jo  ;  ..f  !.'alia.la.iaer..'..V.i ;  green,  bU'J  ; 


Cii/iirrln'  nil'.  fi'J."). 
Catarrhus  lestiviis.  (ll'J. 
Cauda  eipiina.  K  sions  of,  'J72. 
Cavernou.--  br.athin'',  300. 


,1. 
ll 


^^^ 


Uatl 


INDFA'. 


,  ;',u',i ;  i|m 


-I. 

■.,  ;iM  ;  <' 

;  l,,Tcili)-ata\'m.  '.'■'>"; 
iilVcTlioiis  1)1'.  C-^")- 

if,  1("ih; 


(:uy<.rt\y.»7fl. 

fi'ilulitis  ol'tlif  luM'k,  I'l'- 

Ci'iitriim  Hcmiiiviilr,  U'si"""  "' 

C.plial'u'  tc'taims, 'Jo-J. 

,'..,,l,>iln,lv..m,4n7.  ;^^ 

(',.rroinuim.s  iiit.MnmUs,  l.'.'    ■■■"  ■   '  •   " 

,",,-.1. 
(\.rrl»'lliir.  atiisia,  '.'■>".  '''^" 

vorlii.'< I. '•'■"■'• 
C.ri'lx'UiuM.  tiiii.nrs.if. '.isi;: 

rnvbral    urt.Vu.s,  uLrurisn,    of,    lol:!;    art.    - 
r.U.r...s-,so,;  l.>U;.,ub„Usmot■,looH;..,ula^- 
„,.•,l•,.  .,f,  KiU;  ^vpl.■.lUW  en.lait^nu.-    ■ 
loll;  tlinmilH'sisot',  l'"^'^' 
l\.,vlirali'c'itcx,  U'sidusof,  liM). 

.  1  mr  ■  .nii'iir  iiiif,  iniuary, 

,\.n'l.ra!  luwncrrliaL'i',  '.•■'•  •  aiui m  n.  

•,„,,,,)S;ouuvulMo"sin,liA)7;l..nu.ol,.UJ. 

Ccrc'ljrul  IdcHli/.ati'iiu  '.'nT. 

.•('uri'brul  imniiiinii'ui,"  I'^ji. 

"Ccreliral  rlicumatism."  171. 
('..rfbral  Mnus.-s,  tl.i-unibosU  ot,  101;.. 

('orcl.raU.ifU>niii>:,  1008. 
(■..nO.ritis  isw  ENcKriiAi.iTis),  10-21. 

"\:;„;   ,!,nns   oi;  10.;   c,„n,>lu.aUo„s  ....   10„. 
,„„lij.Mumt  ton..,  1o:K  ..r-linary  ton,.,  10.5. 

C'crvio.l  i„u'l.y.i..'i.ini-'''t'^  'J..:!. 
Cervical  l'l''X..s.  lesions  of,  10ii7. 
(■,.,viro-l,iai'liialm'uralj;ia.  110... 
,\.,-vi.'0-(H'>'iintali..'U.al-iu,  101 
(\.sto,l.'S,aisi'asfauolo,  oii. 

Clialioosis.  fp.'>-J. 
Cl.aiiiTf,  ■2".',t. 
rliui-lioii.  -J-Jl. 

r//iir<v>rv,ioiiit,  '.i-J.''. 

(■har.vt-Lii/J.,,  i:ryMi\U,'>< 

('huttirliii,'  tcitli,  lo.'il. 

Cl.wk,  sian-rivucof,  144. 

rlu'i-se  noisoiiiiiL.' by,  n',i:l.  • 

i:ria,-''v'-'->'t-" '■'••" ''^"^•^^'''" 

^^^«;-S^^^^  breathing,  «'b-y..o's  ori^lnai  clo- 
't     ,, ion  o,;7M:i"a,o,>-y,  1001  ;.n.>uy 

,,,,,,.751;  insu„-stioUo.;!'J7;  in  ucule  lub.r 
culosis,a7.^:inm'aM,.ia.s'M. 
.■hias.naan.lt.-a.t.alU'.t.onsot,10a. 

Cliiclit'n-breast,  43ii,  4.jd. 

(■hii'l<i'ii-ro'''  "'^^ 


,'.157, 


,  110.-.. 
vmi'ural. 


,  f,l!l,  soil. 


(•Iiloasmiv!'liilii'*i''"ro'0'  '""• 
Cliloro-ai.ii'Miia  ii.  lOilbisi",  !"'• 

n;l::::s "■"•■■--r;;'":;':' 

1„1.-,;  .lilal..llon..fslonmrb  .,.,,.'4,  1--M'li"' - 
„,io;  f.v.T  in.  7114;  l....rl  Hy.nrto.ns  .....  , 
,„,...st.-.,aiaistu.-b..n.'.  i",7U.V,  U.ro...bo.Hu.  ..., 

7'.I4. 

(•iioi<raai>u,  loio. 

(•li(ilii'i..ia.  ■'■'"'O. 

,.l,„U...,atis,    i..f.vtiv..,    r,(ir.;    s,.,.l.urat.s.., 

r.7«;  in  tyi.l.oia  fcvrr, -27. 
(•holc.oystt..to,..y,r.OU;i..aio..i.onsto,-,....J. 

<  liolirystitis  acuta,  Ml- 
Cliol.rystitis,  acute  iiifeetivo,  :>M. 

(•li,,lcc\stoto...y,  r.fiU.  _ 

,.,,„U,r;,l,'msis,  M\ ;  in  tyrl.o.d  tcvcr  .7. 
,„ole.a.,.siu.ica.l7.V,b..clll«sot,l7.^.;e..ac..,us 

,,17:.;   •„..•».....».,  ^UU;   uoslras,  180;   s.cca, 

i7',i:  tyjilioia,  1711. 
Cliolc-atoxii.c.  17ii. 
Cliulcine,  1^0. 
Clii.lcstcra'.iiia,  .■.•'.0. 
Cl.olestci-ii.  in  liilia.'y  calculi,  .V'S. 

t'lioluiia,  hi'..'.. 
(•h....a.-uaystr..l.bia  lotahs  S41. 

Chorea,  actc,  107'.i;   ct.olo.y   '"-.".''■'•       ;^'. 
Hvu.l.toios  of,  lOSii;  i..feelio..s  on^c.n  ot,  lOHO  , 

:;;U,u...cy.losO;,.ar..lysisiu    U-l;rl.eu- 
„„'us.ua..a,lo71.;M.bool.,.,a.le,loM. 

Cl,...-ca.c...,i..e.loso;cl.ro..ic,  10110. 

Ch..rea,l.ia.itorsi...sm,  lo>8. 

Cl„.rea.y/««'/n!/'/""'""-''^'''''""'-'-l'  '•         , 
,„..ai..sanic;.s,10hr„lON.;,,.n.ly,.cton....l, 

OS-  •  .....ior,  loss;  ,.unae...io.  1088;  i-osl-l.e...  - 

C^aJ;pM.e...ivlc.ic,  ..iol;rbytl.n..c 

!;r{;y;tcric.a,l^'>a;....ne,10;.o;s,..st.c..,m 

l.iMi;  ,S././. //A<i"."f,  lo7'.t. 
Cl...ro.a  l.'leNUses.  sclerosis  of,  lo-J. 

Choroid,  lubel-clcs  ill,  "270. 

Clioroiaitisinsyi.bilis.'.i41. 

rA,H'.sM--«syii,l.to.oinUtany,1110. 

Chvlaunioi.n.t.i.  ■''47. 

Chyle  vessels,  ais..rae.-s  of,  .VI.. 

Chvlo-i.cricai-.rmiu,'i'.'^. 
,-h;iur.a.no..-rarasitie.s.V..;l.arasit.c,3ul. 

,.i;,trichastel,..sis.,f  bowel.  ;..!•!. 

Ciliary  ii.us(ae.  i.aralysi.s  ot,  .047; 

Cirmta,  parasitic,  :'>.'.l.^ 

iUiuex  l.etolarius,  S77. 

Cireulutory  system,  aiseascs  of.  Cs8 

c'ucu.ucision.  inocilation  of  tuberculosis  by ,  2.4 , 

i„  lue.nopl.ilia.  820. 
C\rcu...llex  nerve,  atfeetions  of,  10.0. 
Cirrhosis,  ..f  Uiaiiey,  877  ;  ol  Uver,  5o9 ,  of  lun„, 
04'J;  veiitriculi,  4.17. 


.is">  m.  I  "  .  M  I  chiustropbobm.  11-24 

35. 


in.  65 ;  rheiimatis 


Chills  (see  Uiooiis;,,  in  typhoia  fever.  17. 


.'lavieeps  purpu.-ea,  p..isoning  by,  S94. 


INDKX. 


11. -.7 


Hi;  lv_'Vl't'mii, 
|iliiiiis  ill.  '.■'.•■*; 
llirDiiilxwirt  in, 


ivcr,  27. 

,  IV.');  ('iiiili'iiii'''' 

rus,  ISO;  sii'i'ii. 


of,  lOV'.t;   lifiirl 

s  orit;'"!  "'',  ^'**'"  ' 
s  ill,  1"S3;  rla'U- 

iilc,  UlSl. 
lo'.uj, 

itary.  1"1"'- 
l>iinilvtii'  lorm  i>l', 
.  lOSH;  iiost-lu'ini- 
•,  KMil ;  rliytliinic 
O'.M) ;  simslicii,  'J3'J, 


,  mo. 

IT. 

pnrnsitii.',  301. 

.'•):!;3. 

1047; 


(if.  CSI^. 

tuborcuU)sisby,2f)-l; 

.  of,  lOTO. 

f  liver,  509 ;  of  luufc', 

703. 

iiig  liy,  304. 


ClllVIH  liyMrfi.'ll",  1U0. 

1  m  i.'1'il'''  I- ''"'^ 


iii«-liiii"l  I  iii'i'i'  ■  •■  ' —  ,        . 

i,tlmii>'i-.f.i"M'>thi o:V3;  m  rlimnio 

S'.'J;  ill  mlnTcillosis. ' 


('liiiiati'.  i 


i:lil, 


CldllUH^Mlu  .VXKI.I;  t'l.uM; 


.  .1"^^ 


\>.n. 


Ill  luii'liiriii, 


120,  .'2 1 :  in 


t'lowniMiii  ill  li\>iii'iii,  111''- 

Cmtlim'Uiiipii. '''7'.'. 

Ciilialt  miiiiTH,  iMiii.'ir  uf  Imi;.'  in.  '■'■'■•• 

('oi'i'i.liiiiii  oviliiniii-,  :''!'■'. 

t'lifryilyiiia.  111"'. 

('ncliin-CliiiiailiarrliMa,  :'.0.'i. 

Cic'liiu'  allVi'lii'U  ill  rliililn'ii.  •'"• 

Cii^r-wlii'i'l  r.->piratii'ii.  ;;ii'-. 

Ciiin-sciiiiiil,  Oh;i. 

Cdlil  piifK,  iiiclliiiiliif  i-'iviiiiT.  ^1. 

C.lii',  liiriarv,.-iO:i;  in  apiu'iiaii'iti'' 

unt!i..-ia'ur..ti.;  i.a.iim,  111";  in  pnil'Uni,  Mo 

llMul,  3M,H;  IIIIK'OU!*,  .'141  ;  ri  lial,  K'-.i. 
Cdliou  I'lc'tniiniii.  :>'■'• 
(ulilis,  .li|.lilliinli>',  ''1-;   iiiU''"iis.   .'11;   Miiil'li'  1 

iilctTulivi',  .M3. 

r  ■„//,»'»  law,  2311. 

Cilliiiil  oaiuTr.of  Inn-.  003;  nfi.irito.iiriiiM. '■."(; 

(if  htllllllU'll,    i^'- 

C.lmi,  oulu'.T  iif.  ■•'33  ;  dilatatinii  ,.f.  -.i:.. 

Ciiloptdsis,  ."i43. 

(•,„..a,.lial..ti.,42,-.;.Til'l'f'''-  ""•"'':  '■'•'""  '"•".'- 
Ktroke,  3110 ;  from  iiiiineiilar  cxiTtmn,  Mp1»;  m 
lU'iite  cnocplialitis.  lo2.-) ;  in  avute  yellnw  atro- 
phy, ri.-.2;  in  ali'iilioli,.  poisonini;.  3sO  ;  in  apo- 
plexy, lOiil  ;  ill  c'lTcliral  >ypliiUs,  '34 0  ;  in  a^n- 
..rarparesi:*.  Ii02;  in  niuUiple  M-leM>is,  HOo  ;  in 
pcrnieioiis  malaria.  21.-.;  in  tlinniilin^is  ..f  ..en - 
-     ■     typliniil  fever,  21';  iine- 


pml  ;  ri  lali'ill    tn  rirlU't^ 


pe 

brul  sinu.sen,  lol 

iiiie,  807. 

Ciiiiui  vi>;il,  20. 

Coiiiatose  form  of  malaria,  21 

('(imnia  baeiUii-*,  IT.'.. 

Cimiiion  bile  iliiet,  iib>triu.ti(in  of.  .-lOO. 

Compeiisalion  in  valve  le.siinis.  Ton  ;  periHils  iii. 

740;  rupUire  of,  T4l. 
Coiiipcisite  portraiture  in  tubcn.ubisij..  2i^. 
CompreHHcJ  ilir  disease,  OIpO. 
Compression  u.icl  truetion  ..f  tlie  bowel,  .>".3. 
Compression  parii|)le..'ia.  OTO. 
Coiien.tioiis  (sec  Cvn'-MtKoi  s). 
Coiieussion  of  spinal  eord,  1133. 
Colifiisioiuil  insanity,  3o. 
Coiijieiiital  lieart  alVeetioiis,  70.'.. 
Coii;;eiiilal  stenosis  of  \<\  lorus.  404. 
Coii^'enital  strietiire  of  tlic  bowel,  .■i33. 

Coiiirenital  sypliilis,  -^42. 

ConjuKiita  ileviution,  in  Vrain   timmr.  10^3;  in 
apoplexy,  1002;  in  tnbc.culovis  meningitis, 'JTO. 

Coiijiinetiva,  iliplittieria  of,  140. 

Consceutivc  nejiliritis,  sso. 

Cons  ipatioii,  .•i;!S  ;  in  adults,  ."i38  ;  in  infants,  ri4o 
spasmoilie,  .'■|30  ;  treatment  of,  MO. 

Co'.istitutlolial  diseases.  300. 


Collsllliipll'ill  isee  Tl  ivriti  ll.o-l-''. 
Colilraeled  kidinvs,  «TT. 
Conlraelure,    liystirieal,    HI  I;    "i 

loii.'i;  of  inirsiniX  women,  1 1  lo. 
Ciiiilii^ioii  pmiimonia,  loo. 

Ci.nus  arleriiisus,  Hli.|io>iH  of.  T'o. 

Coniln  medlillaris,  lesimis  of.  liT2. 

C.nvaleseeliee,  fever  of,  10;  fr t>  plmi.l  fever. 

iiiaiia'.'ement  ol,  ts. 
ConvulMOns.  epileptie,  loOO  ;  liysterieal.  1  1 12  ;  111 

„,.„te  yellow  atr.pliy..r.2;  in  aleob..lism,3-o, 

i„  asliiiatii.n  of  pleural   elVusio  i,  OT- ;  m  eeie- 

liial   liiemorrliaue,  lool  ;  in  eerebral  sypliilis, 

■J40,  1000;  ill  eerebral  tumors,  lo-l  ;  ineliniliie 

llriglifs  disi.ase,  >T'  . 

Convulsions,  iiilantib 

43S.  , 

Convulsions,  in  geni  ral   paralysis,  OO.J  ;  in    lie 
patieeolie,  .•|04;  ill  infiintil(.  Iiemiple..'iu,  bdO 
in  ;  ■'i.l-poisoning,  3sl» ;  in  menini.'itis 
Hunstroke  30T  ;  in  typlioid  fever.  2s ;  in  lira 
mill,  hi',0  ;  ,)aei<sonian 
Convulsive  tie.  b'^"*.  I'^-O. 
,   C,„.rdinalioii.disliirbanee 
I  Ciipaiba  eruption.  Ss. 
Copper  l(.st  for  suirar,  423. 
Copra'mia,  ."i3,lt,  TO'J, 
Coprolalia,  lOhO. 
Cor  adiposiim,  740. 
Cor  biloeiilure,  70.0. 
C(ir  bovinum,  711. 
Cor  villosiim,  0^0. 
Coronary  arteries,  in  aiiirina  peefn 

obrueratioii  of.  74T. 
Corpiira  iiuailrigeinimi.  luiiinrs  in 

of,  list. 
CorpulelK.e,  430. 
Corpus  ealloMim.  lesions  of.  Osl. 


m 


loiis. 
i.f  in  tabes 


l<<-s-; :  lesions 


(  (0.;./7((»'.<  disease.  Too. 
Corrii/tlit  pulse, 


TI4. 


ac.iite, 
■i4. 


i;lo  ;   fietida,    0I-. 


fpMll    tlie    iii- 


hyst(.rieal, 

ill   (.lironie 

in  plilbisis 


30(1 ; 
077  : 


durinu 
in     pneiinioiiia. 


Cory/.a, 

.tide 
Costiveliess.  ."i3s. 

C.iiiL'li,  barkini:.  of  puberty.  HI" 
1110;  in  ii''nte  broiiehitis,  0'-'2 
broliebitis,  i;24  ;  in   p.TtUsMS.  O". 

aspiration    of    pl.^ural    etfiisioli, 
lis  ;     paroxysmal,    in 
broneliieeti'isis,    O'JT  :    pamxysMial,   in    tibr.ii.l 
lilitliisis,  314;  stonmeli,  400. 
Coup  lie  soleil.  30.-i. 
Cow-pox,  Of^. 
Cra.'ked  pot  soiui.l.  3oli. 
Crump,  writer's.  lloT. 
Cramps,  in  eliolera.  Is";  in  gout.  41.'.;  in.broiiie 

llrigbl's  disease.  bN2. 
Cranio-selerosis,  437 
Cranio-tabes,    relation 
430  ;  in  rieUets,  430 


elation    to     congenital    syphilis 


■'] 


^l 


ll.o 


INDKX. 


Craw-crnw.  :'.i'.l. 

(■r.H,,l,ilu.:iT-. 

('ivtiMiMii.  .ti.U'inU'.  *li>;  siinradu', -^K'. 

Crcliii'iiil  I'luiin.'!'.  ■'l"-  . 

(•ns.'s,traMrn-imrMiMal,  in  aiiL-io-nniroli I.- 

imi.   Ulii;  ill   l'"'..n,..|or   ataxia,  '.'-^l;  m  l'"!' 


l),...-bllitinM,  ailll.'lllt    (M'C    1)VM'I1A..I.\). 

|),...'lmili"n  inuMiriinnia,  Hl'J. 

|)flavi><l  r.'xiluli'Mi  ill  imciiMiniiia.  I'J.'. 

I»i.|av<^l  M'ii:'ati"M  in  lal»>.  '.'-^l- 

l),.r,riiMn,  a.-ut...  IhT,".;  arutr,  in  U.a.l-i".i^..Min.', 
;>li ;  I'onr^,  11,  T.V>,  T.-'T  ;  •■ximiiMv.s  imI'J;  im 
,„.ut.-   rliwinnili'iii-   171:  in   pn.Min.nnia,   \-:l\ 


ili'lin        I  n»^  « *  ......  , 

(.,U,  in   pnoumnnia.  117  ;  in  nlapsM,.  I.n.i  •  ^      "Ll!,,.  ;>.. 


Iicniin:-.  '■>-■ 
licltniil.  [.anilv.-is  of.  1117". 
li,.liiMi.na\  iii.^anil.v  Mllrr  piiruiLnirui.  I::::. 
l)(liHi.>iis  ..t'lriaii.Uur,  '."'■■-. 
Drnaiilia  i.aral.vti.M..  '.mIu  ;  alrnh,.|  a^  a  fartm-  in, 

!  l)cino.lcx  f.iUi.'iilHnnii,  ::7''.. 

I  „,„,>tinn,  in  ..oi>..n'nital  .vi.!,ili>. '^l-! ;  m  nu'i- 
iMiriul  .^tiiinatitis.  tl.'i ;  i"  i  i>'l.t-t*,  I^m. 


:>i\  in  tyi'lin.-.  tVv.'i-.  .M. 
(•r,«Ki'a  or  alt.rnatinn  imralvsiH,  ','^1,  1""1. 
{'r,.,-»d  s.nv.rv  paralv/iN '■'^•■'• 
(•r,„i|MucMnl.n.noii.sllS;  ^lui.-'nMMh.', '117. 

('r(iu|"iuH  l•llt(■l•iti^.  "il-. 
('i-(ini"iiis  inii-niiionia.  Ins. 
Cnira.TrrlM-i,  li'.sion:.oi','.i>-:i,  I'lnl. 

CniU'li  jianilysiN  \"'"- 
r/«)i(7A^r'«  imls.v. '.i-J'.'. 

Cry,  q.il.Ttio.  I'nul ;  ''>'';";'"^;';; ;';  :;V     "'     ,„.n,u„.-ntoraM„..i.aiu,s,:;7.;. 

,Typtojr..nrti.  ..l.ti.'."nMa.  l;,^  I,,.nna...l.ia,  lo^. 

r-,r.v,7,w../,/,V>'pir»l>.i.-l.  >■'••  .,,,„,„„..,.  '   i,,.nMato.,.paraMtaiiv.  mil 

CyanoMs.in  a.nt-  t,.lK.n.,>los,s,  -"•"■.■    '       „,.>u„aiuation,  in  ni-a,!.. 

Ual  li-art-ai.s.usi.,  7'ls  ;  m  cMMpliN^'iiu. 

(•y.'lojii.'L'ia,  11117. 
Cynaiu'lii'  niali-'iia.  M"*. 
CviioIk'X  liuU'lii'a,  1117. 

Cystio  .li«'"S''.  -'1'  l^""!"''.^-  :'■"  \  '"'  ''"■'■''•  ■' 
c'vstio  ilui't,  ol'struc'tion  of.  .v,.- 


licTimiM.^.    1 ^  11,^,,. 

l),.>,maiuation,  in  nira^lrs,  n7  :    in  nil.rlla,  -.» , 

i„   srail.t   iVvrr.   7'.i;    in    .-niall.l.ox.    H'J ;    in 

typhoia  iVMf.  17. 
Drviatioii.  sivoiiilury.  iMl-^. 

I)ivon!*liiri'  i-'iili^'.  •^^''•• 

Idxtrocaraia.  7'l"i- 

lui-i-ailv    ill,    I"'-;   111 


'  .•■- ,,   ,  ..,  „,„,.    ...;,,.    ^^^u^     Dial'c'tos   iiisipian-,    l-'.; 

.•utam.ms   liW ;  t'^'n-'i-al.   :i''.'.'  ;  .•.■ivbro-l'.n.'i.         ^^^^^.^.^^  ^,,.,^ 


oli'.l. 

Cystine  caU'iili,  Sil-j,  '-.I'J. 

('v>tinuvia,  Sill- 

C'v.titis,   locon.otor    alasia.    ■.i--'.", ;    m   tn.nsvw... 

'myolitis, '.17s ;  tiilicivuloiLs  :;-jii. 
Cvtozoa,  ;!4'.>. 


touUis,  •i:i-.i. 
l,i,a„.t,.s  in>Hitu:*,41'^;  acMito  lonn. -l-J-J  ;  l.ronz- 
■„,.,  ill,  4-i:i:  cln-onif  form.  4-J-.i :  (■"iiia  111.  I-J.. ; 
ai't  ill.  -t-JS;  aiotrtio  form,  4'.!-.i :  L'aii-iviif  in, 
.I-.,-,-  l„.r.'a\tarv  intlii.'iiri'S  in,  41^;  in  ol.rsity, 
IP-   in   .•l.iiarni.  4-J.-.;   lipou'cni'-   I'-nn-   ■'■■^-.i ; 


Cvtozoa,  ;!4'.t.                                           .                      I  ,„,„,".,,,i,.  form,  4-J-.i;  I'aii.'iva:^  ill,  4-Jl  ;  paiKix- 

cVsts,  oliyloiis.  of  mcsont.ry,  ;.47  ;  111   ku  n..  .  ,_  -        ^^^^  ,,arapl.;.'ia  in,  4j7  :  i..i1oratin,' 

"siis  ;  of  l,r..in.    lii-J"  :   poivn.Ti.liali..   1  a  .  -        ,  •          .__  ^.,^. .  ^j^^„^,.j,.^  „,.  ^.,„ .  „,i„...  in.  l-J:;. 

,,,ai,i.  tlin.mbotic.,  Hhih  1  lumcruatio,  .....  ,>,„,,.,,..  "...sphati..,  s,;:-. 


Darrvoa.U.nitis  .M'l.  I.a.  inivM.u,  (ii.\Ni>«i. 

Daiu'ini.'  imiiiiii.  l""'^. 
Daiuly  lever  (acii-iH' '•  •''^■ 
Davaiiu'a  MaiUiLMs^'ariviisis,  r,r,il. 
Dav-blinanoss,  1040;  in  s.'iirvy,  S-Jl. 
Dcaf-inutisni  after  cc.rol>ro-j.i.ina\  fever,  10 
Deafness,  in  eerel.ral   tumor,  10-.':i ;  m  ee 
.pinal   meiiinL'itis,  Hi'l;  in   liysteria,  HI' 


Diabetes,  pliosphatie,  sf,'.'. 
Dial-etie.  eentre  ill  ineaulla,  UD ;  eirrlioMs.  4-.1  , 
c,  4:i5;  plitliisis,  4-.il  ;  tabes,  4-.ih. 

p  1,  sill. 

,  paralysis  of,  Iml-^;  ae^'eiieratem  ot 

.  of.  ioi;s. 

,1,,,.,,.  :,n:,:  aeiitu  ayspeptie.  :.nli :  alba.  Ml; 

W,.ria   in.  ^'X    eliroiiie,  treatment  ol.  Ml; 

olivlosa.  ,M1  ;  eiKlemie,  of  iHil  e,.m,tnes.  .hi ; 

3i;0;  ill  eliiUlren.treat- 


.-|.,...,.    ...- ^ 1  1   ..  ,.  ,.    vi  .  from  aiielivlostoiniasis,  ( 

J^./;,.,V  aiseaso.  lo^s  ;  m  searlet_  lev  e,,  M.  nm.^^^     ,^^^^  .^^  _^^_^^^^^_^^^  ^.,,^  ,_^  ,h.>.,itery, 

in  tabes  aorsalis,  11-4:  nervous,  10,>,.                    ^  ,  .J    j.^  •  in  bvsteria,  1 117  :  in   pbtliisis. 

Deatli,  nioaes  ,.t\  in   tnberei.b^sis,  ;ll,  ;  siuUen,  ^  1.    .^    :,/,,,,„:,i,l   iv'ver.  S^  :   in   uraMiiia.  s,;:  : 

i„„„i„apee,oris.7il:;;inaortiei.is..llie.e..e   ,j  ..1             ;,;,.  ,..„,,i,,,;,,ina,  U.)5 ;  tubular 

,H  ;  in  typboia  tWer.  40  ;  in  pleural  ellusion,  " -  '  u^^     ^^ 


Dta.ilitv,  nervous  (sw  Ni:n:ASTni.;Ni.\),  1122. 
Deeul.iUis.  aeute,  UiU2  ;  ^^.d•^or,s)  in  transverse 

myelitis,  y7S. 
Defeneration,  reaetion  of,  914  ;  m  neuritis,  lO.^b  , 

in  fiu.ial  paralysis,  10,")4. 


,r,44 ;  lieliterie,  rid".  ,       :      m  1  • 

Dintliesis,  -outy,  40S,  414;    biemorrlia-.e.  spi  , 

Uthic    acra.  s.-,0;    tubereulous  or   scrolub.us, 

2i)S ;  nrie  neia,  St'.i.i. 
Di'izo-reaetion  in  typboia  fever,  01. 
Dierotisiii  of  pulse  in  typlioia  lever,  13,  CO. 


INUKX. 


ii:.'.t 


(l-lldiSHllill.', 

*ivc,  '.ii'i'J;  in 
iiiinniii,   1-'-; 


a.  I:;:!. 

ii<  a  l'a''t"i-  in, 


•1-7. 


II  nilulla,  •^'■' ; 
l-l..i.\,    il'J;    in 


ty    in,    t".-':    m 
lnrinl'in>  I'rii- 

■ni,  -l-'J  ;  liroiiz- 
;  I'linia  in.  l-.'' ; 
J  :  i.'ani.'ii  MO  in, 
4is;  in  nl.csity, 
■nil-  ('"nn,  -l-Jii ; 
in,  I'il  ;  I'aniro- 
iS' :  iK'ii'nnitin^ 
urinr  in.  l-'i. 

1;  c'iri-lin>i>.  l-jl  ; 
■s,  -l-Ji'i. 

Ji'^:i'Ui.'i-ati'iu  111' 

..  r.ii'.i:  all>a.  .".11  ; 
vatnunt  (if.  .'ill ; 
A  ciauitrit's.  ".I'lJ  ; 
in  rliilili'i'n.triat- 
■'.i;  in  (Issi-ntcry, 
,  ilT  :  in  i.litlii>is, 
in  m'a'rnia.  >-iu  : 
ina,  o'lii ;  lulmlaf, 

iifMii>ri'ha;.'ii'.  ^11  ; 
ins  or   j.crot'uli>us, 

T,  SI. 
fuvcT,  13,  -JO. 


.liau'n">i^    lV"in     »l" 


.      ,        .     ,,„„„,,,,:o;lnmMiva,i,.n.l      T.n ;  tn  n.i.ral  M.nn.iO.. ;  m  ..'.-In-,  •■' -  • 

^•"'V    '"rr:';::        J        .Ul    in  in.an.il..  !I.n,.-n.l„..- 
.„;  „.aml..'tos..t-",  n.L  ...  l.nn,U..nn.>s 

in...l...v..l..-i-,-.-.;.ntM>I.HM..u,.l..  „^^,  ^,,„„|,  ,,:.                                             ^     . 

/<;,^/Vrris.-..M-.  l.,;in.>^.  n,..v«M.'.  in  I'l'i"'"'   ''ll'M..n.  '.nO  ;   n. 

Diirrstivr  ^v^t.■nl.  .ii-oa->.^  "L  '  "•  1      ^ ,„„„tl,..n.s.  Os;;, 

I '."'•'"I'lO-""' '-'■"■'""' •'■':'•,  ,            ,■,..•,•  of  anili-  liiuul.a-nc. 'JIT. 


4st. 


..■.;..,.,  141;   l'U.illn.  ...^    n..;   ;';;^'~;;  :  „•,„■,;,„„„,  ,,..,V,..o,;^:::>;  nl.,.>- of. -IT-^.       . 

.,,;V!S;lu,nii,W:riain...-;nnn,,n.>  .       ,„^,,  „_,,,,,.„,,,  ,„-,M  ;  l,a,na..,nm  M,  ..•:!. 


i-.'lc  liai'illi 


,,;;;,s;,unni..>     ...^    <■  :,_^,,,,,,^      l.uranm...r.,li.-as.-'i.^'^K..an,a.. 

Ill;  in  nnnnal.,  I-'.   ""^> '.''-."  -v.       ,„,_     /,„,„„,/,•»  niiM.m',  r.''-. 

, ,;  ;  .nrlnni"  i--  '^"  ^  r:-;'^';".':  .l,   i  ,         /.„.,c/,.:N  .nnvnn,r.  71  1. 

U7:  ,.lKn-yn...al.n.;;;..Mu...li.  .  ^V  ^^.^^^^^^^  ^^^^^^  ,,„  ,;^,,  ,;:,.;  .ul.. 

„,..,,,■,;   Hy>..,nio    in.>-.-",        ;-    •      ""^"'"    |'   .^      ,,,,_ 

,r.at.nHit  nf.  l.^"-:  <.f  wnnn.U,  11.'.  i,vsa...V>s,  ln:,7. 

l.i,h.l...n,i,..  ..litis.  M.;.n..nlo.nu..     ^Ml^-  ,  ,';;„,,^„,^_  ,^„.   „,,„„.,,   „,■  ,iv.r  i,..   l:'.i.-'"'; 

of.    Ut;    l.r-..sM..    in    ,.n,un,n,na,    11..,    P  .^^^^^^^^    '....•.■hal,    l:M  ;    atn.rl.a    o.li    in,    1'.-; 

,,,.ss>'s  in  (M'li'.i'l  I'V'^  ■■■•'■  rlil'o.ru'.   I'.i'.i;  ail.litl"''-i'"'>   l'.'^;  "■-'•'"non.  "I, 

l)il.litlH'i'i.i'.  II-'  .,ii]  .  tri.pii'al  i.r  ani'i'l.ii'.  l'.'.'.. 

l,i,,l,tlM'i-oi,linlla.nnK..i..n-.  It-.  I   .,'';,,    ,„.„tr,  -l'- ;  rlironir,   LX  ;    n-nnn., 

„i,,u■.ia,.a,■ial.lu^^;:i.>'■l.''■l'■:•'^■;:;;    „     |  •,,^' 

l>i,,l„..o...„s  itUra-Hnlari.  na.,n.,.'a,.hs.                 |  ,             ,,vs..ri.al.    1117;   in   ^w..-'.   .!>. 

l,i,,l,„-...Ms   i.n.nn.nuia.    (nu.r... u.    Ian.-.-         •■,^,    ,-„„„,  ,;,ii  ;',„  li.varul.l ia,  ■.;•.;-;  ui  ..■^■.- 

,„„s,  i,nc.nn.KM..vn..,  Uh;  in  ..npyoma,  ..,1.  ,',.^,-,,^  ,,-,,,.  ;„  „.,„,,l,a.U;.,  t^"^ ;  i'"  l"-''" 

i„>.>.ao,.a>-.li.l..7n-  in  l.o.M.Mn>.,s.  ......  1^^^^-^^^   _^^,_^.^^^^^   ,.,„,.    .„,    ,„   ,.,,k,   ,„K.ur..^nu 

l),l,loi.ia(s.-i'  Iti.ii-.iK  \  isi'.N'.  1"1'''  ^^1  ^  •,„tnl.nvul..ii-*  lai-.v.i;.'ltin, ''.H'. 

„;.,„;„.a..-av.lia.,.n-a.nH.n.of.V:'.:'.;.V..n>an.n- 
,,    ,„,,„,a         nin.7sl;l,y..-.'ul,nl01:>:^;ma..m.    n- 


-vi  ;  in  tnl.<ivul..ii-*  li 
OijiMi. mania.  "."-"■ 
Dll.yli.liuni  .■aniinnn,  :'■''■''■. 
l)lsintVi.'ti..n    in    aii.l.ili>na,    l.V 

IVviT.  41. 

l.issi'C'tini;  an.'in-isiu.  771'..  ,,,„,„, .- 

l.i,t...niaMs. :;:.!.                     n  .„,  1-1  -ni  ■  D  !     7r^r'in'mitrai'"st.M...si..  V;;:.;  i'M'''>'i;''''''.'^^^^ 
l)i>t.,nunn  laiir.'olalnni.  ....1:   I>.1"'-'^'- •'■■••  '       ',,..„„,  •      ;„   n- •  I,,  „l,tlns,s, 

HuUMnicnn,,    :'..M  ;    1'.   r-Tnic.i...-un,     .■'...1:    l'-         HlnM 


„  ,„,,,ia,.  .lilatatlon,  741:  in  ..hlnmsis.  7:':i ; 
i„  aial.c.i.'  .•oMm,4^.;;  in  n.itral  insntl.ou'nrv. 


„„  ,;.,i..>;  in  i.nc.ininnla.  117:  in  plitlii-'is 
^-liliVin  ....lonia  ..f  tlu'  t'l-tti-.  ^17;   in  ^I'as- 
mclic'larvn-itis.  .'.H;  ur.rnii.'.  ^'m. 
Dystn.l.l.ios,  n.u-ular,  •.•".■";   .•Uiii.-al   f..rn.>  ot, 
''j:)4. 


nianni.  1.:.^.  •'■'-• 
lUttrhh'"  pliiL's.  '■'-''■ 
lUnivsis,  4:1'.'. 
l)ivcr":*  paralysis,  W.<. 
DivcTtioula  ..f  .j-so|ilia.'Us,  \'V> 
Piioluniiis  aii...lfn;ais,  ::..'.'. 
pi.rsiiilynia.  •1''7. 

OotUii'iientOriti'.  1. 

Double  hyart,  7';^.  K.lnno.oc.ns  ais.as,..  :17". 

DoubU' vision,  li'l'.  m  ,n.i\i.i,  ■  — .  ,  .,  ,  .       i.„r,..i,,iw_  ;i7 

Brittlit'.s  aisoaM',  -M. 

l)raPontiasis,  J'i'.'J. 

DraoimouUis  nu'ainrnsis.  .,  .-.  ,        i,,,i.m„.Vis   lo- 

I„.ai.ia..a.,    aial    ai,.litluna.    l:'.s:     mi.l    s.-arU.,  1  M,..ki.i.  Ms.  1  ' 


Kar.oon,i.li.a.ionsofs,.avl..  tVv,r.sl;  am-.ions 
„f,  in  syi-liilis,  ■241,  -JU  :  sNinl.t.niiS  smmlatm- 
nu'iiin'.'itis.  10-7. 

A'W. /)(■.<  niCho'l  in  ..l.i'sity.  4:'.','.  ^ 

l.Vliinoi'oc'ciis  cyst,  lluia  ..f.  :i71.  "'7:!. 

LrhinococMS  iliscasc.  :!7".  __ 

|.\.l,ino,.o,.rns,  ,.n.l..'-"'nous.  .".71  :  .•xo-.nous.  ..,1 , 
iniiltil'.<'iaar.  :'.71.  :m4  ^       ^         _ 

iM.hinorhvma.ns  :ri-as  ;  K,  n.onail..nnis. 


,""n. :.----'- -'-'11;::;::;:*:,.';:::;, 

''^^^■^■'■"'■'-        .         .,  ,„„..  I  K,.t..i.ia.-rais.7.-..-..  .   .     . 

l.rcamy«ta...n,r.Vl.>>-     '■.;  K.-zcnui.  ..f  .h- ...n.uo,  41.  :  in  aiab.tcs,  4..  ;  m 

Drojrav,  carauK',  truatnuMit  oi,  ,-.>.  _  ^^^    ^^  ^ 

;;;:,!"  :i^"i:l  ^f);  l^  ...Ural  in.u.U.i..K.y.  1  Klasti.  .issn.  in  sputu n. 


Ik 


r  '1 


^^ 


INDl.X. 


u   ;     111,  •  •„M.olio-i,.vrlU\suntwior,94-l. 

V.lcrtrdlvMs  ill  iiiu'iirisiu,  T<>. 

Klcl.liiiiitiii.-is.  ■■\''±  „„^tvio 

'^■'■"-''-';::=':'r:;;;:::;r"i;;;;-^- 

ciiiiri  r.    1-.' .   11'   "  ■    1  "•'-  1 

],lilliisis.  o'Mi. 

,„l,„lisn„i.iiamiwmsii.,VVa;.ylioron^Ws 

ii.,v,.hoia,Vv.n.l:<..^-'-l"vU;.-M^^^ 
,:,„l„:v;n.araim7r,T;ini.iu-ui,ioum,120,mn 

'''7' ''■'"■;.'!  •.u.iifv,.si..„U.r.  11.^1^  ;i.tro,,l,io, 

\;i::aaorus,,i>-ationo.'Uu.l.l.u,,    1...        . 

,,.stri.   uU.T,  .IT'.i;   -..i   I'l'l'"-^'   "'•"  "'   '"' 
iiiccrnistiiiuiii,  i''~^T. 
iMiiprostliotoivis  in  trtiuius, -J:;-'. 

.nv.nimiiT!;l.-t.n..lo.y  ■>-.'="--- 

aiiVusc.  '.'""••   im'iiiii'-"'--  l"!'!-  I 


supiuinitivr,    lii-i.V.    ^vllhi 


Slri)mj''t!,    mis 
litio,  '245. 

Kiu>i.-i>iii'''n"''''>'-  ''■"''■  "'*^' 

KiU'hoiiih-oiiKii'l'l'i"^''"'^*- 
l.:„a>vrt.ritis  cf  .sim.i.l  cHirU,  OCT.  ^ 
V,„loc..mUtis.  .uMitc.O'.iS;  oliro.uo,  ,"■  .  ^1  -  " 
Uta,iv..7nl..n,,li.l.ontio,0..;mcUoc^^ 

0M:;'lOSl;i.ilVotiuUs,  Ol)l.;intheUi.tus    .11,, 

Xv,atVvor.To,.i...-l.-..."t.s,u     .,..M. 

„M.,,tio,vi,.iii,  7i»':iu  tviili.na  tuv-r,  U  ,   m 
:,.o,lu,,,sis,..s.TiXi;nuai.n,u.V.JK~ 
cM.is  in,7i">;  uuei'o-oritimisins  m,  ,0-,  mural,  , 
70l\rcoun-in..iiOO;s,.lor,nio,70r;  simple  or 
;orruo,ise,fiO;i;  svi,liiUtU.,^50;  ule.ruUvo.b,0.  J 

Kutcrio  iVvi.r  ,s,.,.  Tvuon.  Fkvf.uX  1.  1 

Fntoritis.  oiitarrluil,  r.or. ;  croupous   512.  d.pli 
Litio.r,l.:inohiUhx.n.508;pl.U'....o.H.us. 

r'i--;  „K.mbnm,ms  or  tubular,  644;  uWonitn.. 

r,i-J, 
•   KiitLTo-oi'lilis.  a,'iit>-.  ''lO. 

KntHwlvsis  in  ,'li,,Kra.  '''l- 
;;;;u.v..n;iis,r,l..:..4;a.a,.aus..utapiH-naK.,.>.. 

,-,l',i;  in  s;ir.'uli  ,i(' i',il,'n.  ■>:;'•'. 

Knt>'r,U't"M^-'''l' ''■''•  ^'"''-  „„, 

Knto/.„a(s,.eANiMM.  I'AHA^n-i-^^'.;''- 
EosinopliiU.s  in  U.iUa.uia.  m„;;   m  tn,.l„n,>M.. 

E'l^naymi.is,  purulent,  .77:  granular,  in  srcneral 

pari'sis.  '.HU. 
El,liL'nu'ral  tVver,  54U. 


K,,i,l.'iin.>liii^moL'l-!niiui-ia.M'^. 

K.l.i.U'iiru'  i-iM'i'ta.  ^''• 
KuiiUmi,' stomatitis.  "'IT. 

r.,,-„U,lvmitis(s,'«.  Oi"""'*'''--"'' •■■-';• 
l.;,iK.p;ia.larv»ta.lo'.is;  nutans,  loi,',. 
:,i,'    v.lo:i:;;auaal,.,.h„lism,lo;..i;an.l    ^:.l^- 
'.    i;,;Mo;,:,:lu.ivai.y  in.  lo.4;in..ir,..n,. 
,,;.lsn,.:;M;in,..nm.lparosis,t.,;-;;mW.K- 

,„,i<,,nin"    "^'■'•-   '"   ''"!/"""•''  ^l"*^''"*^''  "•^'l' 
,       l/,.:/.,.-:;«.^a7.1oUs;,naskc.a,10|iS;i,,,st-.pi- 

U.,,l..y,npt,..nsuM''^'V;pr,"nirsivo>        .   ; 

llfx.Uni.V,  rotat,.ry,loUO;  spn.al,  .'■„  ,  suuu  ,u 

I      trcatmiut  of,  llol. 

ViiUciitlc  tits.  stai.'1'S  ol',  lo'.ii',. 

Ssts,o^^;  in  iiam.r'ini:i.^^':':  >"''-'-->■' 

ri,,us.  Iil4. 
l.-rl,-(i,,ianam-s  syinptom-.'ompUx.  .il.- 
.-i.h-ssvpliiliticspinalparalysis.'.ilo. 
.:,,,„i;,n,;;.4;o„nvulsiv.,i;.4;pm.,vnou.,o,l4. 

El'nsion  i,t' toutli.  44r>. 
Eruotalions,  nrrvous,  49S. 

S.hisl^7;«l---i".l^^>V'"""'"'mr 
J,71;.WlaUos;in,yplioia..v.r,.,.,.m.- 

1      grans,  lW;p"^'n'^'™l'^'"-  .        ,,    ^„.,  ,„,-.  •.,, 
E,vtlu'nm,c.xuautivm.i.M.-.:  ...  rllau'ia,  ...l,  ,  .u 
i      tvplKnaiovor,lT;int„nsill.tis,l.,-. 
'  Kr;tl.r..i.u'lamia.llo,!  U^;x       ^ 

Ksol.ar,sl,.uu'l.ii't?.i"l'^'""l"^'-'"''     - 
F.ustr.m-ylus  giiras.  Wi.  ^^ 

Exaltation  of  laoas  in  L'eu.ral  paresis.  .'.-. 
Exan'l.umiitous  typhus.  4'J. 
Exfoliativu  Jormatitis.  b-1. 
Exophtl.alniio,oitre,8:!t;;  acute. orm^., 

„,, ion  of  electrical  rcslsta..cc  ....  ^■'■' ..1">"''\ 

K;r:,:ot„;  nerves  ,<pa.-alysiso.;Ul40;  spasm 

of,  1047. 
Eve-strain  in  mi,L'i-ai.ie.  UO'J. 
EUconiii.a.e,leviati,„iolM,.l,ra.ntumor.lo... 

I    ^^n  apoplexy.  1002.  ill  tul,eivul„a>...ei.in.ilH, 

I        ■>7'.l. 


Faeiul,   asvnni.et,-y   P^iU.   1141  :  a,ple.,a.         •  • 

T.  ...iat,  .piiv,  11  n-.  u,.uii..vpei-.i-pi;>.  n  -. 

„.,nraivMso.Uoau-™b-"-;:'"'"''>' 
"oi,.-..!   sis  f.o,n  lesion  of  tn,,.U.,..K.n,. 

10o2;  paralysis  from  lesio.i  ,.l   eo.-tcx,  M.,. . 
pai'alvsis.  syi.ipto.usof,  10.,:!. 

E::;;';;^;:S,.,   Mis:  le..tina,  in   leprosy, 

„tl,  l,r,...thei-s    4n->;  Pork-insmiuui, 
S4l  •   l.l  iii,,iltli-ore.iineis.  •«      , 
1„TV;  sv,,liililic,2iv.  intyplio„ltcver,U. 

E,,.,.:;...e;'imulation.n:14.5:;.;eone,vt.,ms,,-1^ 

r);iy  ;  vomiting'.  ">1+' 
Ea-ces.  bacteria  in.  5os  :  in  .i.u.i.aicc,  o4.«. 
E.aiopiim  tubes,  tubc'eulosis  .Tt  «2i,. 
Em..ine  fever  ..see  1:klm.s.n-1kvkkV'3. 


INDKX. 


ir,i 


l;  ill  i'hvi'ni>> 
'.111-;;  in  U-iul- 

ili>;  i.cpst-i'l>i- 
<Uo,  lii',i';:n- 
'j:',7 ;  r<niu'ii-;il 


0;  in  scm-vy, 
il "  s.')'2;  vioii- 

.  ',1  IT. 

111. 

iiiLrvonmis,  o'J4. 


iit'ttT  viicoina- 
1  tVvur,  ">■'<;  ini- 

..llau'vii,:!',!.-.;  in 
.,  l.VJ. 

\,  1'"'-'. 

in-sis  O'i-'. 


I'.irm.  bST ;  <linii- 

in.  ^:;',i ;  piiiiufU- 

iirtioavia  in,  !>■'■'• 

s  ui;  10 10  ;  simsMi 


l.raintiiiiiiiv.  li'i-'; 
ulna.--  imnim-'itif, 


1  ;  aiiiU'LMii,  1"">:''; 
yin'rtn'v''y'  111-; 
inilysis  I'riini  o"l>l< 
,,f  trunk  111'  niivc-, 
u  ,11'  iM.rlrx,  l""i-'. 
:!. 

r.iitinii,  in   loiirnsy, 
■ih:>\  /'(»•/■/«»'»"''>". 
•plioiil  fcvor,  1-t. 
,1.1 ;  ooi.civtions,  r.l'.', 

nmclico,  !Jl'.^' 

i  of,  :!2i'i. 

u  FevkiO,  53. 


l":iri'y,  WS  ;  ii.-ut,'. '.i-l:  ''l"'"" 
Kiiivy-huils,  -S-'rl. 
/■•,(/•/■. '.s-  tulii-n'li's,  .■.■>:'■.. 
Fasciolii  lu'i'alii'ii,  "^■''^• 
Kilt  I'lnbdlisni  in  tliiilirti'.",  4-2i 


nutulrniv,  in  l.yMiTiii.  HIT;  in  lurvi.us  ilys- 

IH'lisiii,  ■>(«';  ti'i-'Uluirnt  111',  IT"'. 
Klfii,  biti^  of.  ".:■<. 
Fliiit'K  nnu-niur,  71",  V-l- 
I'li-iiitiniT  kiilmy,  'il-,  ^''i- 


K„t  cn.bolisn.  in  dm  u-tcs  4-.i..  ^^      ,  i.-i,„,au  1'-v,t,  :v,... 

r„t  n..rosi.  5.1 ; ... .-;.--  ■;,:':':::;,;:;;;,.  i  ku,u.,  i,ri.u.i.i.i, ... ;  ..i i :- :  >^  -■■  -■•• 

l-atty  Jo^cn.M'aUii.u_i.l  ;;;';;;;  ;^;;.;„„,,.  ,  /;„^;.,  ^  kIuIu..  ais..»s,.s  cans.,!  l.v.  :;M. 


iVisoaso),  !*1''  .  .     _,„ 

n,uy  .WcmTutinn  .n...u-!,  7 1:' :  nwnuiinnu,  .  .1... 

Fatty  stiiiiW.  ■■'.m. 

Filirii-'iila,  "l-, 

Fcliris,  oarnis.l'.'-,  ivnu-ivns.  .V,. 

/;  hlhii/x  tfst  for  MiL'ar,  l'.;:'.. 

FiTnifiitation.  tuft  for  su-ar,  IJl. 

Fftiil  stomatitis,  -U-J. 

F.v.r,arbtl,ons.  n.l7;in.b.4-n>,  li^'V"';;:: 

..lamlular.  i;i.-K    by>t.ri.al,   HI'.';   l..nuo,o,H 
*■  .       .         :..     III'.'    in    iicnto. 


Fo'lal  hoart-rliytbrn,  7.'i7. 

Fi.'tus.  cniliR'araiti^  in.  7io:  sypliilis  in.  '.il'J; 
I  inlH'rcnlosis  In,  'J'l'^;  "liiU'  imiuiuonKi  ..1. 
!      ■-'17:  tyiilioiil  fi'vi'r  in.  :;i'i. 

/;.//.    /Irt;lht!i/il(\  Jt'iii. 

FMlliculur  tonsillitis,  'I.'jI. 

F 1  iseu  Diet). 

Fiiuil  iinisonin;.',  301. 

Foot  anil  mouth  diseasi\  317. 

FiirciL'n  bodies  in  intt'stims.  ."34. 

Fourth  ncrvf,  1047  ;  I'aralysis  of,  1047. 


'""''^'■'"'-  -'■•.".'.      ..illarv     Frirtion.    mfdiastinal,    ii-7 ;    l^'noard 


malarial,  '.i.' ,    i"    i ;  ... 

I„u.umonii'iihlhisis,-.n"i03;  .na.ntc.nnluiry 

,ul,e'ri'ul,-isis.'J74:  in  primary  nuiltiplo  ni't.ri- 
f,<  lo:>;i;  in  nicnin'/itio  tubiTi'ulosis,  '2..^;  m 
,.uin>onarv  tuhcrrnlnsis,  3ol  ;  in  pyaMimi,  lo4; 
;„  pylclihlehitis,  snmmrativ.,  r,^o;    ni  _.nt.i'- 


in   iivlulilili'l'itis,  suiMmuiiK-,  ',..!..       ,  , 

MiiLt  iVver.  .1.  :  in  n'lapsin.  t^ver,  54  ;  m     t  ron  aU 

,.,,„Uu.nttVvc'r..l3;insi'arlc'tiVv.r   ";mlKrontals 

.  .    .  ,         .  n    .,..,.       Ml  •     itl     mill- 


Friction,    mediastinal,    '•.^7;    iH'rioardial,    OOo; 

peritoneal,  Co4;  pleural.  ■■■■■%  07";  I'lenro-piri- 

cardial,  3os. 
ffialrcic/i'.'<  ataxia.  '.'lO. 

/'V/u/n  (.•//■■.' sii/n  in  adherent  perieardium,  O'.C. 
Frontal  eonvolutions,  lei-iniis  nf,  I"--- 
Frontal  siiiu.ses,  pentii-tomes  in,  :;7.'. 


Funnel  lireast,  307,  45 


(lait.  ataxie,  !i'J3  ;  in  paralysis  aj/itans.  lo77 ;  in 
psendo-hypertroliliie  museular  j.aralysis,  1I34  ; 
in  spastie  paraplegia,  037  ;  i.seud.i-tabetie,  4'JO, 
lo:;4;  .-h/ijiii'l',  \n  peripheral  neuritis.  lo.M  ; 
in  dialietie  tabes,  4'JiJ. 


reiniui-  oL   iv.-,  V 1.  - 

K.ptieieniiu,  10'2;  in  small-pnx,  50;  ut  sun- 
stroke, 300;  in  upiiendicitis,  524;  in  secondary 
svpliilis,24o;  in  typlioid  fever.  14 ;  in  yellow 
f;,v..r,ls5;  lung,  los;  Malta,  210;  Mediterra- 
nean, 210;  mountain,  340;  Neapolitan,  210; 
imtrid  mali-nant,  1  ;  relapsim.',  53;  I'oek,  210; 

'l,in  .10  '  slow   nervous,  1  ;  splenic,  2'24  ;  spot-  : -; -  1  -- 

''  ,     .      1    '1    1  .  unlio-iii'darial    30,     (  a  actotoxismus,  oO.j. 

ted.  40,  101;  typhoid,   1  •/    '         '  ^    ^■"j',;  '  I  ^all-bladder,  diseases  of^  555  ;  atrophy  of.  500; 

•214;  typhus,  40  ;  undulant   2U,  >ellou,  Is..     ,       ^^^^.^^^^^^^  ^^^  ,,,,  .   aiUaation  of,  505;  em- 

Fever.  idiopathie  interimtten  ,  1  1^.  .  .^.        ^,^,,.,,^  ,,,aominal    tumor. 

Fever,  intennittcnt,  m  absc    s  ^         ^^         '  ^    j      ];.         „„,„.,„„„„  iunammation  o.;  505. 
ai'ue,  2o0;    n  clironie  obstruction  ot  Dilt  pas  .     ,i       . 

"^r^    bv  I'all-stones,  500;   in   7M,/'»-V  dis-     Oallnp-rhythm,  ,..,. 

s  o.  inpva'mia.104;  in  pyelitis,  ss. ;  in  |  (ialloping  consumpt.in,  20 2. 

.^:::;.:i:f:^.r ^---    ,  ;;::;;:s;tr ;:;:;:: SiS 

'  (lanLM-cne,   in   dial)etes,  425;    in  ergotism,  304; 
in  pneamonia.  130;  in  tyiihoid  fever,  1'2,  22; 
in   typhus.   52;    local  or  .symmetrical,   113^; 
mult'iple,  1138;  of  lung.  000;  <,(  mouth,  -144. 
t;anL'renous  stonuititis,  444. 
i;,in-nd\-<  thread  test  fir  uric  acid.  41o. 
'  (las-bacillus  (see  B.Mn.i.es    akuooknks   cM'Sf- 


Filiroid  disease  of  heart,  747. 

Filirosis,  avterio-capillary.  770. 

IVn-f,  inllimmntoiru  3.07  ;    tiiphohh-   n  form.- 

rt'  iKjIc,  31. 
Fiftli  nerve,  paralysis  of.  lO.-o;  gustatory  branch. 

lo,-,l  ;  tmiihic  ehanges  in  paralysis  of,  lo.-,o. 
Fdariahominis  sanixuinis,  F.  baiii'mfti,  F.  diurmi, 

F.  Persians,  30iO  ;  F.  medinin>is.  3ii2. 
Filaria  loa,  F.  lentis.  F.  labialis.  F.  liominis  oris, 

F.  bronchialis,  F.  immitis,  304. 
I'ilariasis,  30o. 
Fish,  piiisoning  by,  303. 
/■',,</(t)-V  brain  murmur.  437. 
Fistula  in  ano  in  tuberculosis.  315.  320. 
Fistula.  lesoplKe-'ii-pleuro-'Utanenus,  40'2. 


I. ATI'S). 

(iastralgia,  501. 
Oastreetasis,  474. 
(iastrie  catarrh,  ac\itc,  403. 
Ciastric,  crises,  4^4,  501,  024  ;  fever.  4i',3. 
Uustric  juice,   hyperacidity   of,  4s4,   '•' 
acidity  of,  501. 


sub 


i;l 


\ 

'.' 

[ 

^ 

f 

t 

II 

^ 

» 

i. 

.( 

'* 

? 

I 

;? 


IN'DEX. 


llC: 


1     ,!--,•  rliuii'al  l"rius  •■t.  1-- 

(•,:^^i^^t"Mly.  •'>''■-• 

(',ii:-tr(ix\ii>i>.  •"■""•  .  ,  „  ,,,,,..,1    ,,,, 

i;.,ui..-urman->>"-"- '"•■"•^■"'"^'^  "'■■-'• 

i;,.o..rniiiiru':il  l(.ii-'U>'.  !•■'• 

(HTiimii  mi»sli'>-  >'.'■ 

(.iiiiit  Lri-i>wtli.  Ill-'- 

Ciiaits  aiul  i.'il-'iiiiti'-i'i.  '  '  ''• 
(■.■,ijunt\siuim.lMrr...nr/a!,N.lH:.. 

tlU'lUltl'l'lilf-'^'  ''■'''■ 

Citrantoi-liynolnis  i:i'-'»>- ■■'■■■■• 

(iliiiiai'is.  J "  "'' 

(ihuuUiUir  iVvcr.  ;.;i."'. 

(,7,  ;,.()■./".<  Ji^t'"^''-"'"  • 

(llionm"t'l>nitii.  1"-"- 

Cllnsis,  '.'T."i. 

ClobuUu  in  uvuk',  -■'". 

t;lobuslivstc'n.'U>,  Ul.i. 

CloimTulo-iu'l'lnlti^. -^T".  , 

c;lo.sv  .U-m  in  arthritis  .U.1..n,Km>  .1'-. 

(■.h.toaluorv..alUvtl„ns..t.ln.-.. 
C.lvoojren,  foriuatlon  ot    l-:o. 
(;Uoo^eniofuu..tinnotl>v.r.-J'.      

;;::;;::":^?;S;;;i.,..ai.,i.^-:^>..M^n.i.au. 

,;,:;;:,Slal    avOn-Ui.    ..i._.-..l.,>.ava;tis,    2.-. 
^,.,,tioiinnia  aiul  lAii^niui.  •:■'■'■        ^     ^^__ 

Cout    407  •.    ao.no.  4U;   .•hrol.u'.  41.1 .    J.^t. 
ton-   ol\4n0;   lur..mary  iMtlm.m...  u,   40^ 

V  r.l.nhulill     IHs;   iMtllUMlCO   ot    food 

,i,,.,,iv   (if   4"'';  ivU-oocUcUt  v\ 
suiilM-i'ssi'il.  11:;. 
tidiity  UldiU'V.  ^77. 


drain,  i.oisoniii.u'  ''Xi  ■'■''• 
(inimlcur,  «lflnsi"iis(>f,  '."■.-'. 

(Iniii'l  "lal,  1"'.'4.  I'^'f  • 
1  (inimilarUiaiu'y.S7. 
(jvaMulomata.imV.tl..us.,.tl.r...n.ln.O. 

I  (.'iniVfl,  ivinil,  '^'•I'J- 

(iri'on  I'unofi',  wi'.'.  __ 

c;rc.n-si>'Un.s>  (»■•■» 'in.... !osi^  )..•_•-• 
(livun-stiok  lra.tiucinri>'luU,4u.. 
■■■     :;l',i. 


i  (Iroi-'arini'la^,  I'araMli 
(iriiuli  rV  I'll.  'J''-'- 
drilH"'.  Ill,  '.I''. 
(,■,•»./)/.'•■■■-•  ti'"""'- "'"''•  ^.^ 
(luiiii-'ii-w"""  iViM^asf.  :>■■■-'. 
(;«//'« .lisoiisr.N41,  _ 

;;:i:4s;onun.s..l7;or, Um,,.Ui;... 

testis,  '.i"'!  ;  stnU'tlltv  (4.  -^iV.!. 

ou,iis,iaiiM<ii.--. '■-->---;''  ;,', 

;      :;:;,;.aUtis.44.;    .vann 1.    in    r.il.ii.-'y 

'      tiiiRTiMilos'is,  :'ai. 
(;uMatnvy  i.avalysis.  InM. 

"•         '     ,    ,i,.,|\.  u:.^:  i.litlilsi.-us. -iw. 
'•'"'''"^•"'T    .;.■    1UW.S,.,'.  4:C,:i,,c.in-l.oM. 

''''•;;t;r^;:;aiai:n:.sis.v,,,i...i.ii..,.'>---'^'^^ 

„,,„„^„„..,„yluria.  ,i....-l.inisau.,  N,.'.    Imki  i-i  . 
lui.t..u,a.4-aura,<.n"-al.i,v:i^ 

i  (,t'UU'Mllt'l->-  •'''''■'• 

i  Uii'iiiatoMiyi'lia.  '■"'■'• 

I  iuviiiat'n'"n'i'>7"'-  ;_'■■•'■ 

I  llaniiatnrrhaoliis.  '."u. 
lUH..iaozoiiul->iiiilaria  ^''... 

'     .  ,    ,1      ..,n,TV    -'.'7;      11   Hll»-IVIll"M>   .It 

sMf    in  ivual  iMii'  11,    ■  I  , 

I     uia.K'y."^^-"'"'"™-'"- 

i  llii-ni'iovti)7.oa,  -i""'-  „   , 

ii;,nio.lol.iu,.va,io.io.i.4,in.a.lor,.s,.,...,. 

H.,,„„vlnlniiii'iuia.  i'''*-  .     .    .     ,     „,,. 

:Uu,i.inuria,^.. ;;;..';- •  - -i^^: ;,;  ^ 

His,s,-,;i:  in  AV..'/"'""'""''^^'"'^'"'   -l'       • 
,      mul.s.vi;  toxio,  s,vi. 
!  Hivmi'-rorii'araiiiin.  <''''^- 
I  lhi.inn-l'>'i-i<"noi"n.  •>~^- 
j  lliiMiwil'liil'"'  ^^''' 

mono  plitliisi- ...    .           _         _  .^  ;,,_ 

losis,  27.V,  in  alK'unsiii,  0 1, 


„tv..ra.  v::;; 


livsti'i'loal,  HIT;  at 


■I 


IN-DKX. 


iKr. 


.liilis.  'jn  ;  ill 

lill    lliul    SliilKll 

idlU'VS.  -J.')!!;  I'l 

ivi-uiMi,  -i'.';  "' 


ill    i.uliu"mii'y 


vutliors,  ir.i!. 
icus.  -JO'-t. 
l',i."i  I   in  <.-irrlii>>i^ 
liii'iiMii.tysis.  -I'.'T; 

ill  Sl•lll■vy,^■J"|. 
0,  b.'i'.i;    iiiir:i.--itU'. 


,f  r.i.'yrt.  3"'i;  i!' 

■uiii.-  I'litliiMs.  31-^; 
II  iviKil  I'ali'Uliis, 
ill  tulii-i'fulii>i^  "I 


..lilor.isi.sT'.'-. 
luic.  in  infants. -1'  ' 


;  liysU'ri.'al.  HIT;  »t 
,„.i'ilc  linmolio-imi'ii- 
■n\r  luiliiivy  tiilii'n'ii- 
■■-  ;->! ;  in  aortic  iu- 


suili.'ioncy.  -^.l:  in  iivtliritl"  sul.jr.'t-*^  '•■■■•: 
in  l.ruiu'liiivlasis.  I'.JT :  in  oiiTlmsis  ni  liuii.', 
i;:,l;  in  fnipliyscMia.  '-"■'.':  in  li>>ti'na.  1117; 
in  mitral  in>nirn'i,Micy,  T'J"  :  in  iniinil  ^l^- 
iiuMM,  r-J.-.  :  in  i.nninioiiia.  11-  :  in  pnliii'i- 
nary  {.'an.irnn.-. 'iii-J  ;  in  MMirvy. -j:; ;  M,inriHM>. 
1117;  .'<ynii>tnins  of,  H'A^  :  tnMtiiHnt  ■>!.  •■■:'■''; 
ill  tvplnml  iVviT. -JS:  rrlati-n  \n  tuh.  r.'uU.M>. 
i;:;;!  i.arasiti,'.  o:'^\  i>erio,lic,  <■■.;■: :   virannu>. 

•''^'-  -  1     1 

llu'in-rrlia.'.',  l,r..ncli...iMilnionary.i.;'.,  :  .'.'rrbi-al, 

w:-.  tVoiii  nirM.|itm,r>-H;;  tVonHlio  stoina.'li. 
■VX>:  in  a.ul,.  vrllnxv  atn.i'liv.  5,VJ ;  in  ana'inia.  ■ 
:w.  i,i.MiThnsis..rtli.'liv.i-..-.:-J;  Incntra.'tr.l  | 
kiilm'v, '^s:; :  in  ;.'astrio  .•anc.T.  H'm  ;  in  >ra>tnr  , 
iiWr,"-l-l;    in   liaiiiopliilia,  >-^'<:  in  liy>tt'ria.  > 
1117,111-:  in  intiisMi>rci.lioii,  ;..17:  in  loiiku'-  j 
niia,  N'.".;    in  malaria.  Ul'; ;  in  nri.lirolilliiaM>.  i 
s'.i-t;  intliciu'w-born.  sI.h;  in  i-mi'iini  lunnoi-  | 
rliasrioa,  .SM;   in  srarli't  levrr,  7'.i ;  in -i'ln-vy. 
,s2:l"  ill  >.niall-l"'X.'i-' :  i"  >I'l^'i'ii'  enlarncincnt, 
•Jl''.,  4','r>;   into  i>aiu'n'a>.  ")--;  into  spinal  ror.l. 
lhi>;  into  .spiinil  nuMnl'ram's'.'io:   into  tiilicr- 
ciiloiis  pvlitis.  :i-J.-.:  in  tuliorciiloMs  of  howoN, 
;il',.:  into  vvntri>4.>s  ..f  brain.  W.>  :  in  tyi'lioi'l 
tVvfr,  10. -.it:  in  yellow  frvi-r.  1^;;  |.ulni..nary, 
:;o-j,i;:t7. 
lln'riiorrliai.'l<'  <liatlH'sis.  >1  t. 
Il.iMnorrlui^rio  .liscaM'S  nf  ttir  n.w-b..rn.  -l5. 
Ilivniorrliax'io  typlioi,!  nvir.  :(•">. 
IliiMiiothorax.  1174. 
Hair  tumors  in  stoiiia''li,  I'.'l. 
Hallucinations  in  liyMiria.  111'.'. 
y/,„T,>o/.s-  L'plov,'  in  ri.krts.  1:111;    in  onl:ir-f.l 

ton>ils,  4"i7>. 
llarvfst-tiu-.'.  :'.7il. 
Ilay-iUstlimM  (liay-lVvcr ■.  >'.1-J. 
Il'iifiiirtlt'-'  noilo.Mtii-s.  401. 
ll.iiiaaclio,  from  icnl.ral  tninor.  lO-Jl  ;  in  n-yv- 
bral   sypliilis,  ■J4ii;   in  moulli-bivallifrs.  4.'>il : 
in  typiioi.l  tV'Vor.  1:.'.  14,  -Js  ;  in  uia-.nia.  s'o  i 
si.-k.  lilt:;. 
llfail-olii'fM'.  poisonin:.'  I'.v.  "'■'!. 
Heart,  aisrasrs  .if.U'.i-  :  .liscas.-s  of,  (hrt.VsXtvaV- 
miiit  of,  7ri'i;  aniyloid  .U'luniriitiou  of,  lio^: 
anriirisni    of,    7-V'!  ;    iitliU'ttV,    71'1  ;    I'rown 
atrophy  of,  7.".0 ;  cali-ari'oiis  (l("i,'i'nrratiiMi    of. 
V.-io;  oon'.'fnital  allVction.s  of,  7il-'p;  ililalatlon 
of.   741  ;  aisiiUii'cnii'nt   in    plciiritio   utl'iision. 
i>17  ;    (lisphu'c'iiii'iit    ill    piu'imiotliorux,    OS'J  ; 
fatty  <lis>'asf  of.  74'.':  frau'm<iitntion  of  flbri's 
of,  74s;  liy.lalia>  of.7."4;  hypertrophy  ot'.  7:lo: 
liypiTtrophy  of.  in   Hrii.'lifs  .li^'asf.  sso  :  in 
( xophthalniiv  (.'oitri'.  s:;s;  irritable.  74.1.  '-'I'l ; 
new  krrowtlis  in.  77>4:  neuroses  of.  7 ■'■■■. :  palpi- 
tation of,  7r..'i:   parenehytnatoiis  ileL'eiieratioii 
of,  748;  nii.tnre  of.  7--:'.:  valvular  .li.-eaM>s  of. 
707;  wounds  of,  7.''4. 
lleurt-iuusclc  in  feveis,  74S. 


llearl-sonnas,  weakness  of.  711 ;  inoren=e.l  loiid 
ness  of.  7:'.'.i;  audible  at  .listalire,  7::!.  s::s. 

Heart-valves,  eoiij;enital   ali"iiialie>   and    leMoiis 
of,  7i;i!;  rupture  ot',  711. 

II,  at,  exhaustion.  :;'.i.^;  ~tn'Ue,  ::'.'.'>• 

Il.h.rd.irs  mnh's.  401. 

Ilc'tie  fever.  :;oii. 

Heel,  painful,  ll'i'l- 

ll.lhi's  te,-t.  <'<\. 

Hrliuintliiasis  ,see  .\mmm.  1'ai: asitk- 1.  "4'.'. 
Heiueral'.pia.  l"lo;  in  .,eurv>,  --1. 

llellllall'Uniose,  s.'>7. 

Heiiiian;e.^tlie>ia.  ill  eerebral  hani'UThaL'e.  H"'"' : 
in  li\sterui,  iU.".;  in  lesions  of  internal  eap- 
sule.  '.i-:l;  in  unilateral  eord  lesions,  w:<. 

llemianopi".  lieteroiiymous,  lo4-.i ;  1 lonymous. 

lol-j;  in  miLrrain.'.  lU'ii;  lateral.  lo4J  ;   nasal, 
lop.';  siu'iiifieanee  of,  \i:\:,:  temp'Ta!.  \'<\-l. 
lleniierania.  11"-'. 
llemiopie  pupillary  inaeii.)n.  lo44. 
lleniipleiria,  looi!;  ero>sed. '.1-4.  I004. 
Hemiplegia,  infantile,  1017:  aphiisiii   in.  I'M-; 
in  dii>litheria,  l.'.o;  epilei'sy  in,  lol'.i;  in  hys- 
teria,   1111;    niental    .lefeets    in,    lols;    p...-:- 
hemipleL'i''  movem.'nts  in.  lol'..;  si.ustieaee.v- 
brali.s  1"!-  :  io  tyiihoi'l  fi;Vfr,  'M. 

HeluipleL'i''  1bl>.lUe,  1 1. 

//, /o.e/.V  purpura,  -I'l. 

Hepatie,  absee.ss,   .".77  :  arlery.   eiilari."Miient   ..f. 

.•i.V, ;  eolii',  i'lr,:'. ;  intermitniit  fevei,  •'ii'i'i :  vein. 

atl'eetions  of,  ."i.'.r). 
Heimtilis,  dillUM'  >yphililie. '^IS;  interstitial  ■  sei! 

CiKiinosis).  .■I'l'.i:  supi'uralive.  .")77. 
Hepatization,  of  luni.'.  11:!;  while,  of  I'oliis,  ■J17. 
Hereditary  form  of  udema.  11 11. 
Here.lity,  in  Uriu'lifs  disease,  -77;  in  diabele.s 

insipidus,  4:!.! ;  in   /■>■/../(•, /.■/,".■<  ataxia. '.'l'.';  in 

;;out,4i>s;  in  haemophilia, -1'.' :  in  I'aramyoelo- 

nus   multiplex.    ll.".o;    in    spastie   parnpU-ia. 

',140;  in  syphilis,  -j:;-  :  in  tiibiTeul.>.,is,  -y.i. 
Herpes,  in  trifaeial  muralL'ia.  ll"'':  in  eerebro 

spinal  meniliL'itis.  lol:iu  febrieula.  :!|:i :  In 
I  nudaria. --'l-J;  in  pneuiii..nia.  I'.'-.;:  /.•■>t.-r.  lloil. 
'   llieeou.'h,    11";-:  ealises  of,    loijs  ;  treatment  of, 

10il;i;  liysterieal,  111'!. 
Hii.'li-tensi.m  pulse,  eharaeters  ot".  774.  s-o. 
'   Hil'po'M-ati.' faeie.s,  .V.'-;  liiij;.'!-.-,  :a-'. :  sue,'U>si..n. 


i  Hippus.  110-'. 

I  ll,..l,ik,u-^  disease.   -o;i;   intermittent    fever  in, 

I      -I'-J. 

11 il.imyia  sealari-,  :;7s. 

Horn-p"X.  <V': 
I  Hospital  fi  ver.  4'.'. 
,    lliintiiKhl'iii'x  idiorea.  1U'.">. 

Husband  and  HilV.diabet.s  in. 41s;  tul.ereuh.sis 

ill.  •.'<'iil. 

I     //»/,/,;»«..,',•..•  teeth.  '.MM. 

I  llvaline  easts  in  uriiu'.  s71,  •>7fi.  »>-<'. 


UG^ 


ISDKX. 


Hvarurtl.ros>s,.hn.uu',-..  .U'U   

uVa, .Tluau.Mo.s;   »o,,un.,W     - 

.      ..-!■    lll■'^■    ullLrii'-'"""  "    ' 
,M0. 

twit.  M-^.  *-'"'• 
ny.lrniHriciinVuiiu. '-.'.'i. 

llVarni.i-nl-nii'imi, '■■"••• 
ll'varoplinliiii, --"• 

llyaro-piH'"'"""""'"^'  ''^'' 
llyar..l>s  vcsu..  tVllur,  r,.i.,. 

llv.  .■titUoi-iix,  iiv.'. 
„y„„„uUTsisa>.„hu„.;H.nuna... 

UviH'i-iioiaiiy,  .M"i.  . 

llvpoiwsthi'si".  ni  nt.iMii,  .  -V .  ,.    i 

•i„rKau.ts,4:>.-,;muna»uraWo,ai.MM,  . 

HyiR'iH'lilorhyaviii,  &'">■ 

llyiH.i-..sn.uul":is.  rluMniuitie 

„,,.,,pyrc.x>a,  hy^-AlU  _^^^^_^^^^^_ 

IVvor,  n«';  insoiuUl  km-f,      , 

r.',m ;  i"  tetuims,  ii3-.i. 
Uv^KTtliyri'ii,  8aT. 
ll'v,H.rtl,yr..iaisi..,  !*">"• 

Uyp,u.Usmh>ln>U-na.lU.  ^         ^^_^^^^_^ 

llyjH.aonnR' ^vnll,^^•  »'  aui->"  I 

fusion,  «:•'>.  ,.  nf  li "■.••);  imnily''>^ 

'of.KMjiS-.sinisiii  of.  )"'>.. 

">l^>'^':"'';\';f:.,,,a,UsM.Mn..it..a.M.rosis.ft.iO; 

llyst.ria,lUl  .  •"'     '  .,      „n.  ,„nvulsive 

conlrm'tur.'s  aiul  .  1  .'■  "  .  .lisordurs  of 

forms  of.  1U-.  "11  ^^j„. 

f;,.nsatioii   111.  111.'.  1  j„i,n 

»"""":''^^-^:^';n      :.;.     M-mpto,i,sof,u:s: 

.notaboUsmm,!  1.',  '••";, ^.^i,  ;„ 
..on-oonvulsivotoni.     t    1  1^^     .^^^^    in. 

in3;.r...Ua    .>•--     ';;;.., ,,,„i  .nanilVs- 
815,  inS;  trauniatio,   H'*--  ^'-^^ 
tations  of.  "lllfi.  _     ^ 

Hvstorical  nncinu  rci'tons,  J..*. 

irvstcro-opikTsy.lOvs.nVi. 

llystorogeme  points,  UlR. 

U.,.-orrani.  poisonin..'  I'.v.  ;!'.13, 
Ico,  typhoia  ba/illus  in,  4. 


Ichthyosis  lintrual^p.  44r.. 
Uhthyotoxisiiuis,  »'.i3. 

l,.tiTUS(Sei^.UlNI-l.-B').  _ 

laincv  in  infantile  h.'inipU^L'in,  101?. 
Miopatliio  a.>"'naa  of. LW/-'".  ••'•■• 
,,,„,„•,,  i„U.rM,i...nt  lVv..rl-<. 

Ileus  (SOI-  StI!.VN'.1'.AT1"V   of    l.ovv   .,    ,..i. 

,  i;;;;:iiity  i,.  intimtii.  iu-niipu-.Ki,  loi.. 

!  l„,Uationinrhor.«,lnM.  „on.atiti^ 

l,„,,,,i;^o,  contau'io.is.  ana   uK.i.ais. 

44J. 

Inipotenoo,  inaialMnis,  4-.. 


in  l.H'nniotor  ataxia. 


oflotrs.  V'J3. 


Inoaiveralion  of  l"'\vil,  .''"a 
,„.„„,rainationc>fan..s.|'|;-..^^--^^        ^_^^^__ 
hulians,  Anioncan    el.ou.i  .i    i 
tionin.t!r,9-.  sinall-pox^-nnnL'. 

liulioamiria,  sc,;'.. 

_uait:c.'stion,  4ti:!.  ,,.„..,lvsis.    '.i4'2; 

Infanf.l.,    convulMons.     lovl  .    l'.>..vly.  i.  • 

scurvy,  si'i. 
Infantilism,  ■.i43.  s41. 

'"•^■'■'!''"''::''";!;r;''ofaoul,,u.l  nature.  34.. 
liifi'ctious  (Uscasi's,  1  ,  "1 
:«:;:onofl,.,.ciinintussusccpt.n,.3H. 

j,„,UK.n/.a,Vi,V,oomprunitionsol,,i,. 

1  hifnsoria,  P'lrasitu',  ili.l.  .,,„,,. r,„^.   Pse.- 

Inhalation   pneumonia  .see   .Vuu.u 

I       MoNi.\),  04-J.  u  ,,nv    -iCi    «3;  protec- 

'--^"^''^'\Trirrv    "ti;,  in  Wa.<.- 

rl;^i'  --..^v^npl^.uc,^..;I.re- 
l''';  '^--i;  Jneumonia,  11.;  preventive  u. 
;:C;e:"r,\MKtui.ereulosls.ransmitteaby, 

.;;inUy.post-aa,riU.3;;.in-;;;j;-r-2nsof 
,„sanity.relati.M.otaunUto.3K       ^^^_^_^_.^_ 

chronic   phthisis  to,   31-, 

disease  to.  71.. 
Insects,  parasitie,  STii. 
Insolation,  3'.i.'>. 

Insular  sclerosis,  MO  .^^^^^^^^^^^_ 

Intention  tremor  (see  \  oi.m^  . 

'•-•••-;r;;n;:::'::;r;v:::of(seeF.vKu). 

Intcrimtteiit  Iinh.  . 
intermittent  hepatic  fever... r. 

hm.v.iii.tentl>yararthros,s     n^. 

IntostitiaUa^truetion  o.>K        ,,t>non,yoosis  of, 
Intestines,  aiseascs   of,   eOo , 
o3r,;aiUitationoi-,Mo.  ^  ^,^_^.^._.^ 


INDFA. 


iior. 


•.  U.'i;  ill   n\-<- 
R.,'),r,?l. 

10  IK. 

,v<.    stOlllilliti-. 
...•IKitor  iltilNlil. 


i,;iriiU>if'.    'J-l-' 


111  nuturc.  Sl'2. 
itioii,  .'jS**. 
',17. 

sniiATIoN    I'SKV- 

.•iitive,  i"  liv'l''"- 
liliiiTuc,  102 ;  pre- 


pro 


lentivc,  in 


SIB  tniusinittcil  l>y, 

;i,„ill-i«ix,  fit- 
,.  :i^l  I  roUit'i'ius  of 
rfliition  of  huart- 


loNAi.  TukmobI. 

„s  of  (see  Fkvku). 

iiifi. 

1118. 

',tS'2,  '.18^. 

■king  of,  1011. 

.'■)4fi. 

ed  by,  288. 

0 ;    iictiniiiiycosis  of, 

0111,  in  tvphoid  foviT, 
-,,  I'.is  ;  ill  Uiberoulosis 


,■  .,.  of   -r- ■  \n  sTT;  oon^'Ollitaloy>ti.■,^'.lS'■""•-'■^"■""''•    .''  • 

of  bowel.  SU';  in  ,MtvHs„s...i,t,on  ot,  ,...,  ,  ..„„;,.„,„,i,  877;  c'ymotir  m.luraliou  ot,  -^^o; 

uloenition  <if.  ■M--                         .                     ,       !  ,•     j|s,.use   of,  S'.i« ;  wliiiioi'owiH  ol,  ;i,l; 

„f,    r.o-.'.   r,:;7;    iliviv-maUon    <it,   ......    nu^*>>-i    I  ,,,'     ,^1,0,.,    sir,;   lar;,'.'    wl.if,  ^71;   mal- 

„;..,.   atlVoUous    ,„;    541;   new    .n.w,l,s   ,M,  ^       J;;;^;;-;^';,,. '  ,„^   ,,„„  ..;;    ,,al,.ai.l,., 

Inli^^inos,  obstru-'tiou  of.  r.^l,  r,;ni ;  a.ut...  r,:Jl ;  |;J^';;,|„,„.,„,„„„,  „,;.,,;;  saivoma  m>;..; ; 

l,y   .„t.rolitl,s,   5:14;  t.y    .^,v..i.   1->U..,  ...4.  l^^l;;;^^^^^^  ,,..;s7;  Miiall  wl,it..  Ui.lM,.y.  ^7. ; 

by  trall-stonr.,  r.U.  r.''-.^               ^           ^                1  ^__     ,^,^^,  ,,.,,„,,^._  ,,.  .  ,v,.ir,li.  of,  •j:.o  ;  tubn- 

l„,..stines,  lurforation  ul.  m  yplH.,-!  I.  ..  1  ■  .  ^,„,,„.,,,„.  ;,,, .,  tu,„o.>  of,  s;,,; ;  unsyniiH.tnr:.!. 
Intestines,  [.riinary  tulHTei.loMs  ot,  -l'  --"'"- 

^Illation  ot;   Wl.   :,■;.;  ;stm.tures>m.ltinHos,  ,^    .                         ,,,.,„, 

on  033;  twists  and  Uuots   in,  .>^3 ;  uleers  ol,  ^  ^ /.|-^^/.  ^^,.'^^^^^  ^^^.  ,_^  ,t,.Ma,...l;  in  .liiOitlieria, 


Intoxication,  detinition  of,  101. 
Intoxications,  oso. 
Intussiisveiition.  ."i:i-J.  .'^m. 
Invagination.  .-.3-.';  po-t-nioi'teni.  ..-.1;. 

Inverse  type  of  ten.peraiure,  in  acute  tubercu- 
losis, 274 ;  in  typhoid  tcver,  1'.. 

Iodide  eruptions,  2:i4. 

IrldopK'ia,  1047;   accoMUUodativc,  lol,  ;  rellex, 

1047. 
Iritis,  syphilitic.  241. -244. 

Itch,37i'..  ,    ,,    .  . 

Itchin.'.of  feet  in  ttout,41.V.  ot  eyeballs  m  -out, 
4ir,;'of  sUin  in  Briu'l>fs  disease,  ss-i  ;  of  skin 
in  jaun  lice,  o4l»;  in  diabetes,  425;  in  cxoph- 

tlialnilc  goitre,  >3ti. 
Ixodes  ricinus,  37il. 

Jacksoniwi  epilepsy,  ',d7,  lOOS, 
Jail  fever,  41), 


l.M. 

A-,,,7,  treatment  of  tnlierculosis,  3-)... 
Kopl'tetanus  of  A''Wi,  232. 
Krcotoxisnms,  3',n. 
Kuliisaijrari,  lo.'i'J. 

I.abvrinthine  disease,  lor.S. 

Lachrymal  ,'land  in  nmn,ps,  01 ;  ,n  Mikulicz,  s 

disease,  44.S. 
••l.ucint;"  liver,  ."i^7. 
Lacunar  tonsillitis,  4.")1. 

I.a  L'rippc,  ','.-.. 

Landilia  inteslinalis.  3,il. 

/,.(Hi//V/''M""'iily^i^'  '•''''• 

l.aparotomv  in  typhoid  fever,  48. 

I.arViO  of  Hies,  disea.es  caused  by  ( my  lasis  1,  3,  s. 

l.arvnueal  crises,  '.<-■'■ 

Laryn'j;isiniis  stridulus,  017  ■.  from  prcssuiv  ot  en- 
larj;ed  thymus,  S44. 


iiiuiv.-i.ru. I",  .-i.-- 1   .  •  lar"eil  thvmus,  .--II. 

Jail  fever,  41).  .--.^,0       1  .irvn"itis,"aeutc,  catarrhal,  015  ;  chronic  OIH 

Jaundice,  548;  bhe-k.  54.;  catarriial.  ...v..  elm-     ^"'^^-^^^^^^^^^^  ,,,..   ,,,,,„,„aic,  017;   >ypl.intic 


uindice,  iH»;  oiac^.  ..i-,  >.., ___ 

luria  in,  .Via;  from  cirrhosis  of  liver,  .572,  ■',■<; 
..pidcmie  form  of,  344,  5.50;  febrile,  344;  trom 
uoutc  vcllow  atrophy.  551 ;  from  cancer  ot  liver, 
.^st;  tV..m  u'all-stones,  5.14,  rM:  in  inlluenza. 
<)7  ;  in  pneumonia,  125;  and  purpura,  -^14,  ..4',> : 
in  »V(7V  disease,  3U;  niali'.'uant,  551  ;  of  tlie 
new-born,    551;    obstructive,    .54s;    toxamnc 

.     t  :..    -111.   :•»  t'..ll.ivu  t**»vt'r- 1,S.) 


new-born,    551;    obstructive,    ;,4s;   /"^»"  "^'  '      '"■j^-    „, 
550 ;  xanthelusniuin,54t);  in  yellow  tover,  I80.     ^^^^•^'^^^ 


aryn^iitis,  aeuus  i.ii.tn. 

„.,lematous,   CK;    si^asinodic,  017;    >yphiht.c, 
t;-'0;  tuberculous,  01'.'. 
Larvnx,  diseases  o(.  015:  adductor  paralysis  ol, 
lOid;  aiue.sthesia  of.  loil-j  ;   hypera^sthesKi  ot,^ 
lo,;-j;  paralv.Ms  of  abductors  of.  lo.;i;  spasm  ot 

the  muscles  of,  lOO-J ;  unilateral  abductor   pa- 
I      ralysis  of.  loiU. 


Jiiw  clonus,  ',131. 
JiL'i-'or,  •37s. 

Joints  (See  AliTiiiiins). 
Junipers,  los'.i. 
••June  cold,"'  012. 


Latah,  lns:i. 
I  Lateral  sclerosis,  primary,'.):^  ;  amyotrophic,  J.>. 
j  Latcritious  deposit,  sO,o. 
i  I.athvrism,  3'.i4. 

!  Leii.l,  colic,  3ss;  in  the  urine,  :.N. 
'  Leiid-palsv,  3s-i ;  localized  forms  ot,  3s8.  ^ 
Lcad-poismiin,'.  Ssii;    acut,.,    3S7 ;   arterio-scle- 
ro.sis  in,  380 ; cerebral  symptoms  in,  3s.,»  ichron- 
ie.3S7;  convulsi.ms  from,3s0;  jrouty  deposits 
in,  389  ;  treatment  of,  3f?'.t. 
Lead-workers,  prevalence  of  ^rout  m,  40-5. 


Kahler's  disease,  allmaiosuria  in,  8.57. 
Kakke,  221. 

Kala-azar,  203. 

i^t'ao-^oi  i\,  1.--,  [■..- 

Keloid  ot  .b/./*.-"".  1  lb'-  '  T  ..•„.lu.ii-tubcrcle, '^04. 

Keratitis,   in   small-pox,  05;  interstitial,   0.   m-  ,  \'^;^^;;^;^^:^l\,,:„ 

heritedsy,.hilis.'.44  L,,,ru  alba.  341. 

Kerato.sisfollicular.s,....0.^  Lepra  mutilans,  341. 

Kerat.isis  mucosa'  oris,  44.,.  aniestlictic.  342  ;  bacUus  Icjira  m, 

Kidney,  diseases  0.^840;  amyloHl  -  Uivaae.    s  ^^^^^  „.,,,„„„,,,,;  ,,0 ;  niacu.ar  ti.ni  ol, 

disease  of.  884 ;  cancer  ot.  ,s'.", ;  caul  ae    N,o  3     .  - 

circulatory  disturbance  in,  840;  cirrhosis  ot,  |      oii ,  tui.ueuia  , 


-      - 


r" 


iir.o 


INDKX. 


..liiv.iru'. '.'■'T  ;  inlaiuuiii. '. 

Liptothrix  ill  iiK'Utli.  ■^".il- 
IaI'Uis  iiiummiiilU,  "',''■ 
l.riu'in,  ■'"'■•i.  . 

,,,,,1,,,,  si.iual    MK-,u,.t:.t,N    1'4,  "  ; 

,,,.  ,.,„,,v..,u..  .;7.;  .rvs,iH.U>N  '•'   •   ''.,^. 

:^  t;     ,;T0    •-■!,., una,u.   U-,-,    17^;  M.aH,., 
!:;    ;nt>iH.n.ulo.i.u.■uu.:..T:,;i.;t..--'- 
l.,,,;;7;>nwlf">l''"'-'-"^'i-'''''''- 

,        ■       s,i-i'    <wnU;   Si'^;    Ivml'luitu'.    wis-,. 

Mood  in,  ^M..;e'un-tiutal,  .      .  J 

,.,.;heV.ai.yin,b>':;;mun,.nals.^o      ,M    . 

„,,,,,.    M)'i;   i.iorbia  uuaUMMV  ..t,  mi...  imnc 
;:;;:,;,;us,H:.:v.,.,>,.i.in,Mn.v..ua.,-,MK. 

siAciio  nn'ilullary,  m',..  ^ 
l.fuliol'laliia  biu'.'alis.  1 1'''. 

l/u'iiU'i-ie  .lian-liu'a.  r.oT.  ^-.  .  ...i.Uvi.li- 
iii^-  -.;■■■■'•                  , 

i;,.rliti.iii- l''''"i- ">  •''•'^'■' 

l.iiuw  atroi'lil-'a'.  I'.'. 

l.iu^'iial  i-nviis,  IW. 

l.ilia>'i'iui'ia.  Hdl. 

l.ilia-iuia.  4'2l,4-i''- 

l.iiiotliymia.  '<W-  ,.  „,,c- 

l.iUt»lH..vulo.is..f,:'.lT:clKUK.K...1.-.B. 

l,'H>\iria.  '^''■t. 
l.itluviiruu  sr.i),  SfiO. 

l.itliio-a/ul  diathesis.  s.V.'. 
l.itliuria.  S,"iO. 

1  Utli'"s  disease.  '.i:5^.  .  ,     ,•    oo 

,  .  ,,f    .-.TT;   aeliiH.niyeosi-.  "I.    -' 

"""■"";•      hilir     and, .-Won  of,  ^sV. 
'""""")":"         ,-aleol,olie,    ^70:  aseites 

I''^^''--^-'-':  :,,'■-,  :>.arsMlavtonn.  57^;  i..l 
'"•f''^''l:;        ;,,       r,7AlKe,norrl,a.e1Von>! 

stoma  li  111.  •'•.-•  ii.M"'"   1    .       ,•,,,,.,.,,     "o: 

.   1    ,.  .,,l,,<\.i    ".'-lo:    111    eliiMii  u.    ■  . 
.-,7,v.  m  tul.eiviiloM--.  ,-,7:;:witli 

,iai.ndieein.:.7-2-.toxK.syiH,.lo."s,iK 

,."""""■  w!' of    .sv:f.,.y.   ^-^^   triinnuata   ol'. 

„„n  ol,  .......  IHU  ,,.„rosi.enuiasis  ot, 

priiiuiry   oauecr  ot,  .'.-.1 


,„lo,sis  ot,;i'Ji':  ill  tyi-l"">l"'^'''-- ''■-'• 

;:S:^sr:^a;;;;ationof.i,M^.-..- 

toiiitis,  '.il'',  •"'•'■■■ 

Liver,  niovulde,  M'J.  fi'-7. 

l.ivin-;  slu'lelons,  VM. 

Loliar  jmeiiiiionia,  in-*. 

/.nbsliiu'n  eaneer,  t-'.'V. 
Loeali/.ation,eerel.ral,'.H'T;si.ii.a..  .'(:.. 

I   l.oeali/.ed  i.eritoiiitis,  .V-J.  ft'". 

l.oi  U-jaw,  '.i:;". 

:   l-oeU-svasiu.  lU'S  ,,,    ,,,^,,   ,v,„,.lnn,s  in. 

Loeoniotive   ataxia.  '.'-!".  l'l.i"i>'      • 
1  .         •         M,    ir'l'     uliu  I  eL'ia  111-  ■'-■' • 

:,.v,,,nns  to.  V.o;,.e,,utedei,res, .,'-,. 
'    ,,,„/,i;on.eie  nerve,  alUetionsot.Ui.O. 

Loose  sliouldii>.  v:'4. 


LiU'ilia  niaeellaria. : 

/.((./((.//••"I'l^''"'"' ■'■''"• 

l,,K-s  venerea  >syi.hilis'.'.!-''V 

Limil.ai.'o.  H"'.  ._, 

LiUMl.arl.l^'^»^'l^'^",'"r      /'To-   .ir,|-.   lono. 
Lu,nlniri.unetureotV»--!..li...     ■' 

i-^-"'--''''''^^^:;';;n;;;;;is,no.^..^'i; 

Liin^.  aetmomveosis   o.    .     .  _^^,_,^,,,. 

,,,,„,„  induration  ol.  I...-.  ^•";^'', 
,,,,iilieationof,lM^i:onTl,os,sol.i4... 

,.„„.disoasesot'(UU;  stone..  2.11,. 

i-»"^^--''''"""'"';!';.;;!;.";;:;..ssofhrainin.i^'n. 

;;::-: -r-:::;:;u:in.-U:  in  oo.,au-,ninei.s. 
i.:ii..- ■^'!-^r>''r''r:s:::;.;u'"'J' 

of.OSm  sl.lenization  ot.   lw..,t>-l-.,  ..1 
047;  tlllierelllosis  ol.  --'.'. 

Lui'iiiosis,  ;V.i4.  ,.  .,,lnn-    "s-j  ;  loeal 

,,,.,,..alenitis.i^.u..3  ;•-;;•;         ,,,,,,, 

tid'ereulous.    .;S-.    f-i"! 

Lyml'liaaenonin.  t-'eneral,  s   .. 

Lynn'liatie  state,  b.i'1. 

Lvml'liii'isiii.  ^■-'''• 

Lvinvli-s^''-"t>""- •'■''-• 

Lsinrli,  vaccine,  71;. 

l,ynirlivesseKaaatat,ou..t,....-. 

l,Yssa.  'i-.i7. 
j  ,.yssoi.liobia.'2..0. 

Mneidar  sypliiliaes.  '^\<\ 
M:iiaisMUis.  :i'.i.''. 
M>.in  en  critic.  tl^iO.tiM.       . 
Ma-,/.e.l.oisoni.V-'by(pellie-'ia 

Malarial  cachexia.  WN-.;l".  ,^,^i^,„. 

Malarial  fever, '20'J;acciaent.a  .md 


INDFA'. 


lltl 


■J  I-,;   lUl'i  1- 
l.'.'T. 


(iVIllli'"'"*'    '"• 

|,lci.'ia  ill.  '■'-■"'  '• 

\rrl  :  lillltii'll 

s  I'f,  ',1-JT. 
H'TO. 


•,  '.i.-pi'i,  i";'.". 

lliIli^lll  of.  I'"'''  '. 
I'l-  lit'.  IH'Utf.  I'''l  • 
(it',  lll'.l. 

...tllt'U'.  '!"'''• 

s  i.nirain  iii.''>'''l- 
,1  ocil.uU-mnui's, 

I  ot'.  i'i">^:  (I'lciiiii 
(■,4:'. :  sviiliilis  I'l'. 


i;M;    Mil'l'iii-iit'^'^'' 


I'.ilO 


nil.  "'.'■"■ 

lUal  iiiKl  I'ltc  K'^loiw 


Mwiiii-ilis  ii.'Utf  ,rivl.r.vs|,;niil,  I'M;  .tMiMiU. 
(■.■ivbro-lMiKil,  \'"'\  ill  irv>iiM-liiN  !.■'■',  1'''.':  i" 

(.'nut.  li:.;  in  l.v|'l"'i'l  '■'•^'■'''  '-•  '■'•■-""•  '"■'''"' 
sivc,  '.i.".7;    l->l.ri..r.  "I-  iiili,nl>.  '.'.''7;    M-i">a, 


i.r,  211'i;  n'stivii-iiutuiiiliiil.  'il-;  nl^'i'l  l'"''i'>  "'• 
■_1.-|;  (■..MilltoM'  forill  nf.  'Ji:.:  I'l.lltilUl.a  lill'l 
IVIllittcllt     fnrm     (if,     -Jl'-'.;     llcMTiptKill     of    tlic 

i.arcxvsni  ill, 'Ji'li ;  L'l'i'i-'niiiliiciil  (listriliiilioii  "1, 

1„„;  i,„.,„„n-lK,.ic  lunii  (.t\:^li;;  ii.t..nuitt..iit.  I       ln.->;  >M.!,ilitic. -i:. :  u,I..ivu,oun -.' 

•J(i:i;    Mu.tcorolo.irical    .•..u.litloii-*    iiilliU'Uoiii-,  i  .Mciiiii- hvu>,1o:; 

-.■l;  iRM-iiicioiis,  'JUT, -Jl.-i;  piiciuiKinla  ill,  lin'.'; 
iliiartaii,  -.il.".;  (lUotidiaii.  'Jl:':  sfas..ii  in,  •Jn4 ; 
sju'cilli'  (.'cnii  of,'Ji>4;  t. Hiirl.-  .■.iii.lilloii.-  inHn- 
ciiciii,'.  ■■^"■'■:  tfi'liaii,  'Jli^. 
Malarial  lul'hritis.  ■:i''.'. 
MaliL.'lialit  jauinlicc.  .'.M 
MaliL'iiaiit  iMiri'iiric  tVv,  r.  li'l. 
Mali)-'iiant,  im>tuli',  -J-J.'i.  ^ 

MalU'in.  ■S.'A. 
Malta  U'ViT,  'JlO. 
Maniiiuiry  ^'laii.ls,  liyi>crtr..ivliy  in  Uil.Hvnlosis 

;;1J;  tiil'i'i-ciilii^is  (if.  :;-.;7. 
Mania  a  i"'tn,  :'•■-•-'. 

Mania,  //(//■•.■.  1"7.'..  .  . 

Mavria.n.,  (iiic.tioii  of.  in  l.i.n,..,.l,ilia,  >-:\  :    in      M.-tu^vi.b.lili.  alU-Uoiis,  .1 
svi.liilis^M:  in  taia-s  (lni>ali>.  i'-7;  in  lulu  r-      Mctatai>al-ia,  1  P"- 
culosis.  :'.'J'.'. 
Marrow  of  lii'iu's.  in  Miiall-li"\.   "'^ ; 
iiiia,  'o;; ;  in  in.'rirK.'i(nis  aim-inia.  7'.' 
Jl,s.j.,.  ./../,  n„n..n,ou.n^,s::\.  \       in  vacnn..  vnns.  ,(■ 

,  J, .  ,ij,,,.|,,,  :.,,;:;  Mi(.'ro(.'(Ka-ns  luiKa'oliitu>.  I0-,  1 ,0.  1,-1 1.  ,1  .. 

Ma'ti™ti,m''^paMn'of  tlic  inil>cl.>  oi:  mM.  Microco,v,i.^nK.lit.liM>.  -^W. 

Mr /l,inn  ;/■■■<  tvtnU-v  imint.  :.:;■'..  Mirroc>  to,  .'.'•^- 

Mca>lcs,  s.V.  coiiiplicalion-  and  sc.incla.  .,f.  -7;     Muron.c-aly.  1 11... 
coiifi.'ioiwio.-^s  of.   s.". ;  .Icxiuainatioii   in.  -7:     Mirrdoclia. -11. 

^nlS:,,  in!  s,;;  ...riuiiu.  -':  i.crio.l  of  incu-  ,  Mi,Mlo   onl.ral    arlcrv.  .n,l,..l,>n,   and   thi-a,.. 
bation  in.  Ml.  !      I-- -"■••'"  >• 

M.a.lviiu.at..xa,nina,ion,..;:.;7.  i  Migraine   1  lo.  ;  nvanun,  ...n 

Meat    i,o.sonin.'  I.v,  "'.'1  :   tulaivulous  iufrrtion      Miliarv  a!,.s,..sM.>  m  tM'l.oul  hvcl.  11. 

l,v  ■•(■.7;  iiisncrtionof.  fortri.d.i.mMl.-„-,.  1  Miliary  iiiK'iin.Mi.,  10-. 

.1/,c,;-,/'.s-divfrticiilnni,  ■>:••-.  .>iiiiiii\  h-m-i,    -t    .     1 

Median  nerve,  all'eeti'.ns  of.  I07I 


Meliin-o-eneel.hallli^,  eiirouie  dilVuM',  '.".o  ;    tn- 

liereillolls,  '^77. 
Meivurial,  tivii,..r.  lo7'.';  M-.inatili.-.  111. 
.Mer\ei>nill-.  l'-'''. 
Mesenteric  artery,  aiieiiri-ni  ..f,  ."il''.;   eiolioliMii 

of,  .".4i;;  tlironiliosis  of,  .'i-l'''. 
Meselltelie    -lal.d>.   tubeivulosis  of,  'J-".  1    tld"l-- 

eul(.ii>  linii..i>.>f.  •.;— ;  in  typhoid  fc'\er,  1". 
Me.-eiiterle  veins,  diseaso  of.  .il.. 
Mesentery,  eiivlous  e>>t>  of.  .-.17;    alVeeliolls   of, 

,Vlil. 
.Metallic  cch...  '■.<■.;  tinlilin-. -0.=,  c-;;. 
Metallotherapy.  Hlc. 
Metastatic  al  scesses.  Ml. 


MeteoriMH   in  tyi'li^id   fever.  ■.;.".;   Irealmdit  of, 

in  leuka-  i       17. 

Microooeei.  ill  dengue.  W\   111  Malta  levd.il.i; 


Miliary  tulaTcle.  ■.i7o;    lul.erculosis,  aetitc.  li,"; 

tuliereiilosis.  elironi''.  -'■'■"'. 
Milli   and  scarlet  fev(  r.  7-.;   and  typhoid   fever, 

(1;  product-.  poi-oniiiL'  l.y.  ".'.'-;  .-ickncss,  ;i44 ; 


Mediastinal  Irictioli.  ''-.. 
Media..>tiii()-pcricarditis,  indurative,  r.s7. 
Me(Ua>tiliniii.  iili'cetiulis  of,  OM  ;   abscess  of,  HSH 
tumors  .      '■<<::  cancer  of,  (W,", ;  emphysema  of,  |      tnbeiviiloii>  iiifeeti..ii  l>y.  li''.. 
i;s7;  pleural  elVusi    1  ill,  iMl :  sarcoma  ol,  i:-."'.     '   Miiid-lilindliess. '.".10. 
Mclitcrrancaii  fever.  2V.i.  <  Mind-dcafness,  '..;,o, 

Me,lnila  ol.lon-ata,  lesions  of.  '.i-4 :   tumors  of.  ,  MiiierV,   iinaMuia   ..r  cael;.  \ui.   :a.o;    luiur,  lu,:. 

iiy-taL'tniis,  lol7;  cancer  ol' Iiuil'.  nni. 
Ml/r/,,/K  W'llr.  tnatni.nt  in  hy>tcria.  11:;1. 
Mitral  incompetency.  717. 

Mitral  steno>is.  7-Jl  ;  eli'ma  and.  7-'l  :  paraly-is 
Mehwia,    in    duodenal    ulcer.    4-f.    in    typhoid  I       of  recurrent  laryn-cal  in.  7-.-' :  l_rcsy,-t-lic  mur- 
fever,  '.i4 ;  in  tubereiilosis  of  bowels,  yi'J  :   lie-  j      inur  in.  :■■■■■•:  rheuniatiMM  and.  ,-Jl. 
onatormn.MS.  ;  Moist  sounds.  :;os.  ^      ^ 

Melano-sarc^ma  of  liver,  asO.  1  Mollusemn  coiilacicMnu.  ,.ara>,te>  m '. 

Melanuri:..  SIM.  M.mophobia.  I1-J4 

Melasma  suprarenale.  ^:n.  '  Monoplegia,  cerebral,  .bl.  .- ;  tacal.  1    .^.  m 

.l/,„;.n-..  disease,  bus.  ,       hysteria.  1 1 14  I  in  traumatic  neuroses.  Ibd. 

Meiiiii.'eal    leem.irrha-c   l".".' :   in  birth  pal-ies,  ;  .l/,,,//,//;/',.  -11  renal  e(,lie.  s-,i:i.  .       .       ,.   , 

Montreal   (General    lb.>.pilal.   autol'sies   111   diph-^ 
theria,  14:1;  in  tyi.lioid   fcver,  «;  .statistics,  of 


]irs.;. 
McL'alo-eel>haly.  lib'.. 
Meiilllucytcs,  7'.'S. 
M,<jii.4ric.,  47.">. 


'j;;8. 


Meninges,  affection  of.  Vcl. 


1108 


INDKX. 


circ, 


n,K.x  leslnn^  in  l."f>0  iwtorxlcs,  r,!V2;  ..f  .lyscn- 
trry,  I'.iii;  of  liinnorrliu-u'  hu.ii11-1".x,  t.^;  <■ 
,„.ommmm,  l".l  i  of  rh.muufu.   f.v.r,  I'm  ;  "t 

tvi'liiiiil  fi'vcr,  I!.  _   ^         _ 

M.mtrral  Mi.i.U-i'"X  'I'i'l'^"'^'  '"-"    "''    "'  '' ' 
Morbilli  Im'inor.-'uipi'i,  ^'7. 
Morbus,  oiiTiiifiis,  71-^. 
Morbus,  0OX.C  ..nibs,  -lol,  .lor,;  ..vn.ruin.  ..., 

IlllU'llloSUS,  sit. 

Morl)iis  nim'ulosiis  ncoiiiitni-uin,  six. 

Morphiiiliabit,  :M;  WvnUwM '^U  ■'"■'■ 

M.iri'liinisiii,  lis.l. 

Mnrpliin""""'i"<  "^'• 

.M(.rpbi|.i\,  1M'>.  .     .  .  . 

Mnrtiiiitv,  in  oH-cbro-si.iniil  mm.n-.tis.  lo,  .  i 

n.K.umonia,   1^1;    in    tv^bnia    frvr.    lo; 

wboo,>i..g->Mni«b,'.>4:  in  VC-U..W  l.v.r,  iss. 

Murtou's  painful  loot.  Hot'.. 

,)/«yci'((«"«  disfiw, '.iT.'>.  ^ 

M„..*(iuitoos,  rclulion  of,  t,.  fuaiia  diseas,..  .,.,1. 

Miitor  traot,  ilisi^a.-ii's  of,  '.i-J^. 

Mountain,   muvnua,    ^lOO ;    iVvcr,  04.1;   sirknc 

Moutli-lireatliinir,  ■1">4.  . 

Mouth,  aisoasfs  of,441;a>y,.llT;putna 

Moti,lo  kidney,  M2,  S4.; ;  dilatation  of  slouuu.l, 

in.  S4S. 
Movalilc  liviT,  ri4-J,  os". 
Muoous  colitis,  ri44. 
Mucous  liatcbcs,  •.;41. 
Mu;.'uct,44:j. 
Muitipb'  jiani-'i-cnr,  11^8. 
Multiple  sclerosis,  '.'M. 

Mumps,  90,  447.                                  ,•.    •  ,    u 
Munich,  reduction  of  typboal  niortabty  n>,  41 
Murmur,  in  aneurism,  VSO;  brum,  4.  .  ;  eanUo- 
r  spU-  torv,a08;  in  eblorosis,  Vt.4;  n.  con.en- 
,lhcart:aiscase,7«t>;/'//"^\T13;mendo- 
carditis,703;inlun,eavi,y,S0«;n.sul,cb.vum 
artery  in  phthisis,  ;iOS;  in  valvular  disease, 
^13,710,  7'iO,  7'.i3.  7'.i(i,  7-27.      

Musea  domestica,  37s  ;  M.  vouutona,  •>,  s. 
ile  callus  in  stcrno-mastoia  in  in.an,s,lu 

Muscle,  diseases  of,  n4S;de,cnera,>onot,m  I 

tvphoid  fever,  f2,  33.  ', 

Mus  ular  atrophy,  forms  of,  934;  hereduyn 

.,-,;V  atrophic  and  hypertrophic  vanct.es,  <..o,. , 
;„n;UleLn,93nuuvenilotypc.93^;i-- 
.rcssive  neural  lonn,  933  ;peroncaU>pc^.V._ 

Muscular  atrophy,  pro,rress>ye  central,  J.S,  M  ,  , 

hereditary  intluence  in,  9'29. 
Muscular  contractures  in  hysteria,  1114. 
Muscidar  dystrophies,  933. 

Muscular  exertion,  coma  after,  sr.9. 

Muscular  exertion  in  heart-disease,  .10,  .4d. 

Muscidar  rheumatism,  40i!.  ^ 

Musculo-si-iral  paralysis,  1070      ^ 

Musical  faculty,  loss  of,  in  aphasui,  .'Jl. 


Mu>iial  murmurs,  71i'',  7i''^. 
Mll-sel  poisoning,  3'.i;i. 
Mval>.'ia,4oil. 

Mvusthenia  gravis  pscudo-pandylica,  .'!.. 
My-cosis  intestinalis,  -J'.;'! ;  pubuommi.  ■^■^'•■ 
.Mycotic  gastritis,  iM- 
Myehemia,  &0'2.  _ 

Mvelitis,  acute,  97rt ;  acute   central,   .',.;  acut. 
■uansverse,U7«;  oon.pression,970;  n>  .ueaslcs, 
hs  ;  rellcxes  in,  97s  ;  transverse,  of  cervical  re- 
gi.m,  979  ;  syphilitic,  24.'.,  ■J4il. 
Myelocytes,  soil. 
Mvelogelious  Icuku'mia,  sO-J. 
M'viasis,  37«  ;  of  nostrils  and  of  ears,  3,  s  ;  of  va- 

I;ina,y7S;  cutaneuu.s.  3Ts;  interna,  3.  s. 
Mtoc^diti;  748;  acute  interstitial,  74s;tibnnis, 
U:  ;  in  rheumatism,  171  ;  segmenting,-!,  ,4    , 

in  tviihoid  fever,  21. 
Mvociirdium.  diseases  of.  74.;:_lesions  ul,  due  to 

aiscasc  of  coronary  aiterio,  i4ii. 
'  Myoeloiiia,  lloO. 
Myoclonics,  lloO. 
Mvoidciua,  30S. 

Mvoi.alhies,  the  primai-y.  933.         _ 
Myositis,  1148;  ossitieans  progressiva,  114.\ 
i  Myotonia,  1149;  congenita,  114'.'. 
;  Myotonic  reaction  of  AVi,  1119. 
:  Myriacbit,  lOs'.i. 
.Mytiloto.xin,  3',i3. 
!   Mvtiloloxisinus,  393. 

'  Myvedcnui,  s4o;  acute,  s42 :  congenital  lorn., 
840 ;  opcl-ativc,  842. 


in  typhoid  fever, 


Nails,  in  typhoid  fcve.-,  IS;  in  phthisis,  313. 
Nasal  diphtheria,  147. 
Naso-phai-yngcal  ..bstiuction.  4.-4. 
Neapolitan  fever.  21'.'. 
Neck,  cellulitis  of.  4r>0. 
Necrosis,  acute,  of  bone,  173  ; 

32. 
Necrosis  in  tubercle,  271. 
Ncn.atodes,  diseases  caused  by,  :3.-)2. 
Nephralgia,  llOi).  . 

Nephriti;,   8.9;    acute,    80!.;    alter    diphtluMia, 
150-  ehronie,  874;   ebrouic  lue.norrhagie,  s.o. 
Nephritis,    ehronie    interstitial.    877;    biemor- 
rha-'cs  in,  882;  i..ercased  tension  in,  S80;n.a- 

Pu-ial    -0',. :  relation  of  heart  hypertrophy  to, 
J-,';  "syphilitic,  250;  urine  in,  8s0;  vomiting 

NephriUs,  chronic  parenclnmatous,  875;    eon- 
^>cpniuu,  _       ,.,..,;,M.P.<    l."i9;     n  malaria, 

secutive,88tl;  in  e.-ysipcl,s,  lo, 

ooy  ;  in  scarlet  fever,  80  ;  ...  typhoid  lever.  31. 
NephHtis,  lymphomatous,  32;  suppu.-at.ve,  88.. 
Neph.-olithiiusis,  syl.  ,.„.,.,,,^m 

Nepbro-phthisis    (SCO    K.i,N.v,    'lrBr...e.i.oMs 

OF). 

Nephroptosis,  542.  s4ij. 
Ncphrorrbapby,  849. 


INDKX. 


\IM 


a,  f'  IT. 


1,  '.'I'T  ;  iic'Uti' 
»;  ill  iiuaMiH, 
)t'  ci'i'vu'ul  rr- 


r^,  r"^  ;  i)f  VII- 

I,  Tl^;  tibnnis, 
■iitiiij,', -l."^^"« 

ions  uf,  due  to 


sivii,  IHO. 


;ongt'liitul  form, 

.htliisis,  ni3. 
,Vl. 

II  tvi>liuiJ  tVver, 

,  1352. 

aCtor  diiilitiu'ria, 
liiviiinrrluitric,  "^T"). 
ill,  STT;  liiviiior- 
MMOii  in,  SSO;  nui- 
rt  liypertrophy  tn, 

in,  s>50;  vomitini? 

niatoUH,  ST5;  omi- 
i  I'lil ;  in  iiialai'iii, 
11  typlioiil  levur.  31. 
2;  suppurative,  S*". 


<EV,     TrUEUCl.I.I)SI3 


N(|iliriitiiiiiy,  ^■-'.). 

Ni'plin)-ty|iliu,.',  ;!1. 

.NiTVf  lll)ri's,  ii\llainin:iliiin  of,  lo;l. 

Nirvi'-riiol  sy  riiptcuiis,  •,!''>. 

••  Ncrv.  -nlorni.H,"  llui!. 

Norvi's,  iiiscii.<i's  oriicriplicral.  liini  ;  iliscasos  of 
ocri'liral,  lii:;s;  (.li>i'a>c^  n.'-pinal,  li'i;7. 

NiTVrs,  lesions  (p|'  iintiri'ir  rniral,  \t>~'d;  eiri'iiiii- 
tli'X,  I11711;  external  iioplileal,  1(i7l';  jiluleal, 
lti7'.';  internal  iin|plileal.  Iii7-J  ;  lorii:  tlioraeie, 
1070;  nieilian,  I1171  ;  inijseiilo-splral,  107(1; 
oliturator,    lo7ii;    seiatie,    lo7-J;   mii;iI|    seialie, 

l(i7-.i;  ulnar,  I071. 

Nervous  iliarrliiea,  .'lOii,  II 17. 

-Nervous  dyspeiisia,  I'.C 

.Nervo\is  system,  diseases  (if,  ',101  ;  diil'iiM',  ii.M. 

Nettle  rasli  isee  I'lcni'AiiiA  1. 

Neuralu'ia,  U'U;  eauses  of,  llol;  eervieip  lirii- 
eliial,  llo.'i;  eervieo-oei'ipital,  10(;7,  lln,");  in- 
thanee  of  malaria  in,  1104;  intereostal,  110,"); 
Imnliar,  lloi; ;  of  nerves  of  feet,  llnil;  plirenie, 
110;') ;  plantar,  lloi;;  red,  1  lii'.i ;  rellex  irrita- 
tion in,  IKU;  treatment  of,  II07;  trifaeial, 
lloA;  viseeral,  lloti. 

Neurustlieiiia.  ll-'.i;  sexual,  llJG;  trauinatie. 
11. •;■-'. 

Neuritis,  ln:il  :  arsenieal,  lo:l."i ;  faseians,  lo:VJ; 
interstitial,  lo;il  ;  of  infant..*,  proirn'ssive  inti'r- 
Htitial  liypertrojiliie,  iTil  ;  lipomatoiis,  l(i:;l  ; 
loeali/.ed,  10:11,  UDi'J;  pareiieliynuitons,  lo;;i  ; 
niultiiile,  lo:il,  Ui:j3;  aleoliolie,  103.1;  en- 
dernie,  :iJo,  lo:iI  ;  in  diplitlieria,  l.'d  ;  in  elironie 
plitlusis,  .'il'2;  in  the  iilfeetious  diseases,  l(t;!4; 
in  typhoid  fever,  'J'.);  reeurrinir,  lo:;.";  satur- 
nine, lo:;,');  traumatic,  lOiJ:;;  oplie,  lolo. 

Neuro|.'lioma,  Iol'm. 

Neuroma,  plexifiu'm,  10,17. 

Neuromata,  10:>7, 

Nenrose,s,  oeeupatioM,  1107;  traumatie.  llJii;, 

Neutrophiles,  sofi. 

New-born,  luemorrhasfic  diseases  of,  .sis. 

New  growths  in  tlie  bowel,  o".:!. 

Niifht-ldindiU'ss,  lOlO;  in  senrvy.  s-J-t, 

Nisrht-sweats  in  phthisis.  ;;oi; ;  treatment  of. 
337. 

Niijht-terrors.  4."i."i. 

Nipple,  PayeCs  disease  of,  3.'.0, 

Nits,  377. 

Noddini;  spasm.  10i;n, 

Nodes,  Hihirdi'ii'f,  4ol. 

Nodes, syinmetrieal,  in  eongenital  syjiliilis,  '^44. 

Nodules,  rlieumatie,  17'-'. 

Noma,  444;  in  searlet  fever.  S'i :  in  typhoid 
fever,  33,  3.-i. 

Norm(d)lasts,  794.  700. 

Nose,  bleedintj  from  (see  Kimst.vxis  1,  i!14. 

No.se,  diseases  of,  Dlo, 

Nummular  sputa  in  pbtliisis,  300, 

Nurse'.s  contracture  of  TrniisDctiu.  1110. 

73 


Nutmei;  liver,  ."..'i::, 
.Vyetalopia,  lolo;  in  seurvy,  •>H. 
.Nysta!,'miis,  I017;  iu  /■'/■/.  i//'. /. •//".<  ataxia, '.I'lO  ;  in 
insula]' selern.^is,  '..'.'.•;  uf  miners.  pi|T. 

<lliesit.\,  4:'.'.». 

(»liM.s>ion,  los;i, 

nbstruetioii  of  li.iwi'ls,  .'1:11  ;  aeiite,  ,'.;i  I  ;  .'hronie, 

i>."»."p. 
Mbturatiu-  nerve,  all'eetion.H  of,  PC-.'. 
Occipital  lobes,  tinnorH  ot',  lO-J:!. 
Oeeipito-cervieal  nein'al;,'ia,  I01I7,  llo.",. 
lleeupation  neuroses,  llo". 
Di'ular  [lalsies,  treatment  of,  lo."iO, 
Oeulo-motnr  paralysis,  reeurririL',  li'li'i. 
llilor,  in  small'iiox,  (is;  in  typlioid  fever,  IS, 
<KdeiMa,  aniiiii  nemMlie,  114o;  febrile  purpuric, 

.sld;  hereditary,  1141;  of  lmi};s,  (l:!(i  ;  ut' iiraiii, 

'.(','7  ;  in  unemia,  s()i;,  '.1117. 

•  Kdcmatoiis  laryn}.'itis,  017. 
0,r/,."ii  method  ill  obesity,  13!(,  7.'-. 

•  Ksopliatrcid  hrnif,  ii'A. 
<K>n|i|]iiL.'o-plctiro-cutanciius  li>tula,  4(12. 
<K>nphai.'ismus,  l.'ili. 

(KMiplunritis,  acute,  l."iS;  chronic,  4."0. 

iKsophau'lls,  diseases  of,  4."i.s ;  I'ancer  ot',  401; 
dilatations  of,  4i!2  ;  divcrtieida  of,  4(1'-';  luemor- 
rlia;.'!^  from  in  cirrhosis  of  liver,  .'.7'-;  [mralysis 
of.  4.")',l;  posl-miirtcm  diu'estion  ot',  4ij'j;  rup- 
ture of,  4(12;  spasm  of,  4.'i;i ;  stricture  of,  400; 
syphilis  of,  240;  tuberculosis  of,  31 S;  ulcera- 
tion of,  4.")0  ;  varices  of  veins,  in  cirrho.-^is  of 
liver,  .■)72. 

Oidium  albiciUis,  413. 

Olfactory  nerves  and  tracts,  diseases  of,  1()3S. 

Omentum,  tuberculous  tumor  of,  2s7  ;  tumor  of, 
in  cancer  of  the  peritonaum,  tiOi'). 

Omodyiiia,  407. 

Onomatomania,  loso. 

Onychia,  in  arthritis  deformans,  402;  in  loco- 
motor ataxia,  02.'i ;  .syphilitic.  241,  21;!. 

Operation  j/'i/'  .w,  etleets  of,  in  e[iilepsy,  1101. 

Operation,  tuberculosis  after,  270, 

0[ihthalniia,  irmiorrlio'al,  with  arthritis,  173. 

Ophtlialmoph'u'ia,  042,  10411;  externa,  lo4:i;  in- 
terna, 1040. 

Oliisthotonos,  cervical,  in  infants,  ;i57 ;  in  teta- 
nus, 232. 

Opium,  poisoniiiL',  diagnosis  from  tira'inia,  SOH ; 
hal)it,  3S4;  smoking,  elVccts  of,  3s4. 

Optic  ncrvu  atrophy,  1041;  hereditary,  1041; 
primary,  1041;  sceoiuhu'y,  PUl  ;  iu  tabes, 
022. 

Optic  nerve  and  tract,  diseases  of,  103!i. 

Optic  neuritis,  1010;  in  idisccss  of  brain,  102() ; 
in  brain-tunjor,  lo21  ;  in  tulierculous  menin- 
gitis, 27.S. 

Orchitis,  in  innlariu,  217;  in  tnmnps,  01;  inter- 
stitial, in  syi)hili.s,  2.j1  ;  in  typlioid  l'i:\i:r,  3'_' ; 


IN'DKX. 


1170 

vuliu'of,  ill  aiiii.'U"xi''.  ■'•■■"• 
(inlictuii.is.  ill '>■'»">"*• -■''-• 
Osteitis  >U:l'..nmiiis,  nil.  ,.,,i,,,uimrv 

Oslo..-iii-thnt-"''>-     li.M""'"!''"'       1 

ori„,.aiti.>ii..u,iin,.,i;--u..u,uUsn.n^ 

IVvor,  M  ;  ill  MHi'i'i'-'""''  W". 
(»varir.stulu'ivul...isot.:V^'".. 
„,,,.......r.i..i..lu.m-tatV.rti.'"«'l>'"<""'''- 

,„,laU.MMinu.>'>il.'uli>^^'''-^-  | 

,Ky^'..M,i.ilmlatiHMsut,maKa..tu..,Mm,.  , 

[iiivuiiionla.  l'''V- 
Oxyuris  vi'i-iirunilaris.  "'"'i^- 

''^^''•^''''"'''i:'i!v' •;;;;:;  la  ,yi.hoia.vv..i-,  IV 

OystiTM""^"""'-  ">• 
Ozii'iia,  tU'J. 


I'a.-liynicniiii/Hi'^-  OM.  ,, ,,,„,,,,,,,,i,i,,.,  V^n, 

l>alate,tulHToul'^sisM\  "IS. 

I'liiinaile  liiaiH'.v,  sl'i.  ^^ 

I'iilmtatloli  "1' I"'"'''-  Vm',  ,,.^   ,nr 

l,a'ic.s,.orc.i,ral,ul'.lniaivm'.'..Mni.- 

I'alsy,  Icaa.  :^'^-  ww-,.  i  •'!'" 

'-'-">^-":;i;:,!;::r^^;,r;i::u;a:;.s..wi:..^ 
''';:r^;:::-';;;::„„.ha,.  i.u..,  -«^  < -  ■"• 

r)'.i4. 

'''""'■'"':;'"aWr^s''^S;"aial.etc..,  422;  calculi, 
•'"''■     ,•,-,■    .unite  l.aM.inrrluvy.c,  r,s;. ;  chronic, 

smiinualivc,  M"^- 
rantophol/ui.  U'.i-l- 

;;«:--^-." > •" "-'■■ -; 

'j49.  I 

l-ura-cusi..  1>»'.0.  ,,„-,..  aeutc  spinal,  of 

Paralysis,  ucuto  "-■'■'"^' l'."  ,.'     ,    M4-i  •   au'itans. 

"  '         :X      o:U;  aiucsthcria,  lO^n;  as- 

l^^^^^"''}'"'%t:'.CT     olchi^il-lexus, 
WaJJ-'"'"'      ";.:'.,-  euvunitlcx  nerve. 


•    ,  ...ih.nsv    VW;   of  facial  nerve,  IfM  ;  <>f 

,.vn,r..ar  WJ;   l.<ii,.lr!/\  l'^";  "'  l""^ 
L' I'sso-lary  iik'cai,  •'"'-•  ,      ,,     .  ,.^    imn  ■ 

,         i,„.t„rs    10,11;  (if  iia.hictors,  II", I. 

• 'T      "       W  ":s    .:i7;  fi-o".  1^"J.  '■■^'■^  '" 
'"   '""■'■"  .'-  .    ,    Ion.'  tl.oracie  nerve, 

l'-""»"^  '""""•  :^'-U::.f  median  nerve. 

^"■"-'"""■■""T     ;,;;>ai     vel070;ofoeulo- 
1071  ;  of  iiiusculo-spiial  luiM,  '    i 

rophv.SillO;  radial,  1070 ;  of  recinn.iu 

r  •     ,-"  •  of  recurrent  laryni-'eal  nerve,  lOM 
;:::;Ji:ryt':isecral  disease,  ;oJ2;  of  SIX,. 

nerve,   io,s;..ftliii^l";'rv|;.; ''•'>''' 
la.rve,  1071;  of  vocal  co,-ds,10..1. 

I'araniyoc'loiuis  multiplex,  ll'''^- 

I'arapliasia,  W^- 

Paraplc^'i.l  ilii^'lii-'.  •'■'>•  ,„,,,•„.,  ft4S  ;  from 

I'aiwlc'la.  from  alcohol.  H^-- 1  ■  '"•'^"  '  '      • 

lnuofspinalcora.'.H;.i;tVoM.  con.prcs      1 

ra,V70    tVo„iha.inorrha.e,>.toe,,ra       «, 

;;lUiU.ry.^.rnio040;hyste,..       41,    m^ 

,,,a,hyrisn,,:.i4;<r..i.n.      2a'::r:h.llis. 
In.rra    IV.'o;    spastic,   '.'■•i  ,    spa.  u.  i 
l;;;;:;;yphmti;.,04o;  from  tumor  o.  the  cora. 

074;  in  tahes,  '.12.'.. 
Parasites,  aiseases  due  to  annual, -4.'. 

l'arasitief:astritis,4t;ii. 
I'arasitie  stomatitis,  4  n. 
Parasyphilitie  utleetions,  242.  UM 
..l.„.,,nncntcracklintr'-ii.ncUets,4n,.. 

Panncliymatous  nephritis,  s,..  ^ 

p,,-„,,„-;ccipital  repon,  brain  tmnors  m.  10... 

••  Paris  L'reen."p"i'-""'"^-; ''>■'"'"'• 
/',,)■/(•(•«.<""'•■•■  •li'^easc.  lo7«. 
Parosmia,  loiis. 

Parotia  bubo  447.  .,„„^  •„,,,,,;  adiriun. 

Parotitis.epiaennc,W,a(.i1ii  . 
•„.,  1,1;  chronic,  417;  orchu.s. 11,  Jl.-!^ 

•i'*'-  ,.      , ,- .  ,iCi,  rabaonruial  sec- 

Pan.ti.is,symptoma.ic^,.aM  ^      ^,^^^_,_ 

tion,447;  Inpn.muoma.l-.  i" '- 1 

•>:',■  in  tvphus  fevir.  ■'-■ 

Paroxysmal  ha^nio^rlol'ii""-'"'  -''•'• 

p.irrot'K  ulcers,  44:'.. 

I'arrv's  aisea.se,  f>:''i. 
|Pate"lhir-tendonrctlex^sccKNKK-Jr.uK.. 

Pathophobia,  1124. 


Pediculosis.  S7''.  ^. 

P...liculus  capitis,  n7r,;r.  corporis,  ri,,. 

Pi.iiomata,  17.  .  ,     . 

P,liosisrhem.iatica,M.V,  1.1  chorea,  10.... 

PoUa^mi.  :V,'.5.  c/  n,.  PyfUTIp) 

P,lvis  of  Uidney,  affections  of  (se.  1  ^  kl.ti. 


LNMKX. 


IITI 


lor.l ;  of 
'47  ;  li^n- 
isal  luTvo, 
\->  ;   labio- 
C;  of  Inr 
torn,  10<a ; 
J,  !..«S;  in 
i\c"k'  lu'rvo, 
iliim  luTVi'. 
i;  (if  ooulii- 
orvr,  Wi-^- 
,usouU\r  iit- 
111,  ill  inVL- 

■J;    of    si\tll 

i; ;  uf  iiliuir 


ic,  !t4S ;  from 
(•(impri'SMi'M 

iti)  oiivil,  '■"'>'^; 
111. '.111,1114  I 

.  'jTT  ;  ill  1"'^- 
.,1  ci'i-L'tinil'is. 
•  (if  tlio  o(ir.l. 

I'.i. 


lors  in,  H'--- 


in.  i'l  ;  dflii'i'i"' 
ill.  'Jl  ;  siifcili''. 

r  iilKlniniiialsei'- 
.u  tyiihoiJ  fi;vi.'r, 


i>jr.uK '. 

,i,.hc  lilcuiitrc.  \>' 

mris,  3TV. 
hiiroa,  li>r). 
(see  I'YELiTipi. 


I'i'iiii0iii.'"i'i  |iiiri)iirn.  ^^W  \ 

l'ciii|ilii),'iis  iic.iimtdniiM,  'Jl'J. 

IViilujitdiiiis.  "iT.'i. 

IVptic  iili'ir,  47'*;  dyhpciwiii  in,  4sl  ;  liirmnr- 
rliujfu  in.  4'^1  ;  pniii  in,  4>>1  ;  IiikIiIiusm  on 
lil-('«sur«  in,  4''-. 

rcptdnci'  in  tlic  nrini',  *"i7. 

I'lTliiralin^'  ulcer  of  l'"'!  in  tabes, '.i'j."i ;  in  ilia- 
lielcs,  4 'J."!. 

rei-f(irati(iii  "f  Im.wcI  in  .lysenlery,  '.'ihi;  in  tv- 
plidiil  fever,  in,  'd't. 

I'eriarteriti.s  j:uniniat(iUM,  'J.'.n;  n.i.lnsa,  7><\ 

I'ericardial  frietion,  tl'.Hi. 

IVriftirditis,  iiss  ;  aeuto  pliistio,  iMi ;  aplninia  in, 
r,\\2\  elironie  ii.llieMVc,  li'.ii; ;  delirinin  in.  OH-J; 
(lyspliiii.'ia  in.''''.'-;  epidemics  (if. ''iS'.t;  epilepsy 

ill,  r,'.i;l;  fi 1  extension  of  disease.  i'i>^'J:  from 

f(ireit;n  body,  'IhS;  in  eliorea.  1"^4;  in  f(etus. 
CS'.l;  in  trout,  41.");  in  rhenmatism.  171;  lueni- 
orrlia^rie, 'li'ii;  liyperpyrexia  in, 'H'O,  t'lfi ;  men- 
tal .symptoms  in,  <'>'.':;;  primary,  'Jss;  pulsus 
puradoxus  in,  O'.'-J  ;  s(.eoiidary,  Ds-^ ;  uitli  ell'u- 
nion,  t'l'.'l. 

reri(.ardiuiii.  adiieriiit. ''.'.ii'i;   Fri,  >!r'/r/i'n  sIltii  in, 

()'J7. 

rerieardiuiii.  dis(.as(.s  of,  ''.>■>;  tiiliereulosis  of, 
'JS.'i;  air  in.  'I'.'s. 

IVriolioiulritis.  Uiryn^'eal.  in  typlioid  levi.r,  'J7 ; 
in  tuberculosis,  till). 

I'eriliepatitis,  .''iT.').  'HI.". 

I'erinepliric  absee.ss,  t'OO. 

rerinuclear  basopliilii^  uratiules,  410. 

reriodioal  paralysis,  ll.'iii. 

Periosteal  cacliexia.  >^'J.'i. 

Teriplieral  neuritis,  lii:;i. 

reristaltie  unrest,  4',is.  1117. 

I'eritona'Um,  diseases  ol',  ."I'.M'i. 

J'eritoiiieum,  tluid  in.  i!ii."«.  'Jo'.':  cancer  of.  f'.ot; 
new  {jrrowtbs  in,  t'i04. 

reritoiiu'um,  tuberculosis  of,  'J;<i'i. 

l'erilon',Pui:i,  tumor  foniiutions  in  tuberculosis  of, 
2(s7. 

I'eritonitis,  neiitc  fjerieral,  :>22.  .'i'jri,  ."iOi) ;  appen- 
dicular, T)-''!,  tifJ ;  chronic,  tlO-2;  chronic  hiem- 
orrliairic,  '104 ;  dilfusc  adliesive,  'iOi! ;  hys- 
terical, .'Ji''.';  idiopathic,  .'i!") ;  in  infan'ts,  (iOO ; 
in  typhoid  fever.  'Jil;  IcuUa.iuii'.  So,"i;  local  ad- 
liesive, liO-.';  localized,  "cjii,  I'.OiV  pelvic.  102 ; 
]icrforativc,  .'>'.tti;  primary,  .'iiiri;  proliferative. 
(io;i;  pyicniic,  5'ja  ;  rliomnatie,  .'Oi! ;  secondary, 
oOC ;  septic,  5'Jti ;  subphrenic.  'iOO  ;  tuberculous. 
'280,  0(14. 

I'eritonitis,  tuberculous,  effects  of  operation  on. 
fiOH. 

Perityphlitis.  ,519. 

"  I'crlcs  "  of  l.di  niiei',  firiO. 

Pernicious  anaMuia.  7i'."). 

Pernicious  malaria.  '.'o7.  \i\^i. 

I'croneul  type  of  muscular  atrophy,  ',)3.'3. 


Pertussis  (see  Wiiooi.iN(i-cor(.ii  \  '.>2. 
Pesta  nia;.'lia.  .'ii'i. 

Pestis  minor,  I'.'l  ;  major.  I'.'l  ;  sid.rans.  lid. 
Petechia'  ill  epilepsy.  lo'.i7  ;  in  relapsiiiv'  fever. 
M;  in  Hcnrvy,  sj'i;   in  sriiall-pox,  ''•.!;  in  Ij 
pliiiH  fever,  .'il. 

Petechial  fever,  lol. 

I'ctit  null,  lo'.'t.  lo;i7;  in  i.'ciier;il  paresis,  '.itVJ. 

/'(i/ir'n  patches  in  typhoid  te\ir,  s;  in  mciuHles. 
hi'i;  in  tuberculosis,  .".r.i. 

Plia;.'(ieytosis  ill  erysipelas,  l.'i-;  in  malaria,  '.io7 : 
in  tuberculosis,  ■.;71. 

I'liaryn^litis.  4  1^  ;  acute,  4  l-- ;  chronic,  44',' ;  sicca, 
41',i. 

I'harynx,  acute  infectious  |ililei;iiion  of,  iUi; 
lm.iiiorrlia;re  into,  44s;  hypeiiemia  ol',  44s; 
(edema  of,  .44.^;  paralysis  of,  li.'''io;  spasm  ol, 
lodl  ;  tuberculosis  of,  ols  ;  ulceration  of,  44','. 

Pharynx,  diseii.ses  of,  44s. 

I'liiladclphia  Hospital,  rclapsiii;.'  fever  at.  in  1W44, 
.■';i:  typhoid  and  typhus  fcvcr  at,  -J;  typhus 
(pidemic  in  lss:l,  -I'.i;  ntnli^ticn  of  cerebro- 
spinal fever,  1"4  ;  of  delirium  tremeii.s  in,  an,';. 

Philailelphia  Inlirmary  for  Nervous  JUseases, 
.•.fa/iflici  !>(  rhiirvu.,  lo7'.' ;  of  epilepsy,  lo'.t4. 

I'hiludelphiii,  ti'bereulosis  In  city  wards,  ;iil(', ; 
yellow-feV(  r  epidemic  iu  17'.'o)  fbi'. 

Plilebitis  of  portal  Vein.  ."'77. 

Plilcbo-sclerosis.  77.'!. 

I'hosphatcs,  alkaline.  hi'.J  ;  earthy,  eilii. 

I'liosphatic  cali'iili,  s'.l2. 

Pliosphaturia,  si'i'-'. 

Pliosjihorus  poi.sonin!r.  similarity  ol'  ac.ute  yel- 
low atrophy  to.  .'i.'iit. 

Phrenic  nerve,  utl'ections  of.  loi'.s. 

Phthiriasis.  .'17fi. 

Phthiriiis  pubis.  .'^77. 

Phthisical  I'ramc.  Jfi/i/ifrrnf-s''  description  of, 
;!(;.s. 

Phthisis,  '_'s',t ;  chronic  ulccralivc,  'SJl;  acute 
pneumonic,  'JSO ;  arteiio-sclerosis  in.  Slli; 
luisic  form  of,  SOS;  15rij;ht"s  disease  in.  .112; 
of  coal-miners,  'JilO,  ('i"cj ;  ehronic  artliritis  in, 
.•im;  cou<rh  in,  SOO  ;  endocarditis  in, 'J!i'<.  nio  ; 
diajinosis  of,  .'31.'?;  distribution  of  lesions  in, 
'-".'4;  erysipelas  in,  Hl.'i  :  fatal  luemorrha(re  ill. 
.■117  ;  fever  in,  .'!04 :  forms  ol' cavities  ill,  '2'm:  ; 
ffastrio  sym]itoius  ot".  "'11;  luemoptysis  in, 
.102;  modes  of  death  in.  .".17;  modes  of  onset 
in.  2its ;  physical  siL'ns  of  .".Oil;  pneumoniii 
in.  .11.');  relation  of  ti-tula  in  ano  to.  ;i'.i(i ; 
fputum  in,  ."ioo ;  simimary  of  lesions  in.  2!'."); 
ty|)lioid  fever  in,  .'51") ;  voniitini;  in.  311. 

Phthisi.s,  liliroid.  ".14.  Dl',':  Horida,  2','-i ;  renum, 
.'i24;  syphilitic,  247:  of  stono-cutters,  20'J, 
(ir)'2  ;  unity  of.  272  ;  vi  ntriculi,  4'''7. 

Pliysiolotrical  albuminuria,  h.")."i. 

Pia  mater,  diseases  of.  ',i.")4. 
I  Picric-acid  test  tor  albumin,  857. 


^^ 


INDKX. 


117-2 


■   1.,,.   ,l;i,',  •  iMi>i"iitli  I'Viilli 

i"  •'''■''"""" '^'•n''iu.-' -'^^''^ 

l>',,.,UU'Htlltioll  Ol  VW'Tl)  .11  \ 

I'lj;*,  tiilxTi'iil'"*'*'"' -"'^' 

I'lii-woriiiH,  ;i.''ii.  „„„,,,,,VH  to  i.rov.'iit.  I'm  • 

ti.HMl,  ll>-l'      , 

I'ltj-rluHis  viT^i''"!'""'  •H->. 
I'lil^UO,  I'lil"'"'"'-''^''- 

IMii.HU'-'.i"""^''*'""^'-'- 
I'lust'u-  \.roiii'liiti>«,  '•.:••:!• 


...iv.  f.v.'. « !  1-"";:' "      ,     1 ..ii-».  !■». 


"     ,  ..A.   .ru.lM.'O...Ml«    l.II.'Uinnlllll'.    uo, 

"'"'"""' 11-'  vs:;  iVv.T  of,  mi; 

•„    I'lip  Lmiv  lu'pulizi'ti""  111.   l>''' 

nl      i-''»   ****    m  I '"  .  1  Ml)  .   trim- 

;!^:r.:.,hitinnut;n:i;t.'M''"""'"'l''- ''"'"' 

^■"'■""!""'  ;„    L^iiou  or  a..,u..iUon.  i;.|^; 

...ntral,  l-^'i;"''"f'^''"'''    '""  '  „^    ,;,o;  contu- 

-■"•r-^t  :^^;■'^^-«='^^^" '- 

^-'••'''''■'"'r:  il  t-tl.uroot,  iuHyi.liUis 
"'''-''■■'VT  Vvc.r'.T;Uirv«l,V.7;W-ar, 
217;  in  t:!''""''  '':.,„•    1"0;  rLuro^ro- 

1-^ -^:;ri.:":^!:;.:™uo;i,\.H;- 

-•r'''^\!"'':;,.ol'.."uilu.niu,l.T;vvl.Uo. 
oiKliiry,  1-1  ,  i>l'»"'     I 
ofllic  foUix,  ••il'- 


-:i:;:;r:;;=:™=» -*«— 

Pleurisy,  ac-i.lc.  Ol,.> ,  •"''>  f  .  ,^,,,„,„^r,  ,174 ; 
■'"  *^:''';:  .  Xuria  r-Lon  in,  luO;  vn^..i- 
,  J^Tculous,  -'.^i,  *>M>  «■'; 


I'lST ; 


I'liriminiinlionioMS, 'ir.'-'. 
l>,u.uino-l-ri.ar.Hnin,  WS. 
l-,u'Uioo-lH'rit..iuwi>", •'•"<• 

l'"^""""-[''"t''S".     „rt(.r    ,n..l,..oto:My, 
•'T'''       "•         r-ti«.uo,..,ssionin,0H3; 

•''ZlS".7     •'■oiniuu.uUir.t.WrcCHl. 

I'nrimiotoxiii,  U'.i. 
I'lR'Uino-tyW'"''''^' "'*■ 


,ub>.rculous,^iS4,0i>'.,'.i'S-  .  a  Poauu'ru.40.. 

in.urisy,  oliroui...  '-■< '.  >"•>■'  ■'  ^'Z'         ,•„,  ,,•.     l>o,lo,lynm.  HO 
,.-,1 .  vaso-i....tnr  i.lu.nouicnu  m,        -  i-„iUilo..vtusis,  .  M.  ,  ■  ■  ■ 


fusion,  67  S. 
I'U'urodynia.  4fV. 

mcuro-veritnuoul  tuU^roulos  s.  -vl. 
I'li'urotliotonos  in  trtiuiiis.  -i- 
I'lcxiforin  nouroinii.  1"'''7- 

VVu'ii  polonieii,  3T7.  ^  of 

nun.bisin,SSG;una.ou     4S     I. 

,enuUirrhosKS7Ty-J^--^^^ 
Tlyniouth.  cTiaoniio  ot  tyi-uoia 

I'lu'unmtosix,  4',i'.t. 

I'lifinmiturift,  I'^l.  «'•*•     _ 

I'ncumo-astric  luinv,  Ulii-.  ^,_^_.^j;^^^. 

Vn-.'n^'-^---":ri..op..,.ea>| 

bnmolifs  ot,  10i..i ,  i."-y    r.  _    „uliiu.nary 

,,luirynL'c'u\  l>rancho.    ot,    lOl.u ,    i  | 

lirant'lifs  of.  101)3.  ^^^^^^    ^^^^   „bsoi'ss   in, 

Pneumonia,  uoute  oro.ipo  -..^  '  (ipninimonic 
^30;  acute  ^l"^'';""'';. '':'.,,  ^'.r, ;  clinical  varie- 
serumin,13r.;  bleca,n-  m.  u  ^^^^^    ._ 

tie.  of,  12«;ooii.i.,  croupous. n     1  1^^_ 

oationsof,l'23;cnsi*m,ll.,J''l''> 


PoiUiloc.ytusis,  ..■.  ..•■  ,,^,,.  ,,y  „„„,„ 

Poisoninir,  iiy  loo'l,  •>•"  .  ' .) 

„„;.,„.»  or,  .Hi  »."»i«"»:"";f;,„ 

r,I,„,:,.,,.iif«»»*"|"» "■■'-■ 

Polyaacnoiiuitii'^'''*- 

p„lyiciuia.  M)».  rccurrens, 

Polyneuritis,    acute    ttbriu, 

1033. 

Polvi>lin!-'in.  ■*-'•'• 

Polysarcia,43;..  __^^^,^^_„,_ 

K- r  :::i'i-^-'>  ^^ rM-;^-^-- 

p,:;:;:;"lo^"^4;tu,non,o^m«-    _^ 

i   P„,aitcal  nerve,  external,  10.-,"" 

1  Porencephalus.  IM".  _  r,r..  suiipura- 

Portal  vein.  5o4;  thrombosis  oi,  o.4 ,      U 

tiou  in,  ""**• 


1NI»KX. 


11T'{ 


llHllllll'll"* 
llliU',     II"  i 

,1'  UmtJ  in. 
T  of,  nil; 
n  ill.  n:i; 

\-> ;  ill  il'ui- 
iii'ir/.a,  1-''  '. 
;  iiiortiility 
lii-iTi^i!*  ill, 
;  ri'i'iirriiu'i' 

;  ri'llll""'   •"• 
,,  i;i2;  truii- 

IIJICX  I'licu- 
ut'ilioii,  '■' I-  '- 
Dii'n'  illU•r^li- 

llSO;  .'(lilt  11- 
>\i  ;  cliiiU'liiii'i 


;;!,■) ;  m  n 


Ullll- 


,  in  h.vi'liili^ 
,1,  127;  l"i'"'-. 
'^(j;  iiU'uroj;c- 
,ti(.ii,lW:  >"•'•- 
iu,  1-" 


wh'ilo 


i-licot<>:iiy,  ''•''?  ; 
inissidii  il>.  '''**•'■' 
At  I'tViirt,  OSl. 


ui,  ;isi'> ;  I'y  ""'"'' 

„ti.,iniuUiUs,'.H«_. 
ij.jo  ;  i.jiiileiuii-'S  of, 
d  iiimtoiiiy  of,y-i3; 

:.  of,  '.113. 

,ni,  y^s,  yu. 


1033 ;    rci'urreiiM, 


,Mms>,  432. 
or.s-l3'i;mliy«<^''-">- 

s  of,  10'23. 

17.J ;  intoriuil,  107-J. 

.U  of,  S54;  s'livimiM- 


rH,|-c'iiilii'li>'  syiiii'loTMH,  lo:C, 

|'..M-hrliii|.ln.'ir    .lioivil,    lol',';    .■[■iUl-N,    lo'.'.'. 

l(i'.i-i;  iikovi'iiicritK,  lol'.i. 
|'i.>l   lliorlclll  lliovi'lllrllt-*  ill  I'liolil-ll  l""lii-,  IT--. 
l'ipRt-plniivii!.'i-nl  iili.><iM'!<.-i,  .(.'.u. 
IVwt  IN  iilioiii.aiiii'ioiii,  I'.';  fliviilinn^"f  Iniii'ira- 

tiiiv,  in. 
/1.^/V  ilim'ii.ii',  '.i"o. 

I'nv.'miiic'.v,  mi.l  iiciitr  yll'W  atroplis,  .V.l  ;  iiikI 
cliorni,    loso;    lui.l    lifml-ili.ti'asr,    V'JH;    iiii'l 
[.litliisis,  :;-J'.i;  iiii'l  l.^i'lioid  iVvcr,  ;i.'). 
I'ri'.^yslolic  iiiiiniiur,  7--'>. 
rriiipUiM  in  Iciilui'iiiiii.  ^o;,.  ^ 

I'lii'kly  lirat  (sw  ririMAiiiA '. 
I'niccs.sinri  ratcrpiUiir.  rlln'l.i  of,  ;'.7'.i. 
I'rofr.tsioiial  spasms,  II07. 
I'roj,'lotti»  of  ta'iiia,  'M''. 
l'roj.'n'Ssivr  imisfiilai-  atropliy,  'J-Js. 
rr(i;.'rii.ssivii   piTiiii'ioii:.  aiiainia,   7'.i.'i;  M'""!  i". 

7'.C. 
rn))iliylaxis.a'.'aiiist  I'liolrra,  l^o;  a;.'aiM-t s.^iirvy, 

S'JI;  Hijiiiiist  tiilii'iTulosis,  ;i:'.o;  au'aiii!*!,  ta  nia. 

;!il7  ;   ajjaiiist   tricliiiia,   ■'■'<'.>[   ii,\'aitist   typhoid 

fi'vcr,  -n  ;  airiiiiist  yellow  fuvcr.  l^s. 
rrosopal;;iii,  1 1".''. 
I'rostiltc,  tulie'ivulosis  of,  :vj(l. 
I'roto/.oii,  (lisciisi's  fiiiLsi'il  l>y,  3  r.i ;  pani>iti>',  iM'.i. 
rniiR-juico  expi.'ctoratii>ii,  Mi. 
rniriiro,  ill  llaittjL-iu'K  disease,  si  J. 
I'niritus  in  dialiftos,  4^."! ;  in  ui-n'iiiia.M'u  ;  in  oli- 

Ktructivc   jaundice,    ."iH';     in     f,'oiit,    \\:<\    m 

dnivcii'  disease,  s3'.i. 
l'sciido-aii^!ilia  jieetoris,  7ii3,  lll.s. 
IVeudo-apopleotie   seizures   in  fatty  lieart,  7.'il  : 

with  slow  pulse,  7i'pO. 
I'.seudo-hiliury  eolie,  MA. 
I'seudo-hulbar  paralysis,  V.Vl. 
I'seuilo-oavernous  si.L'iis,  3o'.i,  i;7o,  (17.">. 
i'seudo-oyesis,  1114. 
I'seililo-diphtheria,  1 1-'. 
I'sc'udo-hydropholiia,  '.i^lo. 
l's('udo-leulv«'iiiia,  Koll. 
rseiido-lipoiiia,  siipraelavieiilar.  Ml. 
I'seildo-ptosis,  lOlii. 
I'seildo-scleroso  en  plai|ues.  '.m'jO. 
I'seudo-tubereulosis  Imruinis  sireptothrii'a,  'Ji'iJ. 
I'silosis,  .->11. 
I'.soriusis,  Ime.eal,  -lli''. 
r.sorospenniitsis.  Hl'.t. 
I'tosis,  forms  of,  IdH'. ;  hysUrieal,  loll',;  in  ataxia. 

U^2;  p.seudo-,  lolii. 
I'tyalisiii,  411,  44(1. 
I'uberty,  barUinir  eoiitrh  of,  1117. 
I'ulex,  irritans,  377  ;  iieiietraiis,  37\ 
I'ulinonal-cerebral  nbsecsses,  loj.'i. 
I'uhiionary  (see  LiNost. 
I'uliiionary  ajioplexy,  li3S. 

I'ulnionary  artery,  selerosis  of,  773 :  perforation 
of,  7.'3i!. 


rulmoniiry  haMiiorrha^'e,  i;:,7. 
I'uliiionary   orillee,  eonjirniial    hsioiis  of,  7'''7 ; 
tuberi'iilosis  ill,  .ill'.,  7i'p7  ;  valve,  IikIoms  of,  7'.;7. 
I'lilinonary      ostei.  arthropathy,      hy  pertrophii-, 

1141. 
I'uNatinu'  pleurisy,  (;7'J. 
I'lilsatioii,  dyiiainie,  of  aorta,  7*2. 
I'ulse,  alternate,  7.'i7  ;  aliastoiiiotii',  771 ;  dierotie, 
13,  yo;  under   inllueliee   of  di^ritdis,   73'.i ;  ill 
terinitteiit,    7'i7  ;    irri'],'iilar,    7.'i7  ;    bi;.'eniirial. 
7.-i7  ;  reeurreiit,  774  ;  tri;.'eiuiiial,  7.'7. 
I'lilse,  eapiUury  (hih)  Uai'iliakv  i  ;  ('un-lij>in,1\  I ; 

water-liatiiiiier,  714. 
I'ulse,  slow,   ill   tiiliereiilMUs  iiieniii(.'itls, '.;7'.i ;  in 

jaiilldiee,  .MVI  1  sei'  liliAi  II VIAIIOIA.  7.'i'.i  >. 
I'ulsiis  paradoxus,  (i'.ej,  iiii-,  7,'ii;. 
I'lipil,  .iriji/ll  1,'alii  rtmii,  in;-.',  1047. 
I'upillary  inaetion,  lieiiiiopie,  I044. 
Pupils,  uiieipial,  1047  ;  ill  neneral  paresi»,  '.M'.'J. 
I'urpura,  h14  ;    artliritie,    Hl.'i ;    eaeheetie,    Ml; 

fidiniin ,  ^!7;  //(HocA'i,  hlO;  infeetiouH,  S14  ; 

iiieehanieul,  Hi") ;  neurotio,  HI.''> ;  pidiosin  rlieii 

inatiea  in,  Hl.'i;  liie rrhat'iea,  «ltl ;  peiiiphi- 

(.'oid,  hl.'i;    simplex,  M.'i;    syiiiptomiitie,   Ml; 
loxie,  H14;  urtiealis,  Si,"  ;  variolnsa,  ij'-'. 
I'urpuric  ii'dema,  slil. 
I'ustule,  inidiijnaiit,  'J-.">. 
I'lilrid  sore  iiioiith,  4  I'J. 
I'yu'inia,     103;    arterial,   7o."> ;    idiopatliie,    lii:i; 

poHt-typlioiil,  3.3. 
I'yieinie  abscess  of  liver,  .'■i7'.i.  .'i^". 
I'yiditis.  ssn  ;  intermittent   tVver  in,  sss  ;  pyuria 

in.  ,ss7  ;  in  typhoid  fever,  3;;. 
I'yeloncphritis,  s-^ii. 
Pylephlebitis  adliesiva,  ,'p.'>4. 
ryleiihlebilis.    in    dysentery,   -Joo ;    in    i>ya'mia, 

U>4  ;  suppurative,  .'■|."i.''i.  .')7s. 
I'ylorus,  hypertrophic  steinpsis  ipf.  4:i4  ;  e.pn<.'eni- 
lal  hypertroiiliy  of,  Hi|  ;  iiiMillieieiicy  of,  .M'O  ; 
spasm  of,  40'J. 
I'yoiieiihrosis,  SSCi, 
I'yo-pneumothorax,  '2^,5,  tlsl. 
I'yo-pneumothorax  subphrenicus,  471',  (ii-d,  «s;!. 
I'yuria,  s.'iS;  in  tyiplippid  fever,  11,  :•-. 

(Quarantine   ii;.'aii!st   yelhpw    fever,   !^S;    aj'aiii^t 

eholera,  ISO. 
Quartan  ajriie,  -'13. 
(Juinrkt^x  lumbar  pimcturi'.  lo7,  'J.'i'). 
Quininit  rash.  77,  S3. 
(Quinsy  (see  Tonsillitis,  Suti  itATivBi. 
(Quotidian  a;;ue,  'Jb'.. 

Rabies,  'J-7. 
Kaoliitio  bones,  434. 
Kaehilis  (seo  HieKKTs),434. 
Kadial  paralysis,  1070. 
Ka^'-pioker's  diseiwe,  2'Ji;. 
Hallway  brain,  1132. 


1174 


INDKX. 


Kliiibditis  Nioll)-i,ni',1. 
Klml"lo-niv.Mnii(.rU\.lnoy.  silrt. 


Uiv.i ;  mill 


lUsyWny  ton^'^u■  in  s.urlot  t.'vrr,  . 
Kiiy-fu'll,""^  (artil.niuyoe'S),  -^-V^'. 

Boleroderiim,  U« ;  cinl^psy  m, 

globimirin  in,  U'!><- 
U:;u.uouoalo,m,o™tion.^n.,lo,.,J-t. 
KoorucU.soonooonVv..rinty,.l.o.,lK'SU,l>. 

U(rtal  orisi'S  in  tabes,  '.fJl. 
U..tu^^ivrital<U^lUs:st^...uvoo,,.4.^^^^b 

ilis  :ii'  '>4'.' ;  tuberculosis  ol.  ..Ji>. 
Kecurront  laryngeal  norve.  paralysis  ot,  l.".l 
Kccurri'iit  pulso,  77t.  ^ 

Keourrin-  nuiltil^le  neuritis,  lo:.- 
Kea  sortenins;  of  l)rain.  lonii. 
Ue.iui.lioaliouorbeart-sounas,,..,. 

Uedux  crepitus,  V3>.^ 
Keflex  epilepsy,  lnnri. 
Uetl.'xes  in    asceiidinK'    P"n>ly'-'^ 

bral    liuMnorrha..'0,   100a,   I'Xnl 

ataxia,  '.•'^■l ;  '»  polio-n'-V*-'''" 


.\r.T[iuiTis    l)i:mi: 


;ili', ;   in  ccri 
in    Iciciiinotor 
acuta,  '.>-W,   i" 


and, 


tyiupaiiitic. 


.:  .  n„ranU"'ui   '.':'.:  ;  M  hysterical  paraplc- 
S::;:n:UU;V;U-.-siven,uscular  atrophy, 

llcuiirtritati.in.  tricuspid,  T'J-i. 

Uclapso  in  typhoid  fever.  :'.n. 

,..,U>psin5T  fever,  r,:'. ;  spirilhun  ol,  ..-i. 

Ucmittent  fever,  '.iUi- 

Kenal  calculus,  hid. 

Ucnal.   colic,   Htrt  ;    epistax.s,    S..L  ; 

syphilis, '250  ;  sclerosis,  s, .. 
AV;H,7»'«typcof  tremor,  in.-.. 

Ken  niobilis,  SW. 
Kosolutioninpneun.oiiui,  1-20. 

Kesonancc,  amphoric,  liO'J,  OS-i 

li.'sJiVat,iry  system,  diseases  of,  .;io.^ 
Rest  treatment,  U21  I  in  aneurism,  .St 

Kelina,  lesions  of,  ln:'>',t, 
Kctinalliypenesth..sia,  1010. 
Ketinitis,  albuminuric,  ln;v..  ;  1,1  ana-ma.  10,,,. 
U;mai;na,  10..  ;l-U,,Mnio,  10-10  ;p..iuentosa 

lOS'.t;  syphilitic,  ill,  lo;l'J.     ^       ^ 
Ketraction  of  heivl  in  moningitis,  -..s.  J. 
Kctro-collio  spasm,  lOii.'). 
Kctroperitoneal  abscess,  'yi-i- 
Uclropcritoiueum.  Ineniorrhairc  into,  o-,. 
Ketro-pharyn..'cal  abscess.  4r.o. 

Uctropulsion  in  paralysis  agitans,  10,  S. 

Kevacciuatiou,  VI. 


purpura  m.  n-i  ,  , 

Klie,uu,itic.'out(sceAKrnurnsI)KVouM,.NsV 

Rheumatic  nodules,  172.  ^ 
Kheumatism,  chronic,  4ii,>. 
Rhcuuiatisni,  muscular.  4o. 
Rheumatism,  subaoute,  17' 
Iheuinatoid    arthritis    (sc 

Rhinwl;   on:    atroplih.     'iH  ;    librim.sa.   M7  ; 

:,ypertropbiea,  on;syplnbt,c.21-. 
Ribs,  reseeth.n  of,  in  empyema,  h,s. 

Uice-wiitcr  stools.  17',t.  ...   ... 

Rickets,  4^.4 ;  acute,  4oS,«2..;h..tal,  SI  1. 

/«(/(iV  di»ea.so,  442. 

Ri.rulitv,  early,  in  hennph'-na,  lOU-. 

R^daitV,  late,  in  licmiple-ia.  100.., 

^  1       .....  ,.f  lirain,  102.1 ;  in  abscess  ot 

Uh'ors,  m   abscess  ot    iiiam,  . 

uJ    .->7',.;   in  »,nu-,  20',.;inpneumoma.n.>. 

l;:S,;;iii:,l.;4;  in  pyelitis. -,S7;  in  tuberculo- 

sis,  2',)',t;  in  typhoid  lever,  1.. 

Risus  sardonicus,  2:j'2. 

Rock-fever,  21',i. 

h'nmbin/.^  symptom,  ',>;2il.  _      „,,,,„.le.'ia, 

,.„,„.nerve  symptoms  in  compression  p.u.ipk.ia, 

'.iTO, 

Unsary,  rickety.  4:'.i'..  , 

Roseola  .see   Uo,.kU,vs„  OK  Tv.M,oi,„.l,,.lH 

domic,  .so, 
"Rose  cold,-' fil 2, 
R„se  rush  in  typhoid  fever.  1,. 

Rotation  in  epilepsy,  loi.ii. 
Rotatory  spasm  in  hysteria,  111.. • 

Rr.theln,  S',1. 

Rm.gh-on-rats."  P""^''"""? ''•''"■■ 
Rouiul-worms, 


Rub  (see,  VuictionK 
Rubella,  s'.". 
Rubeola  notha.  SO. 

Rmninaliou,  400. 

Running  pulse  in  typhoidlewr,.). 

Russian  fever.  0.5. 

,S„/,/,.  ivtc^-thidl.  .Mil, 
I  Saccharomyees  albicans.  44:1. 
Sacndplexus,  lesions  ol,  10,2. 

St   Vitus's  dance,  1070. 

4;„;  subcutaneous,  in  cholera,  I.  1, 

,,  ,.    t  nf  447  •  superseorotion  ol,  44... 

Saliva,  arrest  oi,  'ni  ,  ■  "i 


INDEX. 


11 


iO 


Siiliviiry 


.'liin.ls  lUsfasi's  of,  Wr,  iiifUuHiimtioii 


rnM\tioU!'  ot', 
ikkIuIcs  ill, 
My  111.  liiV  ; 
,.ory.'l',ll''«; 
itis  ill-  1"1  • 
lT-3. 

■ciuMANS). 


:1TI»     Dkkhi:- 

lirini)'*!*'    1 '"  ' 
4-'. 


L^W. 


;  ill  iitisoi'SS  ot 
iieiiiiioniii,  ll'">; 
;  in  tuberoulo- 


simi  iiiinil'loi,'iii, 


>i,  IT;  <n"' 


,  3110. 


T,  '20. 


*,  ill  (liiilu'tic  t'liinn, 

em,  1»1. 
uorotiou  of,  -Ui'i. 


SulVvutio'.i   (s.f   PTVALI.M-.  414,  44.-.;    ill  Miiall- 

IMix,  I'll ;  ill  liull'iir  iianil.vsls,  'j:;'J. 
Siilpin'ritis.  tiiln'iviiloiis,  ;;-jij. 
Siiltiitory  si>iisiii.  lo--',i. 

Siimitoriii,  trcuMiiuiit  ul' tuli^ivulosis  in,  :;.-33. 
Siiii.l-llfii,  ;i7S. 
Siiiinoiniii.  I'il. 
Sariiiun.'  Saniturluin.  "•"'■'•■ 

Siiroiiui,  vciitnc'iili.  4V;i:  in  In'",'  >':ivitics.  V,&>. 
Siiroouystis  .\Iius>'liun,  :;4;i ;  ,-aivo..ystis  liominis, 

»49. 
Siiroonia,  of  h.aiii,   W'^:    of    l<i.ln-'y.    -;ii,;    ot 
liver,   5s;j;    of  liiiiu'.   ''''■■'>;    iiK'>liii.-tiiiiil,    0^..; 
inclanotio,  of  liver,  .'is:!. 
Surooptfs  soaliici,  :iTi'>. 
Suturniiio  neuritis,  Ui'!"). 
Saturnism,  IJSil. 
Siiusa;:e  polsoniiiLr,  -"''1. 
Seapuloilyiiia.  4o7. 
Seiirhitiiia,  luiliaris.  7S. 
Searlatiiia  sine  eni|itiouc,  71). 
Seai-latiiial  nephritis,  so. 

Seal-let   fever,  7.'.:    aii^'iie.se    form,   Ml;    ataetic 
form.  TO;  oomiilieations  ami  se,|Uelie,  sO  ;  e.m- 
tnniousness  of,  7il;  aes.iuaiiiatioii  in,  71' ;  erup- 
tion in,  77  ;  lia'iiiorrluiu'ie  form.  71i ;  iiieiiliation 
of,  77;   invasion  in,  77;  inaligiiaiit,  71';  puer- 
peral, 70 ;  sur>,'ieal,  7'!. 
Sehistosoma  lia'iiiat  ibiuin,  S'li. 
Sc/cinlfiii's  disease,  >1.'>. 
Seliool-nuule  eliorea.  li.'il. 
Sc/iott  treutmeiit  ill  iiiyoear.lial  disease.  7">.i. 
Seiatiea,  U'7:!. 

Seiatic  nerve,  att'eeti<'iis  ot',  107 -J. 
Seirrhous  caneer  of  stoiiiaeli,  4^7,  4>S. 
Selereina  in  eliolera  infantum.  i>10. 
Selereiiia  neoiiatoruiu,  114.;. 
Selerodaetylie,  11 1'l. 
Seleroderiua,  IM.'i. 
Sclerose  en  plaiiues,  O.'ilt. 
Scleroses  of  the  brain,  I'.'o. 
Sclerosis,  eereliro-spinal,  li.">7  :  deu'c^nerativc,  057 
Uevelopmeiital,    IT'S;    inlhinmuitory,     I'.'iS 
scurvy,  b-2'-) :  syphilis  as  a  ''ause  of,  •J4'J. 
Sclerosis,  primaiy,   lateral,   li:'.7 ;    insular,    i'.V.' ; 

multiple,  tTili. 
Sclerosis,     posterior     s|iinal     i  see     Loiomutou 

Ataxi.\),  l''JO;  in  ehronie  eivotism,  :;u4. 
Sclerosis,  primary  eomhiiied,  '.'41). 
Sclerosis  in  tuhereles,  -^71. 
Sclerosis,  renal,  S77. 
Sclerosis,  to.\ie  eoinhined,  0."il. 
Selerostoiniim  duo.leiiale,  3.')U  ;  S.  equluum,  359, 
Sclerotic  irastritis.  -Ii'm. 
Scolices  of  ccliinococeus,  071. 
Seorliutus,  821. 
Scrivener's  palsy,  1107. 


Scrofula,  2S0 ;  allesed  prote.'tive  inoculation  I'y, 

•2Hl. 
Scrofulous  pneumonia,  '272. 
Scurvy,  .s21 ;  infantile,  s2:i ;  proi.liylaxis  of,  s-.'l ; 

sclerosis,  s-_';i. 
Sevliala,  M'.i. 
Seasonal  relations,  of  chorea,  H'Tl';  of  malana, 

ao4:  of  pneumonia,  llo;  of  rheumatism,  M7. 
Secondary  conlractun'  in  liemiple^'ia,  loo.^i. 
Secondary  deviation,  lots. 
Secondary  fever  of  small-pox,  ''.". 
Self-limitation  in  tiioereulosis,  :;2s. 
SemiUinar  space  of  'Jhnih, .  M\i. 
Semilunar  valves,  aortic,  ii.c  .iiip.teni'y  of,  70'j. 
Senile  cmiihyseiJia,  I'.r.l'. 
Sensation,    painful,   loss    of,   in   syrin^'omyclia, 

I'T  ">. 
Sensation,  retardation  of.  in  ataxia,  li2t. 
Sensory  system,  di>eases  ot',  I'^o. 
Sei.tieieinia,  UiO  ;    cryptoi:ciicli 


.•al. 


U'.2;    ;.'ciieral, 
ive,   lo2;  l>osl- 


of 


li'i'j :  goiiorrh 
typhoid,  o3. 
Septieo-pya'iiiia,  I'l  "■. 
Scrratus  palsy,  lo70. 
Scveii-tlay  fever,  M. 
Sewcr-;.'as  and  tonsillitis,  4'il. 
Sewer-jxas  poisoniiiL',  ellcets  of,  "A". 
Sex,  inlluciicc  of,  in  lieart-discii*e,  7211. 
Sexes,  proportion  of,  atlected  H  itli   acute  yellow 
atrophy,   n.M;    in   chlorosis    71'2 ;    in   chorea, 
l(.i7',i;  in  exoplitlialmic  troi' re.  s:;7  ;  in  general 
paresis,  "J'lO  ;  in  ha^niophilia,  sl'i. 
Shakiii),'  palsy,  107';. 
Sliell-tish,  poisonili,'  by,  Sl)3. 
Ship-fever,  411. 

Shock  as  a  cause  of  traumatic  neuroses,  1102. 
Shock,  death  from,  in  acute  obstruction,  5:j."i. 
Sick  headache,  llo2. 
Sickness,  sleepinir.  ■'•''•l. 
.Siderodromophobia,  1 124. 
Sidcroplioliia,  1124. 
Siderosis,  f.,"i2,  fir,4. 

Sitrnal  symptom  (in  cortical  lesions  i,  liso,  1021. 
Silij.niltus  (sec  Iln  coidii  i. 

Sinus  thrombosis  lob'';  and  anainia,  lol'i;  in 
eldorcisis,  7114;  autoelitlioiious,  loir,;  pyaemia, 
nil,"!;  secondary,  in  ear-disease,  lOlT). 
Siriasis,  Wi'i. 
Sitotoxismus,  004. 
Sixtli  nerve,  jiaralysis  ot'.  10|<. 
Skin,  itehiiiu'  of,  in  ura'iiiia,  si;7. 
.S/v)./-('.<  resonance  in   pleural  ell'usion,  W.)  ;  in 

pneuinonia,  1 11'. 
Skull,  of  coni.'enital   syphilis,   24:; ;    of  hy.lro- 
eephalus,  1021';  of  rickets,  43'i ;  percussion  of, 

1027. 
Sleepinj;  sickness,  .",i'il. 
Slow  heart,  7."ill. 
Small  pox,  O'!;  connilicatioiis  ■>!',  04;  conllueiit 


UTO 


INDEX. 


I-  -„',  ■   ili>rrrtr  I'lrlll. 

0O;c.ru,.U..nin.  .■-.  IK. n-h..i,-,  .--""'  >' 

lat>.mh,,:n;;v...i..aU.m.n...;.. 
S,„ans..K„u..u.rv.,a.tc..Uonso,    0     • 

S.M.U,   .lUvUon.   of  >oUsc   ot    (.^cc    OUA 

Nkkvk).  l":'.'^. 
Simlu-v\n,s.imnHiniomso,n>>.^n. 

S„i\,  iutliiHUT  ol.  m  ..ImUi.i.l... 

1„M^  -n--,  in  tvi'lioia  ffvor.  I.. 
S„\vrut  tiv.uncnt  of  iviml  .ulcuU,  hV.O. 

Sdor,  44:3. 
Soriles,  -J-J. 
S(.ro  tliroat,  -W^- 
Sdi/ii  lil'cail,  4:.ii. 

S,,asM..l'"'U,iu«riUTV.-n„uis  11"^. 

^        ,  1     ■,     111-,-,-  iinUVs^ional,  11"' ■ 

after  fa.'i»ll'»'-''l>'^''>  '""•''  '' 

saUatory,  lOj-'.'.  ,,,,.c.lUa.-y, 

Si,ast.o   IM Kipk    u  ,     Hiliti.-,  '.'40;  in 

M4(i:  hvstcni'al,  .i4i  ,  /-'"       .  1 
obiiaivn.'.'iW;  secoudavy, '.'41. 
SiKH-ifi>'iuf>'Otious.lis.as.-s.l. 
sL-itiMroat,m..Uoftyi.h.n.l1.s>..4,. 

Si^rira,  fortit\>'ation,  UU-2. 

^i:::l;:r.;="i. ,.;.-"„i;r;;; 

K   ■,      'lo-"    ill     n.-ular  srli'inM>,   .'■'.'. 
l,aralvM>,   .'o-,    .  ,,„,,ai,ary  alaxia. 

troncral  paralysis,  '."■-.   ". 
.,,r,u;in,H'n>l.vsisa,rU.ms.  1".   ■ 
S,;...ch.s.'.nnin..mUis.iU.rs..U.r..s,.  ....'. 

SiHs\>litliisi>'a.  31-'  ,■  ,..ui.\a  tMiuina  in 

Spina  bilida.  iiivolvonu.nt  ot   wuMa      1 


Sliiluil  a..ossnry  lu-we.,  paralysis  nf.  in.,.l. 
Spinal  apoplexy, '."i-^. 

vessels  of,  'M-,C, ;  emlart-ritis  ot  "-  J^'"        ; 
r  in   ..,vv  liannnrrliau'>i  ii>l"-'"'^>  "'"' 

Assures.     >^.-     ,,^,.^,i.a,ion  of  fi.n,.,ion 

;;r:::r^..;;.--;:--ist'::r. 
£:::-i,;::::;^S:';;n;::..'i-^"--- 

lesions  of,  '.ii'..>. 

Spinal  I'l'ilfl'sy,  '•'"■"•^ 

Spinal  irritation,  U-^"'- 

Spinal  membranes,  luwnorrha.n.  into,, 

Spinal  nerves,  aisoases  ol.  II 

Spinal  neurasthenia,  lVi^>. 
Spinal  paralysis,  atropliio,  'Mi. 


Spirals,  I'lnsflimnfii'",  ""l-  '"'"''• 
Spirillum  of  re)al>Mni:  fever,  r.4. 

Spiroelneteoft)l>ermeier,r.:i. 

::i:S"::;v;::i"U.«-^ '■^^^^^■^■ 

of  silVl;  tumors  ot,  s-4. 
S,ien,  enlargement  of.  in  eon.enital  sypliiUs. 

■>\->  •.i44;  ii\  malaria, -.in:,  ■J.\K 
Si:;;:;i..s.-islonof.i.iliyi.enropliy,sini;mlcu- 

Ua-'uiia,  s"',i.  ^ 

Spleen.  lloatinJ:,^4:^sn;;;eSelslonof^-.^ 

sUen,  in  a.ue,  -^.f  ;:^':\,:' tl^^Ca:!: 

l::^i,!ri:.U:.s.4..,4.T;inal•u,..n--p 
oV«;i,.,yplioiatVver,lo...i;m.M.hus,..0. 

Spleen,  lameture  of,  40. 

Spleen,  n.li.urc  of,  s^:V,m  malaria,  .o,,."U 

pUoia  fever,  U.'J'i. 

Spleneetotny,  statisties  of,  Hl'J. 

Sjileiiie  alitemia.  s:l4. 

Splenic  fever,  'I'li. 
Spleiiization  of  liue-', -.iV-J.  t^;!. 

Spleno-UH';-'aly.  primitive,  s.,4. 

Sponavlitisaeformans,  40:1. 

Sporozoa,  ;54'.i :  pariisilie.  u4J. 

Spotted  fever,  4',',  l"l. 

Sprue, -'jII.  .         p   ,      ,   i'."^- 

^^r-1 :rt:;r':S::::::;::::i;:;:»- 

•1-      rv^filsin  .^so;iii  anlliraeosis,  (...4.   m 

'":::,      Si  rbron:iiieetasis,i;.V;  in  aeuu. 

::     :;;;ti:i^.;i-,ironiel,r..nel.iJ|.4;m 

,„,,n,,„neliitis,0:;o;in^an!:reneotlun..M 

Si;,a,in,0i,liisis.:..O;inpn.wn,.na.l      .     > 

',,u,e    pulmonary    tubereu  om.,      ,0 ,    V 

n'      i;lpva.Mli,..^i:>-"■■'':;>""'"';r;^^'■''^''• 
i„septlele^nl.,l•;^:H>tonslU,:s,l,.l 

st:,i>s,'.piiepti^;>-.  >•:■;;;  ^^--•;;:-;^;•.,, 

status  lympliatieus.bj'i,  suaoui 

SLllinKj-s-  siiin,  sliS. 

Stenocaraia,TOl,  .,.,.  of  mitral  oritiee. 

Stenosis  of  aortu-.ritie.,,l..__.Mi^^.^_^^^_ 

7.2I;  of  pulmonary  oriliee,...,  I'o, 

pid  oritloe,  T'^'>, 
Steppie.'e  i-'ail.  l""''*- 
Stereoraeeous  voniitinsr,  5^4. 
Stercoral  uleers  in  eolitis,  i>13, 
Stertor.  in  apoplexy,  fOM. 

stitch  iu  side  in  pneumonm,  n^,'"l 
00». 


IXDF.X. 


11 


t  ( 


■  uUiciiiUi,  ^||•''. 


,.l,u  .■(ill  in.  ••i"l  ■• 
•nzu,  'JT ;  luviiiii- 
inic'osis,  liri-t ;   1" 

rJ,    iVSi  ;     in    lU'llt".' 

MU'liitis,  li-^i;  i" 

rciioot'liiiii.'.'''''l- 

•iimniiiii.  "''  •  '" 

lis,    '2Tr>;    I'niiK- 

in,  411. 

141 ;  in  riuliH-ar- 

•  ;    ill    lllU'UIU""ill. 

ii\iiiti>'  iV'Vi'i-,  I''"'. 

■rious,  1119. 

cu  til  ;.tli  iM.S-JT. 


of  luitriil  (iritiof, 
iV,  TC.7  ;  of  triciis- 


in  pur|inra,  "IS. 

iu,  115;  i"  rl«iri:»y. 


Stnkcs-A'lains  syn'lnmir.  Vi"'''. 

St.ilidity  of  f;u'..  ill  (.'fluTiil  pansis.  'M'± 

Sti.iiiiiili,  iit'iiti^  ciiiK'c'r  of,  4'.i:'.. 

Stoiuacli.  caiK'iT  of.  4sii;  uIim'Mc'c  of  free  IICI  in. 
4',il  ;  iliau'iiosls  from  jrastrii'  iiU'i'V  an.l  cliroiiic 
(.'asti-ilis  4',i:'.;  lia'iiioiTlia.'c  in,  4'.iii;  vomiiiin.' 
in,  4'.iii. 

StoniUfli.  .lilatatioii  of.  47  I ;  t.lany  in.  IT.">. 

Stoiiiacli,  ilisi,'a..-fS  ol,  l'i:l. 

Sto.iau'li,    atropliy     of.     4'o  :      atony     of.    ,-,00 
I'hroni.'  oalai-rli  i>f.  401;;  .ro>ion-  of,  I'W;  for- 
cijrn   t.o.ru's   ill,  4'.tl;    Iih-inoitIki.t   flolll,  4^1 
■lli.-i;  liair  tmnors   in,  4',i4 :   luui-osc-*   of.  4'.iT  : 
lioii-|.ani>ci'oiis  tiiiiio|-s  in,  4'.il ;  tnluTi'ulosis  ot, 
yi'.l;  uK-iT  of,  47^;    wa.^liili.u'  out   of  ,lavau'c', 

47 -i 

Stomatitis,  441  :  aouto.  441  ;  alilithou-.  fll  ;  I'l'i- 
ilcmic.  ■117:  fetid,  44-J  :  follicular,  ■)  tl  :  LMn::rr- 
lioiis,  411;  mercurial,  444:  neurotica  chronica. 
44:i;  [.arasitic.  44:! ;  iilcurativi-,  44-J;  voicular, 
441  ;  uraMiiic,  Si^. 
Stoiic-cuttcr's  iilithisis,  'Ji'.'.',  i''.''2. 
Stools,  of  acute  yellow  atn^i'liy.  ."■">•-' ;  of  clii>lera, 
17'.i;  of  aysontery,  l'.'.'>.  I'.i7,  \W.  "f  tyiihoi.l 
fever, -2:5;  in  lia'matemesis,  4'J7  ;  of  obstructive 
jaunilicc',  0 1'.i. 
Straliismus,  lul'*. 
Strantrnlation  of  bowel.  .'i">l,  ti'M. 
"  .Struwiierry  "'  tonttue  in  scarlet  fever,  7-*. 
Stiv|itoeoeoi    in   dipbtlieria,    141  ;   in   empyenui. 
ti71;  in  eiuloearaitis,  7i'2;  in  luieunioifui.  11/,; 
in  iieritonitis,  ,J'J7;  in  pyivmia.  Hi:!;  in   rlicu- 
inatic  fever,  10^;  in  scarlet  fever,  77:  in  >ei'ti- 
caMiiia,  li'cJ;  iii  tonsillitis,  4,'il. 
Streptoi^occus  ili|ilitbcritis,  14-2. 
Stre|itoeoccus  erysi|ielatos,  l.'i7. 
Streptoeoeeus  jiyoi/enes  in  erysipelas,  1.'7. 
Streptotlirix  actinnmyees.  •2:'..'i. 
Strictures  ami  tumors  of  the  bowel,  'i",:). 
Stricture  of  bile-iluet.  ."I'ln. 
StrietU'v  of  colon,  cancerous,  ri">.'!. 
Stricture  of  intestine,  .'i:!.'! ;  after  ilysentery, -JoO, 

5:3:!;  after  tuberculous  ulcer,  -jl'.i. 
Stricture  of  o'sopbairils,  4i;o. 
Stricture  of  pylorus.  4;t4. 
Stron^yloiilcs  intc^tinalis,  :>!4. 
Stronirylus,  :'>."i'J. 
Strumitis,  s:iii. 

Stuttcriiii.'  in  moutb-breattiers,  4.'a'i. 
Styriaii  peasants,  arsenical  habit  in,  W\. 
Subclavian  artery,  murmur  iu  and  tlirobbiiej  of, 

in  )>hthisis,  :',os,  ;',0',i. 
Sub|ihrenic  peritonitis,  lioO. 
Subsultus  tcudinuni  in  typhoid  fi'vcr,  -JH. 
Succussioii,  Hip|iocratie,  il«-'!. 
Suceushion  sphisli  in  dilated  stomach,  47''>. 
Sudamina  in  typlioid  fever,  17. 
Sudden    death,    in    anuinu    pectoris.    7'M 


aortic  insullieieney,  TIU;   in   coronary  artery 


I      disease.  T47  ;  in  cnlarL'e'l  thy nnis,  «4 1 ;  in  i.leii- 
I      ral  eltiisions,  i;71;  in  status  lymphalicus.  s-27  ; 

in  typhoid  fev.T,  4o, 
:  Sudoral  fi>rm  of  typhoid  fcvcr.  Is. 
Suirar  in  the  urine.  4'j:i. 

Siilphoeyanides  in  e\eess  in  >aliva  in   rluiima- 
I       tism,  170. 

'  Sun-stripUe,  ;'.'.'.'i;  afler-etVects  ipf,  :'.'.i7. 
Suppression  of  urine,  s:,o. 
Supl>urative  mphritis,  ^^7. 
j  Suppurative  pylel'hlebilis,  ."i."i.'). 
■  Suppurative  tonsillitis,  4.'r2. 

Suprarenal    hoilics,    diseases    of.   s-Js ;    hiemor- 
'      rha'.'c  into.  s;;'j ;   tulierculo^is  of,  •.:;■.!;   luuiors 
of.  s;',-J. 
Sur:.'ical  Uidiicy,  ss7. 

Su>iicn..ion  in  comiovssion  parapU'L'ia.  '.i7'J, 
Sucalimr   in   acute   rheumatism,   lii'.i;   in   a;:ue, 
■Jl-.';    in    diabetes,   iS-'.:    in    phthisis,   .mm;:    in 
pya-mia,  I'M:  in  tyi.hoid  fever,  IS;  in  uleera- 
ti'\e  eiidocaidltis.  7"! :  profuse,  in  rickets,  VM\: 
uuilaleral.  in  I'crvlcal  caries,  '.'71  ;   unilateral, 
in  aneurism,  7'-2. 
Sweatiliir  sickness,  ;;4il. 
Si/f/iiiliiiiii'K  idiorea.  lo;!l. 
Symmetrical  jL.'anL'r<nc.  ll"s. 
Sympatlictic     jraiiu'lia,     in     .I.A//"'//'---     di>ease. 

Sympathetic  nerve  tibres  (-cc  Vaso  motoU'. 
Symptomatic  parotitis,  1 17. 

Syncope,  fatal,  in   diphtheria,    l.'l  :    in   ciuduic 
'disease,  71--',  7.">o;   in   i.hthisis,  ;;1T:    in   pleu- 
ral ell'usion,  1171. 
Syncope,  '.ocal,  ll"i7. 
Synovial  rheumatism  (see  (biNouumivAi.  Uni;r- 

MATISM),  -.'I'l. 

Synovitis,  iroiiorrhu'al.  li.">7. 

Synovitis,  symmetrical,   iu   coie_'cliital    syphilis, 

•J44. 
Sypliiliilcs,  macular,  'Jlo;   papular.  -M":   pustu- 
lar, -'40:  si|uamous.  241  :  the  late.  241. 

Syphilis,  2:N:   aci'ldiMilal  infection  in,  2;!s:  1 

ipiired,  210:  amyloiil  dc;,'cncration  in.  242; 
bone  lesions  of,  214;  con.L'cnital,  212:  early 
nerve  lesions  in,  24."i ;  irmnmata  in,  2;!",i:  hered- 
itary transmission  of,  2!!^ ;  moiles  of  inleetion 
in,  2;!s;  of  brain  and  cord,  244.  1020;  of  cireu-^ 
latory  system.  2.'iO;  of  .liircstivc  tract.  24'J ;  of 
liver',  24S;  of  lull".',  247:  orchitis  in,  2.")1  ;  l>ri- 
niary  stage  of.  240;  prophylaxis  of.  2."i2  ;  renal, 
2.'iO;"  seconilary  sta.^'c  of,  240;  tertiary  stae;e  of, 
241 ;  visceral.  244. 

Syphilis    and    dementia     iiaralytica,     242,    241'., 
iall. 

Syphilis  and  locomotor  ataxia.  242.  !ejO. 

Svphili:  hieriiorrhai;iea  iieonatonmi.  24u,  fela. 

Syphilitic  arti^ritis,  24.">. 

Syphilit.'  fever,  240. 

Syphilitic  ne[ihritis,  2.J0. 


in 


117S 

Syphilitic  Vl'<l''"'"*;-''• 


INDKX. 


chronic  cw'tisni,  :i'j4. 
Tubes  .lorsalis^^riis.uuai.ivu',  .'■... 

Tiibos  nu'si'iiti'ri^'"-  •■i'^:^- 
TiuOic  fi-ivl)riilc,  l^.  •^'^- 

■'-""''- ''";!'^':^:l^::';;„„.asUK.nio,n2.^;  par- 
",0T;  lit  ri^'llt.lll>^;X'■'"'• 

^'T;:2T;M;aii....i.nsisT...n,-i,..,.. 

Tivuius.,ginutuorn..aiociini.lU.ta,oM,. 

TuMiiii  Holium,  :>''■'•  , 

T.i,.-wor,ns:>-Mv^.|t,no,Uon^..^^^^^_^^^^^^. 

Taste,  aisiurl)aiie.>  ut.  l""", 

Tea,  neuritis  eausod  by,  10.,.>. 

Teohon.yza  fusea,  HT'J.  ^^^^^^^^^^^   ^^^^   ;„ 

''^^'^''''r~*'l^s;.,.;iU,is..n.44.;ero 

sionot•,.».l^,;//"^•/"/^s'-".S^-l",44■''» 

tile  stiMiuititis.  44.'. 
Teiohoi.si,i,llo-J. 

T..le,n.rlurserami.,1108.  .     ,..,       „a 

Tenil>eniture  sense,  loss  ol.  ni    . 

T,,niK.rut«re,  subnorma  ,    n   m  uu  ^^^  ^ 

^^'^'-r'^^^t^Hion    I'^n    inmalU,.OU, 
1001 ;  in  beat  exhaustion.  -.'■  .  ; 
!.,,-,.   in  vul.nonary  tubereulos.s,  .0.,    n 
"  „;„.ntis  ---y  ■inuneima,  s^iid. 

bereulous  niel'iUiJitis.  -i-  . 

^"'""''       .        •     „  ,„■.,!, r-,..    1104;  in  neuvasthe- 
Temler  points  mneuialu'ui. 

uiiv,  II-'''  .  .  .         o,-, 

Tender  toes,  in  typboul  fever,  -o. 
Tenaon-retleNes.seeUKn,KNKS.. 

T,.nninal  infeetions,  Ih... 

Tertian  a^n.e.  'Jl'.i.^  ..yi-bilis  of,  251  (sec 

Testes,  "ibereulosis  ol.  oJj.  sypiiu 

"'«"■■•"■""''•  .„„- „f  -"ll  •  neonatonini,  2aO. 
Tetanus. -10  ;  biieilbis '^t, -.>l  , 

T..ta.n.s.  >'''l'''"''';: -•.■';,  ,,,-a,,„„,„v.  1110;  epi- 
Tetany,  n..;anertb      nl  .^^^^.^^^^^^^,_^ 

aeinio  or  rheun.at.e,  IKU  .    '  ;„ 

.tonmeli,  4T.-i.  mo;  m  n.yxceaeuia,  in 
(vplioid  fever,  ".0. 

Tetroilon,  poisonini,'  by.  S04. 

Thera,.euf.e  test  in  syphilis.    ^1. 

Tlierapv,seru....inpb>?'"',l-'3' 


:s:::;;;:  !::::;£  o.;.nsyrin,o..niyeiia,.:. 

(if  imnilysis  ot.  Iii4i>. 

•riwirneie  duet,  tiibereiilosis  ol,  _,*. 
ilirxidetWniity  ot;  in  nioutb-breathers.  4 

i„  riekets,  4W.  phthisis,  21;;, 

Thorax  in   eniphysenia,  '^s  ,         i 

oOli. 
Thoni-headed  worms.  'M.'. 
yAr-r/HiviW/V  dis.'ase,  4u7. 

Tliread-woriii.  :l'i:^- 

'i"'''-''"';''^ "':;:::,;' vi-'tn  diphtheria.  ur,;i.. 

Thrombi  m  heait.  i-j.  '         i 

pneumonia,  114.  , 

Thrombi  in  veins  in  typhoid  .eNer,.l. 

Tlivombi.marantie.  101...  ^^.  ^,^,^^,_ 

jKirtai  vein,  ri;)4. 

Thrush,  4411. 

Tlivmie  asthmii, '''''^-    ■'^'  „,  q, r  . 

'")'""  ,    ,.  .  ,,,•  oiT.  tximors  ot.  9-t'' . 

persisteiiee  oi.  .  •  ■ . 

,\i.n  death  in,  s44.  _  j^. 

Thymus;rland,inaeromejraly.ll4..,a>>de.    1 

tiialniie  goitre,  ^4r>. 
Tlivroid  abseess.  8Srt.  r  v.'i  ml 

nivxo'dema,  oi- , 

Thyroid  trlaud.  diseases  of,  b35. 
Thvroidisni.  P4:!. 
Tit-  eonvulsif,  lO.''"'.  1"««- 
Tio  douloureux,  1105. 

Tieks.  ".TO. 

Tinnitus  aurium.  lor.i. 

Tintement  metallique,  TSS. 

.lieeo,in.U,eneeo.;onthehcan,.0^ 

T.n,ue,a.ophy^ot,^..:--;-;;^;^ 

^;:itmT;tubere,ilosiso,;«ls;umU.t- 

.•iVMUUminwhoopiniX-eounh.  JJ. 
"'     ;  -    .  ..oiite  4r.l;  albuminuria  in.  4..  J, 

T'"-'"""'V  •'';"  4,;     in  the  ne.ly  married, 
ondoearditis  in,  4..-, 

■*■''■  ,        •     dr-.f  fonieidar,4r.l;b>^'"""'". 

Tonsillitis,  ehr,mie.4^;4iob^^^^^^^^_^__^.^_ 

4M;suppurat.v,4.-;^  .,„,,,, 

31S. 


INDKX. 


1179 


10-10;  sig"^ 
iithiTs,  4.',.'i : 


(•rill.  lir. ;  111 

, -1- 

[OOS;  of  otTi- 
rciiis,  1U15;  «il' 


tumnTS  of,  845 ", 
,t  of,  s4-i  ;  >*"''- 

■llj;  ainK'XoliU- 


)f.  841!.  ini. 

-■sory  tumors  of, 

c.   ofll  ill  oretins, 

„.>'r   of,  Sort;  i" 

L'oitro,  8"i'>;  '"' 

-,1)0 ;  tuiiior.s  of, 


loiirt.  T'U. 
iiMiiii  of,44r.;  poo- 
,r    iHiriilysif,   93-2  ; 
.is  of,  -^is;  uniliit- 

piiri'sis,  yO-2;  "l^'^'r 

jtjii.  ya- 

liliuiuiininai"- •*■>-■' 
,ho   iH'wly  luurricJ, 

iouliir,4,-l:liuniiuir, 
,1  rlieuniivtisiii-  4ril. 
,.,ili  of.  4.-.I1 ,  I'lie^-'^y 
4,-)4 ;  tuViuroulosis  of, 


TonsiU,  diseasi's  of,  451. 

Toi.hi,  411. 

Tiipiciil  diiii-'iiosis.  siiiiml,  '.mU  ;  eiTcbriil,  '.CO. 

Toronto  (iciicrul  llnspitul,  stiitistiev-t  of  typlioid 

fever  at,  •!. 
Torticollis,  40rt,  hWi:   coii^reiiitiil,  1004;  IViiil 

u.syiimietry  in.  loiU  ;  simsiuodie,  lOiiO. 
Toxie  vtiisti'itis.  4'')r>. 
Toxiiu's.  ill  M'litii-a'iiiiii,  101. 
Tnielieal  tiiL'triuu'.  V^o. 
Truetion  aiieiirisiii,  TTV. 
Tranoo  in  hysteria.  111:!,  11 1'.». 
Trauhe''s  scinilunur  space,  I'.ii'J. 
Trauma  as  a  factor,  in  delinum  trnucns,  r,-^-i\ 
in  neurasthenia,  liy-J;  in  piieuiiioiiia,  lO'J;   in 
tuberculosis,  '-'"o. 
Trematoilcs,  aiscases  caused  hy,  :!.'il. 
Tremliles  in  cattle,  ;i44. 

Tremor,  alcoholic,  3^1,  lUT'.i ;  in  draves'  disease, 
83'J;  hereditary.  loT'.i;  liysterical,  loT'.',  1115; 
in  exophthaltiiic  goitre,  ^311 ;  lead,  3VJ  ;  in  pa- 
ralysis asitans,  1077;  A'e«./«'.<  type  of,  1115; 
neililc,  107'J  ;  simple,  1U7'J ;  toxic,  107'J ;  voli- 
tional, in  insular  sclerosis,  liSO. 
Trichin.i  spiralis,  354;  distribution  of,  355;  sta- 
tistics (f,  in  American  hoirs,  355;  in  (_ieriiiaiiy, 
3,"i,");  nil  dcs  of  infection,  3.')i'i. 
Trichiniasis,   3.54;   epidemics  of,   3.')0 ;   propliy- 

laxis  of,  3.'i;i. 
Trichoceplialus  dispar,  304. 
Trichomonas  vat.'inalis,  351 ;  T.  hoiuinis,  -351. 
Trichter-brust,  3o7,  455. 
Tricuspid  orifice,  stenosis  of,  7:iO. 
Tricuspid  valve,  disease  of,  7-5  ;  insulUcieii''y  of, 

7-J5. 
Triu'cminus  (see  Kiftii  Xf.uvk). 
Trismus,  neonatoriiiii,  '^30;  hysterii.'al,  1114. 
Tromnier'a  test,  4-23. 
Tropliie  disorders,  1137. 
Tropical  dysentery,  l',i5. 
y'/'OMSA'caiiV  symptom,  in  tetany.  HID. 
Tubal  pregnancy,  ruptured,  simulating  peritoni- 
tis, 000. 
Tuberclcbacilli,  25;i,  .301. 

Tubercle,  diduse   inf.Urated,  '>'i ;  niiliury,  -270, 
'l\i7> ;  dianges  in.  •.i71  ;  strii(!turc  of,  270  ;  nodu- 
lar, 270. 
Tubercles,  miliary,  in  chronic  [ihthinis,  2'.l5. 
Tuliercula  dolorosa,  10:i7. 
Tuberculin,  '.'iil  ;  test,  '_'5S  ;  treiitmcnt,  335. 
Tuberculosis,   acute,   273 ;    general    or    typhoid 
form,  274 ;  meningeal   form,  27i) ;  pulmonary 
form,  275. 
Tuberculosis,  25>< :  bacillus  of.  25'.i,  301  ;  changes 
produced   by    bacillus,  270 ;  chronic   miliary, 
2'.)5  ;  of  circulatory  system.  327  ;  conditions  in- 
tluencing  infcctiim.  207  ;  congenital.  202;  die- 
tetic treatment  of.  33.'') ;  distribution  <if  the  tu- 
bercles in,  270 ;  duration  of  pulmonary  form 


of,  320  ;  hereditary  transmission  of,  20i2  ;  indi- 
vidui     oropliylaxis  in,  330  ;  infection  by  meat, 
207,    ■    ■vtioii  by  milk,  207;  infection  by  in- 
halation, 2i;,-. ;  inoculation  of,  204  ;  in  infants, 
310;  in  old  age,  3.10;  •iiedicinal  treatment  of, 
330  ;  modes  of  death  in  pulmonary,  :'d7  ;  modes 
of  infection  in,  202;  natural  or  si.ontanc-.;.-., 
cure  of,  331 ;  of  alimentary  canal,  317  ;  of  brain 
and  cord,   321;   of  Fallopian   tubes,  320;   of 
genitourinary  system,  322;  of  kidneys,  324; 
of  liver,   320;  of  lymphatic   system,  2^0;  of 
mammary  gland,  327  ;  of  ovaries,  320;  of  peri- 
cardium, 2S,") ;  of  peritonieum,  2si',  ;  of  pleura, 
2s4;  of  prostate,  320;  of  serous  membranes, 
'_'h4  ;  of  testes,  320;  of  ureters   and  liladder, 
325  :   of  uterus,   320 ;    of  vesiculie   semiliales, 
320  ;  pregnancy,  intluenee  of,  in,  .320  ;  prophy- 
laxis in,  330  ;  pseudo-,  202  ;  pulmonary,  2sii  ; 
and  typhoid  fever,  33 ;  and  valvular  disease  of 
heart,  310. 
y.v ,''«(//'«  treatment  of  aneurism,  714. 
Tumors  of  lirain,  lo20. 
TuMiiel  aniemia,  3110. 
Twists  and  knots  in  the  bowel,  533. 
Tympanites,   in   intestinal   obstruction,  535  ;   in 
'peritonitis,    5ys ;    in    tuberculous    peritonitis. 
2s7  ;  in  typlujid  fever,  25  :  as  a  cause  of  sud- 
den heart-failure,  545. 
Typlilitis,  51'„i. 

Tvphoid   fever,   1  ;   abortive   firm,  34  ;  afebrile, 
"l7,  ;i5;  ambulatory   form,  1-1,  34;  aniemia  in, 
19  ;  and  tuberculosis,  V.\ ;  bacillus  of,  3  ;  chills 
in,  17;  circulatory  system  in,  10;  diabetes  in, 
33;  diarrho-a  in,  23;  digestive  system  in,  22  ; 
Khrlich'i  reaction   in,  31;  erysipelas   in,  33; 
grave  form  of,  34  ;  liajniorrhage  in,  10  ;  hanii- 
orrliagie,   35 ;    historical   note   on,   1 ;    in  the 
aged,  35  ;  in  children.  35  ;  in  the  fo'tus,  30  ;  iu 
pregnancy,  3,") ;  laparotomy  in,4>*;  liver  in,  11, 
27;  Maidstone  epidemic  of,  5;  nieteorism  in, 
25;  mild  form,  34;  modes  of  conveyance  of,  5; 
nervous  system  in,  12,  28  ;  noma  in,  33,  35  ;  os- 
seous system  in,  32  ;  oysters  and,  0  :  parotitis 
in,  23 ;  perforation  of  bowel  in,  10,  2ii ;  peri- 
tonitis ill,  20,  47;  post-typhoiil  elevations  of 
temperature  in,  10;  prognosis  of,  40;    proph- 
ylaxis of,  41;    pyuria    in,   11,    32;    relapses 
"in,  30  ;  renal  system  in,  31 ;  respiratory  system 
in.  27;  serum  therapy  in,  47  ;  skin  rashes  in, 
17;  s]ileen  in,  20;  tender  toes  in,  30;  tetany 
in,  30;   varieties  of,  53;   Wikd'^  reaction    in 
typhoid  fever,  38. 
Typhoiil  gangrene,  12,  22. 
Tyiihoid  septiciemia,  33. 
Typhoid  spine,  32. 
Typhoid  state   in  obstructive  jaundice,  550;  in 

acute  yellow  atrophy,  552. 
Tyiiho-malarial  fever,  so  called,  30,  214. 
Typhoto.xin,  8. 


INDEX. 


1180 


liii'Ilt    I".   ■"■  ' 


■I'yrHti'xioim,  sya.^ 
•l'*vr<iti'xi^ii'»>' "'■'■"'• 

^"«- ^":'^  '"!•>'':::!     ribe   now-born,  .m: 
Vl^.H-   ot    mouth,    •»■'-•  j,^,^,  ;„  hillilU:', 

n,  nursin)-'  womuik  44...  '  i  1 

^^'-         ,..    ,-..,H.rion,tm,.oflnot,luta\H.s, 
rU'or,  V^ptK'.  4,s.  l'>_ 

,,.1-,-  in  iWiibe'is,  4-J.>. 
l-u'cniuvo  vwWnvd\Us,  W'-'. 
VU'i-rs,  /'.<;•/■<./••«.  44;;. 
l-mar  nerve,  urtVoOons^otl^.l. 
l-,K.\n»r-Kiav.oaenu\>s....K. 

r„eonseu>usues.,seeeoM..). 

^•'''"'""^Sv'';';:^^  .unutestation.  of,  8CC; 

ooiua  m,  bu  ,  c  ^^^^^  .^^  ^,,„.  ,,,,„a- 

'^"•""^';i;?r\;,"ri,hi:sa>seasc..s4;  latent, 
'"■'"  '"'     "  ',    e    in%07  ;  o.aen>a  of  bru.u  in, 

;.;..;;  (Utl.ate)  of  «oaa>n^'oul,  4... 

VrutcsintUeun'W'*''''^- 

;.;.,,..  annate.),  amorp;-^.^ 

l-roter,bloeking  o,  ^'^^  ;:^"\, ,,„•,, r,„uvsi.  of, 
•r,0  •  tulierevaosif  ot,  .v-^. 

L'rio-aeUlbeaaacbe  41,,. 
rrie-ao-ul  theory  of  SO"t,40S. 

Urinary  ealetiU,  b',''^-  ;„„  „,;  S50. 

rrine,  a..o"naie.  "Hhe  .    «'  ^^     ^^  ^j.^^,,^^,,,  ^70-. 
l-rh.e.  aensity  ot.  .n  «">'  ^  J  ^^  "  ^,,  .  i„  aiabetes. 
•,,  W,rome   Hr-.b,  s  a>.  «- 
.i.^:,;-,n.babetesinM!iiau>.  ^.^■^■ 

l'v>ne.'b>e.uo.\ob\nUK^^|i.  ^^^.^.^^,^._  .^^.j,, 

,rhu.H>aeUteyeU.s  .^^^^^^^^ 

^trave  antenna.  -  !  •. '  ^  ,i^,,„„.  ,u.UUu.,4^S; 
betes  iuMl'"'"^-  *  :  ,,.^.,,,^.Vm  l.V,! ;  in  i-'out, 
•„,  aipbtberia.  1.'"  \  ">  '  ;  ;  '  .  .  ,„i,i,uu.tio 
•  U    4i:i.  4ir,;in  .ia'>'">" '•■.'■,„  .    ;„   ,i,„te 

.„r:on>a.  M^:>; '" ''"r'":;;:'r;;\;:;:,,„ia  tever. 

vnbno,.Hryt«i-ere;.lo.>^..n-.J^;^.l 
in  ;  oxalates  in,  hi.\  ,  V  ■      ■        .   ,   .    aisease 
Uri.;,  quantity  of.  in  ebr^n^    J    f  in  aiabetes 

,:e:t;,;i<.non..Mi;r-:-^ 


^-■l-!"""^''";n,;,„rnieioUsameuna,7^n>. 
Vroliibn.  in.Teusu  ot.i'>l"-y^ 

^^^'"-^^"'''XrCi"-'"^'^''''^^^ 

Irtieana,  Biter  tail'   -  Nkiuotu' 

,,„,,,,;    ^=';'"\  ""..iMMnail- 

V,.x.Co;  intyvboiaiever.lN 

rtenis.tu\>ereiilosis..t.  .!.;>.  4.4s,  slR. 

.  (■   I m •  inta  '■■"on  01.  «■  1 
Ivula,  o.aenuiot.41.   , 

Vueeination,  ««;  '"a.U,   '"  "  ^ 

1        "1  •  uieers.  VI  -.  value  ot,  ..i. 
raslies,  il  .  ""■^'  ■  '    ^^ 
1  Vueeine,  untityplio.a.  4..    ^  _ 

Vaeeineiynivl'-''l""r7";'-;,   .„.   ^,,„ena->7.^"l' 
Vaee.nia.  i;b;l'^-t^-'-'">"-^    "'• 

71.                       _ 
Viirelno->Vl'l"'"''  ''■ ^.-1 

V;;;;;:eila.74;b.,no.ba.W^^^ 
VavieenabulU->...,     .^j        ^       ^^j,,.^.^,,^4,Vj. 
V»riees,o.sopba^e,a.    n      nl  ,,,^  r,'.. 

Variola,  5fi;ha-<-'"^-;;^;-,;:,  ,3. 
Variola  luemorrba-.ea  in  >tnlo.  a, 

Variola  sine  erui'tio"e,  '.4. 

Viuioloia.  r.o,  IW. 

V«so-nu.toraisoraevs.41..<.  ,,.(  .     ;„ 

Vaso-n,otor    ais,urbane>    m^         _^^^_^,.^^,^. 

..bronie  pleunsj,  oM  ,   \        .,,„>v,.litis,'J77; 
tre,b"'.t;  inl>emierania,UOo,mi  . 

inneurals-'ia,  li>-'_i'  ,..•,,,    irtl,5  ;  aiastolio 

i,„Uai>so  of,  tj'.i.  ,  \'>"''i 
m.lerusls  of,  77:!.  .      ^,^,^ 

r  ■":;*"-:;;*":,;.  .n  - - 

risni,  77H.  7b«- 
Venereal  aisease,  5SP, 
V::;eseetion  (see  lUoon,.^--). 

'''■"""r':^Sabraib.taUonof(byaroee,ba- 
Ventrieles  ot  Diani. 

Vc.ntrieularlnoniorrba^c^,.... 
Vervueaneero,e>uea-^*-^^^^.^,^^,_^,^,;,,,,,,-l. 

Ver.ebralartery.obs    ua  J     ^^^^^^^_^^^^..,,,^,,. 

Verti.'o.  aua,t.,r>.^lo.-b- '  ,„.ain  tun.or,  UV'i ; 
^'■••'rtri;bV;intlnne,10.s;e..aennerara- 
j;astric.4li.i,  i-'o* 

Viearious,ci,istax.s,hl4.  h.u.    i  . 
Viseeroi'tosis.  ,V11. 


IXDKX. 


ilSl 


ill  obstruc- 

i.iUary  V't-'- 
,uiu"^i'S  ill. 

iiiu'inii'.  7''''- 
,-);  ill  Kliiiiii- 


I  ;    ^n'lUTll'.i?!-'''' 


id  tiilHi'ovilesis, 


II,    !•)• 

,  of  liver,  4511.  ^ 
02,  153  ;  VI  v;i,  .5'.'. 
I,  iVJ,  i:.3. 


...rl.s,  y7K  >" 
,xoi>litluilnii'"  t-'"^- 
•  in  inyt-lilij*, 'J'  <  \ 

in,  I'^l"';  'VuistiiVio 
in,  311-1"^-^'"-''' 

■,i;s. 

a\nn  of,  I'V  m.cu- 


iiinimcc,  I-''',  •''• 


Vitilij,"ii>l>'».  "'l''. 

VciL'iil  fruiiiiui.-,  H'.',  'i'l-'*;  ' 

Voii.'U  (^fC  Sl'Kl.rM). 

Voi.'c,  ,ilt.Tiai"ii  cf,  ill  moiali-l>iv;itliers,  4..'- 

Viilitioiml  tiTuii'i-,  '.i.'i'.'. 

Volvulus,  .'>3;i,  J37. 

Vomicu,  5iH''.;  si>ri"«  >'•'• '"  I'li"''"-'^'  •'"■'• 

Vomit,  blii.'lM  l«'i ;  ooUci-tsrouii-i,  4:in.  _ 

Vo,„itili-,in  .l,W/«<y»ai..-ras..,SW;  ill  /.''•«;//'/■* 
■  li-^Misu,  ^•>l•,  ill  >'>ivh.-:a  ul)SL'Css,  lO'Jli;  m 
cfi-obnil  tuu.oi-,  luiil  ;  ill  elmmi''  obstruction 
of  iiitcstin,...  .■.:;.-.;  ill  '•liroiii''  uloonUivo 
plitliisi.,  311;  in  gall-stone  oolir,  .y.4.;  in  «»s- 
tiir  I'lini'iT,  4',Hi;  in  ij'i'^tric  ulctT,  4-(l  ;  m 
ac'uto  olistniotioii  of  iiitcsiines,  534  ;  in  tubur- 
i.ulous  nu^niiijiitis, '.iTS  ;  in  niigrniiif,  IK'3;  m 
ntTitonilis,  DiiS;  in  siimll-pox,  -.'J;  nfrv.nis, 
4'.i;.;  pi-imiiry  perioJic,  4U1I  ;  slcivorucuous, 
rj.'it;  uni'iiiio,  Mi7. 
Vulviti>.  uU'i'nilivf,  in  iiumsU-s,  s7. 

WiiU-liaiHT,  iHusoniiig  I'V  ar^'iiii'  in,  VMl 

Wart-l'ox,  113. 

Warts,  iM)st-iMortciM,  'J'll. 

Wasliiiit;  out  stniiiiioh,  17'J,  177. 

Watur-luiiiiiiH'r  jiulsi',  714. 

Water,    infirtioii    by,   in    .liplitb.-ni,,    b'.-s ;    n 

cholera,  177  ;  in  typiioia  fever,  5. 
"  Water  on  tlie  brain,"  -~'''- 

WJnr,  synclroiue  of,  -^7'.',  loot,  10-J3. 

ir.(7Vaisease.  344. 

KVW/«'/'.< 'lisease,  SUI. 

IIV/'H /<•/!■. Vlieiniupie  i>ui.illary  inaetioli,  1044. 

Wet-paek,  s4. 


Wbip-woriii,  3ii4. 
White  ^ol■tel.ln^' of  brain,  looy. 
W  bite  thrombi  in  heart,  7-3. 
Whuoiiing-eough, '.i-J. 

IC-m'^'/V  disease  ^see  Eril.KMh:  ll.KMoOLoulN! 

UH  OK  THE  NkW-IIoUNI,  -43,  >1^  -"JJ. 
'•  Wiii'fed  seapube,"  3o7. 

Wintrirh-n  si,i,'n,  30'J. 

ir.,/7/..:,  mulitilii  'If,  fi-'l. 

W'nol-sorter's  disease,  -J-l,  --''■ 

Wdrd-ldindlie.ss,  '.'V.I. 

Word-deaflie.ss,  USD. 

W(ird-dunibne.s.s,  1)',I2. 

Wormian  liones  in  hydroeepbalus,  lOii.L 

W  onus  ^see  I'au.\sitksi. 

Wounds  of  tlie  heart,  7.'i4. 

Wrist-drop,  1071  ;  i"  lead-poisoniii;,',  3.11. 

Writer's  eramp,  llo7. 

WrylieeU,  loi;4;  spaMiiodie,  loi;.->. 

XaiitlieUisUia,  .'il'.l. 
Xanthine  ealeuli,  •-■.'■J. 
Xalitliomatu,  4-J."i,  .M'.',  •''''>5. 
Xaiithop>ia.  3.'.3. 
Xerostomia,  447. 

Yellow    fever.    ls-.i;    baeteriolo^'y   of,   1S3;    epi- 

demies  of,  IS'J. 
VuUow  softening  of  brain,  loo'J. 
VoUow  vi.^ioii,  353. 
}',,/,<  dietary  in  oliesity,  440. 

Zona,  lloO. 


NO). 


on  of  (bydroeeplui- 
130. 

I'.i. 


THE    END. 


■vvieal.  earics  of.  071. 

,n  of,  lOU^. 

,,.ebelUir.  OSC ;  in  m- 
brain  tumor,  U'-.^^ ; 
c,10oH;endeiiiiepan'- 

,ulosis  of.  320. 
h'.eiiioptysis,  f>37. 


THE  DISEASES  OF 
INFANCY  AND  CHILDHOOD. 

J-'ur  the  I'xe  of  StuiJentu  ami  P radhUmcvn  of  Mnl'iv'iuc. 

By  L.  EMMETT  HOLT,  A.  M,,  ]M.  I)., 

rrofetsor  of  I)m<ms  of  Chihire,,    in   the  .\ew   York-  lhl:jrU„ir  ;    Atlei,.li„<i  /%^'V<""  to 

tlLt  'jiithica'   Ihspitd  and  to  the  .\>im-n/  nml    C/iild's   llwpitnt,   .\c«'   iork; 

ComuUinij  r/ii/sidaii  tn  the,  Si-w  York  liifont  .tx;/liiin,  and  to  the 

JI'i8/jit(d  for  liiiiitimd  and   CrqiiiUd. 

With  7  full-page  Colored  Plates  and  203  Illustrations.     Cloth,  $6.00, 
sheep,  $7.00  ;  half  morocco,  $7.50. 

SOLD    ONLY    nv    SUnSCKIPXIOX. 


American  Medico-Surgical  Bulletin: 

"This  work  is  in  <'vcrv  sense  oftlio  wonl  ii  now  Look  ;  for,  while  tlio  liest  work  ol'otlier 
authors  ill  this  ,m,l  ,,the'r  cuntries  lias  been  drawn  ui">ii.  e>pe,'ially  that  in  the  forni  of 
niono-raplis  and  in  tlie  tiles  of  pialiatrie  Hterature,  tlie  majority  is  clerive.l  troni  the  author's 
own  clinieal  ,>l.servations.  Obsolete  dieta  haiulea  .l.,wn  from  text  book  to  text-book  are 
Iiere  coiispieunuslv  absent,  and  nothinu'  li:is  been  aceepted  which  has  not  been  oareliiUy 
tested.  ...  It  is  not  venturintr  too  mueh,  after  a  eareful  perusal  of  tliese  pau'es,  to  pri'diet 
for  this  volume  a  pre-cmiMent  and  lastiii.'  position  amoiii;  the  treatises  upon  this  sub.ieet. 
\Vc  heartily  reeoimnend  tluit  it  tind  a  plaee  not  only  in  the  lilu-ary  of  every  physieum,  l>ut 
wide  open  at  the  elbow  of  every  man  wh.)  desires  to  deal  intellijrently  with  the  problems 
wliieh  eonfront  him  in  the  treatment  of  infants  and  children  intrusted  to  Ids  cure." 

I/ashville  Journal  of  Medicine  .• 

"  This  ma  'iiifleent  work  is  one  oftlio  most  vahiaMe  roeent  contributions  to  niedieal  liter- 
ature. It  will"  rapi.lly  win  its  way  to  a  front  r.mk  with  other  standard  work>  upon  kindred 
subjeets.     It  is  as  nearly  eompleto  as  a  treatise  upon  this  subject  can  be." 

Virginia  Medical  Semi- Monthly  : 

"  When  one  recalls  the  te.ichin.'s  of  a  decade  or  two  a!,'o  and  compares  tlio  incincati..n8 
of  to-dav,  he  can  searcelv  help  reeo!.'nizinir  that  'old  thin.'s  have  passed  away,  and  all 
thin 's  liave  become  new.'  Tlie  volume  before  us  is  practically  the  record  ot  mtormation 
obtained  bv  the  author  from  eleven  years  of  special  study  and  practice,  so  that  nearly  every 
subject  is 'presented  fn>m  th.i  standpoint  of  personal  observatiMi  and  experience.  I  he 
inf.u-mtition  irivcn  is  tiierelbre  reliable,  for  Dr.  Holt  is  a  close  observer  and  a  earetul  student 
of  his  ripe  .'Xi>ericnce.  ...  In  short,  this  book  appears  to  ns  to  be  the  best  all-nmud,  up-to- 
date  book  for  practitioners  and  students  of  e' 


children's  diseases  tliat  we  know  of.'' 


Medical  Progress  : 

"  The  work  betbre  ns  is  one  which  reflects  iiroat  credit  upon  the  distiniruished  author. 
Pr.  Holt  has  loiif,'  been  known  as  u  most  industrious  and  paiu.takiii!,'  iiivesti-ator  and  in 
this  volume  he  sustains  that  reputation.  The  work,  we  may  say  in  a  sentence,  is  i''  X  "P 
to  the  requirements  of  the  times,  an.l  there  is  no  advance  known  to  pa'diatrics  which  hM 
not  been  fidly  dealt  with  aoeording  to  its  merits." 


D.   APPLETON  AND   COMPANY,   NEW   YOPJ-T. 


A.  TEXT-BOOK  OF 
GENEPvAL    SURGERY. 

VOLUMH  1. 

M.  D.    ^VM■  Ul  Jllu»l rations. 

nc!,i,,«al  Sur,„r.,.     T™.*."'  '';»  .'t/'Sl" "-"  SI.'""  5  "«  "'" 
Olotlx   85.00;  si:;^;rS^OO  per  jolumo. 

bo.t  for  the  use  ol  studa  .  ^^^^^^^^^  .^  ^  ^  ^       „t  1^.  «  -  o>,>;«^^^  ^i,^.,,  ,,e 

Si.uoEUY,  as  r'-^'««"*'^i!"      ,oaV,  und  ou  Keoional  Stiu.tu^. 
SuuoKKV  ANi.  >';^«;:';;(^/j  If^.'^;,,,  wiU  soon  bo  on  press.  ^^ 

two  volumi^s,  the  snoiia  oi  scwuca-l  Pathology,  .s  'f  ?«  >  .^'=' ^1  ^  „,,plies  not 

-:SX^r-^'        '  .aevotedtothe.r,er.ot.ho,.^.^^:--;t 

sp;nc  and  spinal  oord ;      .=' ^>;',';^^  j'^  Vhiexa,  of  the  f«ec,  ot  tire  nose   «      ^^^^^  i 

crauial  bones,  ot    he  binm  »  'J  "f  ;     x.  of  the  car,  nnd  "♦  ^''V  the  arvnx  and  truchea.  and 
iuwB,  of  the  •"?"'^.'^''^l'"';r;dVurS  diseases  of  the  '1'-^^^,  ot  the  nr.v  ^^^    ^    i,^ 

^irikon  includes  "y""f,  ""    ^^^g',,,  covers  injuries  and  diseaKS  ot  t_  .^^^^  ^^^^^_  i^eluduig 
of  the  a3sonha,us         ho    "  ;^._^^^  of  the  surgery  ot 


01  tue  st.ui',  ■■■  •••- 
sp;nc  and  spinal  oord ;      .=' ^>;',';^^  j'^  Vlnexa,  of  the  f«ec,  ot  tire  nose   «      ^^^^^  i 


ODIUIU  "-i"-  »"" = 

D.  APPI.ETON  AND  COMPANY,  KEW  YORK. 


ed  fri'iii 

'I'lLTON, 


Nkwis  a. 


Hf.njamim 
JjEWIs  a. 


o. 


popscspcs  as 
p,  befiuiniiii,' 
trufturc.  It 
■lected  lis  the 
practitioner. 

on  Geneha'- 
ter  there  ure 

\  to  the  expo- 
is  iiyplies  not 
>rk  covers  ttie 
,  with  s'.iecial 
,lons  for  tlieir 
)f  the  various 

■k,  thorax,  iwd 
lie  scalp,  of  ilie 
il  fossre,  of  tlie 
,s,  Tlie  fcfoiid 
id  tracliea.  and 
irax  and  of  the 
cord,  including 

■arities,  and  the 
jonsulting  other 


IRK. 


